Spotlight On Multicultural Retina Practices

The editors of Retina Today spoke with some of the most diverse retina practices across the country to find out how they handle cultural differences within their patient bases and the myriad benefits of fostering cultural diversity within their practices. Here’s what they had to say.

–Rebecca Hepp, Editor-in-Chief

Retina Today: How does your practice address cultural differences among your patients?

Basil K. Williams Jr, MD: While we do not have a specific policy or set of guidelines in place to address cultural differences, we consider a number of factors in approaching the broad and diverse patient base in our practice. The goal is for the entire team, starting with receptionists and continuing with the technicians, photographers, and physicians, to approach each patient with curiosity, empathy, respect, and humility. With this approach, we seek out both potential and actual barriers to care and address them as needed.

Nika Bagheri, MD: The best way to provide superlative care to patients of all cultural backgrounds is to achieve diversity within your own organization, from the front desk staff to the office leadership. There also has to be internal education regarding cultural differences that may affect patient care. This could include having instruction sheets printed in multiple languages, recognizing the roles family members play in certain cultures, and appreciating the different fears patients may have about vision loss depending on their backgrounds.

Aleksandra Rachitskaya, MD: Healing is a complex process that requires patients to understand their disease and engage with their treatment. Thus, insight, awareness, and understanding of the dangers of unconscious bias are paramount. My team and I try to do our part to improve patients’ experiences by acknowledging and adapting to each patient’s cultural background. Studies have shown that patients who share the same racial or ethnic background as their physician are more likely to have a better experience, as reflected by patient rating scores.¹

RT: How does a culturally diverse staff help your practice connect with your community?

Dr. Williams: I learned the value of representation early in my training. While shadowing a family practice physician during my first year of medical school, an older Black gentleman pulled me aside at the conclusion of his visit. Ensuring that no one else was within earshot, he told me how proud he was of me. Iterations of that scenario happened countless times with my Black patients throughout my training and continue in my current practice. I also noticed that speaking Spanish to members of the largely Cuban population in Miami during residency dramatically improved the patients’ level of comfort and the rapport I had with them. Similarly, having a culturally diverse staff allows a deeper connection with the community at large, cultivating trust between physicians and patients that ultimately leads to better interactions and improved patient care and outcomes.

Dr. Bagheri: It is crucial when possible to hire staff with local ties and ideally to groom leadership from the same background as each individual office’s distinct patient base. This will result not only in a stronger organizational culture, but also superior patient care. Studies have shown that underrepresented minority (URM) patients may achieve better outcomes when a treating facility includes URM physicians.²

Matthew A. Cunningham, MD: We maintain a culturally diverse staff, and we have found that it helps us connect with our patients and others in the community. It also helps us understand cultural topics or issues that we would not otherwise be aware of but that are beneficial to know as physicians.

Mr. Albert Shirakian: Ensuring that our patients’ cultures and languages are represented in our practice provides them a level of comfort. Many who do not speak or read English feel comfortable coming into the clinic without a family member, knowing that familiar faces and a familiar language will be greeting them. This creates a friendly environment and great long-term relationships with our patients that resonate within the community.

Dr. Rachitskaya: We serve many patients for whom English is their second language. When I worked in Miami, I was amazed at how Spanish-speaking patients would prefer my broken and grammatically challenged Spanish to English, even though these patients’ own English was, in fact, significantly better than my attempts to communicate in their first language. I speak several languages, and I use my skills to build rapport, but in our practice we ensure that a professional translation service is available either in person or by phone for those who prefer it.

RT: What challenges have you encountered in caring for distinct ethnic populations?

Dr. Williams: The most difficult recurring challenge for me is bridging the language barrier between myself and members of distinct ethnic populations. We can provide patients with video-based translators in nearly every language available, but I often find it difficult to develop the same level of rapport with these patients because of the presence of an intermediary in the conversation.

Another challenge I’ve encountered is in dealing with patients whose cultural beliefs place an emphasis on holistic medicine over Western medicine. At times, this has led to the rejection of necessary medical or surgical treatments in favor of natural remedies.

Dr. Bagheri: In retina, one of the biggest issues is patient adherence to appointments and treatment plans. We have fantastic anti-VEGF medications to treat wet AMD, diabetic retinopathy, and other potentially blinding conditions. The Achilles heel of current anti-VEGF treatment, however, is the need for persistent and often continuous treatment, with functional visual benefits sometimes lagging behind anatomic ones.

Effectively communicating and achieving understanding of the need for adherence across cultural and language barriers can be a tremendous challenge. Some ethnic populations have respect for physicians but view doctor appointments as a symptom of illness: The more often you go, the sicker you must be. In other instances, there may be a culturally based reluctance to report symptoms that may be important for the treating provider to know, such as new distortion or vision loss between visits.

Dr. Cunningham: Although each individual is unique, it is important to be culturally sensitive to challenges that may be distinct to a culture or ethnic group. There may be an underlying distrust of the medical community, for instance based on a historical event such as the Tuskegee Syphilis Study. Often, seeing a health care professional from a similar cultural background in the clinic may put a patient at ease. Other patients may not believe their ocular condition is due to an underlying medical condition, such as diabetes mellitus.

In central Florida, Spanish is the second most common language, but many of our patients speak Vietnamese, Portuguese, or Creole. Having trained in Houston, I learned enough medical Spanish to complete an eye examination without assistance, but I am fortunate to have other members of my health care team who can communicate with patients in these other languages.

