Latasha Wade, PharmD
Sally A. Arif, PharmD, BCPS, BCCP
Akesha Edwards, PhD, PharmD
At the end of this case, students will be able to:
- Explain how systemic racism can affect patients
- Discuss the role of culture in health beliefs, behaviors, and practices
- Identify methods to elicit patients’ health beliefs and practices during an encounter
The Census Bureau projects that the US population will become considerably more diverse over the next two decades. By 2044, half of Americans will belong to an ethnic minority group, with one in five persons being foreign-born not too long after.1 Despite this, the healthcare system in the United States continues to be inadequate in the provision of care to persons of color because it has been infiltrated by the brutality of slavery and the persistence of systemic racism. Throughout US history, advances in medicine have relied upon the use of slaves and Black bodies.2 Infamous experiences such as those of the Tuskegee syphilis study participants and Henrietta Lacks are notable cases of racism. The actions of the healthcare professionals in these, and many other cases has led to the erosion of trust in healthcare professionals as well as the healthcare system. Systemic racism leads to negative outcomes for persons of color, such as less access to preventive care, poor management of pain and increased rates of maternal mortality.3-5 Patients of color have responded by seeking healthcare professionals with similar backgrounds as theirs, if available. If suitable options are not available, patients may opt to minimize their interactions with the healthcare system, leading to negative outcomes such as non-adherence to provider visits and medication, as well as an overall decrease in health-seeking behavior. As a result, the burden of health disparities on the US healthcare system continues to be a significant issue.
As the US population increases in terms of racial and ethnic diversity, the likelihood that healthcare professionals, including pharmacists, will encounter patients whose health beliefs, practices, and behaviors are different from their own or those customarily accepted in the United States will also increase.6 These health beliefs, practices, and behaviors are guided by the culture to which a patient identifies. Culture is defined as the “integrated pattern of human behaviors that includes thoughts, communications, languages, practices, beliefs, values, customs, courtesies, rituals, manners of interacting and roles, relationships and expected behaviors of a racial, ethnic, religious or social group; and the ability to transmit the above to succeeding generations.”7 As such, culture may affect how a patient perceives their health, what a patient believes causes their illness, how the illness is experienced, who a patient seeks out for care, who makes health decisions in the patient’s family, and the patient’s treatment preferences. For example, pharmacists may encounter patients from cultures that use alternative medicine and healers in combination with or in lieu of Western medicine, while men make health decisions and extended family play an integral role in the care of loved ones in other cultures.8 Consequently, in addition to the culture of medicine, pharmacists must understand, appreciate, and take into consideration the cultural diversity of their patients in order to effectively care for a population that is becoming more racially and ethnically diverse.9 It is understandable that there will be instances where evidence-based medicine conflicts with culturally-competent care as the former seeks to standardize health care for all while the latter emphasizes the importance of caring for patients as unique individuals.10 What is important to note, however, is that evidence-based medicine and culturally-competent care can co-exist when the patient is proactively included in discussions about their care, their health beliefs and practices are elicited and respected, and there is clear and honest dialogue between the patient and the pharmacist.
Culture also plays an important role in the way we communicate and awareness of cross-cultural communication models can improve patient care outcomes.11 This understanding requires a pharmacist to address barriers to effective communication that can arise during a patient encounter, which includes lack of knowledge about cultural differences, fear and distrust of others, stereotyping groups of people, and poor non-verbal communication/active listening skills (e.g., lack of eye contact [if culturally appropriate], dismissing patients with limited English proficiency). These barriers, if left unchecked, can impact a pharmacist’s ability to provide culturally sensitive care and further perpetuate inequitable care to already disadvantaged populations.12
Gaining knowledge of various cross-cultural models/tools that exist to enhance effective communication can provide strategies to cultivate genuine and culturally sensitive relationships with our patients. For example, the LEARN model is used to build trust, and allow for the pharmacist to negotiate a care plan with the patient, while the SOLER model can be used to promote active listening and establish an empathetic, respectful relationship with the patient.13,14 Psychiatrist and anthropologist Arthur Kleinman created a series of open-ended questions that also can be used to gain insight into the patient’s worldview, lived experience, social context, and spirituality as it relates to their illness.15 These questions can be used in a respondent-driven interview approach for the pharmacist to better understand the patient’s perspective by asking “what kind of treatment do you think is necessary? “what do you fear most about your illness?” or “what are the most important results you hope to receive from this treatment?”
