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three two one liftoff good afternoon everybody my name is megan butler and i'm a part of the liftoff pgh team and it is my pleasure to welcome to you to today's session cultural competency in healthcare education led by a doctor abdessalam and dr judy chang so today's conversation should be a really interesting presentation with revised education models workplaces and institutions can bring physicians into the multi multicultural conversation and help clinicians at all career stages to better serve patients and ensure the brightest future for our region so today's conversation is going to be focused on making sure that physicians and other healthcare providers in our region are better prepared to offer culturally and linguistically competent care so with that i am going to pass off today's session to dr sudhi and dr chang well thank you so much megan it's a pleasure to be here we would like to really express our gratitude to leftoff pittsburgh for this partnership and also for making space for this as you said very important conversation uh that's going to be um adding a lot to the part of the conversation in the in the conversation i would also thank my colleague dr chang judy for participating in this as well and so um this is going to be our outline today we will work through the meaning and value of cultural competency why we need it in our lives and how to best approach it and we will also illustrate with various examples from our work that pertain to uh cross-cultural communication so what is uh cultural competency and please feel free to supply your responses as well as we go so we'll be asking questions throughout the presentation so cultural competency is the ability to function effectively in cross-cultural and cross-linguistic environment it can be thought of as a chart for perceiving and interacting with the world around us it's about being flexible reflective and accommodating it's about appreciating differences and creating safe spaces to learn about others it is about improving empathy and understanding in the workplace and beyond it's about collaboration teamwork critical thinking and diversity and most importantly also it is about engaging others rather than just accepting them and for the past it has been uh this has formed a big part of a project that we have been working on titled the cultural engagement playbook the scope of cultural competency is broad but these are some principles and premises to keep in mind we belong to several cultures at once and they're not static if you even think of something like our own identity as individuals we operate along several social frames i am here today as a co-presenter as a collaborator i'm also a father i'm a husband i'm a teacher i'm an educator so so we are different people so parts of our identities are emergent in context based on where we are and who we are and who we are talking to culture is expressed through individuals not stereotypes so we have to give people a chance to tell us who they are in those specific situations rather than uh boxing them in blindly in categories so the goal is to understand individuals in their cultural context every human encounter is a cross-cultural one to some extent so i could be having a conversation with my own brother we grow up together and that could be cross-cultural because we have different experiences and different educational backgrounds and a number of other things that come into play or encounter might also have different needs in that particular in that particular conversation my brother could be my doctor for example so so cultural competency is important in every aspect of our lives and has a big relevance in healthcare as we will show you today an individual's culture is made up of multiple different factors as can be seen here in any given situation or decision it may be impossible to isolate the driving factor something that might be driving a person's behavior or a person's style so any and even if we were to put this sculpture in their microscope and their conversation analysis microscope it might be really hard to know exactly what's driving a person's behavior is it age is it gender is it the language is it literacy is it experience is it religion so these things are very interrelated so these are these factors or to be precise cultural variables work together sometimes and it's very hard to isolate which one is driving a person's behavior culture has long been compared to an iceberg deep inside like our core values family narrative identity and more and this has also been articulated very well in liberty prance i don't know if some of you read that the little prince where it says listen it is what is essential is invisible to the eyes and again this is part of the difficulty working class culturally and class linguistically speaking going off the fact that diversity means different things to different people in 2017 i invited students faculty and staff to the university of pittsburgh studio to discuss what diversity means to them i embedded three questions in my casual conversation with them what does diversity mean to you what is the value of diversity in your life and work and how can we achieve it following the murder of george floyd and the current pandemic i have taken these questions off campus and into the community virtually doing this work has shown me clearly that cultural competency continues to be work in progress as the value people assign to diversity varies greatly depending on their definition and please participants feel free to share in the chat box what diversity or cultural diversity means to you and the value of it in your life and work and also your opinions about how we can achieve it so there are several arguments why we need to address cultural competency a simple one is ongoing shift in demographics according to the american community survey over 55 million respondents spoke a language other than english in the home and that's 140 percent increased from a similar survey in 1980 45 percent reported some degree of limited english proficiency that's about 11.5 percent of the total u.s population you can also think of it as about one in seven americans do not speak english as their first language and these are some local members from pittsburgh and allegheny county five point eight percent are foreign-born county residents eight point three percent of fundamental city residents 48 that's a 48 increase since 2000 and it is expected to continue asian