Announcer: You're listening to the Intermountain Podcast with Dr. Mark Briesacher.
Mark Briesacher: Hi, this is Mark Briesacher. I'm the Chief Physician Executive at Intermountain Healthcare. Today we're going to have a really great conversation about cultural competence. I'm joined today by Natasha Ovuoba and Carlos Martinez-Morales. Carlos, we met a few, maybe two months ago, when I was down at Intermountain Medical Center and I had a chance to meet your team. That was a great day, I learned a lot, but the best part of the day was actually going down to the ER with you to watch you do what you do every day, where do you help teams communicate well, communicate effectively, with patients and families. And that was a remarkable conversation.
Carlos M.: Yeah, it was great to have you there. And you know, sometimes being in the office I get a little rusty so it was great to go down and actually get back to the basics and do some interpretation. Yeah.
Mark Briesacher: I just remember watching the patient and how so much more relaxed he was and his family was with you being able to answer questions and help the nurse communicate with them, because there was a lot going on with that patient, and I could tell it made a big difference.
Carlos M.: Yeah. I think that's the best, the most rewarding, part of my job, is that I can tell patients light up when they see someone who they can identify with. Not just the language part, but also the cultural part too, that they can relate and feel like, "Oh, they're going to understand what I'm trying to say and convey that in the right context."
Mark Briesacher: Yeah. And Natasha, we actually just met, although even in these first 15-20 minutes, I can tell that we're going to have a lot of fun.
Natasha Ovuoba: Of course.
Mark Briesacher: And you're with the Equity and Inclusion team here at Intermountain. Would you mind just sharing a little bit about yourself, what you do, and then Carlos, I'll come back and ask you the same thing as well. This is a growing area for us and you all are part of a really important team here at Intermountain.
Natasha Ovuoba: Yes, so our office focuses on all things diversity, equity, and inclusion. My role is actually new to the organization. It was created just this year. I've been in the role for a few weeks now. It consists of myself, [Jan Stookey 00:02:56], who focuses a lot on health literacy and the patient side of equity and inclusion, and then Brenda Voisard, who is over our student programs. She's our manager over those programs and focuses on sort of that pipeline that can help feed into our organization in terms of diversity. I would say that our little office focuses on, I would say, three key things. And again, it is building a really robust pipeline, how are we attracting diverse candidates? And then within the organization, how are we retaining and growing the caregivers that we have here? How are we helping them see a future within our organization for themselves and wanting to stay? And then really I think this is where Carlos' team comes in, how are we helping them see and learn the lessons around cultural competency so that we are better informed when we are dealing with our patients, our members, and our consumers?
Mark Briesacher: And Carlos, you say that is a part you step into. Tell us a little bit about your team and what the team does.
Carlos M.: Yeah, so we have a languages services team. We have a team of very talented interpreters, trained and qualified interpreters, in five different languages that we offer in-house interpretation for and we then have vendors or suppliers who can help us with the other 80-something languages that we see every year. We see about 96 different languages here in Utah. I think people maybe don't realize how diverse our population is and how that diversity continues to grow. We have a very great state, it's beautiful, and it has a great economy, and people are noticing it. Since the Olympics in 2002 we've seen a huge spike in how this diversity is growing, so we provide interpretation services 24 hours, during all hours of operation, in all these languages via in person interpreters, we have video interpreters, and we have telephonic interpretation as well.
Mark Briesacher: I actually wish that everyone could stop by and meet your team. They are a really great group of people, really committed to helping other caregivers at Intermountain when language needs to come up. I mean, it was so evident to me that everybody there is all-in on just doing as much as they can and helping as many people as they can.
Carlos M.: Yeah. It's an awesome group of people and really dedicated to making sure everyone has that equal access to services and they experience ... the language barrier doesn't hinder their ability to experience extraordinary care like everyone else.
