Next Generation is a BWH Clinical & Research News (CRN) column penned by students, residents, fellows and postdocs. This month’s column is written by Nidhi (Rhea) Udyavar, MD, a fellow in her second year of research at the Center for Surgery and Public Health, who has completed a junior residency in General Surgery at Duke University, where she became interested in health services research in the context of trauma surgery.
Failure to deliver thoughtful, cross-cultural care can have disastrous consequences, despite our best intentions. Consider the case of Antonio*, a middle-aged Spanish-speaking-only gentleman from a cultural background that idealized stoic hyper-masculinity. He underwent an uncomplicated proximal gastric resection, which was followed by an uneventful four-day hospital course. Unfortunately, no one on his care team spoke Spanish. At 5 a.m., when rounds took place, there was no professional interpreter available, and the specially programmed phone used to remotely contact an interpreter was out of order. Unable to effectively communicate, he didn’t ask many questions of his team, and responded to theirs by either shaking his head or nodding. Two days after he was discharged from the hospital, he returned to the emergency room in hemorrhagic shock from a bleeding short gastric artery. He was dead within a week.
While Antonio clearly suffered a technical complication that could have happened to any patient, there is no doubt in my mind that the communication barriers between him and his team, as well as his culturally-driven tendency to stoically minimize his own symptoms, played a role in the late and catastrophic presentation of his complication. Cases like his are not uncommon. It is tempting to blame the communication failures that occurred on a broken system, not on the behavioral practices of individual physicians, but the evidence and logic suggests otherwise. In order to understand the underlying causes of racially and culturally-based health care inequities which lead to cases like this one, I sought mentorship in health services research from Dr. Adil Haider, a pioneer in surgical disparities research and the director of the Center for Surgery and Public Health.
I was certain about one thing when I began working with Dr. Haider: I did not want to merely define or continue to publicize the problem of disparities in surgery; I wanted to develop strategies and techniques that would ultimately eliminate health care inequities. I endeavored to apply my aptitude and reverence for teaching, cultivated over the years in which I taught music, to educate surgical residents and empower them to provide high-quality, equitable care to an increasingly diverse patient population.
We sought to address the potentially controversial assertion that racially-driven disparities in surgical care are related to poor cross-cultural communication between surgeons and patients through an educational initiative known as the Provider Awareness and Cultural Dexterity Toolkit for Surgeons (PACTS) Project. In conjunction with our colleagues at Massachusetts General Hospital and Beth Israel Deaconess Hospital, we are currently in the process of delivering a series of four interactive, experiential learning sessions to the general surgery residents at each of the three Harvard Medical School-affiliated institutions. We’re focused on teaching skills that are central to cultural dexterity, or the adept use of mental and physical skills to adapt to unique patients and contexts.
Truthfully, I had no preconceived notions about how the residents would respond to the concept of cultural dexterity. I assumed that most surgical residents were at least peripherally aware of the fact that there are sociocultural nuances associated with treating patients from diverse backgrounds, and that there are differences in health care access and quality along racial lines, but beyond that, I could not predict how our efforts to teach cultural dexterity would be received.
What we’ve encountered thus far is an enthusiastic, unanimous acknowledgement that the current system is inadequate. All participants, regardless of their level of training, have agreed that the lack of structured cultural dexterity training often impairs their ability to build trust, establish rapport and engage in patient-centered care with patients whose cultural practices are unfamiliar. In a striking example of how experiential learning can foster empathy, surgical residents from all three institutions were asked to play the part of a medical interpreter, responsible for repeating the dialogue verbatim (in English) bi-directionally between the English-speaking “surgeon” and the fictionally non-English-speaking “patient,” a deceptively straightforward assignment that had intriguing—and occasionally comical—results. As the role-play scenario progressed, the resident portraying the interpreter would inevitably feel compelled to ask his or her “surgeon” colleague to slow down and give the “interpreter” time to convey smaller, more manageable packets of information. All the residents who played the role of the interpreter eloquently described the unique challenge of recalling and repeating the words accurately without adding their own embellishments. Many residents—even those who had professional experiences of their own as medical interpreters–expressed a newfound appreciation for the interpreter’s important role as a member of the care team.
At one of our first sessions in January, an intern astutely remarked that developing cultural dexterity means realizing that, when it comes to taking care of a diverse patient population, “it’s not about you.” Her point, which resonated powerfully not only with the other participants but also with our study team, was that the humility and desire to do our due diligence for all of our patients is a virtue of our profession that we must constantly fight for, against the barrage of personal stressors and disillusionment that can afflict us over time.
As surgeons must learn principles of tissue-handling and hemostasis, we must also be taught to apply a specific set of principles to understand and address culturally-relevant situations that arise in our practice. We often speak of the importance of practicing surgical techniques to enhance our manual dexterity, which allows us to perform increasingly challenging surgical maneuvers as our skills improve. Developing cultural dexterity will allow us to approach our increasingly diverse population of patients from a perspective that promotes compassion, understanding and individual empowerment.
*patient name has been changed for anonymity