Bridging the Gap between the Individual, Community and Hospital in Critical Care Medicine

Archana Bharadwaj, MPH, CHES

Critical care is an arena that is particularly in need of culturally competent care given the acute, uncertain nature of this specific type of care. In “The Importance of Cultural Competency in Critical Care,” held on Saturday, March 19 at the IARS 2022 Annual Meeting, three panelists discussed the value of cultural competence, compared cultural competence to humility, and highlighted opportunities for culturally competent communication in the ICU. Intensivists and experts in health disparities Vivek Moitra, MD, Linda Liu, MD, and Ebony J. Hilton, MD, offered solid, research-based solutions which present an obtainable, definitive path forward towards cultural competency in the ICU, critical care and beyond.

Vivek Moitra, MD, Division Chief of Critical Care Medicine at Columbia University Medical Center, launched the session with his presentation on “How Cultural Competency Improves Critical Care.” As defined by the American Hospital Association (AHA), cultural competency is “the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including the tailoring of health care delivery to meet patients’ social, cultural and linguistic needs.” However, Dr. Moitra stated that cultural competency can create a false sense of understanding of others. Therefore, he argued, cultural humility provides a more meaningful approach by acknowledging that unconscious biases can persist despite developing cultural awareness. According to “Cultural Humility: Essential Foundation for Clinical Researchers,” cultural humility embraces lifelong learning and provides a flexible approach unique to individuals.

Practicing cultural humility begins with an awareness of personal biases, which can create blind spots, Dr. Moitra explained. Through debiasing, or efforts to reduce bias, blind spots can begin to be addressed. A great first step is to become familiar with the different types of biases. Applying insights from a study conducted by Google on characteristics that make a good team, cultural competency can be facilitated in a critical care setting by ensuring equal conversation time for all members and sensing how different members in a team are feeling. In doing so, psychological safety can be created. According to Dr. Moitra, “Humility is about creating the conditions of psychological safety so that everyone, including our patients, is comfortable being themselves.”

Linda Liu, MD, Vice Chair of Quality and Safety at the University of California, San Francisco (UCSF), built upon these insights during her presentation on “Situations in which Cultural Competency Can Prevent Conflict in the ICU.” The ICU is an especially challenging setting for patient-provider communication for numerous reasons, including uncertain patient outcomes and limited time for communication. Three areas she emphasized for improved communication are 1) cultural preferences, 2) religion, and 3) language.

Some ways to address cultural preferences are to have discussions with patients about who they consider to be family members, the desired role of family members in care, and the preferred family spokesperson. Meeting with the entire family along with social work and other care teams can help clarify care goals early on and ensure questions are answered. With regards to religion, respecting the family’s preferences, including rituals and beliefs is important, and religious leaders such as rabbis and priests can assist in these conversations. Finally, navigating language differences can be managed through printing information in multiple languages, using shorter sentences, and asking patients to repeat what they learned from the conversation. Together, these skills can facilitate communication to promote a shared understanding that honors that complex and dynamic nature of culture.

The panel wrapped up with a presentation by Ebony J. Hilton, MD, Associate Professor of Anesthesiology at the University of Virginia, on “Teaching Cultural Competency: Because Half Truths Cost Lives.” She explains that race influences health outcomes through many pathways including biology, culture, and environment. A startling example of racial disparities in health is the ongoing COVID-19 pandemic during which, according to GOODSTOCK Consulting, one in every 353 African Americans has died since 2020. A contributing factor is that per the U.S. Bureau of Labor Statistics, a greater proportion of Hispanic/Latinos and African Americans served as frontline workers in comparison to White Americans. In addition, data from the Virginia Department of Health on “COVID-19 Emergency Department Visits” showed that, although Latinos and African Americans were more likely to present to the Emergency Department, Whites were more likely to be hospitalized. These findings suggest that providers were more likely to take complaints of White patients more seriously.

An understanding of disparities is crucial for providing quality care in the ICU. As Dr. Hilton explained, patients in the ICU often cannot speak to providers. Taking a holistic approach to patient care requires an understanding of life circumstances, which may lead to disparities in care received, in order to account for the factors culminating in the patient’s admission. She encouraged physicians to disrupt disparities through serving as a bridge between the individual, community, and hospital thereby helping patients leverage available resources.