EDUCATION AND TRAINING

JAGS 50:1582–1589, 2002© 2002 by the American Geriatrics Society 0002-8614/02/$15.00

The ETHNIC(S) Mnemonic: A Clinical Tool for Ethnogeriatric Education

Fred A. Kobylarz, MD, MPH, John M. Heath, MD, AGSF, and Robert C. Like, MD, MS

Geriatrics healthcare providers need to be aware of the ef-fect that culture has on establishing treatment priorities,influencing adherence, and addressing end-of-life care is-sues for older patients and their caregivers. The mnemonicETHNIC(S) (Explanation, Treatment, Healers, Negotiate,Intervention, Collaborate, Spirituality/Seniors) presentedin this article provides a framework that practitioners canuse in providing culturally appropriate geriatric care.ETHNIC(S) can serve as a clinically applicable tool foreliciting and negotiating cultural issues during healthcareencounters and as a new instructional strategy to be incor-porated into ethnogeriatric curricula for all healthcare dis-ciplines.

J Am Geriatr Soc 50:1582–1589, 2002.Key words: clinical tool; ethnogeriatric education; cultural

competency

H

ealthcare organizations, providers, and policy mak-ers are becoming increasingly interested in the deliv-

ery of more culturally responsive services to our nation’sdiverse population groups. Reasons cited by the George-town University National Center for Cultural Competenceinclude: “(1) responding to current and projected demo-graphic changes in the United States; (2) eliminating long-standing disparities in the health status of people of diverseracial, ethnic, and cultural backgrounds; (3) improving thequality of services and outcomes; (4) meeting legislative,regulatory, and accreditation mandates; (5) gaining a com-petitive edge in the marketplace; and (6) decreasing the like-lihood of liability/malpractice claims.”

1

It is projected that, by 2030, older people from popu-lations classified as racial and ethnic minorities (African

American, American Indian/Alaska Native, Asian/PacificIsland American, and Hispanic American) will constituteone-fourth of all older Americans.

2

Currently, minorityolder people constitute more than 16.1% of all olderAmericans (

�

65).

3

Between 1999 and 2030, the older mi-nority population is projected to increase by 217%, com-pared with 81% for the older white population. For exam-ple, the number of older African Americans will increaseby 128%, older American Indians/Alaskan Natives by193%, older Asian/Pacific Island Americans by 301%,and older Hispanic Americans by 322%.

3

These broad classifications encompass many differentcultures of origin, and diversity is often greater withinthan between groups in terms of health beliefs, attitudes,and perspectives on the delivery of health care. Healthprofessionals who care for older minority patients need torecognize this heterogeneity, avoid stereotyping and “cook-book” approaches, and employ therapeutic strategies thatresult in more culturally appropriate care.

The goals of Healthy People 2010 focus on the elimi-nation of health disparities while improving the overallhealth of the American people.

4

Many of the health-pro-motion and disease-prevention objectives apply directly tothe care of older people from diverse backgrounds. Olderpeople from different racial and ethnic minority groupscontinue to experience troubling health disparities in ac-cess to care, service utilization, quality, and health out-comes.

5,6

The literature reveals a consistent gap in deathsfrom heart disease, cancer, and stroke, the three leadingcauses of death in older people.

7

Healthcare policy makers and other advocates haveproposed cultural competency as a strategy for reducingracial and ethnic health disparities.

8

Healthcare providersneed to understand the effect of factors such as socioeco-nomic status, education, race/racism, ethnicity, culture,sex, disability, and sexual orientation on the health andfunctioning of the older population. The American Medi-cal Association (AMA) has defined cultural competency inclinical care as “the knowledge and interpersonal skillsthat allow providers to understand, appreciate, and workwith individuals from cultures other than their own. Cul-tural competence involves an awareness and acceptance ofcultural differences; self-awareness; knowledge of the pa-tient’s culture; and adaptation of skills.”

9

Healthcare providers in geriatrics become more cul-turally competent only with the support of the healthcare

From the Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey.

Dr. Kobylarz’s work has been supported by the Bureau of Health Profes-sions’ Geriatric Academic Career Award 5 K01 HP 00003. The opinions ex-pressed herein are those of the authors and do not necessarily reflect those of the funding agency or the institutions they are affiliated with.

Address correspondence to Fred A. Kobylarz MD, MPH, Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, One Robert Wood Johnson Place, P.O. Box 19, New Brunswick, NJ 08903. E-mail: kobylafr@umdnj.edu

JAGS SEPTEMBER 2002–VOL. 50, NO. 9

THE ETHNIC(S) MNEMONIC

1583

system. Cultural competency must also be institutional-ized; techniques that have been proposed include, but arenot limited to, cultural competency training, medical inter-preter services, recruitment and retention of a diversehealth professions workforce, coordination with tradi-tional healers, collaborating with community health work-ers, culturally competent health promotion, involvementof family and community members in decision making,and administrative and organizational accommodations.

10

Healthcare delivery systems have multiple, often-com-peting responsibilities to comply with legislative, regula-tory, and accreditation mandates in the delivery of cultur-ally and linguistically competent healthcare services to allpatients served. Recent federal requirements seek to ensurethat all people entering the healthcare system receive equi-table and effective treatment in a culturally and linguisti-cally appropriate manner.

