Communication Skills for Working with Asian Americans with Cancer

M. D. Anderson Cancer Center
Date: 2/2/ 2008
Duration: 0 / 49:42

Lynne Nguyen, MPH, Health Disparities Research

Introducer:

So now we get into the segment of our program I've been looking forward to so much related to exploring opportunities in culturally diverse populations and I'm so pleased to have Dr. Lynne Nguyen with us. She has been working closely with us in a number of different areas in our C Corp and in particular has just played a substantial role in helping us with our minority participation community and she is going to talk about communication skills for working with Asian Americans with cancer. Thank you Lynne.

[Pause]

Dr. Nguyen:

Okay. Good morning every one. I'm really glad everyone's refreshed with their coffee. I know we are running a lit bit late so I'm going to try to stay on time and I'm not going to go over every slide. I have put in a lot of information because this is a training that I have presented for five hours to medical students. I presented for two hours to nutritionists and nurses and a lot of other social health human services staff. So what you're getting today in 30 minutes is the cliff notes version. I'm going to go very quickly.

Okay. So there's a lot, I've timed out the presentation to your needs, which is working with Asian American patients and in particular recruiting them to clinical trials and there is a lot of things you need to know that I'm not going to go over. You need to know about the data. You need to know about the community infrastructure, the system barriers, the patient barriers, and last of all which I will cover is the culturally and linguistically effective communication skills. What you need to know about the data just very, very quickly don't just look at proportions and race. Here in Texas if you look at the proportion of the population that is Hispanics is 36%. When we look at the cancer registry data, only 17% of patients are Hispanics, so, you know, obviously if you are going to compare your recruitment rate to the population data you're always going to be off. You need to compare with the population of people who do get cancer. So I can share with you some more M. D. Anderson data later if you are interested, but that's all I'll say about that. You also need to know about really this is the key piece to recruiting people from different cultures and ethnicities and different languages as you really need to know the community infrastructure. Who is providing services in the community, where do people go to get information, really these will be your key informants population. You need to know your own system barriers. There is quite a lot of that and I'm finding it out, I mean at M. D. Anderson I think we're doing a really phenomenal job with recruiting minorities and women to clinical trials, but we always have lots of opportunities to be improve and you know you might want to look at your staffing barriers. If you are interested in recruiting Spanish speaking audience, but you don't have anyone on the staff who can speak Spanish that could be a significant barrier. One of the examples I always like to give is when I was working with a community based organization and they were trying to, they had received some funding and they were offering driver's education classes to the new immigrants then they had a receptionist and they really just promoted it, they put lots of flyers, they went on the news, they went on the radio, and they were really only getting Chinese speakers to these classes and they didn't know why because they had, you know, people ready to teach the classes in Vietnamese, Chinese, Spanish, etc. What we found out when we looked into the situation a little bit further was the person who answered the phone, the receptionist who answered the phone for people to call in is Chinese American and she speaks Chinese so when people called and they realized that there was someone that could speak their language they were more likely to participate and sign up for the class and the other people just thought well this program really isn't for me. So, then when of course, then when we got a Vietnamese speaking receptionist, then the makeup of the class changed to be all Vietnamese speakers. So, think about your all the system barriers and sometimes you know that is, that requires a hard look. Oops, did I miss hit something?
How do I go backwards? Okay, got it. Okay, so patient barriers. There is a lot of those as well and I cannot go too much into that, but of course, one of them is communication barriers. So the presentation format is I will really talk a little bit about stereotyping versus generalization, what are the influencers of a community swirled view. I will give you a little bit of background in Asian Americans and the cultural and health beliefs and then we'll discuss some communication tips and ideas. And the general concepts of course the generalizations versus stereotypes, I really want you to keep uppermost in your mind as you are listening to my tips and suggestions and all of the information I'm going to tell you about the community is really generalization, I mean you should take the information I share with you as a basis for understanding the patients, to help you when you are faced with those kinds of situation where the patients' behaviors and actions don't make sense. Then it will help you to figure out why isn't it making sense because it is making sense in their world perspective. It should not be used to predict behavior, so that's very important to remember and one example of course is how if I tell you that Asians are maybe perhaps more stoic, they are less likely to express pain, and Hispanics are more likely to be expressive and express pain, I mean this is a generalization and you know there has been examples where perhaps someone might be more reluctant to give a Hispanic patient pain medication because they might feel that oh, you know, this community is very expressive and they really don't need that much pain so I'm not going to give them the pain medication, so you really do want to be very, very careful in how you apply the concepts that I'm about to share.

