Interprofessional Communication-A Call for More Education to Ensure Cultural Competency in the Context of Traditional, Complementary, and Integrative Medicine.

Culturally appropriate communication between healthcare professionals and with patients is widely recognised as a cornerstone of high quality, patient-centred care. The widespread use of traditional, complementary, and integrative medicine (TCIM) necessitates that patient-centre communication and cultural competency in healthcare extends beyond race, ethnicity, and languages spoken to also include an awareness of, and respect for the diverse range of healthcare practices, paradigms, and lexicons that patients and practitioners use. Education can equip practitioners with the necessary communication skills and expand their knowledge about the therapies and practices that patients are accessing. In this viewpoint essay, we aim to 1) emphasise the importance of respectful, culturally competent interprofessional communication and collaboration that mutually supports patients' care needs; 2) note the impact of a political agenda that perpetuates medical hegemony and has discriminated against, and marginalised TCIM practitioners and the people who use these services; and 3) highlight the importance of educational initiatives that support inclusive, culturally competent, interprofessional communication and collaboration between conventional and TCIM healthcare practitioners.

A Culture of Health must embrace a wide variety of beliefs, customs, and values. Ultimately it will be as diverse and multifaceted as the population it serves.

Introduction

Culturally appropriate communication between healthcare professionals and with patients is widely recognised as a cornerstone of high quality, patient-centred care. Conversely, communication breakdowns are a leading cause of avoidable patient harm and adverse events, with resultant medicolegal implications.[2,3] Effective interprofessional communication and collaboration are interactive processes characterised by the respectful sharing of accurate, clinically meaningful, and timely information using commonly understood terminology and lexicon. Proactive inclusion of patients and caregivers in this process is referred to as “patient-centred communication.”

Central to patient-centred communication is cultural competency. In the context of health-care, cultural competency “includes an awareness of, and respect for the diverse range of health care practices, paradigms, and terminologies that patients and practitioners use.” In cross-cultural situations, cultural competency lays a foundation for effective collaboration between healthcare practitioners and their patients. Cultural competency, enables healthcare systems to deliver services that meet the social, cultural, and linguistic needs of patients and practitioners alike. Whilst a core focus of delivering culturally appropriate healthcare is to address ethnic and racial disparities, the widespread use of traditional, complementary, and integrative medicine (TCIM) necessitates that cultural competency also includes the ability to recognise other personal and professional cultural biases that may inadvertently marginalise patients who want to use TCIM. Education can provide practitioners with the necessary communication skills and a clearer understanding of the indications, rationale, treatment approaches, and anticipated outcomes of the different therapies and practices that patients are accessing.[5,6]

In this viewpoint essay, we aim to 1) emphasise the importance of respectful, culturally competent interprofessional communication and collaboration that mutually supports patients’ care needs; 2) note the impact of a political agenda that perpetuates medical hegemony and has discriminated against, and marginalised TCIM practitioners and the people who use these services; and 3) highlight the importance of educational initiatives that support inclusive, culturally competent, interprofessional communication and collaboration between the diverse range of healthcare practitioners that patients choose to consult.

Patient-Centred Interprofessional Collaboration and Communication

Collaboration and communication between all health care practitioners (HCPs) play an important role in the provision of safe, appropriate, patient-centered health care. Healthcare is evolving from a physician dominated, unidirectional model, into a more collaborative partnership oriented around multidisciplinary teams and patient preferences, needs and values. In this model of patient-centred care, there is an emphasis on information sharing, transparent communication, care coordination, and empowering patients as an active participant in the decision-making process.

Coupled with an abundance of online information, empowered patients, particularly those with chronic and complex conditions, seek out TCIM therapies and practitioners. Many of these services are provided independent of the conventional healthcare system and may be self-prescribed or accessed via self-referrals. Providing healthcare environments and communication pathways that enable patients to be transparent about the practitioners they consult and the self-care therapies they use is therefore important. Equally as important, is to ensure that all the practitioners involved in a person’s care have the opportunity to engage in and have meaningful, cohesive, patient-centred communication,[2,3] and use commonly understood terminology that reflects a value for cultural diversity and inclusiveness.

Failures in interprofessional communication pose risk management concerns and can increase patient burden. For example, pharmaceuticals and natural products might be commenced or ceased without adequate consideration of the clinical impact or patient’s preferences. Other information, such as laboratory and imaging results may not be readily available or understood, and therefore ignored or misinterpreted. Along with delays that can adversely impact clinical decisions, communication failures can lead to investigations being unnecessarily repeated with extra costs to the patient and/or insurer. Conflicting advice and management plans are also more likely, and this may compromise the patient-provider relationship and the patient experience. This adds to the burden many patients experience in attempting to accurately communicate their health information and explain their management choices.

Professional Cultural Divides

Patient-centred communication requires mutual recognition among all players, that they form a connected healthcare team in partnership with the patient. Known communication barriers between medical doctors and other conventional healthcare professions include a lack of trust, respect, shared values, common language, and clarity of roles. These barriers are reinforced by the current hierarchical health system with its associated training, regulation, and funding of the different professions. The prevailing medical hegemony and its associated professional boundary work further amplifies these barriers, with TCIM practitioners often being excluded from the standard interprofessional communication cycles.

