Friday, April 16, 2010

Cultural Sensitivity

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A delightful couple, pregnant with their first child, came to the office to interview me, to help them decide if I was the right pediatrician for their baby. We had a lovely chat and I felt that I was doing well. At the very end, they asked a question. “Do you have many Asian patients? Do you find you have to ask questions a different way with them or that you have to take a different approach?“ I took these questions as an inquiry about my level of cultural sensitivity. I had a long answer. For the record, though, these people looked by their facial features to be of Asian ancestry; the last name appeared to be of Japanese origin.

“It’s the Bay Area, “ I replied. “What are the odds?“ They agreed it was pretty likely that I had some Asian patients. This was the beginning of my reply.

I told them I took care of a group of about 8 or 10 families from Mongolia. They all live near each other because only a couple of them speak any English at all, and the language barrier is substantial. taking care of them has sometimes been a challenge. there are no patient-education materials available in Mongolian. AT&T has available translators via telephone in dozens and dozens of languages, but Mongolian is not among them. I called UNICEF at the United Nations in New York. They did send people to Mongolia, but they had no patient information. Same story when I contacted the World Health Organization in Geneva, Switzerland. At one point I had a polite exchange of emails with the Minister of Health in Ulan Bator, Mongolia. He or the person composing the emails under his direction and signing his name, had good English-Language skills. His office had no written materials on child health in Mongolian. These families are Asian. Am I culturally sensitive with them? Probably not. Since communication is so difficult, we need every extemporaneous sign language technique we can come up with just to convey information.

So cultural sensitivity is not helped by a language barrier. I take care of these Asian patients, but do I take care of them differently? Yes, I suppose so, but it’s not because of a cultural divide.

I’m reminded of a classmate in medical school. When he was 14, his parents and he joined many others on a small boat headed blindly from Vietnam out into the South China Sea. Obviously they made it, and he’s now a fine surgeon. What should I know to deal with his family in a Vietnamese-friendly way? Are Koreans different?

When I was in business, there were no courses that were required, but everyone knew that Japanese investors and businessmen expected certain salesmanship behaviors when they were entertained in New York. In Japan, a completely different set of rules applied. I wasn’t called cultural awareness, it was called good business. In Hong Kong, it was often thought best not to mention that you’d just had a successful series of meetings in Tokyo.

So what was this nice couple asking me? If I had other patients who, by their visible bodily characteristics, appeared to be of Asian descent? Nearly half the human race is of Asian descent. Were they asking if I treated my patients of Japanese descent as if they were Japanese? I don’t know. How many generations have been born in the United States?

I take care of a nice family, for example, with a hyphenated last name. They are all American citizens. They say that they are Brazilian. When their kids were born, I encouraged the parents to speak only Portuguese to them at home. The mother’s ancestors were from Portugal. She looks like a European might. The father’s ancestors were Chinese. He looks Asian. The kids are…adorable. Is this an Asian family? I don’t think even the father’s parents speak much Chinese, back in Brazil. How Asian to you have to be? How Asian to you have to look?

No institution with which I have been associated over the last 20 years or so has failed to offer--actually require, I think--a course of some sort in cultural sensitivity. As demanded, I have wasted valuable hours in these courses. In one, the head of a fabulous Spanish-language health clinic gave a presentation on cultural awareness to the Latino community. Assuming that language wasn’t a barrier, what could I do with that? Ask a proud Ecuadorian if they identify more with Mexicans than with Americans. Ask someone from Spain. Will I learn about the distinctions of all those who speak Spanish in a short course or lecture on cultural sensitivity?
I have a family from Yemen. Devout Muslims, they appreciate that I never extend my hand to the mother. I try to be respectful and to the point. I don’t even close the exam-room door when I see their kids and the father isn’t with them.

I think that doctors--people in general--look fake when they try to be someone they’re not. I also think that doctors can be particularly culturally insensitive. But I think it’s cynical political correctness to require learning cultural sensitivity. What they really need to learn is just sensitivity.

There’s no way that patients will perceive a doctor to be sensitive in a 5-minute visit. The doctor you’ve never met, comes in while reading the chart for the first time, doesn’t know your name, does humiliating things to you, then leaves without hearing your complaints or insights. In which culture is this considered acceptable? What part of the world do you have to be from to feel better after this encounter?

If physicians are going to be culturally sensitive, they must first spend enough time with the patient to listen. Maybe they can take a course on reading body language and eye contact, tone of voice or listening skills. Maybe they can learn to interrupt just a little bit less. This would go a really long way towards sensitivity to what a patient really needs. I don't think it's helpful to put on an air of paternalistic cosmopolitanism—like an anachronistic white man's burden—that says to patients that overeducated well-to-do Americans can feel inappropriately self-confident about learning in an hour what they have taken a lifetime to master.

It's nice if you and your auto mechanic grew up in the same neighborhood. But it's a lot nicer if you find a mechanic who treats you well, listens to your complaint, and actually fixes your car. Which one would you choose?

Medical management (and this applies equally to corporate management) shows astounding hubris to impose an unsupported belief that patients will perceive as a better experience a visit with a doctor who has memorized a few facts about your grandparents' country of origin. Whether the patient is from Mongolia or Malaysia, Brazil or Burundi, I don't pretend to be something I'm not. If doctors could spend more time, could simply have more empathy, listen to their patients and think about what it's like to live a day in their shoes, cultural sensitivity would just be sensitivity.