Okay. It won't go forward. You know, I've seen this happen to other people and I've always thought they were just technologically challenged, but I... Oh, that that would help. Actually, no it's probably where the PowerPoint set up. Let me restore the settings.

Okay. Thanks. I have included a couple of these icons. I thought they were very nice. This is by a Chinese artist who was born in China and raised in Germany and she did a series of these icons and the blue of course is the westerner's perception and the red is the Asian person's perception and that's how the two groups view each other. And she lives in Germany so that's not a hot dog, I think that's a wiener or whatever they call it and of course beer. One of the things I try to get people to think about is of course this was influenced when I watched the Titanic, but there are culture iceberg because what you see about a community on the top, you see the art, you see the traditions, you see the celebration, and in Houston in about five days, you will see all of the exciting dance, music, food, and dress for the Lunar New Year and so, you know, this is what informs your opinions and understanding of the community. What you don't see what lies underneath the water, the family roles, the values, and those behaviors even though the time perceptions that actually if you don't understand that, that really could sink your ship and of course the health beliefs and how they learn and the kind of expectations that they would have of you as physicians and nurses and researchers. So, I really wanted to bring in all of these components of world views because my Asian cultural background is not the only influencer of my attitudes and my beliefs and my behaviors, I'm also a woman and I'm college educated that changes my perspective significantly. I belong to a certain socioeconomic group, I am, the fact that you know my religious orientation, my sexual orientation, they all inform my beliefs and behaviors. I worked with the deaf community, for example, and the deaf being deaf has its own cultural implications being handicapped or physically disabled or mentally disabled brings with it a separate cultural perspective that I think unless you are in that culture, it sometimes you don't, you don't see the little things that could trip you up. So to be very, very thorough in your cultural assessment when you are with your patients and with the community as you are talking to them. Think about the level of the person's ethnic identity, are they assimilated, are they bicultural, are they marginal or are they traditional? I worked with, as a consultant for the Houston Police Department and at that time they had a large gang problem with the Cambodian community and they wanted to really recruit, they wanted to recruit a Cambodian person to the police force. They weren't able to get one, so they were able to get a cadet that was Cambodian Chinese and when I met with him and I did the training to the police cadets which I used to do and he, you know, I, I really felt from talking to him that he was very, very assimilated. He had been brought up in the US. He had been born here and he really didn't understand the Asian mindset and from the questions that he asked and from the presentation that I gave about Asian culture, you know, he really just disagreed with everything I said and he said, 'That's not how Asians think anymore.' I mean that, that's not true and I, you know, it really, I was concerned about it and a couple of years later, I was able to talk to the police sergeant and they said he pretty much, they've taken him off working with the Cambodian community because no one in the community will talk to him because he was so offensive in his behaviors and his attitudes that you know he felt everyone, he understood the community because of course I am you know Cambodian Chinese, but he really didn't understand the community. He had a very specific mindset about what it was that was Asian.

What is marginal?