11–13

Although some improve-ments have been made in addressing cultural and languagebarriers through the availability of bilingual staff, face-to-face medical interpreter services, contracted communitylanguage banks, and telephonic interpreter services in hos-pital settings, the real-time availability of these languageservices, specifically in ambulatory office settings whereolder patients receive most of their health care, remainsproblematic.

ETHNOGERIATRIC EDUCATION FOR HEALTHCARE PROFESSIONALS

Improving the quality of services provided through inte-grating cultural competency training into health professionsschools is an area of growing interest.

14

Movement towardsthis effort in medical education at the undergraduate

15,16

and graduate

17,18

level include the Liaison Committee onMedical Educations’

19

and Association of American Medi-cal Colleges’ (AAMC)

20

recently approved cultural diversityaccreditation requirement and the American Council forGraduate Medical Education’s

21

incorporation of attitudes,knowledge, and skills in humanism, professionalism, andcultural sensitivity into training for medical students andphysicians. Professional societies such as The Society forTeachers of Family Medicine,

22

The American Academy ofPediatrics,

23

and The American College of Obstetriciansand Gynecologists

24

have published relevant recommendedguidelines. Family medicine,

25

internal medicine,

26

pediat-rics,

23

and psychiatry

27,28

have also developed educationalprograms in this area.

As related specifically to geriatric healthcare training,the term “ethnogerontology” first appeared in the 1970sin literature describing cross-cultural aging.

29

In 1987,core faculty members of the Stanford Geriatric EducationCenter adapted the term “ethnogeriatrics” specifically forhealth care for older people from different cultures. Themembers of the national collaborative on ethnogeriatriceducation have recently revised a core curriculum in eth-nogeriatrics to provide a comprehensive and detailed cur-riculum for all types of healthcare providers to increasetheir cultural competency in the care of older people.

30

Toimprove the access and use of services and ultimately thequality of care older people from diverse backgrounds re-ceive, a core ethnogeriatric curriculum has been proposedat every level of healthcare professional training.

31

A criti-cal next step is the operationalization and integration of

this curriculum into geriatrics educational programs anddemonstration of its effect on clinical practice.

THE ETHNIC(S) MNEMONIC

Once cross-cultural areas of differences are recognized asbeing important in health care, a means of addressingthem is needed, based on a more thorough understandingof these differences and their implications. The concept ofthe illness explanatory model (EM), developed by Klein-man et al.,

32

has been used to develop specific teachingtechniques for understanding patients’ perceptions of theirillnesses and effective methods of negotiating acceptabletreatment. EMs are not intended to replace the standardmedical history-taking process but rather are proposed toserve as a framework within which to facilitate communi-cation during clinical encounters. Existing EM frameworksinclude Listen, Explain, Acknowledge, Recommend, Negoti-ate (LEARN),

33

Background, Affect, Trouble, Handling, Em-pathy (BATHE),

34

and Explanatory model, Social andenvironmental factors, Fears and concerns, Therapeuticcontracting (ESFT).

35

In applying the EM concept to cross-cultural clinicalencounters, Levin et al. developed the mnemonic, ETH-NIC, as a practical interviewing tool and framework forclinicians to use in addressing cross-cultural healthcare is-sues with their patients.

36

The ETHNIC mnemonic wasdesigned to be integrated into the routine 15-minute visitbetween physicians and their patients in the ambulatoryoffice setting, the hospital, and other ambulatory settingsbut is also applicable in other healthcare settings. It fo-cuses on the acute and chronic sick visit but can also beapplied to preventive care measures. The present authorshave broadened the mnemonic to ETHNIC(S), by includ-ing the letter “S” for Spirituality and to remind the practi-tioner to elicit the health and illness beliefs and practicesof seniors and their caregivers. Each letter refers to an as-pect or domain of the cultural aspects of health and illnessthat are important for the healthcare provider to exploreexplicitly. Table 1 presents the mnemonic with suggestedprobes to elicit additional information.

Description of ETHNIC(S) Mnemonic

Explanation (E)

Within the context of geriatric healthcare interactions, thelack of questioning or explanations offered by an older pa-tient may reflect a passive role that sometimes can impedecross-cultural understanding. Some older people may bereluctant to provide a response initially, whereas othersmay avoid this issue with a reply like, “That’s your jobdoc.” Gentle prodding and the use of normalizing phrasesfrom the provider, such as, “I often learn important thingsfrom hearing people’s ideas about why they are ill andwhat they think should be done about it” may be effectivein eliciting this information.

If patients do not offer explanations, ask what con-cerns them about their problems. Included in the explana-tion is also the inquiry of how older patients perceive thatothers view their condition. This is important to elicit be-cause the opinions of other caregivers, whether present inthe clinical setting, at home, or living miles away, may beas important to patients as their own explanations.

1584

KOBYLARZ ET AL.

SEPTEMBER 2002–VOL. 50, NO. 9 JAGS

Finally, the role that the media may play in this aspectshould also be noted, if the patient offers. This may facili-tate subsequent communication with the patient using acommon point of reference. Many older people receivehealth information from a diversity of sources of variablereliability. Healthcare providers from one cultural back-ground may have limited awareness of the media sourcesused by patients from different cultural backgrounds.