latino and african communities have grown by 50 percent and in pittsburgh we have welcomed about four direct refugees placement from 33 distinct countries this information comes from the allegheny county department of human services later 2015. another argument why we need to address this is a legal one federal laws require that service providers so if you are a hospital or a clinic that receives any form of federal funding you are required by law to meaningfully accommodate people with limited english proficiency and they underline meaningfully as a linguist i'm aware that there is over 100 languages spoken just in the state of pennsylvania so to expect having in person translators and interpreters of language brokers all the time might be hard but we can definitely in the discussion explore possibilities of making that happen this is also part of the executive order uh 13 1616 which led to public law 101-52 1994 which led them to the creation of office of minority health which was charged with developing what's called class standards and that's culturally and linguistically appropriate services which consist of 15 principles a general one make sure that we provide effective equitable understandable and respective quality care and it also consists of these three interrelated themes about governance leadership and workforce communication language assistance engagement continuous improvement and accountability but let's remember that checking a legal box to provide language accommodation is not enough the job of interpreters and dynamics of working with interpreters can be hard again participants if you have had any experiences that you'd like to share please feel free to do so in the chat box against the claim or general assumption that doctors hold more power in an interpreter mediated medical interview interpreters function as interaction managers bridging a disconnect between patients and their physicians and thus hold more power and if dr chang would agree with that interpreters speak the language of the doctor or the healthcare provider and they also speak the language of the patient so in a way they are able to control information and topical development uh as well of of the medical interview we should keep in mind that even in idealized production format question answer interpreted medical interview takes longer than same language visit and this is something to keep in mind when you are budgeting our time seeing patient who are limited english proficiency this is a simple exchange how are you it has to go through the interpreter back to the patient i'm doing fine they tell that i'm doing fine great just that takes twice twice as long but production formats in interpreter mediated medical interviews are not always ideal we have possibilities like exchange b where you have these side conversations can you ask the patient how they are doing and then you have a side conversation back and forth back and forth back and forth and the health care provider providers left out exchange c is possible where we observed conversations happening between interpreters and doctors and the patient is uninvited left outside of the interaction this was a study that used conversation analysis videotaped interviews same language visit and compare them to interpreter mediated visit so if you look at the first part from same language visit there were uh 55 questions from the healthcare provider and so answers were 53 and only two were not answered and that's amazing i think you know dr chang agrees as well i think that's pretty good that only two were not answered by uh by uh by the provider however in interpreter mediated visits the number of questions 33 which is alarming by the way the number 33 questions is much less than 55 questions even if it has to do with the time being reduced but not past the provider were 18 questions no answers for so 22 questions were completely lost this comes from another study by arangori and colleagues and so if you look at the chart above the diagram the first one the top one there's sort of a typo in the original publication so that patient should be 25 percent and physician 20 25 and interpreter talks about 50 and again that's idealized right because it also depends on on the language at play i speak arabic and arabic is a very verbose language so sometimes one sentence in english might require three sentences in in arabic to fully uh capture the the meaning but again that's ideology so when these interviews are actually timed and subjected to a conversation analysis the findings were interpreters spoke actually 27 of the time patients spoke 24 percent in physicians 49 so likely then one of the conclusions we can draw from here is that interpreters were summarizing were not passing maybe certain answers to the provider and were deleting perhaps information so while we are rightfully concerned about the building places to come up with the right equivalent sometimes it's hard to come up with something equivalent in the target language or to mediate conversation to align with pragmatic filters of the target and source languages we also need to worry about what we are asking interpreters to do right are we asking them to deliver negative news and this is something that's usually not accounted for in most of the studies that we have looked at are we asking interpreters to pass complaints most of the time depending on the relationship between interpreters and patients interpret interpreters become very hesitant to transport delicate matter information we also need to keep in mind that the job of an interpreter the job of the provider and also the patient is hard when you are working in interpreter mediated conversations as i said earlier social factors affect our health where we live learn grow and work they matter more than the quality or type of medical care that we receive so there are those differences in health that are natural at a certain degree they are acceptable because we have no control over them but there are also differences in health due to our socioeconomics education literacy and the environment where we live and grow and they are preventable and are therefore unfair and must be eliminated based on information from the american medical hospital association about 1.7 million individuals experience homelessness 3.6 million people can't access medical care due to lack of transportation so they might have access to health care but they have no transportation to take them to the hospital to be seen 40 million people face