CC: “My mother is leaving the hospital today.”
Patient: KS is a 62-year-old Hispanic female. She is being discharged from the hospital after recovering from DKA.
PMH: T2DM (diagnosed during this admission)
- No history of prescription medication for any medical condition prior to admission
- Initiated on insulin glargine 10 units subcutaneously every evening during admission
Additional context: Upon entering the room with the pharmacist, you note that KS appears well rested and in a good mood. Present in the room with KS are two adult women, an adult man, and a small child. They were in town to visit KS when she was admitted to the hospital. The pharmacist introduces themself to KS and those present with her and asks permission to initiate the counseling session. KS looks to one of the women (RA), who states “Please do.” While discussing the insulin prescription, you notice that KS has remained quiet and frequently glances at RA. The adults appear uncomfortable.
- Pharmacist: “KS, do you have any questions about your insulin prescription?”
- RA: “My mother primarily speaks Spanish. We asked one of the nurses if someone who spoke Spanish could meet with us but were told there are no Spanish-speaking providers at this hospital.”
- Pharmacist: “Your mother? Oh…um. I didn’t realize you were related.” RA has darker skin compared to KS. “I noticed that you and your family seem a bit confused about the insulin prescription. Don’t worry…your mother will get used to giving herself injections. It’s pretty easy. Or you and your husband can help her!” The pharmacist then turns to the male present in the room. “You can help your mother-in-law and wife, right?”
- RA: “He’s not my husband; he’s my brother. SHE [pointing at the other adult female in the room] is my wife, and we are my mother’s primary caregivers. We need to talk to a curandera first…”
- Pharmacist (interrupting RA): “Oh, please excuse me. I am so sorry. I thought he was your husband. Um, here is a medication guide with pictures that explains how to inject your insulin. This may make you all feel more comfortable with giving the injection. I give this pamphlet to all my patients who are started on insulin for the first time. It is a really effective treatment for diabetes.”
- RA: “As I was trying to say, we need to speak with a curandera first before my mother can take this medication. Our family believes in spiritual and natural ways of healing the body. Does the hospital have a curandera or someone who specializes in spiritual healing that can meet with us? If you have copies of the pamphlet in Spanish, that will allow my mother to familiarize herself with the medication…just in case we decide later that she needs to use the insulin.”
- While the pharmacist makes a phone call, you overhear RA tell her wife, “The people in this pamphlet don’t even look like us. There’s never anyone who looks like us in these health brochures…unless it’s something negative. It’s like these brochures are only designed with a certain group of people in mind. Ha! Unless we are talking about that stop smoking poster of course [RA points to a poster on a nearby wall in the room].”
- Pharmacist: “I just learned that we only have the pamphlets in English. Although we do not have a curandera in our hospital, we do have a chaplain who is Christian. He is great. Let me contact him for you.”
- RA: “I think we’ll just take the prescription and try to find help for our mother elsewhere. Thank you.”
1. What instances of systemic racism are present in this situation?
2. How could these instances of systemic racism impact KS in terms of her care and wellbeing?
3. What cross-cultural conflicts or issues can you identify between the pharmacist and KS/the family (e.g., communication, assumptions)?
4. How could the pharmacist have interacted with KS and her family more effectively?
5. What methods could be used by the pharmacist to explore the role of the family during this encounter?
6. What strategies could the pharmacist have used to elicit the patient’s health beliefs/practices?
As pharmacists, it is essential to keep cultural diversity at the forefront of each patient encounter. Doing so will allow us to effectively and appropriately interact with, treat, and provide care for our patients as individuals, and not as members of a group to which we have unconsciously (or consciously) assigned stereotypes, biases, or generalizations. It is important that pharmacists remember that our own health beliefs, practices, and behaviors are rooted in the culture(s) to which we belong, including the culture of medicine and/or a historically dominant culture in the United States. Because these cultures may be unfamiliar to, different from, or create conflict with those of our patients, pharmacists need to be conscious of institutional policies, practices, and cues in our healthcare settings that may prevent all of our patients from fully engaging in the healthcare system and receiving culturally-responsive care.