Treatment (T)

In inquiring about treatments or interventions that pa-tients have employed before the current encounter, thehealthcare provider needs to be explicit in asking aboutany and all treatments that a patient is willing to share atthe time of the encounter and not just the ones that a pa-tient perceives would be acceptable to the provider. Thestrong desire of many older patients to seek the approvalof the physician may lead them to present just that infor-mation that they feel the physician will agree with andavoid other information that might provoke disagreementor disapproval. Older patients from varying cultures tradi-tionally use complementary and alternative medicine (CAM)treatments; these should be explored explicitly. Foster et al.reported that 30% of Americans aged 65 and older were us-

ing alternative medicine in 1999, with the two most com-mon modalities being chiropractic and herbal.

37,38

To en-courage patients and their caregivers to talk about CAM,providers should ask open-ended questions such as “Areyou doing anything else for this symptom/illness/condi-tion?” or “Are you taking any over-the-counter remediessuch as vitamins or herbs?”

Healers (H)

Similar to the above treatment issue, this item explicitlyseeks to explore all providers, both medical and alterna-tive healers that older patients might be consulting in addi-tion to their usual source of health care. Given the increas-ing prevalence of alternative healthcare utilization by manyolder people, especially for chronic conditions such as ar-thritis and cognitive impairment, this item is important toallow the patient to disclose any other sources of health-care. This item also implicitly acknowledges the provideras another healer but not necessarily the sole healer for thepatient.

Many practitioners find it challenging to work withalternative providers and need to strike a balance betweenrespect and autonomy for their older patients’ choices and

Table 1. ETHNIC(S): A Framework for Culturally Appropriate Geriatric Care

EXPLANATIONDirect question to be asked: “Why do you think you have

this . . . (use the patient’s phrase for their) symptom/illness/condition?”

Probe questions to be asked: What do friends, family, and others say about these symptoms? Do you know anyone else who has had or who has this kind of problem? Have you heard about/read/seen it on television/radio/newspaper/Internet? (If the patient cannot offer an explanation, ask what concerns them about their problems).

TREATMENTDirect question to be asked: “What have you tried for this . . .

(use the patient’s phrase for their) symptom/illness/condition?”

Probe questions to be asked: What kind of medicines, home remedies, or other treatments have you tried for this illness? Is there anything you eat, drink, or do (or avoid) on a regular basis to stay healthy? Tell me about it. What kind of treatments are you seeking from me?

HEALERSDirect question to be asked: “Who else have you sought

help from for this . . . (use the patient’s phrase for their) symptom/illness/condition?”

Probe question to be asked: Have you sought help from alternative or folk healers, friends, or other people who are not doctors for help with your problems?

NEGOTIATEDirect question to be asked: “How best do you think I can

help you?”Try to find options that will be mutually acceptable to you and

your patient and that incorporate your patient’s beliefs rather than contradicting them.

INTERVENTIONDirect statement: “This is what I think needs to be done

now.”Determine an intervention (e.g., diagnostic, pharmacological,

psychosocial, educational) with your patient that may also incorporate alternative treatments, spirituality, healers, and other cultural practices (e.g., foods eaten or avoided in general and when sick).

COLLABORATEDirect question to be asked: “How can we work together on

this and with whom else?”Collaborate with the patient, family members, healers, and

community resources.SPIRITUALITY SENIORS

Direct question to be asked: “What role does faith/religion/spirituality play in helping you with this . . . (use the patient’s phrase for their) symptom/illness/condition?”

Tell me about your spiritual life. How can your spiritual beliefs help you with this?

JAGS SEPTEMBER 2002–VOL. 50, NO. 9

THE ETHNIC(S) MNEMONIC

1585

potential adverse interactions of treatments. Encouragingdiscussion of alternative providers and their treatments es-tablishes a certain level of trust that can help facilitate fur-ther communication.

Negotiate (N)

This item tries to establish whether the older patient iswilling to work with the current provider to seek out-comes that will be mutually acceptable to the provider andthe patient. This item builds on the previously identifiedbeliefs in a jointly acceptable manner. Negotiation impliesthat both parties are actively seeking to work together.When applied to the care of an older patient for whom acaregiver is involved, that individual, whether a familymember or involved friend, needs to be explicitly acknowl-edged as well. In the particular areas of providing end-of-life care to culturally diverse older populations, this itemmay focus on functional outcomes or symptomatic relief.This item also explicitly allows for the identification of ex-pectations from the patient or caregiver that the providerwould otherwise consider unrealistic.

Intervention (I)

With interventions, providers and older patients or theircaregivers discuss and mutually propose their courses ofaction (e.g., clinical preventive services, diagnostic testing,medication, psychosocial counseling, rehabilitation) in ad-dressing the needs identified earlier. This item allows forthe blending of clinically appropriate healthcare serviceswithin the context of the developing culturally competentencounter. Careful attention to a patient’s responses as re-vealed through the prior steps can assist providers in con-structing a more effective bridge between the scientific un-derstanding of the symptom/illness/condition and a patient’scomprehension of the situation. Those clinical interventionsthat the provider may have been ready to propose beforeproceeding through the earlier steps can now be modifiedand individualized based upon the information received andprocessed in the above steps. In chronic disease states beingmanaged during end-of-life care, there is great variability inthe potential interventions that the provider or the patientindividually might consider appropriate but now, at thisstage in the process, can be more likely agreed upon.

