2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

CROSS-CULTURAL COMMUNICATION
Sidebar. Tips for Practice to Overcome Language
and Literacy Barriers
To overcome language barriers, obtain support from
colleagues or institutional leadership to provide
professional interpreter services. There are national
standards for interpreters, but the quality of
services and depth of training are quite variable.
You may want to consider offering training for
interpreters to familiarize them with terms often
used in complex oncology consultations and in clinical
research. Remember that using minors for
interpretation is illegal and that family members
often distort the content of conversations. In the
United States, health care organizations are obligated
by law to provide language assistance services
either in person or via remote interpretation
services at no cost to patients with limited English
proficiency. 22-24
To overcome literacy barriers, check the patient’s
reading level and explore any possible learning
disabilities that could interfere with proper use of
medication or compromise the ability to discuss
options for treatment. About one-half of Americans
are considered to have limited health literacy,
which affects their understanding of basic medical
terms, their ability to follow directions for diagnostic
procedures and therapies, give their consent for
research, and engage in a real dialogue about treatment
options.
tated by cultural norms and influenced by beliefs in an
afterlife. Knowing and understanding these issues in advance
allow physicians to provide direction as death
approaches. Trust has been described as an iterative process,
requiring steadiness and honesty. 15 In fact, distrust is
often the cause of misunderstandings or miscommunication
and may contribute to disparate outcomes. 15 Breaches of
trust committed decades ago by medical researchers in the
United States still haunt relationships with African Ameri-
Author’s Disclosures of Potential Conflicts of Interest
Author
Lidia Schapira*
*No relevant relationships to disclose.
Employment or
Leadership
Positions
Consultant or
Advisory Role
1. Farmer P, Frenk J, Knaul FM, et al. Expansion of cancer care and
control in low-income and middle-income countries: a call to action. Lancet.
2010;376:9747.
2. Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting
Ethnic and Racial Disparities in Health Care. Washington, DC: Institute of
Medicine; 2002.
3. Betancourt JR, Renfrew MR. Unequal treatment in the US: lessons and
recommendations for cancer care internationally. J Pediatr Hematol Oncol.
2011;33:S149-S153 (suppl 2).
4. Fallowfield L. Truth sometimes hurts but deceit hurts more. AnnNY
Acad Sci. 1997;809:525-536.
5. Greene JD, Cushman FA, Stewart LE, et al. Pushing moral buttons: the
cans patients, who may harbor suspicions about the integrity
of research and refuse to participate in clinical trials. 16
Similar doubts about the motives of researchers are also
expressed by patients who have experienced discrimination
or harbor concerns regarding the privacy of personal health
information.
There has been considerable interest among philosophers,
psychologists, anthropologists, and ethicists in studying
truth-telling and disclosure of both diagnosis and prognosis.
In the United States and many Western countries, patient
autonomy and involvement in medical decision making
remains the key driver for full disclosure of health information.
Autonomy trumps other ethical and social concerns. 17
Research and practice have shown that most patients can
cope with grim information and, with guidance and support,
come to a resolution of their emotional pain. 18-20
Physicians vary in their level of comfort with such disclosure,
and despite the increasing availability of communication
skills training, practices are often informed by
instinct and shades of paternalism. 12 The same is true of
patients and family members, who often keep important
information from each other. Negotiating these fundamentally
private issues remains an important task for
clinicians.
At Harvard Medical School, instruction in cross-cultural
communication begins in the first week of the first year. In
small groups, students discuss their reactions to film clips
and texts chosen to highlight the plight of new immigrants
and the challenges of delivering care in a pluralistic society.
Using case-based learning and with expert facilitation, they
are guided to articulate and identify solutions for complex
communication problems. Courses are designed and delivered
by multidisciplinary faculty to drive home the important
message that the lessons learned are fundamental for
good practice and broadly applicable. Didactic sessions follow
Kleinman’s explanatory model of illness, which stimulates
inquiry and patient-centeredness and avoids
stereotyping. 21 Lessons in cross-cultural communication are
later inserted into other course materials to reinforce the
message that good clinical care is based on understanding
what is fundamentally important to each patient.
Stock
Ownership Honoraria
REFERENCES
Research
Funding
Expert
Testimony
Other
Remuneration
interaction between personal force and intention in moral judgment. Cognition.
2009;111:364-371.
6. Greene JD, Morelli SA, Lowenberg K, et al. Cognitive load selectively
interferes with utilitarian moral judgment. Cognition. 2008;107:1144-1154.
7. Greene J. From neural ‘is’ to moral ‘ought’: what are the moral
implications of neuroscientific moral psychology? Nat Rev Neurosci. 2003;
4:846-849.
8. Greene J, Haidt J. How (and where) does moral judgment work?
Trends Cogn Sci. 2002;6:517-523.
9. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians
and its prediction of thrombolysis decisions for black and white
patients. J Gen Intern Med. 2007;22:1231-1238.
e87