Can You Hear Me Now? Part III

For me, the question “Can you hear me now?” has been ubiquitous, both as it relates to the ever-elusive quest to be an effective listener and as it relates to d/Deaf and Hard-of-Hearing (D/HH) professionals in the medical laboratory. Interestingly, my research for both of those discussions disclosed a recurrent theme of culture—work culture, American culture, Deaf culture, culture of listening, diversity in culture—the list goes on. I’d like to, again, ask the question in a setting of language barriers, misinterpretations, cultural variations, attitudes, and stereotypes—how can we really hear each other through the “cultural cobwebs” in the medical laboratory?

Diversity in the workplace has been proven to foster stronger problem-solving skills as well as promote innovation and adaptability.¹ The United States and, by default, US laboratories continue to become more diverse. According to the United States 2010 Census, within the prior decade, the number of people reporting their race and ethnicity as something other than non-Hispanic white has grown by 25 million, with the largest increase in Hispanic and Asian populations.² In addition to race and ethnicity, variations in religion, age, social groups, and sexual orientation show that we are becoming a melting pot in every way imaginable. How to appropriately interact with each other in light of these differences and effectively increase the cohesion and strength of our laboratory team can be a challenge. While I may not be able to provide solutions to these challenges, the first step is recognizing these differences through the lens of cultural diversity in the medical laboratory team.

This discussion is even more fitting at a time when the commitment of the American Society for Clinical Pathology's (ASCP's) Center for Global Health has recently included soliciting volunteers from our membership to further support the Partners for Cancer Diagnosis and Treatment in Africa, as well as further developing its dynamic leadership team. Also, with growing numbers of ASCPi international certified members as well as international membership options, ASCP is quickly becoming a progressive international melting pot for medical laboratory professionals.

So, what is culture, how does it affect the medical laboratory, and how would one achieve cultural competence? Culture is defined as “patterns of human behavior that are part of a racial, ethnic, religious or social group . . . with social groups [defined by] age, generation, ableness, body image, and mental illness.”³ According to the National Institutes of Health, cultural respect is “critical to reducing health disparities and improving access to high-quality health care that is respectful of and responsive to the needs of diverse patients.”4 While all medical laboratory professionals may not be visible on the front lines of health care, we are not immune to the effects of cultural diversity. Examples of this include interactions between phlebotomists and patients on the floor, blood bank technologists and nurses, pathologists and surgeons, pathologists' assistants and residents, flow cytometry technologists and lab managers, or laboratory volunteers traveling to foreign countries on behalf of ASCP. To that end, a litany of published literature has been dedicated to cultural respect and competence in nursing,⁵ medical education,⁶ and even animal science laboratories¹—but not in the medical laboratory.

In the setting of direct patient care, according to a recent 2016 systematic review of cultural competence in health care, a lack of cultural competence leads to a lack of patient satisfaction and trust.⁷ In fact, I interviewed Angela West, a multicultural specialist at Virginia Commonwealth University (VCU) who works with the Partnership for People with Disabilities and is currently developing a grant that investigates this very issue. She draws experience as both an Asian American woman with cerebral palsy and as a professional who for many years worked as a cultural broker. Her grant is focused on bridging the cultural competence gap between healthcare professionals and minority/disabled patient populations to promote a positive and effective patient experience. While cultural competence, she explains, is “knowing the facts” about the nuances of culture within health care, she suggests that cultural humility is taking competence one step further and applying a more progressive approach by admitting our lack of knowledge and then communicating our willingness to learn.⁸ As an aside, I did encourage Ms. West to consider the medical laboratory as a part of her research. So, to those of you VCU medical laboratory professional readers out there: thank you for your patience and potential contribution to her research. My hypothesis is this: If patients feel a sense of distrust and lack of satisfaction, medical laboratory professionals likely experience the same disconnect.

I’d like to try an experiment. Close your mind’s eye, and define culture and what it means to you. Did the concept of “American culture” come to mind? Does America have a culture? In fact, it does. Americans are known to be self-reliant and independent; they strongly believe in equal rights, emphasize and encourage personal choice, believe in promoting the achievements of the individual, have a linear sense of time (in general), and utilize a direct communication style.⁹ Can you relate to any (or all) of those attributes? Many other cultures do not share these qualities, making team dynamics a challenge. These differences can affect communication and body language, and create stereotypes, prejudices, misunderstandings—all of which can negatively impact our potentially dynamic team.