Collaborate (C)

Collaboration refers not only to the patient and providerdirectly involved with the encounter, but may also involvecaregivers or family members, any other healers the pa-tient may have identified earlier, professionals from otherdisciplines, and community resources. The item does notnecessarily ask for the patient to agree with all that theprovider has proposed but rather to mutually discuss andshare information about how the therapeutic relationshipcan best develop. The item is similar to “therapeutic con-tracting,” which has been proposed in other patient en-counters in which the physician and other providers seekto effect change, but emphasizes the interactive naturerather than a provider-dictated course of action.

26

Some older patients may choose not to make a mean-ingful agreement here, especially in the course of a brief

first encounter. Instead, the initial focus of collaborationwould be on the development of a trusting interpersonalrelationship that may eventually become a therapeutic alli-ance. Further understanding of the patient’s responses andrelationships can help guide decisions about the need towork with other individuals and organizations.

Spirituality (S)

Spirituality is often a neglected factor in the health care ofolder patients.

39

The concept of spirituality is found in allcultures and is expressed in a patient’s search for ultimatemeaning through participation in religion or belief in God,family, naturalism, rationalism, humanism, and the arts.The AAMC Task Force Report on Spirituality, Cultural Is-sues, and End of Life Care

40

has proposed outcome goalsfor physicians to incorporate awareness of spirituality, andcultural beliefs and practices, into patient care in a varietyof clinical contexts.

Although recognizing the value of spirituality in theabstract, many healthcare providers feel uncomfortableaddressing the topic during the course of direct patientcare. In addition, many older patients and their accompa-nying caregivers may not expect to be asked about theirperceptions of the influence their spiritual beliefs have ontheir health conditions. Nevertheless, healthcare providersshould be prepared to respond to spirituality issues thattheir older patients coping with chronic illnesses, advancedirectives, and end-of-life care might raise. The role ofprayer as an intervention for illness or disease and the spir-itual meaning that the suffering can bring to illness experi-ences for some individuals are both examples of how spir-ituality has great relevance in the care of older people fromvaried cultures. Having the provider acknowledge these is-sues in the presence of the patient can demonstrate cul-tural sensitivity to an issue often not addressed duringclinical encounters. In instances in which the older patientis struggling with end-of-life issues, having the healthcareprovider raise the spiritual dimension of the patient’s ex-perience may itself provide for hope and important mean-ing for the encounter. Once the issue is raised, some olderpatients may then provide a spiritual history, which can berecorded as part of the social history, but, sometimes, spir-itual issues may arise earlier in the encounter and can helpdevelop rapport. The ETHNIC(S) mnemonic does nothave to be followed in a linear fashion. It can provide anopportunity to explore spiritual issues at any time and al-lows for rapport to be developed to facilitate this degree ofsharing of cultural and spiritual perspectives. It also mayfacilitate providers sharing their own spiritual beliefs andvalues, when appropriate, with the patient. This can oftenenhance the therapeutic relationship between provider andpatient in a unique and often mutually satisfying way.

Clinical Application of the ETHNIC(S) Mnemonic

The following case vignettes provide selected examplesfrom our experiences in caring for culturally diverse olderpatients and illustrate the clinical application of the ETH-NIC(S) mnemonic. The health- and illness-related atti-tudes, beliefs, and values discussed in each individual caseshould not be used to stereotype or generalize about a par-ticular ethnic group.

1586

KOBYLARZ ET AL.

SEPTEMBER 2002–VOL. 50, NO. 9 JAGS

Case 1. Meaning and Management of Chronic Illness

A 65-year-old Hispanic man presents to the physician’s of-fice with poorly controlled type II diabetes mellitus. Al-though his native language is Spanish, he speaks “limitedEnglish” and says that he does not need an interpreter.The nurse’s intake note says that he is here for a “routinecheck-up” and has “not been feeling well lately.” The pa-tient has been coming to the office for 1 year but is seeingthis physician for the first time. His medical record indi-cates that he often has expressed somatic complaints thatthe doctors have not been able to match with any specificdiagnosis beyond his diabetes mellitus. Chart notes alsoindicate that his prior office visits have often occurredonly when his “home remedies” have not been effective inhelping his vague symptoms. He has undergone diabeticteaching and told a diabetes educator that he understandsdiabetes mellitus as meaning “high blood sugar,” and hemust “cut out eating sweets.” He is supposed to be takingtwo different oral diabetic medications every 12 hours, fora total of four pills, although, based upon his most recentblood work, it appears that he is not adhering to his medi-cations.

At this particular visit, he complains of fatigue and, asthe physician asks more about each symptom, he raises ad-ditional complaints of dizziness and headaches. In re-sponse to the physician asking about what his own expla-nation is for all these problems, he says, “The diabetes isnot what is making me sick. I feel symptoms all over mybody and think I may have been cursed.” (E) He has goneto a

curandero

several times over the past year (H and S)who has performed certain ceremonies involving the appli-cation of oils to the body and burning incense to try to dis-pel the curse (

mal

). He believes that this healer is the onlyone that can remove the curse. For his headaches, hedrinks bitter herbal teas that his family sends from hiscounty of origin that he must sweeten to make drinkablebut feels are helping. (T) The patient wants to keep goingto both this office and to his “other healer” (the

curan-dero

) because “both can help me.” He was afraid to men-tion the

curandero

to the previous physicians because“they wouldn’t understand.”