hunger and 11.8 percent of households in the united states are food insecure and this is a detailed summary of the various components that fall under the category of social determinants of health and their impacts on health outcomes such as mortality life expectancy and functional limitations and of course they include some of the areas we have talked about now like cutting linguistic competency language literacy and education as well as economic stability physical environment social determinants and behavior factors drive 80 percent of health and matter more as mentioned earlier than health care so going to the doctor having insurance to go to the doctor has a very small percentage in the overall health of an individual place and zip code matter sometimes few miles few miles mile or two can make a huge difference in life expectancy sometimes it's 20 years difference and so we need to keep that in mind as well food matters and if you look at some of the scary numbers even in pittsburgh 21.4 percent are food insecure and in allegheny county 14 and that's very concerning we can't talk about social determinative health and not address them in the context of kovid 19 as well low-income housing and shelters can't provide social distancing as we are experiencing and we have experienced since march social distancing is a privilege i'm very grateful and happy that i live in a town house that has a driveway and a backyard where i was able to take my children out but there are lots of families who lived in crowded apartments in crowded housing lots of people couldn't afford to pay rent because they lost their income lots of people became food insecure language access as we talked about earlier is also important many people many limited english proficiency population in pittsburgh there were times when they called me is it okay to go out today because we were not sure what the governor was saying you were confused about quarantine isolation shelter in place those those terms are very technical that people had really faced difficulties understanding and making decisions about their next moves and their social isolation some of us have high-speed internet so we're able to log into zoom and and and connect with our families and friends but lots of people did not have that kind of access release the conversation floor to my colleague dr chang thank you thank you dr sudhu for making such a compelling argument for the importance of cultural competency in health care and then this essentially is where we want to transition a little bit to bring us to the question of how how do we actually have cultural competent culturally respectful conversations in healthcare both dr sudhi and i have focused our research on patient provider communication and it's been exciting also to collaborate with each other and learn from each other's expertise you know for me as a healthcare provider i've benefited from having the expertise of someone who's so well-versed in linguistics and humanities to really sort of inform the work that we do from this work we then have been able to identify skills and approaches that then we're translating into teaching healthcare students medical students trainees how to improve their communication with patients and so i just wanted to share some of them some of these examples with you now next slide so one of the studies that um that that was funded by the agency for healthcare research and quality was looking at a particularly vulnerable group in a particularly sensitive topic and so this study sought to understand how healthcare providers can best ask and talk about intimate partner violence with their female patients at the time that the study was commissioned um although multiple medical organizations advocated that health care providers should be asking all of their female patients all their adult female patients about animal partner violence there was little guidance on how these conversations should actually occur and so our study used focus groups with women who experienced him at partner violence to learn how they would advise healthcare professionals to have these conversations next slide point and so a key component that i wanted to point out was that the design of the study which was to focus on the voices and perspectives of the women themselves was crucial to understanding the context and culture related to their experiences this approach allowed us um to address that doctor-patient asymmetry that oftentimes occurs in these visits and essentially is illustrated by this conversation and so as you can see here the doctor is actually asking a question to try to explore intimate partner violence however in the patient's response you can see that her interpretation is regarding neighborhood safety next slide please in terms of some of the findings um and themes that arose from this particular focus group study um we saw that there were three main things one was to give a reason for asking which was that women wanted to have a sense of why we were asking in order to reduce the stigma around this sensitive topic so as this quote oops if you can go back to the other one as this quote illustrated if the doctor prefaced it with part of my routineness to ask this of everybody then you don't feel singled out a second theme was ensuring a safe non-judgmental and supportive environment um and as this particular participant indicated that that support can be really impactful with regard to their sense of comfort but also sense of self as this woman described just with a simple caring word you feel that you are really worthwhile that they care about you about your situation and then the third theme was to actually provide information and resources about intimate partner violence regardless of disclosure the women explained that disclosure can sometimes be hard but that they would still find the information resources and supports useful even though they weren't ready to disclose as this one women described they can say well look man well if it hasn't happened to you that's good but just in case it does happen to you here's the information these themes have become crucial in center points to how we are now guiding some of our training in terms of teaching medical students and other professionals how to address intimate partner violence it's certainly a component of the trainings that i do with medical students and it has also helped to be some of the um or inform the universal counseling and universal um resources approach that the futures without violence