Patient Approaches and Opportunities
While most discriminatory behavior by healthcare professionals is not subjectively experienced as intentional, the impact of such behavior contributes to racial disparities in healthcare.16 As pharmacists, we need to consistently ask ourselves “What is my personal interpretation of assigned value based on how someone looks, acts, or presents themself and how is this rooted in my own bias?” Our goal must always be to get to know our patients as people at the start of every encounter and do the same for whomever is with them. Treating patients with mutual respect requires that we treat them as they would want to be treated, not as we would want to be treated. We need to be diligent and consistently evaluate our environments for institutional policies and practices that perpetuate systemic racism and negative stereotypes of patients.
Related chapters of interest:
- Ethical decision-making in global health: when cultures clash
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- Experiences of a Caribbean immigrant: going beyond clinical care
- The great undoing: a multigenerational journey from systemic racism to social determinants of health
- Journal articles:
- Arya V, Butler L, Leal S, Maine L, Alvarez N, et al. Systemic racism: pharmacists’ role and responsibility. J Am Pharm Assoc 2020;60(6):e43-e46.
- Evans MK, Rosenbaum L, Malina D, Morrissey S, Rubin EJ. Diagnosing and treating systemic racism. N Engl J Med 2020;383:274-6.
- Feagin J, Bennefield Z. Systemic racism and U.S. health care. Soc Sci Med 2014;103:7-14.
- Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives-the role of health professionals. N Engl J Med 2016;375:2113-2115.
- King CJ, Redwood Y. The health care institution, population health and black lives. J Natl Med Assoc 2016;108(2):131-6.
- Colby SL, Ortman JM. Projections of the size and composition of the U.S. population: 2014 to 2060, Current population reports, P25-1143, US Census Bureau, Washington, DC, 2014. . Accessed January 27, 2021.
- Washington HA. Medical apartheid: The dark history of medical experimentation on Black Americans from colonial times to the present. Doubleday Books. 2006.
- Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci. 2016;113(16):4296-4301.
- Bower K, Robinson K, Alexander K, Weber B, Hough K, Summers A. Exploring experiences of structural racism and its influence on maternal and child health. J Midwifery Women Health 2020;65(5):718-719.
- Alsan M, Garrick O, Graziani G. Does diversity matter for health? Experimental evidence from Oakland. Am Econ Rev 2019;109:4071-4111.
- Bonder B, Martin L, Miracle A. Achieving cultural competence: The challenge for clients and healthcare workers in a multicultural society. Generations: J Amer Soc Aging 2001;25(1):35-42.
- Goode TD, Sockalingam S, Bronheim S, Brown M, Jones W. A planner’s guide—infusing principles, content and themes related to cultural and linguistic competence into meetings and conferences. . Accessed January 27, 2021.
- American Academy of Pediatrics. Culturally effective care toolkit chapter 2: health beliefs and practices. Engaging patients and families. Providing culturally effective care. . Accessed January 26, 2021.
- Bussey-Jones J, Genao I. Impact of culture on health care. J Natl Med Assoc 2003;95(8):732-735.
- Hasnain-Wynia R, Pierce D. Practicing evidence-based medicine and culturally competent medicine: is it possible? Virtual Mentor. 2007;9(8):572-574.
- Shaya FT and Gbarayor CM. The case for cultural competence in health professions education. Am J Pharm Educ 2006;70(6):1-6.
- Diggs AK, Berger BA. Cultural competence. In: Berger BA. Communication skills for pharmacists. 3rd ed. Washington, DC: American Pharmacists Association; 2009:199.
- Berlin EA, Fowkes WC. A teaching framework for cross-cultural health care. W J Med 1983;139:934-8.
- Egan G. The skilled helper: a problem management and opportunity approach to helping. Pacific Grove, CA: Cambridge Brooks/Cole. 2002.
- Kleinman A, Eisenberg L, Good B. Culture, illness and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978;88:251–8.
- Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Health Care Financ Rev 2000;21(4):75-90.