Mark Briesacher: So this term cultural competence, I'm glad you brought that up. Can you maybe describe for everybody what cultural competence is?
Natasha Ovuoba: Yes. So cultural competence refers to the ability of health care providers to recognize and respect patients with diverse values, beliefs, behaviors, and linguistic needs.
Carlos M.: Yeah, so a lot of times people think cultural competence, they think, "Oh, people that come from other countries," they say, immediate assumption. But no, even between our neighbors, culture is active and it's very diverse. We all have a different culture. We all have, based on our belief systems, whether it's religion, whether it's political affiliations, our practices and the way that we see the world is so different from one to another, so it's adapting our thinking, have that humility and curiosity of thinking. It's not about treating others the way I would like to be treated. It's about treating others the way they would like to be treated, that platinum rule instead of the golden rule, and then creating that toolkit, the techniques, to know how to find out what other people's beliefs and values are and then how do we adapt our care to them?
Mark Briesacher: First of all, I'm really struck by the fact that when I hear things like we have 96 different languages that come from people who live here or visit our state, that's actually much higher than I would have guessed if you had asked me to guess. I was probably more than that 40 to 50 range. But I also know just by watching our community over the years and reading good reports and analyses like from the Kem Gardner Policy Institute, our state really is becoming much more diverse. What do you think it means to someone when I as a physician, as a pediatrician, what does it mean to them when I am culturally competent and actually recognize and am aware of that even to the point of phrasing things in different ways to meet them where they are at?
Natasha Ovuoba: I think it allows our patients to feel safe. Honestly, it comes down to that safety. For a patient to come into our organization, into one of our clinics, into one of our hospitals, and again, being in a hospital already is such a vulnerable state. To feel like I am hurt. I don't know if I have the funds to cover what this bill will be. I don't know what to do. So add on top of that, I don't speak English and there are a lot of English only speakers here and maybe add on top of that I'm a different religion than maybe Christian. Maybe I'm something different. I want to wear a head wrap or I want to ensure that maybe my beard isn't shaved for any procedure that I have. I think to have someone come in and say, "Hey, I see the culture that you value and the beliefs that you practice and I want to accommodate those needs," it allows that patient to feel safe so that they can open up and you can better meet their healthcare needs.
I think that's really what it comes down to because someone who, I mean, think about what Carlos' team does. Someone who does not speak English, if you come in and you're just speaking to them in English and you don't think about getting them an interpreter, how are they ever going to tell you what's wrong? Where are they in pain? What help do they need? What have they tried at home? They're never going to get robust comprehensive health care that we are able to offer them if we don't meet their cultural needs.
Carlos M.: Yeah, and the concept of illness, the concept of the onset, what brings illness, what heals illnesses, the concept of death and dying, it's so different among different cultures that if we just treat everybody in the same context, they're not receiving the information in the spirit it was given. So for a provider to be able to understand how to adapt their care, how to approach, how to ask the right open ended questions like, "What do you think is causing this problem," and giving that opportunity for that patient to open up and say, "Well, in my culture we think that it's the evil eye," or whatever it is. It just opens up a channel of conversation and they don't feel like their beliefs are being diminished or disrespected or dismissed, and you can adapt your care to be inclusive of their beliefs and Western medicine.
And that's something that we see a lot is that when patients feel like their beliefs are being put aside or not valued, they tend to turn around and then go home and not follow the prescribed care. And that's where we see them come back to the emergency room over and over. And it's not always language. It's often, "Did I feel listened to? Did I feel like they understood me?" And if they don't then they don't follow through. So it's critical.
Mark Briesacher: Yeah. "Did I really experience being seen and understood as a whole person?" It actually just strikes me this is such a humanistic idea that it's every culture and it crosses all of those. And so, thank you. That's very helpful to me. The platinum rule. I think that's actually a really cool way to think of it as well. So again, I'm a pediatrician and so I'm thinking, "Well, how would I do this?" Let's say I had a family come in to see me and they are Croatian and, you know, what commonly happens or happened to me in practice was that neither the mom or the dad, they did not speak English, but their child did. And so maybe they came in with a 3-year-old and then their 12-year-old could speak some English, a lot of English actually, and yet I knew from the training that we had received that that's not okay to use a family member as an interpreter because there are medical terms.
