Editorials
Moving Beyond Cultural Stereotypes in End-of-Life Decision Making
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article on page 515.
Imagine that all of our patients are invited to attend a "cultural competence” workshop called "Understanding the Medical Culture,” where they will learn how the strange and mysterious environment of medical practice affects physicians, so that their otherwise incomprehensible behavior seems at least somewhat understandable. They will be offered handy tips that would allow them to predict physicians' behavior, such as the following:
• Physicians always want to be in control and typically interrupt patients after they have spoken for about 18 seconds.
• Physicians believe in always "doing something,” even if there is little scientific basis for it-especially if it is well-reimbursed.
• All physicians take Wednesday afternoons off to play golf.
This imaginative exercise should remind us of two important points. First, as physicians, we bring our culture (or cultures) to the clinic just as much as patients bring theirs. As was taught nearly 30 years ago,1 and as we have been reminded more recently,2 every physician-patient encounter is a cross-cultural exercise-even if the physician and patient grew up on the same street in the same small town.
Second, although the efforts of Searight and Gafford3 in this issue of American Family Physician are well-intentioned and potentially beneficial, ultimately we must go beyond focusing on the unfamiliar cultural characteristics of certain subgroups. We cannot predict a patient's preferences and values by categorizing him or her into a hyphenated ethnic group any more than someone else could predict exactly how we will behave by categorizing us as physicians. What begins as a genuine desire to respect our patients can too easily deteriorate into an attempt to over-simplify "culture” into something that can be diagnosed and treated.4,5
True cultural competence requires humility and curiosity, and the willingness and flexibility to understand and respond to our patients' beliefs and the way they wish to be treated. It may not be appropriate for certain patients to be told the truth about their condition or to be asked explicitly about end-of-life care planning or advance directives. But it is very unusual for persons from any culture to resent frank inquiries into the nature of their own cultural beliefs and practices, so family physicians need not fear beginning such a dialogue.
Avoiding cultural dissonance does not require physicians to learn the nature and history of a whole variety of cultural beliefs and practices. Instead, physicians involved in end-of-life care should be sensitive to the arbitrariness of their own cultural beliefs in the value of telling the truth to patients and allowing them to participate in decision-making. Effective cross-cultural care in this setting requires a willingness to learn each patient's preferences and to negotiate mutually acceptable alternatives. For example, patients who prefer not to know their prognosis should be allowed to designate a representative to receive information and make decisions for them.
Searight and Gafford remind us that there is at least as much variation within other cultures as there is in the white European-American population. Furthermore, many patients who might be expected to be closely aligned with our "physician culture” are instead turning to a variety of alternative therapies and practices. Allowing our patients and their families to be our educators and informants, and developing mutually acceptable alternatives to our habitual practice, takes time and resources. Family physicians should appreciate the great value of making this necessary investment and the profound cost of failing to do so.
The Authors
Howard Brody, M.D., Ph.D., is University Distinguished Professor in the Departments of Family Practice and Philosophy and in the Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing.
Linda M. Hunt, Ph.D., is associate professor in the Department of Anthropology and in the Julian Samora Research Institute at Michigan State University.
Address correspondence to Howard Brody, M.D., Ph.D., Department of Family Practice, B-100 Clinical Center, Michigan State University College of Human Medicine, East Lansing, MI 48824-1315 (e-mail: brody@msu.edu). Reprints are not available from the authors.
REFERENCES
1. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978;88:251-8.
2. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med 1999;130:829-34.
3. Searight HR, Gafford J. Cultural diversity at the end of life: issues and guidelines for family physicians. Am Fam Physician 2005;71:515-22.
4. Hunt LM. Beyond cultural competence: applying humility to clinical settings. Accessed online January 10, 2005, at: http://www.parkridgecenter.org/Page1882.html.
5. Santiago-Irizarry V. Culture as cure. Cultural Anthropol 1996;11:3-24.
Linking the Hospital and the Office in Cardiovascular Secondary Prevention
Cardiovascular disease and stroke cause 38.5 percent of all deaths in the United States.1 Despite the existence of guidelines for secondary prevention of cardiovascular disease from the American Heart Association (AHA) and the American College of Cardiology (ACC),2 many patients with acute events leave the hospital without these evidence-based therapies.3 Observations from primary care practices4 show that 95 percent of physicians questioned intended to treat patients with elevated cholesterol levels, but chart abstractions from their patients treated for coronary artery disease show that only 18 percent of patients reached their goal low-density lipoprotein cholesterol levels. These observations and other evidence of treatment gaps,5 despite significant opportunities to learn new clinical evidence and guidelines, suggest that the solution to closing the gap lies in changing systems of care. Technology initiatives such as the Physician Office Link from the National Committee for Quality Assurance and the Doctor's Office Quality-Information Technology program from the Centers for Medicare and Medicaid Services (CMS) help offices develop the technology infrastructure to help underlay systems of care.