Oh, marginal are, and I'll give you an example. Marginal are let's say most likely to be a refugee population. Many of them have come over, they have lost their homeland so they don't feel like they belong there anymore. They come here, they don't fit in so they actually don't feel connection to their original culture, but they don't feel a connection to the new culture and those people actually would be at most risk for psychological problems and would probably be your most difficult patients because there is, it's very difficult to approach them from a cultural perspective as you know to, to be able to present information in a culturally relevant way. Thanks for asking. So you know, gosh, you know, I don't think this is true as much any more, but for a long time I think many people think of the Asian community as the model minority and if you, if you look at the community as a whole, this is data for the Houston area, certainly it looks like a model community because you know as a whole and aggregate 59% of them have college degrees, you know that the divorce rates are lower and gosh darn it, their kids are always the valedictorian of the class and they are so well behaved, but when you break them down by the different Asian groups then you find out that at least in Houston the Vietnamese are much more significantly to have not graduated from high school, really it's the Filipinos that are the most likely to have college degrees, and that the South East Asians are least likely to have insurance and can it, does anyone have any guesses about why Filipinos would be the most likely to have college degree. I think it for the Houston area it's about 76% of Filipinos have college degrees. Filipinos 18 and older...

[Inaudible]

No they come here with the degrees.

[Inaudible]

Well actually we do. What happened was back in the 80's we had a severe nursing shortage in Houston and where were they getting the nurses. They were getting from the Philippines where the, the system over there was very similar to here, so they were bringing in a lot of Filipino nurses, so that's why and actually now I think they are bringing in the African nurses like the Somalis and the Nigerian nurses. Okay, any other thoughts about why maybe South East Asians or may be just Asians might be higher uninsured rates? Larger proportions of Asians are small business owners, or they might work for small businesses, so they are less likely to have insurance and of course if you're trying to recruit people to clinical trials not having insurance is going to be a significant barrier, so you might want to build that into the protocol or have some resources to help them or if you are thinking that you know the trials for sometimes researchers build in a lot of procedures in the trial that might not be covered by Medicaid or Medicare then you know the person really couldn't be able to afford that and this is for any population. Think about what will be covered by insurance. I'm going to skip that. Again you know I won't go over all the, the reasons why physician-patient communications are so important, but this is, when I show this icon to any of my Asian friends, they are all laughing because it's so true, it's how, you know how the western trained person would state an opinion and how an easterner would share his or her opinion, so if you are working with that, this community you know I really encourage you to have a lot of patience and to wait and to ask questions but wait for the information to come up because it's not going to be a direct answer, even when it's a question it's not going to be a direct question. It will be very, very roundabout and it's really frustrating sometimes, but it's, it will be worth it. And another thing that I think would be helpful for physicians to know is, you know, the, the whole concept of you really have to have a relationship with your physician before you can really share any personal information. For example, if you are a young woman and you go visit your gynecologist and you know as a physician you would want the patient your patient to be aware of Paps screenings and, you know, other cancer prevention practices, but if were to ask the young woman who you know is unmarried, have you ever had a Pap screen, and if she knows what it is, she actually might be offended because many Asians feel that you would only need to be screened to get a Pap smear if you are sexually active and if she is a single young woman and you ask that then you are making the assumption that she is sexually active. You know, so, so to bring something up you know sometimes you might even think about how you might bring that up. You might want to talk about Paps and you might want to talk about the recommendation, you know the recommendations, the guidelines, and what, what the NCI recommends or whatever or what you know as a physician recommends or your institution recommends and so. And I wanted to just put up a list of contrasting cultural values and really the Chinese and the Vietnamese cultures are significantly shaped by the teachings of Confucius and Lao Zi and Confucius really taught that a society organized under a benevolent and moral code would be prosperous and politically stable and that rigorous adherence to these codes would yield social harmony and as an antidote for violence and war. So the five cardinal relationships that Confucius offered to the people. He said that the relationships between the ruler and the ruled and between the husband and the wife, between parents and children, between older and younger siblings, and between friend and friend, and with the exception that the relationship between friend and friend all of those other relationships are hierarchical, so in the Asian culture, relationships are very much hierarchical. As a care provider, you are above and as the patient they are below, of course what this means is if you are giving the patient many options and you are leaving it up to the patient, the patient might say well aren't you the doctor, why don't you know this and you know that again, that could undermine their confidence in you. I have actually, I have heard that this is also a geographic trait that southerners are more likely to have that expectations of physicians and that northerners actually are more wanting more to be empowered and to make their own decisions. And Lao Zi who was the founder of Taoism had some fundamental notions about how the universe was constructed as well. He said that it was this the Yin which is feminine, the feminine, the dark, the passive force and then there is the Yang which is the masculine and the light and the active force, so you all can tell that Lao Zi was a man. So his belief was that, that the forces both oppose and compliment each other and you can never just have one force, you have got to be balanced, you've got to have both force, you cannot separate them. And the key to life was defined the Tao and the Tao is the way between the Yin and the Yang and the middle ground is the compromise. So both of these philosophers actually much less concerned about the truth, but very much concerned about finding the way and I think the contrast with that I think in a medical field is many clinicians feel I think especially western trained clinicians and we are so grounded in the training that we feel that ours is the only right way and sometimes that will be a significant barrier in even opening us up to hearing what the other person is saying, so you always think about that and you know for the health care discussion is always a series of negotiations that both sides can have valid positions and there is a balance between both. And here is a couple of more icons that was cute. The punctuality perceptions and social contacts. Actually I was telling Mike early, I am sure Mike must be part Asian.