And I guess when I'm also learning in this conversation is that there's cultural things as well that may not be fully appreciated. So how would I approach that scenario? New family, I need to talk with the mom to understand what's going on with the baby, and obviously I don't speak Croatian?
Carlos M.: Yeah. I think the first thing is definitely immediately get an interpreter. We can schedule interpreters for many of these languages for visits. If this is an on-demand visit like the ER or InstaCare or something that wasn't planned, we have access to interpreters via video or phone to make them easily accessible at a moment's notice. And like you mentioned, that 12-year-old child is likely not to have the medical terminology that they are able to convey that back and forth. They don't have the maturity or the objectivity to really convey the information. There may be sensitive information that we don't want to put that child, even if it's a 17-year-old, in a position to convey sensitive information. Family members or friends, they tend to add or omit information based on what they think is important.
So those are big challenges and reasons why we don't use family members or friends even if they are those and bilingual, that person is not an objective party. And we see this often where people come to the ER and family members are like, "No, we don't need an interpreter," because they don't want their loved ones to know their diagnosis and providers think that they do. So that's very key. But there's also the cultural context that an interpreter, a trained interpreter who's also bicultural and not only bilingual, can bring to the encounter because the interpreter will know history about their country, the place and the culture that they grew up on, that their children that live in the U.S. have never experienced.
So being able to alert the provider that, "Hey, this is the interpreter speaking. You maybe want to be aware of this practice or this belief system," that that unqualified interpreter will not be trained to do. It brings a lot to that encounter. It's a big part of what interpreters do. It's not just about language. That's why we just don't hire anyone who's bilingual to do this job. There's a code of ethics to follow and a lot of training that goes behind being a good interpreter in the medical setting.
Mark Briesacher: I love having these conversations because I learn something every time, and I'll confess, I've never thought of it in the context of being able to apply the history of where you're from and how that impacts how someone might think about their health or think about what's occurring to them from an illness perspective. And you're exactly right, if we understand that, then that helps us adjust the plan.
Carlos M.: Yeah. A lot of the people that we serve come here to Utah, it's a refugee state, as refugees. So they come from countries where the government persecuted them and the government in many of these countries ran the healthcare system. So there is a built in distrust in the healthcare provider and the healthcare system as being part of the reason why they left. And sometimes if we don't consider that, the interpreter needs to adapt what they're doing to that context and provide that background to the provider so that they understand why they don't want to go grab this prescription. Why don't they follow these instructions? Why don't they want these tests done? So yeah, there's a lot of that that goes on that interpreters can help bridge that gap. And one of the tools we have at Intermountain, we have the Cultural Guide. This Cultural Guide is available at all of our caregivers in an electronic format to intermountain.net and it has 34 of the most commonly found cultures in Utah and it has a one page summary of what are some generalizations.
We don't want it to be used as a way to stereotype and assume that everybody from Croatia is going to believe these things. The idea is to provide the caregivers with general commonly known facts about how those people perceive life and healthcare and common practices and things of that nature. Who makes decisions in the household? What is the communication style so that the caregiver can then read that and they know, "Oh, I'm going to ask questions that will allow me to find out if this applies to my patient so that then I can provide that care."
For example, on the page on Burmese speaking culture, it talks about the fact that in that culture you hand out everything with two hands and handing something one-handed is offensive. So a nurse inadvertently may just grab the discharge instructions and hand them to a patient one-handed and that patient may take offense to that and there was no intent on that, but we didn't know. So that information is there for us to read in advance and prepare. So in your example with that Croatian family, you could find that page and see, "Okay, let me see, what are some of these things that don't make sense in my cultural context, but I need to be aware of in their cultural context." So it's a great tool that I think is very underutilized by our caregivers. The Cultural Guide.