national advocacy organization has been using and trying to promote to other healthcare providers next slide so the presence of the computer makes certain conversations including those about sensitive topics such as domestic views very difficult but computers now as you could see in this and you need the exam the exam rooms so we need to know then how the information that dr chang has described is inputted into the system and how technology machine learning and natural language processing account for cultural information additionally we also need to consider that some patients may have distrust of information technology that might need to be addressed so where do we go from here well we can go in a million directions right but one thing is for sure we need educational programs in our hospital systems and in the curriculum to address diverse aspects of cultural competency and an example here is the med edu 2240 a master's level course that i could direct through the institute for clinical research education this is a concrete example we talked a lot about the value of medicine health so this is a concrete example of integrating images into health intervention or clinical care it focuses on cultural and linguistic competency to demonstrate how these skills enhance our understanding of social determinants of health and working with limited english proficiency and so on and so forth and this is a snapshot of our syllabus that was published in european journal for person-centred healthcare in 2017 those are the themes and we have highlighted a couple of them already in the earlier part of the conversation talking about appreciating language uh linguistic competency and also patient centredness and as well as social determinants of health an important part of the course is also the connection we make with our communities through field trips to religious center and this image here is from a visit we did few years ago to the islamic center of pittsburgh with our fellows and residents who are signed up for the course a chapter that came out recently in an edited volume diversity across the discipline we highlighted an important exercise we require that our trainees think about the cross-cultural or cross-linguistic encounter and think about it define the problem and share what they learned from the problem and how we would teach it to others so thanks to a grant from the provost office in the david berg center we looked at about 70 reflection essays and we categorized them best also to learn what kind of themes our trainees are interested in in addition to offering opportunities to learn about and appreciate different cultural perspectives and experiences we also learned a bit about the key components that are necessary in order to actually educate competency and there are two key elements that have been a part of both having cultural competence sort of interactions as well as teaching about cultural competent interactions and these two are safety and space making sure that we've got the time and space for reflection and for people's perspectives to be shared next slide the key components in terms of like when we're trying to advocate the interactional styles and the key objectives that we're hoping to convey are demonstrating respect making the patient feel heard and understood and conveying caring and concern there is a type of communication style or skills set of skills that has been being taught across the world actually the academy of communication and health care is one organization that has been using this approach to train healthcare providers in terms of patient provider communication skills and these are the different components that actually are the focus of that in terms of each visit one is to set the stage which is making sure that there is appropriate introductions and making sure that the patient is comfortable and then beginning the visit by eliciting the patient's concerns and understanding what their agenda is and their set of priorities before the provider actually starts to mention what their priorities would be the emphasis is on using open-ended questions and they use an ask tell ask model meaning that you would begin with open-ended questions focusing on the patient's perspective before offering information guidance or counseling and then end with that open-ended sort of tech approach and then finally one would finish the visit by confirming mutual understanding and ensuring that the patient's key agenda items had been addressed next slide okay another me so one other example is a humanities at work project that we have created in collaboration with dr chang department of obstetrics at mcgee women's hospital school of different department school of medicine department of family medicine included linguistics school of business and education uh so we created which builds both in the humanities and health initiative and the linguistic internship which um dr chang plays an important role is we she hosts every year few interns to analyze uh to analyze data medical interviews obstetrics visits primary first obstetric visit and look for different linguistic sequences how doctors solicit concerns about uh intimate partner uh violence so we've been collaborating with her for about seven or eight years now we also place our students with the english language institute with 3m uh model which is now 3m virtual technologies semantic compactions upmc enterprises rtq lab wiki tongues and and livington so these are again educational opportunities available to our student population as part of the dietrich school of arts and sciences at the university of pittsburgh and this is the initiative that we started with at the beginning of this talk humanities and health initiative we have been holding events once a year bring it's a cross-unit partnership to talk about social determinants of health linguistic competency and a number of other relevant topics so cultural competency encompasses many fields and as we have shown through examples it is important in every aspect of our lives and has relevance in health care addressing social determinants of health is important for improving overall health reducing health disparities eliminating unjust health outcomes differences that are rooted in social and economic disadvantages broad inclusive and personalized approaches work because every person has unique uh social uh social services and needs and one size fits all approach does not work health is important all places i think most of the time we tend to address