The physician responds by acknowledging his con-cerns that his symptoms could be a combination of his be-liefs about the curse and his diabetes mellitus (E and N).The physician comments that the blood work results sug-gest that the patient is probably not taking the medicationprescribed. The patient replies that the

curandero

told himthat he is probably taking too many pills and that is whyhe has not yet been able to remove the curse (E). The phy-sician then suggests a modification of his current prescrip-tion medication regimen so he takes fewer pills daily (I).The patient agrees to give this a try (N). The physician alsoasks him to bring in the herbal medications that he is tak-ing so that the office staff can determine what he is actu-ally taking and asks him to follow up the followingmonth.

Case Comment

In the above case, the use of the ETHNIC(S) tool allowedthe physician to develop a therapeutic alliance with the pa-tient and explore the meaning and management of his

chronic illness. The physician and patient established arapport that allowed the patient to share his explanationfor his current symptoms that had previously not been re-vealed. Although the specific health and illness beliefs de-scribed here are clearly individual to this patient and notgeneralizable to all patients of Hispanic descent, their de-tail and relevancy for the treating physician are important.Some Hispanics may consider illness to be “unnatural,”and

curanderos

or

espiritistas

may be sought to assist withphysiological, psychological, social, or spiritual maladjust-ments.

41

The physician here neither validated nor repudi-ated the advice and care the

curandero

provided but sim-ply acknowledged this individual as another healer whohad seen the patient.

Diabetes mellitus is a chronic condition that is oftenchallenging to treat because of the multiple interactions ofdiet, medications, and lifestyle factors, which are greatlyinfluenced by culture. The patient’s recent use of comple-mentary and alternative treatments should be evaluatedbecause of concerns such as toxicity and the potential fordangerous medication interactions.

Case 2. Addressing End-of-Life Care Issues

An 87-year-old Chinese-American woman is admitted tothe hospital with vomiting and weight loss. She speaks adialect of Mandarin and requests that her two sons serveas interpreters during the emergency room assessment andsubsequent admission. She has been seeing a neighbor-hood Chinese woman known for her skills in traditionalherbal medicine from local markets as her only healthcareprovider for years at home, where she lives with her ex-tended family (T and H). Her sons and their families ap-parently managed months of progressive fatigue and asso-ciated functional decline at home until the vomiting couldnot be relieved and the family insisted on bringing her tothe hospital.

Initial emergency room medical investigations re-vealed significant anemia, abnormal liver function testssuggestive of possible metastatic disease, and a gastric out-let obstruction noted on radiological studies. Through thefamily, the inpatient clinical team requests that the patientbe asked for her consent to undergo an upper endoscopyprocedure. Her son reports that his mother consents butthat the results of any biopsies are only to be reported tothe family (her two sons) and not to the patient herself.

As part of the admission process to the hospital, theattending physician requests a Chinese-speaking inter-preter through the hospital language bank, and a dietaryworker is identified who can adequately speak the pa-tient’s own dialect. With the family members absent andusing this nonrelative interpreter, the patient states thather vomiting made it impossible to stay with her sons any-more and that this is what is wrong with her (E). She con-firms that she would agree to anything her sons wish herto have done in the hospital and that she wishes them tobe informed of the results of “all tests.” She wishes only tobe directly told “what I must do next.” She signs the con-sent for the endoscopy that subsequently reveals an exten-sive gastric malignancy (N). The gastric outlet obstructionis partially relieved through laser ablation done as a pallia-tive procedure. The diagnosis of metastatic gastric cancerwith its poor prognosis is given to her family only, and,

JAGS SEPTEMBER 2002–VOL. 50, NO. 9

THE ETHNIC(S) MNEMONIC

1587

through her son’s interpretation, the patient is told the en-doscopy was able to “open her stomach a little” (I). Thefamily appears grateful to learn that the vomiting may berelieved and, away from the patient, report “knowing”that their mother was dying before bringing her to the hos-pital.

The patient’s nausea appears to be better controlled,but she refuses to eat the soft diet hospital food presentedto her. She does, however, begin to eat the rice her familybrings from home, because they report that she has neverhad food presented to her without rice (C). The family ispleased that her vomiting is now improved and wishes totake the patient home. They are made aware of the poorprognosis, including the potential for hemorrhage and re-current gastric obstruction and will consider hospice ser-vices. The patient and her family express much gratitudethat she is able to return to her son’s home where, accord-ing to the family, she will be much more comfortable dy-ing in accordance with her religious tradition (S).

Case Comment

In the above case, the use of the ETHNIC(S) tool allowsthe hospital-based clinicians, patient, and family to ex-plore and address culturally appropriate end-of-life issues.Clinicians need to understand the diverse ways that peopleexperience and cope with death and dying and developgreater awareness and sensitivity to preferences in end-of-life decision making.

42–48

The use of language interpreterservices illustrated in this case allowed the treating clini-cian a better perspective about the patient’s own wishesand perception of her condition. In this particular in-stance, they were well represented by her children in thisclose-knit Asian family but are reflective of only this par-ticular case.