We have faced recent challenges related to COVID-19. Many of our patients live in multigenerational households and rely on other family members for support with medical visits. During the pandemic, communication with some of these patients has become challenging. Virtual clinics have been helpful in these instances to allow the patient and family members to be present.

Mr. Shirakian: Distinct ethnic populations approach health care differently, with varied concerns and anxieties. It is our responsibility to try to deliver the highest quality care in a manner that is sensitive to these issues. This includes being vigilant that staff members and physicians are 100% respectful and considerate in addressing these concerns.

Dr. Rachitskaya: I am lucky to have a team that represents the diverse community we serve. It is common to hear different languages spoken as technicians greet patients. Retina specialists often see patients more frequently than any other medical provider. The patents share with my staff their life stories, their successes, and their fears. A patient’s living situation, including support system or lack thereof, can affect access to care and compliance. Understanding the issues that patients face outside my office allows me to provide better care.

To improve patient–physician communication, I also try to engage family even if they might not be present for an appointment. Challenging situations might still arise. I remind myself that, however difficult the situation might be, I am here to take care of the patients and their conditions.

I would also note that it is a two-way street, and sometimes the patients might not be culturally sensitive to the caregivers. If there is discrimination or inappropriate behavior toward my staff, I try to address it the moment it happens and ensure that a patient is educated that such behavior is not acceptable at our institution.

RT: Can you share some success stories?

Dr. Williams: A Latino patient was referred to me for a conjunctival lesion concerning for ocular surface squamous neoplasia. He had missed multiple appointments because of his work schedule, and ultimately we extended our clinic hours to ensure that he was seen. Given his work and social situation, surgery was the most appropriate treatment. He was apprehensive about surgery, but his demeanor clearly eased after we had an extensive discussion in Spanish. He ultimately agreed to proceed with surgery and had an uncomplicated course.

A second success story involved an older White patient with ocular lymphoma. With COVID-19–related restrictions at the cancer center, he was not permitted to have family members with him in the treatment room. The patient was resistant to treatment during our initial discussion of his clinical diagnosis and recommendation for radiation treatment, given his age. A biopsy was needed to confirm the diagnosis, and he requested to have family input on his decision. We held a video conference with his daughter and repeated the discussion in its entirety, after which he left to weigh his decision with additional family support and input. The patient agreed to the biopsy, which confirmed the diagnosis of lymphoma, and underwent radiation for definitive treatment.

I consider these success stories not just because of the positive clinical outcomes but because they remind me of the importance of meeting the patient where they are and treating the patient as a whole person.

Dr. Cunningham: A Russian-speaking male in his 60s was referred for a retinal tear in his left eye. He spoke little English and was by himself. During his examination, I could tell he was apprehensive, scared, and confused. Despite using a translating app, I could tell he did not understand what was going on and why he needed laser treatment. At that moment, we found out that one of my billing specialists was from Russia and spoke fluent Russian. I had her translate the exam findings and the risks, benefits, and alternatives to laser treatment. I immediately saw relief in his face, as he nodded in agreement. This story has replayed itself in dealing with patients from other cultures that speak a specific language.

Another success story at our practice has been with the use of telemedicine during the COVID-19 pandemic. We were one of the first retina groups to initiate a hybrid telemedicine platform. This has been especially helpful for our patients who reside in multigenerational households. We can limit their exposure while still reviewing all pertinent imaging and giving our impressions to the patient and family members on one video call. This has been extremely helpful.

Dr. Rachitskaya: Sometimes one person stopping and listening can make all the difference. I vividly recall an elderly gentleman under treatment for wet AMD. We saw him frequently, and on this particular visit he was extremely polite and appreciative, as always. However, something was off. He confided that day to my fellow, who was of the same gender and ethnic background, that he had been feeling depressed and had been having suicidal thoughts. We rushed him to the emergency room, possibly averting a catastrophe.

RT: What advice would you give to practices wishing to improve their cultural diversity?

Dr. Williams: From a practical standpoint, practices need to identify what diversity exists in their community and ensure that comparative data is available to assess progress. Hiring should focus on the broad definition of diversity, including, but not limited to, race, gender, nationality, religious background, and sexual orientation.

Improvements in practice-wide cultural diversity start on an individual level. When leadership and staff focus on improving their own understanding of cultural diversity, an environment that fosters a deeper understanding and acceptance of diversity is likely to result. Additionally, formal training and implementation of practice policies and guidelines can also improve the cultural competence of the staff. It is extremely important to foster an inclusive environment so that the culturally diverse team is retained.

Dr. Bagheri: Three simple rules:

• Diversity is crucial at all levels of the organization, from the leadership on down.
• Be flexible, and have each office location’s staff and patient resources reflect the needs of the patient population.
• Do not get satisfied or stagnant! Empower your team to give you feedback to constantly strive to be better at addressing cultural differences.

Dr. Cunningham: I believe a culturally diverse staff has significant advantages that go beyond simply connecting to patients from similar cultures. I would advise that every physician evaluate how they can make their staff a better reflection of their community at large. Also, we should all be offering professional development on the importance of diversity in the workplace.

Mr. Shirakian: Take the time to analyze the demographics of your patient base, referral sources, and local community to identify gaps that may amplify any discomfort a patient may feel during medical treatment. Ensuring that patients are comfortable and confident in explaining their chief complaints, during what may be a challenging time for them, will be remembered and appreciated for years to come.

Dr. Rachitskaya: Cultural diversity should not be an afterthought. It is important to be aware of the patient population being served and have a concrete plan on addressing these issues.