health in the clinic but really need to look at health in our neighborhoods in our work environments and work together to create a diverse inclusive and just environment for all people and thank you very much i would like to just make some quick acknowledgements i'm really very grateful again to my colleagues and partners at leftoff pittsburgh megan butler who has been working with us for a number of months putting a wonderful event together and natalie stewart her colleague and mara left and also our colleagues the humanities and health colleagues at the university of pittsburgh and uh colleagues at the icre the is the research and education where the where we ran the master's level course that we have highlighted earlier and our community partners have been hosting our interns for diverse experiential learning opportunities and also thankful to our interns themselves and if there are any additional follow-up questions we have put an email there thank you and we are looking forward to the exciting part of having a discussion with everyone thank you great thank you so much dr sudy and dr chang for leading us in that great presentation at this point like dr sudhi said we would like to open it up for questions from the audience so please feel free to type your questions either in chat or in the q a panel specifically either way we'll be able to receive those questions and share them with our panelists today so i'll go ahead and start us off with a question and this is actually inspired by a session we had earlier today at liftoff pgh we hosted a session earlier today with kids plus pediatrics who has a local pediatrics practice here in pittsburgh um and one of the themes that they discussed in their presentation was the role of trust and a relationship between a provider and a patient and just how fundamental that idea of trust was in the care relationship so i wanted to pose that as a question to both of you what role do you think trust plays in this conversation and cultural competency and how do you think that physicians and other providers can um in you know integrate elements of trust into their care models trust is essential it's absolutely essential um and especially with regard to patient provider interactions um you know it it's it's even more important because there have been communities and individuals who have experienced harm and therefore there may even be the need to regain trust or actually build that trust what we've noticed in terms of some of the communication approaches though is that a key component of building trust is creating that safety in that space and really helping to give a platform or at least a sort of a um helping to center sort of the patient's perspectives and and experiences as well as their needs and concerns and giving space to allow them to express to express their distrust actually to express their unhappiness to express some of their frustrations from the past and then create you know um a dialogue to be able to move forward yep and i i trust is pretty much everything that we have said and we didn't say that's the whole thing building trust is that's the best outcome you want to have in and it applies everywhere in my own classroom too i have to work hard as well to build trust with my students they have to know that i'm an expert they have to know that i am here to help them i am not their opponent i'm your partner and i think so and engaging really the key is to engage people in their care if your patients are engaged then they'll work with you it's like you know there's a methodology called the flipped classroom you know where people end up doing more work because you know you sort of empower them and you give them the tools and they buy into it and i think it's important one challenge that we are currently about to face is now we have a vaccine we've worked very hard to have a vaccine will communities take that will trust will they trust our system and that's the right thing and that's where humanity has come in you know it's not it's a medical question it's a public but it's it's really largely humanity's humanities question but building trust is privacy people have the need to be able to trust you even working with limited english proficiency you know if you're bringing an interpreter from the community patients might not be as willing to come forward with information because they're worried that the person you brought they see them at the local religious center and the worries so we have to also be very careful about the participants that we invite in our clinics and so but yes it's a great question building trust is everything and hopefully that's helpful and we are happy to expand if there are any follow-up questions on that as well no that's great thank you so much for your responses we do have a few questions coming in via chat so stacy says i appreciate your great your great efforts and educating health professionals on having difficult conversations with patients how do you translate these efforts into written communications or resources that are provided to patients absolutely i think that that can be something that we have to think with a lot of intentionality as well um in order to make sure that what materials we're producing are appropriate and applicable to the individuals to whom they're targeted um the things that we've used before have been to try to speak in the voices of the targeted audience as much as possible and so oftentimes you know sharing sort of concerns but then acknowledging that that may not necessarily be the same concern that everyone might be having the other component is to make sure that the language is accessible and appropriate i think sometimes those of us in the health professions when you're used to kind of speaking your own language with your colleagues and such like that it is that some of these words and terms and phrases and even ways that we frame things are not what others may absorb and so part of that is to make sure that we do that and i think a lot of it is to actually partner with the communities and populations in the creation of these educational and resource information to make sure that they've been vetted essentially by the individuals who'd be using them yeah i think dr chen covered perhaps everything that i want to add to that i think that's uh engaging communities in in the making is is definitely an important step in happening thank you great we have another question from jean marie following up on megan's question how does trust and