Mark Briesacher: I'm really struck by the fact, also, that if a patient and family sees us doing even just a few things to be aware and be competent with respect to their culture, I suspect they'll be very forgiving of other things that we don't do right because they know that we're trying and learning. Have you had experience with that?
Carlos M.: Yeah. Yeah. I think that there was an experience of this patient in one of our hospitals who was going to surgery and she, from her culture and her background, she wore a-
Natasha Ovuoba: A hijab.
Carlos M.: ... hairdressing or a scarf over her hair, and going into surgery there was a lot of concern. It was the patient's first surgery and there was a lot of concern from her and her family about modesty and the meaning behind that and that that will be taken away as soon as she went under or went into the emergency room. And one of our caregivers was really, I guess we could say cultural competent in this case, and she made sure that she understood the meaning behind that and offered comfort by letting them know we're going to keep it on for as long as we can and if we need to take it off, we're going to use a surgical cap or something else to cover you. And as they were rolling the patient down to the OR, they were able to maintain it on instead of taking it off, which would have been the regular practice of taking everything off before the patient is taken to the OR.
And just that act of cultural sensitivity and acknowledgement meant so much for this family. I mean, they were in tears, just thankful that someone understood what that meant for them and that was able to accommodate it. And we see things like that with our caregivers happening all the time. I think sometimes we focus on what's going wrong, but there's a lot of things that we are doing right as well. I mean, I can think of a lot of situations related to language services and how thankful people are when we've been able to catch things and avoid mistakes due to things like that.
And this may not make sense for someone who doesn't speak the language, but for example, we had a patient who came to the OR and kept saying [foreign language 00:20:55]. And for most people when they see fatiga, that sounds like-
Natasha Ovuoba: Fatigue.
Carlos M.: Fatigue, right? So [foreign language 00:21:04], the bilingual caregiver who was registering was like, "You know, we see patients in the order of, you know, we're kind of full, and we'll see you when we can," and the patient kept saying [foreign language 00:21:16], and they kept assuming, "Oh, he's saying that he has fatigue." And then one of our interpreters was kind of walking by and heard the patient say [foreign language 00:21:25] and understood by the accent that this person was from the Caribbean and the Caribbean fatiga is used to describe asthma. So this person was coming in with shortness of breath and having issues with uncontrolled asthma and ended up being someone who was homeless and didn't have ... Then all of a sudden that changed the situation. "Oh, we may need to pay more attention to this person. They're not just here because they're tired, fatigued, they're having an asthma attack." So examples like that of situations where understanding culture beyond language can make an impact in care.
Mark Briesacher: Beyond the dictionary language, right?
Carlos M.: Right.
Mark Briesacher: This is slang. It's language habits of a place. And we have them here, and yeah, that's actually a pretty cool story.
Natasha Ovuoba: That's an amazing story. And one thing that I think all of our caregivers can benefit from is really to acknowledge our assumptions because in that moment, if that caregiver had thought, "Huh, they keep saying fatiga, fatiga, and it seems like they're kind of really, really in distress." If they had possibly could have gotten an interpreter sooner and helped that patient a little bit sooner, I think that could help us.
Carlos M.: And that's where unconscious bias kicks in because I think when someone saw this person visibly looking of what we assume a homeless person looks like, disheveled, not shaven, and maybe having not showered recently, and someone is in the middle of the winter saying, "I need the ER because I have some fatigue," there's the assumption, "Oh this person is just looking for a warm bed to sleep on. This is not important." So our unconscious bias immediately kicks in and this is not because we're bad people, we all have unconscious bias. We all have assumptions built into our brain. It's the way for our brain to cope with so much information that we receive all at once all the time, right? So we make quick assumptions so that you can react to them quickly. And it's a way to protect ourselves.