[Laughter]

I'm actually very punctual so I'm not a very stereotypical Asian, but you know the implication for the clinician is if you are running a trial and you need them in the lab at you know a certain time five times a day exactly so that you can get the labs, you know, get do the blood work, well you really have to stress that you've really got to talk about the importance of being there on time and you know say it in a very nice way and explain why that's very important because that's going to be critical to them coming. I wanted to give an example, when I was visiting a Native American Health Clinic in Oklahoma they, it's a beautiful clinic, it was funded by the Indian Health Services. They had you know a wellness center, they had a pool, exercise machines, what they had they had doctors, nurses, social workers, what they didn't have was Native Americans, I mean when I came there, there was like maybe two people and when we were talking to the leadership team, the physician was a young physician just you know not long out of residency and he was very much the, you know, very much caring about the community's health. He knew there was a lot of health disparities, he knew about the blood pressure, the diabetes, he knew all of those clinical stuff, but he was very insistent that everyone make the appointment, everyone show up on time and if you are late, you don't get to see the doctor, you know, and so really the, the visits tapered off significantly and that was very interesting because he didn't see that his whole approach to medical care didn't fit in with the community's perception of time and perhaps you need to be a little bit more flexible. I think people were coming in pretty late too, but you know that's certainly something that you can work with the community and increase their cultural competency as to how your system works, but in a less perhaps less forceful way. So here are some cultural values for the Asian Americans, and again, you know think of this as generalization and don't use it as a stereotype. Age and family the respect for that of course the hierarchy I've talked about before, younger people defer to older people, that goes for the sibling relationship as well and parents often obey to an extent which baffles many American children, so as you know a young person growing up, I think that many of my friends were just shocked at what you know when my parents said no you can't do this and they don't have to be around and I still don't do it, you know, it's very much it's ingrained in you and you just don't deviate from that and there is a respect for education and wisdom and this actually works in your favor as you know if you are clinicians people do want to hear your opinion, people will do what they ask you to do so if you are asking, you are explaining why a mammogram is important, you are explaining why a colonoscopy is important and you say that you know you need to do it so at this time you know they will do it. So I mean and the studies bear that out that when the physician makes those recommendations, they will be more likely to be adhered to.

[Inaudible]

The icons?

Yeah the icons.

