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The Time Objection: Cross-Cultural Care and the Ever-Shortening Office Visit

5/1/18 8:38 AM


The most common objection

I've given hundreds of presentations on culturally-competent care to busy clinicians around the world. At the end of my talk, someone always asks the "time question." I know plenty of other clinicians are thinking it, but don’t want to appear insensitive. So I wait for a brave soul to say, “Dr. Green, you’re telling me that if I want to be culturally competent, I have to do all of these things on top of what I already have to cover? I have to ask my patients how they understand their condition? What their religious practices are? Whether they trust me? I’d love to—but I just don’t have time!”

This is by far the number one point of resistance to incorporating cultural competency into clinical practices: No time. I'm overwhelmed. I have 10 minutes to see a patient. Don’t ask me to do anything more. I get it. I’m a primary care doctor myself. Time is tight and the work keeps expanding. But here’s why it doesn’t have to take a lot of time to practice culturally competent care—in fact, it can actually save you time.

How cultural competency saves time

A lesson from Taiwan

In 2016, I gave a lecture in cross-cultural care in Kaohsiung, Taiwan. Dr. Tsai, a respected teacher and busy nephrologist at the university hospital, listened with great interest. Afterward, he approached me. “Dr. Green," he said, "do you know how many patients I see in a half-day session? 60.” I nodded, and waited for him to raise the inevitable time objection.

Instead, this is what Dr. Tsai said: “What you talk about is what I do every day. It helps me get to the root of the problem so I don’t waste time.” I was elated to hear that cultural competency helped this overloaded clinician save time.

Dr. Tsai went on to describe the case of Mrs. H, a woman from a rural area outside Kaohsiung. Mrs. H’s kidneys had failed, and she had developed severe anemia requiring a blood transfusion—which she refused. Dr. Tsai was perplexed. Patients in Taiwan don’t typically refuse treatment.

Rather than resorting to the force of authority, Dr. Tsai asked a simple question: "Why?" The blood transfusion was very important for her health. He was concerned about her, and wanted to understand why she wouldn’t want it. It turned out that as a devout Buddhist and vegetarian, Mrs. H didn’t want to contaminate herself spiritually with the blood of someone who ate meat.

Dr. Tsai explained to her that blood transfusions are not whole blood anymore, but purified red blood cells with the liquid serum removed and cleansed of contaminants. It was her choice, he said, but he hoped this might help her feel better about the idea of the transfusion. Mrs. H agreed to the procedure. Dr. Tsai told me that this conversation took about two minutes, and probably saved him hours in ineffective attempts to convince her, as well as wasted follow-up visits.

Learning to ask the right question at the right time

Cross-cultural care can be complex. But rather than attempting to be medical anthropologists, clinicians need to get comfortable with a basic communication skill set and apply it judiciously—in order to ask the right question at the right time.

The person-centered approach to cross-cultural care describes this skill set. One way to master it is to pick one small thing to focus on each week and practice it with as many patients as possible (musicians call this woodshedding).

Here are some examples of a person-centered approach to cross-cultural care:

Scenario 1

Clinician: Do you have any customs or traditions that you practice that might affect your healthcare—dietary or religious practices, for example?
Muslim patient (with diabetes): Yes, it’s Ramadan this month and I’ve been fasting during the day.

Scenario 2

Clinician: You seem a bit skeptical. What have your experiences with taking medicine been like in the past?
Puerto Rican patient: I’ve only had bad experiences with medication. I’ve gotten rashes all over my body, liver problems, headaches. That’s why I try to avoid them and use natural treatments instead.

Scenario 3

Clinician: Have you had any trouble getting your medication?
82-year-old Italian American patient (who has not been adherent to her heart medication):
Well, honestly, it’s just so expensive. I haven’t been able to afford it.

The advantage of culturally competent care

Some cross-cultural questions could easily be on a patient intake form, or asked by medical assistants to save the clinician time. But regardless, the key is to break through any misunderstanding early and often. Yes, we are all busy, and asking lots of open-ended questions can be time-consuming. But with experience, you’ll quickly hone in on the right one to unlock the answer and crack the case. As your communication improves, you will actually save time during office visits. More importantly, you'll make fewer mistakes and build stronger relationships. Cultural competency has the power to both improve patient outcomes and enhance your own professional fulfillment. Don't consider it a hindrance. Consider it an advantage.


Learn about our Jumpstarter Award for cultural competency training

Alexander Green, MD, MPH

Written by Alexander Green, MD, MPH

Dr. Alexander Green is Co-Founder of Quality Interactions, Associate Professor of Medicine at Harvard Medical School, and Senior Investigator in the Division of General Medicine at Massachusetts General Hospital.