Communication blocks between the conventional and TCIM professions have strong historical roots. Since the turn of the 20th century, the medical profession began systematically marginalising TCIM practices, framing them as illegitimate, unscientific, alternative medicine cults where quacks and charlatans deceive gullible, vulnerable patients.[9,10] The effects of these delegitimising campaigns and policies have been long lasting and widespread. Even in established clinics that integrate TCIM and conventional medicine, biomedical dominance has been identified as a barrier to interprofessional communication and collaboration within the clinic.[5,12] Medicolegal and licencing uncertainties also remain, especially for medical practitioners who practice or are interested in integrative medicine.

Every organized group maintains a proprietary culture, within which, there is a tendency for “blindness to a domain of one’s own culture, where its power and prestige make it invisible to member participant observers.” It should therefore come as no surprise that inter-professional hierarchies and competition between the various TICM professions may also be in play. Indeed, lumping all these professions into one group is misleading. Not only are there substantial different in practices, lexicons, and paradigms, but also education, training, regulation, and funding. This heterogeneity adds further complexities to ensuring high quality TCIM services, and appropriate interprofessional collaboration and communication.

Education is the most powerful weapon you can use to change the world. (Nelson Mandela 1918–2013)

Communication Training and Education

We have argued there are clear political and cultural influences that have historically prevented effective interprofessional communication and therefore inhibited patient-centred care that is equitable, inclusive, and safe. In addition, the basic differences in how practitioners are trained, their roles and scope of practice, their ‘medical’ terminologies, and professional cultures are reflected in the way different practitioners think and communicate. Education can play a vital role in overcoming political and cultural barriers and filling current gaps in the training of healthcare professionals. This will require a multi-pronged approach that aims to bridge communication gaps with, and between TCIM practitioners to foster effective interprofessional collaboration and patient-centred communication.

Multiple studies have evaluated and recommend interprofessional training programs that employ standardized tools and simulation exercises to improve interprofessional communication skills, professional cultural competency, and practitioners’ and patients’ experiences.[5,6] For the most part, however, these educational programs and initiatives focus on training conventional healthcare practitioners.

TCIM practitioners are also calling for more support and training in interprofessional communication. In response, the Australasian Integrative Medicine Association (AIMA) established a working group who developed the ‘Interprofessional Communication AIMA Guiding Principles for Letter Writing.’[4,14] The aim was to develop a written resource to support communication between the diverse range of healthcare practitioners that are often involved in a person’s care. The resource includes background information about TCIM and medicolegal considerations within the context of the Australian healthcare system, the principles of interprofessional collaboration and patient-centre communication, and instructions for how to write formal letters of correspondence along with a set of five letter writing templates to assist practitioners with introductions, red-flags, referrals and replies and thanking their colleagues for collaborating. The templates draw on the widely used ISBAR framework (Identify, Situation, Background, Assessment and Recommendation) that is designed to facilitate a meaningful and focused communication between healthcare practitioners and bridge professional cultural divides. The AIMA guidelines have also been used to inform the development a continuing professional education training module on interprofessional communication. This education module is currently under peer review and will soon be available to practitioners in Australia and potentially more widely.

In the US, whilst there is an understanding of the need for such educational programs, at a national level there is no cohesive, centralized interprofessional communication training program or curriculum. For instance, the Academic Collaborative for Integrative Health lists Interprofessional Communication as a core competency skill. However, it is our understanding that a formalised program is yet to be developed. Instead, educational institutions and professional bodies must develop their own programs. The risk is however, that ad-hoc curriculum development increases the likelihood that the content and delivery reinforce, rather than breakdown existing cultural biases and professional divides.

Along with improving communication skills and know-how, interprofessional education must also ensure practitioners have sufficient knowledge and awareness about the different types of therapies patients are using and other practitioners are implementing. An understanding of both conventional medicine and TCIM therapies is required to provide meaningful content about potential indications, benefits and risks when communicating with patients and other practitioners. As such, along with initiatives like the Australian training module, we also recommend experiential learning programs that implement focused strategies and systems designed to help practitioners overcome their engrained, professional cultural biases and assist TCIM and conventional healthcare practitioners to work together in collaborative clinical settings.

Conclusion

Respectful, culturally competent interprofessional communication that mutually supports patients’ choice of multiple health services is critical to the delivery of safe and coordinated healthcare. We have drawn upon historic and recent literature to highlight how medical hegemony has intentionally or inadvertently thwarted efforts to broaden interprofessional communication to include TCIM practitioners and the people they care for. To address this, we posit education as the voice of reason. Further educational initiatives are required to support inclusive, culturally competent, interprofessional communication and collaboration between the diverse range of healthcare practitioners that patients choose to consult. Coordinated national and international collaboration that collates and reviews educational initiatives with a view to developing standards in interprofessional communication is an important next step. Such a collaboration would be aligned with, and supportive of the World Health Organization’s strategy in developing proactive policies and implementing action plans that strengthen the role of traditional, complementary, and integrative medicine in keeping populations healthy and safe.

The great aim of education is not knowledge but action. (Herbert Spencer 1830--1920).

Interprofessional cultural competencyextends beyond racial, ethnic and language to includean awareness of, and respect for the diverse range of health care practices, paradigms, and terminologies that patients and practitioners use. 4