Clinicians must access appropriate interpreter servicesfor their patients. The Office for Civil Rights (OCR) Au-gust 30, 2000, Policy Guidance

12

provides an importantdiscussion about acceptable language assistance optionsthat can be used when caring for patients with limited En-glish proficiency (LEP). According to the OCR PolicyGuidance, keys to Title VI compliance in the LEP Contextinclude “(1) Having policies and procedures in place foridentifying and assessing the language needs of the individ-ual provider and its client population; (2) A range of orallanguage assistance options, appropriate to each facility’scircumstances; (3) Notice to LEP persons of the right tofree language assistance; (4) Staff training and programmonitoring; and (5) A plan for providing written materialsin languages other than English where a significant num-ber or percentage of the affected population needs servicesor information in a language other than English to com-municate effectively.” The problems that can occur whenfamily members or friends are used as interpreters are dis-cussed, and the prohibition against the use of minor chil-dren is emphasized.

Case 3. Negotiating a Mutually Acceptable Therapeutic Plan

A 78-year-old Italian woman who has been visiting herson in the United States for the past month is brought tothe hospital clinic for recurrent knee pain. She is beingseen for her third appointment in 2 weeks and complains

of worsening left knee pain. As per the patient’s ownwishes, her son acted as her interpreter for the first two ofthese appointments, but an Italian-speaking neighbor hascome with her for this visit. At the time of her first ap-pointment, the diagnostic impression was osteoarthritis,confirmed by x-ray, and a prescription for a nonsteroidalantiinflammatory medication was written. Weight reduc-tion and a knee brace were also advised, along with a re-ferral for physical therapy. She returned a few days laterfor the second appointment, having neither filled the pre-scription medication nor seen the physical therapist, andreported that the knee was worse. Sample medicationswere given to the patient, along with reinforcement aboutneeding to adhere to a routine walking program and seethe physical therapist. At today’s return appointment, shecontinues to say, “My knee is no better after having takenall the pills.”

Working with the Italian-speaking neighbor, the phy-sician asks the patient about what she thinks is causing herknee pain. She initially responds by looking away, statingthat, “I wouldn’t presume to play doctor.” With furthergentle questioning however, she reports feeling that herknee pain must mean that “something bad is going to hap-pen,” because her last episode of knee pain happened backin Italy just before the death of her husband (E). That epi-sode of arthritic flare-up had almost made it impossiblefor her to walk behind his funeral procession until herphysician gave her a “shot in the knee” that helped im-mensely (T and H). She is currently visiting her son in theUnited States because of his marriage ceremony, which iscoming up in 5 days, and fears not being able to walkagain. She wishes she could now receive a shot but reportsthat her son had previously told her, “Doctors in thiscountry don’t do such things.” She felt intimidated aboutasking for such a shot during prior visits with her sonpresent, but now, with him absent, specifically asks if shemight receive a knee injection (N). She wants to be able towalk up the aisle at her son’s wedding without a cane. Af-terwards, she plans to return to Italy, where she will usethe rather “unsightly knee brace” that she already has butdid not bring with her to this county. She is overjoyed tolearn of the possibility of receiving an intra-articular ste-roid injection and agrees to go to physical therapy only af-ter learning that this was not a first step for a subsequentjoint replacement surgery but rather for local modalitytreatments (I and C).

When, at the end of the encounter, the physician in-quires about how the wedding plans are going, she admitsto being upset with her son for “not having a church wed-ding.” She reports not sleeping but instead spending mostevenings “walking the floor and worrying.” She thinksthat this has also worsened her knee pain. The name of anItalian-speaking priest is provided, should the patient wishto discuss her concerns about this matter (S).

Case Comment

In the above case, the use of the ETHNIC(S) tool allowsthe physician to explore cultural and psychosocial issuessurrounding the patient’s symptoms. Together they negoti-ated a mutually acceptable therapeutic plan in the contextof an acute encounter. The patient initially chose to have afamily member (her son) serve as an interpreter. Although

1588

KOBYLARZ ET AL.

SEPTEMBER 2002–VOL. 50, NO. 9 JAGS

the therapeutic interventions proposed in the patient’s firsttwo clinical encounters were medically appropriate, thepatient did not initially accept them. This case also illus-trates how older minority patients have differing ideas ofthe meaning of their own illness from those of their health-care providers. Clinicians who are able to effectively elicitthe meaning of illness from their patients can develop adeeper relationship, which may foster improved therapeu-tic outcomes. ETHNIC(S) can be used with patients fromall racial, ethnic, and sociocultural backgrounds.

CONCLUSIONS

Cultural and linguistic competence is an essential compo-nent of providing health care to older patients. The mne-monic ETHNIC(S) provides a framework for cross-cul-tural interviewing that physicians and other healthcareprofessionals can use and easily integrate into ethnogeriat-ric curricula. It is neither a scoring sheet nor a detectionscheme to uncover hidden cultural issues but rather a clin-ically applicable tool for eliciting and negotiating culturalissues during healthcare encounters. These issues are rele-vant in the wide variety of ambulatory, home health, hos-pital, and long-term care settings where older patients re-ceive services.