Oh the anger is, you know, that I think, we will get to that in a minute. Two seconds. Propriety, the focus on propriety is that you've got to have self-control and you've got to have self-control in all aspects of your life, so public displays of emotions or public displays of affections particularly, no holding hands in public are frowned upon so a sign of maturity is the ability to control your own reactions because really it's only a child that cannot control his or her reactions and I you know so again this is the anger part where if even if you are angry you are smiling and people don't display a lot of emotions so people might smile when they are embarrassed. If you are talking about a topic that they are that people don't usually talk about, if you are touching upon you know the, the discussion touches upon any area for the woman between the neck and the knee that's a very private area and if you are a man physician you know that's actually even more embarrassing, so they smile but internally they've shut you off already, you know they are very embarrassed. So people smile when they are embarrassed, they might smile when they are very angry, even you won't know it because you don't display your emotions, only a child displays emotions and I you know I was telling Mike earlier that I used to do a lot of community work and focus groups and facilitations and I saw that you know when I worked with the African-American community, in particular focus groups, I loved it because the community was very sharing, they are very much wanting to share the information with me and I as you know someone who wanting to get the information it was very helpful, but when I worked with a Asian community, we were actually talking about community concerns. People don't really share because you know this will bring us to the next part of respect for propriety and harmony. You don't want to lose faith. If the community is concerned about gangs and what I do is in the focus group is I stay behind after the focus group, you know, I take a little bit extra time to clean up and somebody will come up to me and say oh you know my, my son is in a gang and I am not sure what to do and so then we start talking about it and we start talking about resources that can help because they are not going to bring that up in a large setting because that is you know shameful and it makes not just the parent lose face, but the entire family loses face, you know this whole, the concept is same for someone with a mental disorder that is very much a face losing proposition there and so you don't want to talk about it because actually it might affect the marriageability of the single people in the households, the same for cancer. People sometimes have a belief that cancer is all genetic and so that that family must have bad blood, so we don't want to talk about it because you know gosh my sister is unmarried and I don't want to hurt her chances of getting married, no one wants to marry into a family with bad blood. So you know some of these will you know requires a lot of information sharing and trust before the family will be able to discuss it openly, you know, perhaps with others and with you. So of course the concept of me it's always the group well being and not the individual well being. I was watching a Discovery Channel Program about baseball last week and it was comparing the difference between baseball in the US and baseball in Japan and it said they were saying in the US you know actually the whole issue with steroids has been in the news and that actually is not an issue in Japan and they were, their theory is that in the US to be the hero you've got to be the one that hits the ball the hardest, you have got to be the one that hits it out of the ball park, the furthest, the hardest hitter and those are the ones that get the attention, but in Japan the hero in baseball is the one that makes a sacrifice for the team so the ones that, that makes those sacrificial plays that enables his team to win, so you know, very different and they actually showed some you know Japanese baseball players versus American baseball players and of course you know there is big Japanese too, but these players are much smaller, so it's not really that big, it's a very different perspective on group versus individual. Again, the concept of face is when you're talking to a patient and you are explaining about a clinical trial if the patient says may be it's probably a no. You can certainly you know share more information if you think that will be meaningful and helpful, but sometimes you shouldn't take a no as a no at first time, sometimes you need to present the information several times, but a maybe is a no simply because they don't want to embarrass you, they don't because you know if they say no directly is an insult because you have just turned someone down, you have just embarrassed them, so you want to make it as soft as possible and so even in the Asian language, the language is not very direct and it's very evasive, because it allows people many face saving opportunities. See and this stoicism you know of course you don't express pain as much and you don't want to complain, you want to keep everything as harmonious as possible. I think one way that I can imagine this is if you look at the example of Vietnam. It's a country that is smaller in size, smaller than California, but it has got 85 million people, China is a country with about a billion people, you know a fourth of the world's population, so when you, you know, then everybody lives together you have got extended families living within a home, you have the great grandparents, the grandparents, the parents, the children, the grandchildren and in crowded conditions like that, you've got to have a lot of very you know you have to have your own, you don't have the physical space, but you have to have that emotional space to be able to allow people to navigate those relationships without hurting feelings and the issue of karma that's very important to many Asians are Buddhist and with Buddhism one of the beliefs in Buddhism is to believe in karma that it's actually a very, very tough religion because the philosophy is the philosophy of ultimate responsibility, you ultimately are responsible for everything that happens to