Ethnogeriatrics Promotes Cultural Competence in Medicine

By Jaimie Lazare

As the population of ethnically and racially diverse older adults increases, so does the need to identify and address health care disparities.

In the near future, health care will experience a boom not only in the number of older adults but also in the number of ethnic and racial minority older adults. While minority older adults made up 20.7% of the US population in 2012, that number is expected to increase to 39.1% by 2050, with Asians, Native Hawaiians, and other Pacific Islanders contributing the highest numbers to the population growth of older adults.1

This anticipated increase has underscored the importance of the American Geriatrics Society (AGS) Ethnogeriatrics Committee developing a position statement that acknowledges health care disparities and their impact on health outcomes, facilitates culturally competent communication, and provides quality care to older adults.2

Ethnogeriatrics: Addressing Bias in Medicine
Ethnogeriatrics is a term specifically for the health care of older adults from different cultures, and it's important because our demographics are changing, says Fred Kobylarz, MD, MPH, an Atlantic Philanthropies Health and Aging Policy Fellow and a geriatrician and associate professor in the department of family medicine and community health at the Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey.

"The phrase 'silver tsunami' is often used in geriatrics as the term for the elder boom or the boom of older adults who we're expecting to see in the next 30 to 40 years," says VJ Periyakoil, MD, a clinical associate professor of medicine at Stanford University School of Medicine, director of the Stanford Palliative Care Education and Training Program and the Stanford Hospice and Palliative Medicine Fellowship Program, and chair of the AGS Ethnogeriatrics Committee. Periyakoil says that the 'silver tsunami' is actually 'silver-brown' because it is the population of ethnic minorities that is exploding the population of older adults. Consequently, as the population ages, the United States is going to become a majority-minority nation by 2044, she says.

Periyakoil says that factors such as the complexity of medicine, the regression of patients as they get older, and physicians' biases contribute to the poor quality of care of multicultural older adults. Physicians' knowledge levels and socioeconomic status may stand in stark contrast to those of their patients, meaning that physicians may simply not understand their patients' issues. This is where it's essential for clinicians to assess their bias in every patient encounter, she says.

"Bias is a loaded term, and it doesn't necessarily mean negative; bias could just mean that someone has preexisting models on how to approach a particular problem in a patient," Periyakoil says. "For example, studies have found that African Americans diagnosed with hypertension don't respond to ACE [angiotensin-converting enzyme] inhibitors. So physicians who don't prescribe ACE inhibitors to African Americans could be seen as demonstrating bias. But these data are based on real knowledge and studies; this is one example in which clinicians would have to pause and assess whether this decision is negatively affecting their patients."

"Providing culturally appropriate care involves awareness and acceptance of cultural differences," Kobylarz says. "Older people from different racial and minority groups experience health care disparities not only in poor health outcomes but also in access to care, prevention, and quality." For example, he notes that African Americans diagnosed with heart disease have been found to receive fewer revascularization procedures following cardiac catheterization.

To improve health care outcomes and prevent health inequities among ethnically older adults, the AGS Ethnogeriatrics Committee has provided a minimum set of quality indicators to improve health outcomes. The Committee developed the following questions, which can be asked and documented across different health care settings, to incorporate culturally competent communication during physician-patient encounters:2

• What is your ethnicity?
• What is your preferred language?
• Do you know that interpreter services are available free of charge?
• Do you want to choose one of the available interpreter services (online, telephone, in person)?
• How much education did you complete (none, <7th grade, ≥7th grade)?

In addition to asking these questions, physicians should be self-aware of potential biases and perceptions that may be a barrier to providing quality care to older adult patients.2

"So the first line of the recommendation that I would have [is to] be aware of your own beliefs and biases and focus on what matters more to patients," Periyakoil says. "The best way to align with someone is to have an interest-based alignment by asking them what matters to them, and then structuring your care to focus on what matters to them. It's really helpful to have patient-centered, family-oriented care where they are able to convey what their goals are."