Friday, April 2, 2010

Piecework Economics and Slow Medicine: Churn Rate

“Piece rate is more suited to repetitive crew work (e.g., boysenberry picking, vineyard pruning) than to precision planting, fertilizing, or irrigating. As the tie between individual work and results is diminished, so is the motivating effect of the incentive on the individual.”     --Gregorio Billikopf
It’s the money, stupid.  I don’t write about money much, though I haven’t forgotten everything I used to know about it.  I try to keep both this blog and The Empathic Pediatrician about medicine.  Sometimes, however, te topics of money and medicine overlap.

Primary-care doctors like me are paid by the visit.  More visits, more money.  There’s a huge incentive to see patients as quickly as possible.  This can be called efficiency if you’re the insurance company paying for it.  If you’re the patient, what is it?

It’s certainly not to your advantage.  I strongly believe—more strongly as I become more experienced—that taking the time to get to know a patient, which in my case is typically a child, has enormous benefits and increases efficiency, though defined within a different parametric model.

I found this fantastic essay on piecework economics by Gregorio Billikopf when he was at UC Davis working on farm worker pay systems.  It’s balanced and well thought-out.  Farmers have to be fair and consistent in the way they pay people in order to keep them motivated.  Deception and mistrust are always possible in the context of thin profit margins and hard work, however, so they have to be careful to honor their commitments.
Doctors who do a lot of procedures have accomplished such dominance over the medical system that they are paid per procedure.  More procedures, more money.

Everybody, as far as I know, is stuck with the same 24 hours in a given day.  How many visits can you do in that day?  I know of physicians doing 40 visits in 8 hours, and taking an hour for lunch.  That’s about 5 or so minutes a visit.  With the time needed for physically moving from room to room, what do you think?  4 minutes?  You might have a chance to say that your chest hurts but not explain that you can’t afford your heart medicine.

The specialist doing procedures has even more incentive to perform quickly.  If a patient is seen who might or might not benefit from an intervention, which choice would the doctor make?  What if the procedure cost $2000?  What if they could do 10 or more in a day?
 
Obviously, I wouldn’t be writing about this if I didn’t think it was a problem.  As always, I hope, my view is not a dogmatic one.

As in so many things, the people who run medicine are so comfortable in their Procrustean Bed that it would be irrational of me to expect from them a measure of horizontal thinking.  That’s not quite fair, I guess.  They haven’t walked 30 years in my shoes.

This post is really about Portfolio Analysis.

About 7 or 8 years ago, I made a house call to a modest home.  I examined the toddler in the living room, while mom was in an adjoining room.  I had made a lot of house calls, and thought it was interesting that I was seeing the kid alone when the mom was obviously concerned enough to call me to come over.  The child was OK—I think she felt better just because I came to the house and looked her over.  It was a brief awkward moment, since I didn’t know if I should just call out to the mother that I was done.  The girl sensed this, and took me by the hand into the other room.  “She’s trading,” the child explained.

There, in front of 2 big screens filled with numbers, charts, and several moving tickers, was the child’s mother.  “I’m done,” I said.  After a brief discussion of the illness I added, “nice setup.”

She went on to tell me that she had quit her job and was trading stocks full-time.  She described a little bit about the amount of information she had at her disposal.  She also described her confidence in being able to make money consistently, day after day, by taking advantage of small movements in stock prices.  I wished her the best of luck, and left the house as quickly as I could.  I knew some things that she just didn’t know.
She had only limited experience of a couple of years with financial markets.  Nearly every model of market activity makes some fatal and incorrect assumptions.  I knew this because I had looked for and failed to find this kind of El Dorado she thought she knew.  For example, she and her model assumed that markets were continuous.  Which is to say that if things turned against her she could get out.  That’s true until it stops being true.  There are many times that the markets drift up or down for years at a time, until the one day that a world leader dies or a bomb goes off and all the markets are suddenly closed.  She could wake up broke.  And the illusion she had of information quality was astonishing to me.  She was getting information many minutes behind those who knew it first.  She wasn’t seeing trades—she was seeing the history of trades with a 15-minute delay.  The pros, just like used-car dealers, often kept the best for themselves.)

Sadly, this delusion applies to professionals, too.  Maybe that’s obvious from the amount of our money they lost in the last couple of years while getting paid so well for it.  There’s now a substantial body of important research that shows that professional investors—the managers of big and well-known mutual funds and pension funds of all kinds—simply don’t do better than you would do if you just bought one of those stock indexes and left your money sitting there.  In fact, the more they tried to beat the market by thinking they could pick the stocks that would outperform and get rid of the stocks that would underperform, the worse they did.  In professional jargon, this is called the Churn Rate.  It’s a measure of how often the manager was buying and selling, buying and selling, with every iteration costing transaction fees and causing taxable events.  For doing this, and doing worse than doing nothing, the manager’s substantial pay was deducted from your investment return.  You paid for it.

And this is a part of how I look at this aspect of the backwards financial incentives facing physicians.  There’s no financial incentive to get the patient well, but there’s a big incentive to increase turnover.  What patients need is simply not considered in any part of the system.

I would like to get to know each child, each family.  If insurers had the long-term perspective of somebody investing for their distant retirement, they’d see it my way.  Much slower, more thorough visits to cover every issue.  Continuity with a single doctor who can manage some of the burden of a chronic medical problem.  This would result in reduced need for future and costly interventions, fewer emergency visits for unaddressed problems, less need for expensive medications, and happier, healthier patients.  It would save money.  Most physicians, I think, want to provide really good care.  Let them, and they will.