Although ETHNIC(S) can be helpful in facilitatingcross-cultural communication during clinical encounters,it does not address important systemic, institutional, or in-terpersonal barriers to access and culturally competent care.These include poverty, classism, ageism, racism, sexism, ho-mophobia, other forms of bias, prejudice, and discrimina-tion. Additional limitations include the need to address dis-ability-related issues and communication impairments thatare common in older people, such as hearing, language, andcognitive barriers. Future empirical research is also neededto study the effectiveness of ETHNIC(S) and other tech-niques designed to enhance cultural competency in healthprofessions training programs and clinical care settings.

Developing cultural competence is an ongoing, life-long journey for individuals, families, organizations, andcommunities.

49,50

The cultures of patients and their caregiv-ers, healthcare providers, and healthcare systems may notbe in concurrence. It is important that differences in expec-tations, priorities, therapeutic goals, and roles be recognized.Maintaining “cultural humility,” avoiding stereotyping, en-gaging in mutually respectful communication, and fosteringempowerment in relationships are critical.

51

The challengefor practitioners therefore is to develop and nurture culturalcompetence in the care of their older patients.

REFERENCES

1. Cohen E, Goode T. Policy Brief 1: Rationale for Cultural Competence in Pri-mary Healthcare. Washington, DC: Georgetown University Child Develop-ment Center, The National Center for Cultural Competence, 1999.

2. U.S. Bureau of the Census and National Institute on Aging. Racial and EthnicDiversity of America’s Elderly Population. Profiles of America’s Elderly. Wash-ington, DC: U.S. Bureau of the Census and National Institute on Aging, 1993.

3. U.S. Census Bureau. Population projections of the United States by Age, Sex,Race, Hispanic Origin and Nativity, January 2000. Available at http://www.aoa.gov/minorityaccess/intro.html Accessed August 17, 2001.

4. Healthy People 2010. Available at http://www.health.gov/healthypeople Ac-cessed August 17, 2001.

5. Lillie-Blanton M, Hoffman C. Racial and ethnic disparities in access to medi-cal care. Med Care Res Rev 2000;57:5–10.

6. Mayberry RM, Mili F, Vaid IGM et al. Racial and ethnic differences in ac-cess to medical care. A synthesis of the literature. The Henry J. Kaiser FamilyFoundation. October 1999. Available at http://www.kff.org Accessed August17, 2001.

7. Gornick ME. Disparities in medicare services: Potential causes, plausible, ex-planations, and recommendations. Minority Health Today 2001;2:17–30.

8. Goode T, Harrison S. Policy Brief 3: Cultural Competence in Primary HealthCare: Partnerships for a Research Agenda. Washington, DC: GeorgetownUniversity Child Development Center, The National Center for CulturalCompetence, 2000.

9. Davis BJ, Voegtle KH. Culturally Competent Health Care for Adolescents: AGuide for Primary Health Care Providers. Chicago, IL: American MedicalAssociation, 1994.

10. Brach C, Fraser I. Can cultural competence reduce racial and ethnic health dis-parities? A review and conceptual model. Med Care Res Rev 2000;57:181–217.

11. Federal Register. National Standards on Culturally and Linguistically Appro-priate Services in Health Care. Office of Minority Health. Vol 65:80865–80879. Washington DC: December 20, 2000. Available at http://www.omhrc.gov/clas Accessed August 17, 2001.

12. Federal Register. Policy Guidance on the Prohibition Against National Ori-gin Discrimination as it Affects Persons with Limited English Proficiency. Of-fice of Civil Rights. Vol 65:52762. Washington DC: August 30, 2000. Avail-able at http://www.hhs.gov/ocr/lep/guide.html Accessed August 17, 2001.

13. The Provider’s Guide to Quality and Culture. Available at http://erc.msh.org/quality&culture Accessed August 17, 2001.

14. Hedrick HL, ed. Cultural Competence Compendium. Chicago, IL: AmericanMedical Association, 1999.

15. Lum CK, Korenman SG. Cultural sensitivity training in U.S. medical schools.Acad Med 1994;69:239–241.

16. Flores G, Gee D, Kastner B. The teaching of cultural issues in U.S. and Cana-dian Medical Schools. Acad Med 2000;75:451–455.

17. Zweifler J, Gonzalez AM. Teaching residents to care for culturally diversepopulations. Acad Med 1998;73:1056–1061.

18. Culhane-Pera KA, Like RC, Lebensohn-Chialvo P et al. Multicultural curric-ula in family practice residencies. Fam Med 2000;32:167–173.

19. Liaison Committee on Medical Education. Standard on cultural diversity.Available at http://www.lcme.org Accessed August 17, 2001.

20. Association of Medical Colleges. Teaching and Learning of Cultural Compe-tence in Medical School. Contemporary Issues in Medical Education. Associ-ation of Medical Colleges, 1998 Available http://www.aamc.org/meded/edres/cime/vol1no5.pdf Accessed May 20, 2002.

21. American Council for Graduate Medical Education. Outcome project: Gen-eral competencies. Available at http://www.acgme.org/index.htm AccessedAugust 17, 2001.

22. Like RC, Steiner RP, Rubel AJ. Recommended core curriculum guidelines onculturally sensitive and competent health care. Fam Med 1996;28:291–298.

23. American Academy of Pediatrics. Culturally effective pediatric care: Educa-tion and training issues. Pediatrics 1999;103:167–170.