confidentiality play into women seeking care with children in tow or without available child care and not able to freely answer the leading questions relative to potential domestic violence and then there's a second part to this question so also if there is an interpreter involved how does that play in um and then there's a third part to the question so what is the success of interpreters in telehealth visits if there are three remote entities in that virtual visit um so feel free to address that you know um but you know certainly in terms of safety and confidentiality and privacy especially with the transition from in-person visits to telemedicine there's been a really highlighting of the issue of privacy because as you can see you can see me but you don't know who's behind the camera right you don't know who's sort of off to the side out of my screen um and so there there is the need now for us to be really careful about how we bring up different topics and what we're um what kind of position we're putting people in if we're framing things in perhaps as a way of like screening you know if we're actually asking a direct question to actually ask them to reveal some type of information about themselves and that could be in the case of having you know children um in the room as well you know any child who speaks you know who can hear and speak can then also share sort of what they listened um to um when to somebody else um and so that sort of rule of confidentiality isn't necessarily applicable to that particular child and the same sort of thing with interpreters now formal and professional interpreters are bound by confidentiality and professional guidelines um and so that's why there is a preference to actually use you know specifically trained and professional interpreters in our visits but there are certain sometimes in which an interpreters are more community volunteers or um you know personal affiliates of the patient themselves um this is one of the areas where that last theme among the three themes that um i mentioned i think has been even more emphasized meaning that instead of framing things as questions like is this going on with you if we actually provide it as universal counseling by saying you know what there's a lot of stress going on and we hear that there's a lot of issues with regard to safety including domestic violence you know increased substance use problems with mental health we want to provide everybody with the resources that can address these things so i'm gonna give you these brochures or i'm going to give you these series of numbers or websites or other links and that's for you to use or to share you know it doesn't matter if it's affecting you but we know it's affecting a lot of people we're going to get it out there and so that's one way to safely get the resources out to individuals when they may not feel comfortable disclosing yeah yeah yeah thank you this is also again a great question and thank you dr chang for addressing a big part of it and so so what we're emphasizing in our teaching cultural companies is work in progress so we don't teach knowledge about cultures we talk about cultures but really it's an approach and it's an approach that depends on context and participants who is involved and where and what type of visit and what's the topic and what is the purpose i think those questions are always relevant so you're not going to walk into an exam you may have taken the training i am ready i think we really what we emphasize in our training is have sort of that very it's relativistic there's nothing absolute right and so we're talking about interpreter for example or their work we also have to think about the number of scenarios interpreters in obstetrics visit might not be the same as um orthopedics encounter so we have to think about the type of visiting what that visiting tells an obstetric visit does entail sensitive topics having to do with eliciting information about domestic abuse and so on and so forth but also the multimodality aspect of it and i think some of this stuff is also being addressed at the conference you know in terms of in the context of technology with television and telemedicine i think we have to quit mother's day if you're calling somebody in the room and you're asking them about intimate partners how their partner could be in the living room and yes you could be you could be overhearing the conversation so they might be hesitant to be more um uh more forward but so and this also example reminds me of an example that a colleague of mine who has been teaching the course with me as well where she was seeing a muslim a patient who came to her clinic and the muslim female patient brought a male a neighbor a volunteer from the community for the visit and she had to make a very good decision would she count this as a visit or not counting it as a visit might not be the best thing for the patient because she was going to ask delicate matter things and having a male person translate that to a female muslim likely as we have seen in the earlier graphs likely that information might need might be deleted or not passed along to uh to the provider i think there was also a part that's sort of more of a human human human computer interface where it's a it's a telehealth and you have an interpreter in one location you have the patient in another location i have not personally observed that as a linguist i would love to have my hands on that kind of data to really understand there are challenges of bringing participants together remotely i can think of one situation that's also multimodal but your the participants were in person we had somebody and an aunt who needed asl and a mom who needed spanish interpreting and so an interview that was supposed to be 20 minutes end up being an hour and so but again the really the point is keep in mind participants um there physician patient who else is there interpreters they're the you know are the community volunteers are they are hospitally independent and the purpose of the visit if you visit like dr chang's visits are mostly involved delicate matter topics and sensitive topics then we have to be mindful of who the participants are megan i hope we addressed all the branches of the question it's a great question and it it really brings a lot of important pieces together yeah no i think you did so great job there um and that's a really interesting conversation i hadn't thought about the privacy implications of telemedicine not only not necessarily knowing who's on the