The AHA's Get with the Guidelines (GWTG) program is designed to address the secondary prevention needs of patients at the highest risk-those hospitalized with cardiovascular events, transient ischemic attack, or ischemic stroke. GWTG addresses this need by providing a structured, inexpensive quality-improvement solution for cardiovascular care. The program conforms to the AHA/ACC secondary prevention guidelines, the CMS performance measures for acute myocardial infarction and heart failure, and the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) ORYX core measures for these conditions. The GWTG collaborative model uses AHA staff and volunteers to provide evidence-based measures and clinical science expertise, blended with system change solutions, such as preprinted orders, discharge protocols, and chart reminders, that are developed and shared by multidisciplinary hospital teams. The program features an Internet-based, point-of-service data-collection tool that includes decision support and performance feedback to hospitals, including comparison of their data to aggregate data from the entire project or a large group of similar hospitals.6
In addition, the GWTG program includes customized patient education materials that can be printed from the Internet before the patient is discharged. A summary letter that includes diagnosis, procedures, risk-profile information, and pharmacologic and lifestyle interventions can be generated by the data-collection tool and provided to all pertinent physicians at the time of discharge. This rapid communication provides a valuable and timely link for office follow-up and helps provide the necessary communication between hospitalists or subspecialists and primary care physicians.
This effort by the AHA is targeted at the hospital for several reasons. One of the strongest predictors of cardiovascular events is a prior event. Thus, the hospital is a logical point to identify patients with events who will be at risk for subsequent events. Risk and the need for prevention are often abstract and hard to personalize as a motivation for behavior change. Hospitalization represents an important teaching opportunity when the concept of risk suddenly becomes real for patients and their families. Initiation of secondary prevention measures in the hospital significantly increases adherence to preventive medications in the first year following an event.7 Hospitals have been required to measure and improve quality of care for many years and have infrastructure in place to address the requirements of JCAHO and CMS. Approximately 4,300 U.S. hospitals provide care for the highest risk group of patients with cardiovascular disease. Thus, from a systems perspective, the hospital is an appropriate place to begin improving cardiovascular secondary prevention. Building effective hospital systems is an important first step in improving outpatient secondary prevention by "getting it right” at a critical moment and reducing the burden in the office setting.
Published data from GWTG8 demonstrate significant improvement in the number of patients who receive guideline-recommended secondary prevention measures before post-hospital follow-up. Too often, time in the office is spent on the more difficult task of educating patients about the need to start medication that the subspecialist may have failed to start in the hospital. When patients already have received counseling and have been started on pharmacologic therapy such as aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and statins, valuable office time can be used to titrate medication and reinforce adherence to medication regimens and lifestyle changes.
The Centers for Medicare and Medicaid Services provided resources for program development and analysis under contract 500-02-MA03. The conclusions and interpretation of results are the sole responsibility of the authors and do not necessarily reflect the position or policy of the U.S. government.
The Authors
Kenneth A. LaBresh, M.D., is vice president for medical affairs and quality improvement at MassPRO, Inc., Waltham, Mass., and associate professor of medicine at Brown Medical School, Providence, R.I.
Patricia A. Tyler, R.N., C.C.R.N., is senior manager for clinical effectiveness at the American Heart Association, Dallas.
Address correspondence to Kenneth A. LaBresh, M.D., MassPRO, 235 Wyman St., Waltham, MA 02451 (e-mail: klabresh@maqio.sdps.org). Reprints are not available from the authors.
REFERENCES
1. American Heart Association. Heart Disease and Stroke Statistics Update. Accessed online January 7, 2005, at: http://www.americanheart.org/presenter.jhtml?identifier=1928.
2. Smith SC Jr, Blair SN, Bonow RO, Brass LM, Cerqueira MD, Dracup K, et al. AHA/ACC scientific statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 2001;104:1577-9.
3. Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001 [published correction appears in JAMA 2003;289:2649]. JAMA 2003;289:305-12.
4. Pearson TA, Laurora I, Chu H, Kafonek S. The lipid treatment assessment project (L-TAP): a multicenter survey to evaluate the percentages of dyslipidemic patients receiving lipid-lowering therapy and achieving low-density lipoprotein cholesterol goals. Arch Intern Med 2000;160:459-67.
5. Sueta CA, Chowdhury M, Boccuzzi SJ, Smith SC Jr, Alexander CM, Londhe A, et al. Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease [published correction appears in Am J Cardiol 1999;84:1143]. Am J Cardiol 1999;83:1303-7.
6. LaBresh KA, Glicklich R, Liljestrand J, Peto R, and Ellrodt AG. Using "get with the guidelines” to improve cardiovascular secondary prevention. Jt Comm J Qual Saf 2003;29:539-50.
7. Fonarow GC, Gawlinski A, Moughrabi S, Tillisch JH. Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol 2001;87:819-22.
8. LaBresh KA, Ellrodt AG, Glicklich R, Liljestrand J, Peto R. Get with the guidelines for cardiovascular secondary prevention: pilot results. Arch Intern Med 2004;164:203-9.
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