But it affects us when we think stuff like that, we forget the human side when we assume things, so it's very important to always take a step back and just be very patient-centered. Because it happens to all of us. We all have to be watching for that. And that's part of what we're always training in our modules and we always talk about unconscious bias because it plays a big role in how we interact with people, especially when they don't look or sound like us.
Natasha Ovuoba: Yes.
Mark Briesacher: I'm also struck by, in that story, it highlights what a medical interpreter brings to the conversation, to the encounter, to the care that's being provided, which is it goes way beyond the language skills. The fact that this interpreter realized that, based on the accent, that this could be going on. To me that highlights why it's so important that we have your team to help all of us in the care of people.
Carlos M.: Yeah. I train interpreters in the community as well and have that opportunity to train people who are interested in being interpreters and how to become medical interpreters, and that's something that I tell them all the time when they come in. It's like you may speak Spanish from one country today, but by the time that you become a good interpreter, you're going to have to speak many different Spanishes. I mean, it's all one language, but you need to learn the culture. You need to learn the slang. You need to learn the medical terminology as it pertains to anyone that you may encounter. So in languages like Spanish, that there are so many countries that speak this, there's a lot to learn. It's a lot to learn to be able to do the job right and catch these things because like I said, language is only one part of what we do. There's a lot more to convey information properly and safely in a medical setting because everything could be critical. You never know what is. So you have to catch them.
Mark Briesacher: And that is true for every language.
Carlos M.: Yeah.
Mark Briesacher: English in England is different from English in Scotland, which is different from English in New England, and in Alabama, and in California, and even here in Utah it's-
Carlos M.: Yeah, even within Utah.
Mark Briesacher: Yeah, I guess. Oh, my mind's going a mile a minute here, and what I'm thinking about is even just how could I learn more? So how could I, how could all of our caregivers out there, learn more about this? You mentioned that we have the guide and I'm sure we'll be providing that as part of this and having links to it because I think constant reminders about what's available is important. What else are we doing to help our caregivers be culturally competent?
Carlos M.: Well, this year we had our fifth annual Cultural Competence Symposium and we already have a date for next year, it's going to be May 29th of 2020 at the Intermountain Medical Center. We spent a full day of networking, people from all practices in healthcare, and learning so that we receive learning opportunities about different cultures, about different segments of the population that may be underserved, and this includes people with disabilities so it's not always ethnic or linguistic variations. And then we have skill building activities so that you walk out of there with not only an awareness of different cultures but tools in your tool belt of, "Okay, this is what I can take back home, back to my practice today, and start implementing on how to better serve our patients." We're pretty proud of this event. We're really excited about it. Next year, Natasha is co-chairing the committee-
Natasha Ovuoba: Yes. For the first time.
Carlos M.: ... with me. Every time we sit together and talk about this, we just have way too many ideas.
Natasha Ovuoba: There's so many different things that we can teach about cultural competency. I mean, it's limitless and if caregivers aren't able to make it to a full day conference offered by us, which we still hope that everyone can, it's open to everyone, not just our clinicians, but we also have diversity week that we host every year. This coming year, diversity week 2020, is going to be co-facilitated by all of our Caregiver Resource Groups. I hope everyone is familiar with what our Caregiver Resource Groups are, but they are organizationally supported groups of caregivers brought together by common interests, shared characteristics, to help in achieving some goals, whether that is goals around community outreach and how we can better serve our patients, or about career development and career enhancement. So they will be putting on the events for diversity week 2020.
We also have two different cultural competency centered modules, one on an overview of cultural competency and one on LGBTQ+ inclusive language. In addition to that, on the equity and inclusion page on intermountain.net, we have quite a few resources there. We talk about inclusive patient care, we talk about inclusive patient care and inclusive workplace skills, we have our previous cultural competency symposiums recorded and up there on the presentations tab in addition to our diversity week presentations, our keynote speakers for those weeks, and also our women in leadership presentations that we've had the last few years. So a lot of really great stuff for our caregivers to watch, listen to, learn, and we hope that it will really just start a discussion among teams, that managers will bring these to their huddles and just find ways to get their caregivers more engaged in cultural competency and find ways to be involved.