Periyakoil notes that one essential component toward fostering quality care for ethnic older adults is the Stanford Letter Project. "We ask them simple questions such as: What matters most to you? What are your life goals? What are your future milestones?," she says. "We use that information to tailor therapy to be patient centered and family oriented; it helps to get to a common understanding and develop a therapeutic physician-patient relationship."

ETHNIC(S): A Tool to Cultivate Culturally Competent Dialogue
"Once cultural differences are recognized, there's a need to elicit additional information. One of the ways to do this is using explanatory model frameworks," Kobylarz says. "One example of an explanatory model framework is the ETHNIC(S) mnemonic. It's an interviewing tool to address cross-cultural health care issues."

Kobylarz says each letter in the mnemonic refers to a domain of the cultural aspects of health and illness that are important for providers to explore. The following are the domains: explanation, treatment, healers, negotiate, intervention, collaborate, and spirituality as well as seniors. As a guide, direct questions and probe questions are provided as a framework for each domain. One example of a direct question from the explanation domain would be to ask patients to explain why they believe they have particular diseases or conditions. If clinicians need to probe further, they can ask caregivers about patients' symptoms or ask patients to describe their fears or concerns about their medical condition.3

Kobylarz adds that the ETHNIC(S) tool is also published in Spanish.4 When working with interpreters, the message being conveyed may get lost during translation. So providers who don't speak Spanish can provide this tool to interpreters, he says.

"One of the key points here is that every physician-patient encounter is a cross-cultural encounter. There's no cookbook approach to treating patients," Kobylarz says. ETHNIC(S) is a tool to establish trust and elicit information needed to provide appropriate care. The tool is designed to be integrated into routine visits and across different health care settings and provides an opportunity to explore each of the different cultural domains as they may come up. The tool facilitates sharing information and building trust to develop a therapeutic relationship between the physician and the patient. But it takes time because that may not happen on the first or second visit, he says.

Ongoing Efforts Through Education and Training
"We need to focus on communication and education, and communication should stop being a 'soft skill,'" Periyakoil says. The notion that clinicians have a very limited amount of time with patients is inaccurate and prohibits adequate care and communication. To stress the importance that culturally competent care is feasible in the time that clinicians have with their patients, Periyakoil says that Stanford medical students watch a video in which she shows them in a two-minute patient encounter direct substantiation of ways to perform either effectively or ineffectively in such a patient encounter. The take-home message is to teach students that skill rather than time is the limiting factor in providing high-quality culturally competent care to multicultural patients.

Other programs include Stanford University's Curriculum in Ethnogeriatrics, which is a five-module core curriculum with 11 ethnic-specific modules, Kobylarz says. Another curriculum is the Doorway Thoughts: Cross-Cultural Health Care for Older Adult series, which was developed by the Geriatrics Committee of the American Geriatrics Society. There's also the Portal of Geriatrics Online Education, a repository of educational materials that have been incorporated into medical school education, residency, fellowship programs, and other disciplines such as nursing and social work, he says.

"Nationally, CMS [the Centers for Medicare & Medicaid Services] provides an approach for advancing health equity by improving the quality of care provided to minority underserved Medicare beneficiaries. The Equity of Care initiative also has goals for increasing cultural competency training," Kobylarz says.

Kobylarz points out that one of the issues is that once cultural competency is integrated, it must be reinforced. "You can go through a course or a lecture, but the challenge is reinforcing this through all levels of education, he says, adding that New Jersey is one of the states that now require physician licensure renewals to include cultural competency credits.

— Jaimie Lazare is a freelance writer based in Brooklyn, New York.

References
1. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States. US Census Bureau website. https://www.census.gov/prod/2014pubs/p25-1140.pdf. Published May 2014.

2. Developed by the American Geriatrics Society Ethnogeriatrics Committee. Achieving high-quality multicultural geriatric care. J Am Geriatr Soc. 2016;64(2):255-260.

3. Kobylarz FA, Heath JM, Like RC. The ETHNIC(S) mnemonic: a clinical tool for ethnogeriatric education. J Am Geriatr Soc. 2002;50(9):1582-1589.

4. Kobylarz FA. A Spanish language version of the ETHNICS mnemonic: a clinical tool for health care professionals. Caring Hispanic Patients. 2005;2:21-24.