Medical laboratories within large academic institutions may experience some of the most heterogeneous cultures. I spoke with a colleague who actively works with residents and medical laboratory professionals in both anatomic and clinical pathology whose countries of origin include Syria, Jordan, China, Pakistan, Mexico, Germany, Africa, and Vietnam; the staff also includes someone who is hard-of-hearing and another who identifies as being LGBT. This incredible pool of individuals may not align or even be able to relate to the American cultural characteristics I previously listed. As such, when working within a diverse workforce, lack of cultural competence can cause a dynamic that works against us, not for us. In the setting of work shortages and budget cuts, lack of cultural competence is that last thing we need to add to our list of frustrations.

Additionally, I reached out to ASCP's very own chief medical officer, Dan Milner, MD, MSc(Epi), FASTMH, FASCP, who currently oversees ASCP’s programs and policies related to global healthcare initiatives. I was seeking jewels of knowledge from a man with a deep passion and energy for serving international countries, who is boundlessly committed to laboratory diagnostics across the globe. Training on the very specific nuances of each country's culture can be nearly impossible. However, he and ASCP have constructed a diverse team whose members are culturally competent in each of their respective countries. ASCP volunteers are matched with and prepped by highly skilled and competent individuals, making volunteer efforts as seamless as possible in this regard. The advice that he did offer related to communication. As I mentioned previously, Americans are forward and have no reservation when we have questions, for example, when performing new coagulation equipment training or learning at the grossing bench. This can be quite the opposite in many foreign countries. He suggested that a “less didactic and more interactive” method of instruction would be most appropriate when working with international trainees.¹⁰ This can apply both in and outside of the United States.

I also discussed additional considerations with Rex Famitangco, MS, MLS(ASCP)^CM QLC^CM, previous chair of the ASCP Council for Laboratory Professionals. Rex was born and raised in the Philippines, and has worked in Saudi Arabia and now here in the United States. He discussed the difference in workplace culture in the (generally) more formal countries accredited by ISO 15189 under the President’s Emergency Plan For AIDS Relief (PEPFAR) program. He shared experiences being a Filipino working in Saudi Arabia and the considerations for faith and prayer time that took precedence in the day, and discussed pay/accommodation inequality on the basis of nationality.¹¹ For someone living or working internationally and coming to the US for employment, or vice versa, a number of considerations need to be made—all related to culture.

Overall, our medical laboratory and ASCP membership is extremely diverse. With ASCP we are stronger together; however, I feel we can still grow stronger yet. To achieve that, we need to become well versed in our own culture, and furthermore achieve cultural competence (or the more progressive cultural humility) within our medical laboratory team. We need the tools that can teach us how to remove cultural barriers, avoid misinterpretations, avoid stereotypes, or even employ an interactive vs didactic approach to communication.

In conclusion, you may be wondering why I asked if we can hear each other through the “cultural cobwebs,” and achieve this mysterious cultural competence, yet didn’t provide any tangible examples of how. Well, frankly, that wasn’t my goal. My goal is to call ASCP to action to develop culturally competent guidelines that will help our phlebotomists, international volunteers, international students, and every other medical laboratory professional become culturally competent. Diversity is proven to be the key to success in the workplace, and we need the tools to make that diversity work for us, and not against us.

References

1. Alworth L, Ardayfio KL, Blickman A, et al. Diversity in laboratory animal science: issues and initiatives. J Am Assoc Lab Anim Sci. 2010;49(2):138-146. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845999/ .Accessed January 2, 2015.
2. 2010 Census Shows America’s Diversity. Release CB11-CN.125. United States Census Bureau. http://www.census.gov/newsroom/releases/archives/2010_census/cb11-cn125.html. Published March 24, 2011. Accessed January 3, 2018.
3. Kodjo C. Cultural competence in clinical communication. Pediatr Rev. 2009;30(2). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719963/. Accessed January 5, 2018.
4. Cultural Respect. National Institutes of Health. http://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect. Updated February 15, 2017. Accessed January 3, 2018.
5. Cai D-Y. A concept analysis of cultural competence. Int J Nurs Sci. 2016. https://www.sciencedirect.com/science/article/pii/S2352013216300795. Accessed January 2, 2018.
6. Cultural Competence Education for Medical Students. American Association of Medical Colleges. Published 2005. http://www.aamc.org/download/54338/data/. Accessed January 5, 2018.
7. Alizadeh S, Chavan M. Cultural competence dimensions and outcomes: a systematic review of the literature. Health Soc Care Community. 2015;24(6). http://onlinelibrary.wiley.com/doi/10.1111/hsc.12293/epdf. Accessed January 3, 2018.
8. West A. Interview (via telephone with English interpreter present). January 2018.
9. Mindess A. Reading Between the Signs: Intercultural Communication for Sign Language Interpreters. 3rd ed. Nicholas Brealey; 2014.
10. Milner D. Interview. January 8, 2018.
11. Famitangco RF. Interview. January 12, 2018.