24. American College of Obstetricians and Gynecologists Committee Opinion.Cultural competency in health care. Committee on Health Care for Under-served Women. Int J Gynaecol Obstet 1998;62:96–99.

25. Culhane-Pera KA, Reif C, Egli E et al. A curriculum for multicultural educa-tion in family medicine. Fam Med 1997;29:719–723.

26. Carillo JE, Green AR, Betancourt JR. Cross-cultural primary care: A patient-based approach. Ann Intern Med 1999;130:829–834.

27. Garza-Trevino ES, Ruis P, Venegas-Samuels K. A psychiatric curriculum di-rected to the care of Hispanic patients. Acad Psychiatry 1997;21:1–10.

28. Thompson JW. A curriculum for learning about American Indians and Alas-kan Natives in psychiatry residency training. Acad Psych 1996;20:5–14.

29. Jackson JJ. Race, national origin, ethnicity, and aging. In: Binstock R, ShanasE, eds. Handbook of Aging and Social Sciences. New York, NY: Van Nor-strand Reinhol, 1985, pp 264–268.

30. Chee YK, Choi EE, Enslein J et al. Core Curriculum in Ethnogeriatrics. 2ndEd. Yeo G, ed. October 2000. Available at http://www.stanford.edu/group/ethnoger Accessed August 17, 2001.

31. Henderson N, McCabe M, Scott VJ, et al. Ethnogeriatrics. In: Klein S, ed. ANational Agenda for Geriatric Education: White Papers. Washington, DC:Bureau of Health Professions, Health Resources and Services Administration,1996, pp 81–102.

32. Kleinman A, Eisenberg L, Good B. Culture, illness and care: Clinical lessonsfrom anthropologic and cross-cultural research. Ann Intern Med 1978;88:251–258.

33. Berlin EA, Fowkes WC. A teaching framework for cross-cultural health care.West J Med 1982;139:934–938.

34. Stuart MR, Lieberman JA III. The Fifteen-Minute Hour: Applied Psycho-therapy for the Primary Care Physician, 2nd Ed. New York, NY: Praegers,1993.

JAGS SEPTEMBER 2002–VOL. 50, NO. 9

THE ETHNIC(S) MNEMONIC

1589

35. Betancourt JR, Carrillo JE, Green AR. Hypertension in multicultural and mi-nority populations: linking communication to compliance. Curr HypertensRep 1999;6:482–488.

36. Levin SJ, Like RC, Gottlieb JE. ETHNIC: A framework for culturally compe-tent clinical practice. In Appendix: Useful clinical interviewing mnemonics.Patient Care 2000;34:188–189.

37. Foster DF, Phillips RS, Hamel MB et al. Alternative medicine use in olderAmericans. J Am Geriatr Soc 2000;48:1560–1565.

38. Eisenberg DM, Davis RB, Ettner SL et al. Trends in alternative medicine inthe United States, 1990–1997. JAMA 1998;280:1569–1575.

39. Levin JS, Larson DB, Puchalski CM. Religion and spirituality in medicine:Research and education. JAMA 1997;278:792–793.

40. Task Force Report on Spirituality. Cultural Issues and End of Life Care. Amer-ican Association of Medical Colleges Medical Objectives Report III: Contem-porary Issues in Medicine: Communication in Medicine. October 1999. Avail-able http://www.aamc.org/meded/msop/msop3.pdf Accessed May 20, 2002.

41. Welch M, Feldman MD. Cross-cultural communication. In: Feldman MD,Christensen JF, eds. Behavioral Medicine in Primary Care: A Practical Guide.1st Ed. New York, NY: McGraw-Hill, 1997, pp 97–108.

42. Hopp FP, Duffy SA. Racial variations in end-of-life care. J Am Geriatr Soc2000;48:658–663.

43. Irish DP, Lundaquist KF, Vivian J eds. Ethnic Variations in Dying, Death, andGrief: Diversity in Universality. Washington, DC: Taylor and Francis, 1993.

44. Blackhall LJ, Murphy S, Frank G et al. Ethnicity and attitudes towards pa-tient autonomy. JAMA 1995;274:820–825.

45. Davis A. Ethics and ethnicity: End-of-life decisions in four ethnic groups ofcancer patients. Med Law 1996;15:429–432.

46. Braun KL, Pietschi JH, Blanchette PL, eds. Cultural Issues in End-of-Life De-cision Making. Thousand Oaks, CA: Sage, 2000.

47. Innovations in End-of-Life Care. Available at http://www.edc.org/lastacts/Accessed August 17, 2001.

48. Kagawa-Singer M, Blackhall LJ. Negotiating cross-cultural issues at the endof life: “You got to go where he lives.” JAMA 2001;286:2993–3001.

49. Betancourt JR, Like RC. Editorial, a new framework of care. Patient Care2000;34:10–12.

50. Bureau of Primary Health Care, Health Resources and Services Administration,Department of Health and Human Services. Cultural Competence: a Journey.Available at http://www.bphc.hrsa.gov:80/culturalcompetence/default.htm Ac-cessed August 17, 2001.

51. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence:A critical distinction in defining physician training outcomes in multiculturaleducation. J Health Care Poor Underserved 1998;9:117–125.