other side of the screen but also if you're doing the telemedicine visit from your own home do you feel like you have the privacy that you need to disclose certain information i think that's a really interesting implication of the new virtual visits so that's a great question and really great comments there um we have a two-part question that has come in from brandon who asks what are your thoughts on utilizing a cultural ecology approach to understanding cultural overall and the culture of an individual and then i'll read the second part of the question too how do you teach students to address the subjective nature of culture how culture is perceived and understood by the patient in the clinical setting i i do know that tank have you used and i have not used the cultural um ecology approach in my my work i have not so i wouldn't be able to speak to that but i guess it is making me think about some of your exercises that you use in your course such as the culture box yeah um it might be something to talk about yeah so the so our uh the teaching how the approach in which we uh we we deliver um our cultural competency training is really about it is very participant very participant driven rather like like i said or you will not bring in again whatever we're teaching one it is participant driven because we would like to align what we are doing with the reality of the clinics but also with the reality about demographics but most importantly with the reality of the train of the trainees themselves who they are where they come from their background and i think that's that's that's important again because by creating a climate in uh in the classroom where people if we're trying to teach trainees to engage their patients but you are not teaching them how to engage each other then that's not gonna that's not gonna have to give them an example a concrete example and usually at the end of training we get really very good feedback that you know that the environment we have created has allowed them some level of disclosure that wouldn't have been possible in other uh in other environments and megan please we're gonna ask again if you could you don't mind reading the second part of the of the question as well sure so the second part of the question was how do you teach students to address the subjective nature of culture how culture is perceived and understood by the patient in the clinical setting well so yeah so culture is is a very is a very broad concept as i mentioned earlier it's and and and and and it also it interacts with several cultural variables and it's really very hard as i mentioned earlier in my presentation um sometimes to interpret a person's behavior is it does it you know i say something and swedish says something okay is does it have to do with the fact that i am from morocco does it have to do with the fact that i'm a linguist that it has to do with the fact that i am a father it has to do with the fact that that's just my person so it's really it is subjective it is uh it is it is broad but the idea is to really teach it the method is to reteach it as an approach to teach people to be critical thinkers to teach people to look at individuals rather than stereotypes we're not judging people by their accent by their language by their physical looks but we're actually rather creating an environment where we are allowing them a chance to tell us who who who they are right and so that's so it is so in that regard you know saying it again it is really a work in progress and again even if we do the same exercise i did with diversity and asking people what culture means to them we're going to elicit a variety of responses we have to ask them again what how the value culture in the work environment their responses again will depend really on how they define uh how they define culture to begin with so it's a very broad very broad concept but really by relying on reflective exercises to teach people to think critically about things rather than relying on general assumptions of stereotypes is really an important thing to embed in uh in a training i hope that addresses these two related important questions as well there are some approaches to that we i think that there have been out there in terms of how to teach the especially healthcare professionals um some aspects of this you know one is the open-ended sort of questions right to making sure that people sort of have open-ended strategies um but another is um one that's promoted by the american balance um organization american balance society actually and um those were balance groups um balan groups were created by a psychologist michael ballant back back after world war ii and which um these were reflective exercises that are facilitated by individuals who kind of keep a safe space to allow providers to actually reflect upon interactions that they may be having with patients especially ones that they are feeling are challenging or they're haunting in some sort of way and then allow the group to in a more imaginative way kind of try to imagine what might be the contextual elements that may be related to both the provider and the patient and then the relationship that's at hand yeah and and megan and really again to further expand this question is really it's also about being mindful of language i think language is where it that's that's the tricky part you know so we also teach our students to think about the language or the linguistic choices that they make every day how are you saying things really how and the tone and the words because there is not the thing about language there's multiple ways to say the same thing right you can say how are you can say what's up you can say what's going on you can but and each one of them has interactional implications and even i think dr strange mentioned this earlier also how you frame questions you might ask a question to a patient about are you safe at home and you might get an answer and you may ask that same question a different way you might get more uh more information as well so how we compose language is and there's a lot of things that we take for granted we're using language and just that's just nature of language how we you know if you look at how we close conversations this is something they have done some work in 2009 how how doctors close conversations with with patients also very important are we allowing people an environment to expand more who gets too close it's also a language and power question too right so those are so really being mindful