you and they you know, sometimes they, they say that whatever you do in this life, you are sowing the karmic seeds and those karmic seeds might flower in this life or they might flower in the next life, you just don't know when they are going to flower, but when they flower you deserved it, so I mean you know that's a very simplistic explanation of Buddhism, but so again you know sometimes that affects of course when someone gets cancer, you know they think is it something that our family did, is that something that I did perhaps, perhaps. Perhaps we've angered the ancestors or we have done something bad, so you know may be we deserved it, may be we don't, we shouldn't fight, maybe you need to just accept your fate and turn down the chemotherapy and you know as from the clinical perspective you might think you know this is a completely curable cancer, why aren't, or this is a completely treatable condition, but they are very resistant and you know and so I think that this frustration on the other side and I think that of course influences the relationship between the physician and the patient and it certainly influences trust when they sense that you are frustrated. So some perspectives on health and healing. As I've mentioned before personal modesty is a cardinal virtue. For women the area from the waist to the knees is considered especially private. I remember my grandmother lived with us for a long time and I actually never saw her between the waist and the knee and I actually never saw her arms because she always had on long sleeves as well. She never said anything about me though, because I you know of course I wore shorts when I went to play tennis and she never said anything but I you know for those areas I, they were never exposed. Public displays of affection that's not you know you don't do that. You might see parents hugging their children and actually that's becoming much more common, so you know as a provider I would say be more formal rather than less formal and don't for some Asian cultures don't touch children on the head and we will talk about that a little bit. Sometimes there is a fear of technology. There is a fear that sophisticated western technology will always find diseases and the cure for whatever condition they have is going to kill them and I've heard many, many of these stories between my grandmother and her friends and you know usually it goes like this: You know so and so was just fine and her kids and sister thought she go get a checkup and guess what they found this and they made her go into the hospital to treat it and now she is dead. So the really you know the western technology is just too sophisticated it's going to find what you know in our own country they wouldn't be able to find and they are going to treat us with the western medicine and the medicine is going to be too strong and it's going to kill us. There is sometimes a lack of preventive care because they only treat symptoms when it is associated with a disease, they have symptoms and so there is no symptoms, there is no disease, so it's you know sometimes it's difficult to. In Vietnamese, there is a saying that don't search for ghosts and you will find them, so why should I go to search to see if there is something growing in my chest because I mean if I look for it I am going to find it. And we, excuse me, we actually saw that when we did a mammogram outreach to low income Asian women in southwest Houston. We found very high rates of abnormality because this was a never before screened group and one in one woman that when she, we found the there was a lump in her breast and we heard her talking to her friend and said, I didn't have the lump before I went through that room and after I came out I had the lump, so you know, it's these kinds of conversations that make people very leery of the western invasive techniques and of course there's a belief that sometimes that diseases can be induced naturally by bad air, bad blood, internal imbalance, there is too much heat, there is too much cold and you can intervene by putting your body back into balance. You could do it by cupping, by coining, by rubbing, so you take when you take something out of the body you're going to make that person more cold, when you put something into the body you it makes them more hot. So you know there is many beliefs about the Yin and the Yang concept and foods also have Yin and Yang meanings didn't attach to them. For example, green tea is considered cold food, so if you are a young person, the young person will be more hot, you could drink green tea, but don't drink too much because it's going to make you too cold and you know cancer is considered hot because you think about it, cancer is cells that are growing unchecked and you cannot kill them, it's pretty hot, so of course they think this is why green tea works on cancer, but very sweet foods like fruits, you know, water melon would be considered a hot food, meats would be considered hot, so if somebody has a cancer they might not want to eat too many hot foods. They might want to be trying to eat cold foods and then you are telling them to you've to got to stay with this diet, but the diet has, you know, protein and other things that might be considered hot. They might not be eating everything that you want them to so think about what you know what would fit in that you might want to give them a diet with more beans because that could you know it's a vegetable and it actually would be colder. And I remember many people, you know, that died in the past, there was a word for that they were just struck by a bad wind so you know diseases could be brought on by a bad wind and they use it to explain when people just keel over from a heart attack or for whatever reason and they just say it's a bad wind and that explains everything. For some cultures like the Cambodian, diseases can also be induced spiritually. You know that's why you have your healers to try to appease the spirits to help you, you know, to get on a more balanced relationship with the spirits and it could of course be karma consequences of actions in this life or past lives and it's not just your own personal karma, it's the karma of your entire community, it's the karma of your family, the people that you've chosen to align yourself with.