Mark Briesacher: What do you all think it would take for us to be the most culturally competent healthcare organization in the country?
Carlos M.: It may sound cheesy, but it really takes everybody being committed to this goal. It's just getting everybody on board and learning and sharing the information. I think we have great support. We have great policies that support inclusiveness and equity and we have the support of our leaders. We just need everybody to get engaged, to catch the bug.
Mark Briesacher: Catch the bug.
Natasha Ovuoba: Yeah. I'll add that I think it also takes humility and empathy. Again, just take a step back, picture yourself in someone else's shoes, see how that person might be feeling, see what issues they face each day and really be humble enough to say, "Okay, I want to help you. I don't understand what you're going through, but I still want to help you."
Carlos M.: I think Brenda Voisard had an experience when we went to this event representing Intermountain in the Hispanic Chamber of Commerce once, and their keynote speaker was speaking in Spanish, and Brenda was like, "Oh, you know, I'll sit here and I'll listen to," and I offered, I said, "Brenda, I can interpret for you. This is kind of what I do." And she's like, "No, I think I'm catching the key points." A little bit through it, I'm like, "I cannot do this. I cannot just sit here and not interpret." So I just started interpreting and simultaneously interpreting kind of like next to her and after that she was like, "Wow, I had never needed someone to interpret for me before." That was such a big difference how I was able to connect and understand and go through this message with this keynote motivational speaker that was there that she would have missed on.
And I think, I mean, sometimes it takes being in that situation. I don't think we all have the opportunity or had the, well let's call it the opportunity, to be in a situation where we were in the minority, when we needed to be accommodated to in order to help us achieve our goal through something. And yeah, there's no better way to get in someone else's shoes than to be in that position. So I don't know how we get all of our caregivers to feel that way, but we can do other things, we can seek opportunities. Simply asking open ended questions and following the instructions that are in the equity and inclusion page about health literacy. That's a great start. Just asking patients open ended questions that allows them to express and convey their beliefs and ideas, that alone can make such a big difference.
Mark Briesacher: When we were getting to know each other before starting this podcast, we talked a little bit about where each of our families immigrated from. So, mine immigrated from Eastern France, Western Germany. Natasha.
Natasha Ovuoba: My family is from Nigeria.
Carlos M.: And I grew up in Puerto Rico.
Mark Briesacher: I was sharing my family's recipe for sauerkraut, and the secret being sauteed onions and apples. I heard a story once that in almost every culture there is a dumpling and the dumpling, if you pay attention to the dumpling or the pierogi, you see the thing that binds us all together. I'm a foodie, so this resonates with me. And then you see how we're different all at the same time. And so I guess I share that because having this conversation with the two of you just reminds me just how we are all connected and that by focusing and thinking about cultural competence and having a growth mindset around what else can we learn today, I think you're right Carlos. We should just be intentional about how important this is and that's how we will become the most culturally competent healthcare organization.
Carlos M.: There's more that binds us, there's more things we have in common among each other, than there are things that make us different. I think if we start looking at it through that point of view that lists, "Okay, so there are things here that are different, let's find our commonalities and let's build on that."
Mark Briesacher: Well, May 29th. Friday, May 29th, 2020, I think that's going to be a great day. So thank you to the two of you for co-chairing that and for the work you do here at Intermountain. I hope you know how big of a difference you're making. I saw it when we were together and I know everything that your office, Natasha, is working on. It's such important stuff and I'm really grateful for that, so thank you so much for this conversation.
Natasha Ovuoba: Thank you.
Carlos M.: Thank you.