of how we're using language is uh is critical as well that's a great point so i know we have just a few minutes left for today's session so i think this will be our last question this question comes from emma in the chat the question is how do you advise providers to navigate respect for culture while also addressing cultural health practices like fgm i believe female genital mutilation or anti-vaccination beliefs it seems like a delicate balance yes yeah it yeah it's a it's a very um it's a big question yes i mean i um i support uh involving as many participant as possible in the conversation i have been part of conversations locally that involved an end of life discourse and so obviously there is religion aspect to it and the imam was involved with the family as well i think it's important to be as open to evolving uh community members that a particular family have trust in talking going back again the commercial cluster we have to make sure but we have to be respected one of the one we have to acknowledge those things as well culture is important and so one of the one of the videos that i shared with our students uh muhammad kuchi dikuchi that's it so an example of a class cultural cross linguistic encounter mohamed gucci the patient in the film refused chemotherapy because the way chemotherapy was broken down to the patient it meant to the patient that the patient was going to be carrying a pump which would then interfere with his oblige and again that's it's okay if it does but then again nobody's in a position to question another person's religiously but it really came down to the very beginning of the translator didn't actually in fact translate very well what community that have been involved you know they just put a technical term out there and left it with the patient to make sense of it and the patient concluded that it's going to interfere with this oblash but one of the things that i liked in that in that film is that the physician at one point says you know what at one point the patient said um our day has been chosen for us is a pious muslim and he really liked the physician's answer it was such a a culturally and linguistically competent one saying it is my job as your doctor to help you feel better until that day comes and that was an accident whether the provider believes in a day of judgment or our days have been chosen for us but at least the provider was able to acknowledge that and that's sort of sort of very engaging way to um to involve the patient in their care and yeah that's another example i think the the how we can kind of tread that delicate balance you know we're seeing a lot of different personal beliefs that may be culturally related maybe politically related may be housed within different sort of belief system that might have different significance and yet not necessarily be compatible with scientific knowledge and medical facts and so i think um as a healthcare provider one of the things that i tend to fall back on is exactly sort of what sudhi's example demonstrated which is trying to find sort of the mutual vision the mutual objective we both want you to have the healthiest pregnancy there is i want you to have the healthiest children as possible and so it is my job to provide you with the medical facts and scientific evidence that is going to allow you to have that and in some cases that's going to run counter to certain beliefs and i respect your beliefs but it is really my job to make sure that you stay safe and so that's why i'm providing you with this information yeah and any and again to keep in mind bringing back this slide again these things again sometimes you don't really know 100 percent whether certain things are cultural or religious or having just to do with literacy so you really have to keep in mind and the thing about culture as broad as ambiguous and complex is that these capsule variables work together and it's very hard to dissect which one is of these are really prompting a certain response by by somebody so there are some strategies that um the field of motivational interviewing can sometimes be borrowed to use you know in terms of again that ask which is tell me more about your beliefs or tell me what you think tell me what you're wanting and then you know how are we going to make that happen when there are these two things there but also you know especially with regard to certain things that might have might generate a lot of ambivalence let's say like the general the female genital mutilation you know one of the things that i'd want to ask is how do you personally feel what's right about this you know and what are what are the things that that you're concerned about what are the things that you want so great thank you so much on that note i think that we are about at times so on behalf of the entire liftoff pgh team i would like to thank dr sudy and dr chang for joining us for a really great and engaging conversation today and thank you also to the humanities and health initiative at pitt for being such wonderful partners as sudhi said we've been collaborating over the past several months so it's really excited to see the partnership continue through this session thank you everybody for joining us today that is the last session today for liftoff pgh but we have another really jam-packed day tomorrow so we hope to see you all back at noon we have a pre-recorded mindfulness yoga session led by venture outdoors if you said it will be available after that time as well so feel free to watch that at any point you are available at 1pm we are having a lunchtime conversation hosted by local journalist natalie bensivenga who is going to talk about how to find a seat at the table um as a young professional when you feel like you're being excluded from certain spaces or certain conversational certain conversations so that'll be really focused on advocacy um strategies for young professionals at 2 pm we have a session on demystifying buzzwords in healthcare so if you've ever wanted to learn more about fire hl7 um natural language processing any of those buzzwords in the health and innovation space we hope you'll join us for that um and then at 4pm tomorrow the center for women's entrepreneurship at chatham university will be hosting a networking session focused on the role of women in health innovation so another really jam-packed day tomorrow thank you everybody again for joining us and thank you to our two panelists we hope to see you again tomorrow thank you thank you thank you thank you thank you