So somethings to assess for is low health literacy and you know this could be for any culture. It could be for even English monolingual English speaking community, I am not saying it's low literacy but low health literacy where the person doesn't really understand about a mammogram or doesn't understand about a Pap smear or you know a PSA exam so and you know if you look at all of the information that authors written at a very high level, so it's even harder to understand. So some, some clues that they that you might see that might indicate low health literacy is they brought along someone else to help them assimilate all the information, but you know they might be mimicking other patients how they are behaving, they might ask advise, you know my mother-in-law does that a lot she will ask everybody in the room, but you know what are you in here for and what you be, how are they treating you and then she will go and she will talk to the you know her physician and say, well so-and-so is you know has diabetes, but they are not doing what I am doing, you know what, why not, so you know it's a lot of not you know not having that complete faith in the physician, but I think actually that's probably due because all of her kids are physicians and she asks all of them the questions until she gets the answer she wants. You might see incomplete or incorrectly completed forms. You might see that when they get written materials that you hand out to them like how to care for yourself or how to care for the that the wound or whatever they might hand it off to another family member, you know, so when I sometimes when I work with patients I just might say, you know 'Can I help you fill out the form.' Sometimes they'll say I forgot my glasses and I can't, you know I can't read it or they might withdraw during an explanation because they really you know don't understand what you are saying and I think that so many clinicians are so used to clinical words that we don't even in our mind think of them as clinical words any more, but trust me to the lay person and in particular to a lay person who might not speak the language as a first language, those are very clinical words. When there is a lot of missed appointments including for specialty, or diagnostic tests, it might be because they don't understand the importance of it. They don't realize how you know how serious the condition that they have is. So you might want to assess that. When you see frequent errors in self-care or medication usage, actually that that used to happen a lot more, I saw that a lot more in the Asian community because the prevailing thought was that you know Americans are so much bigger than me and this medication is made for Americans so I am going to half it because that will be more appropriate for me because of course if I take these medication, you know, of course the western technology is what it is that it make it very, very strong and powerful so it's going to be too hot for me and I am smaller and I really should just take half of the pill and may be for half of the day. So you can learn to be culturally competent. And again, you know, it takes a little bit more time, it takes a little more time to work with the patient and sometimes I know that's a challenge because we don't have time. Communication style, it's more indirect, it's a more, so use a more formal approach. You might in a group setting you might want to talk to the oldest person first and just don't assume that when someone nods yes, and I know you all know this, that it means that they agree, it really is just a courtesy saying I hear you. There might be for working with Asian groups that unless assimilated there might be significantly less eye contact and because this is respect, you don't look at someone you respect in the eye, you look down. They might prefer a greater physical distance than the mainstream, they might, we talked about the minimalist gestures and I think one thing that's helped a lot when I've worked for the community when I, when I've trained other nurses and whatever when they're working with the community that they are not speaking the language, they're you're having to use an interpreter one thing that really helps to show your respect for that person is when you are handing something to them hold it in two hands, even if it is a business card, hold it in two hands and give it to them. If they are giving you something, take it with two hands and that is very respectful and I think that really helps to set the tone of the meeting or your consultation. I have seen that you know for even you know for many non-Asian practitioners when they don't speak the language and they are doing the best that they can, but when they know just a minimal signs, that behavior, that really helps a lot. The problem handling style and this is very frustrating to many westerners too is that sometimes you know you dance around the problems, but a lot of times you don't even solve the problem at all, you just ignore it and go on. Communications, best practices, of course, you don't want to ask yes/no questions, you want to ask open-ended questions, tell me about how you do this, show me how you would do this, avoid the negative questions. Sometimes people ask questions that I don't know how to answer it. Haven't you taken your pills today? Have I, I don't know what that means. You know how many pills have you taken today that's much easier to understand. You know you think about the directions when you tell them about how many pills to take, is it two pills a day or two pills twice a day, each time two pills, I mean make sure that they know exactly what you are saying. I remember this is with a Hispanic community where once a day is un se, you know, the un se is 11 times so that there is a, you know, difference there, so make sure they really understand what you are saying. Give them a little bit longer time to answer, don't help people when they... Avoid jargon and people really, I mean I think some, we don't I mean really pay attention to what is jargon because a lot of times we have no idea what, you know, we are saying that, I know when I started, I was talking to someone because I was raised in Texas, pretty much I grew up here and you know when you say I'm fixing to do something, I tell you these northerners don't know what that means, how can you be fixing to do something, are you going to do it or not, what do, why do you have to fix it? So and thus talking to you, you know English speakers. Working with interpreters, I know many of you know this, make sure that you are speaking directly to the patient, don't speak to the interpreters. Telephone communications, I know we do a lot of people have to call in to sign up for the clinical trial and it is very difficult sometimes, if no one's there and they have to navigate all of those push one, push two options. Be very, very explicit and the next stuff I can't emphasize that enough. Language barriers, you can see that, it is very self-explanatory. Be very cognizant of which particular group you are working with, if it is an undocumented group or refugees in particular, this bury a lot of fear about putting things on paper about documentation, so you know all the paper work that you have to do for clinical trials is very nerve racking because as you know refugees are many Asian refugees that escape from the Khmer Rouge or escape from the communists, having been gone through the re-education camp experience and it is very horrifying and so this is could be very stress inducing and you know they don't want any information documented, written down, and why do you need all that information, why you know for such details. Some more do's and don'ts you have them in your files, so I won't go too much, just for kids be careful about touching them on the head because I know many Cambodians believe that's where the spirit resides and if you touch them on the head they might, you know, lose the spirit, their soul, so you can touch them on the arm. And I guess you know that the establishing relationship with the physician, don't be surprised if you get an older Asian patient and they start asking you about your family life, I mean you know they always ask you whether you are married because if you are not, they will know someone who is single to introduce to you, and they'll ask you, you know, a lot of very personal questions, but that's their way to get that relationship going with you so that they feel that they know you and that you know who they are as well and this is an example of what happens when communications go awry. This is a person who is of course a southerner who moved up north and she asked her friend that she has a long haired cat and she wanted to get her cat a line cut, and a line cut is a cut where you know you, you cut along the lines of the body to keep the cat more comfortable in hot weather and her friend said, 'Well of course they can do any kind of cuts here' and so she goes to the pet shop and she asks for the line cut and this is what she got.

[Laughter]

That cat looks very mad, and you know it's very important don't put so much pressure on yourself to be correct. You are who you are, you know your personal enthusiasm, your dedication, and your commitment to your patients, this is you, but you know be cognizant of these issues if your patients are doing something you don't understand, ask, and I think that people are very, very tolerant and they are very accepting knowing that we, you know, it's a different culture, so just ask, don't you know don't ask so bluntly and directly, but you can ask and use a culture broker that's someone who is familiar with both cultures. And the last word is you know, we know the golden rule, was to treat others as we would like to be treated, but the new golden rule really should be treat others as they would like to be treated. That's it. Thank you.