--- title: Cultural Bias and Inflexibility Impedes Communication and Contributes to Poor Outcomes description: In this medical malpractice case study, a patient’s ethnic background and limited English proficiency obstructed her care. image: https://files.norcal-group.com/hubfs/doctor-talking-to-hispanic-mother-and-daughter.jpg --- - [Sign In](https://secure.proassurance.com?hsLang=en-us) - g Search Site [Contact Us](https://www.proassurance.com/contact-us/?hsLang=en-us): **844-466-7225** [![PRA-MMI-Logo®-RGB](https://www.norcal-group.com/hs-fs/hubfs/PRA-MMI-Logo%C2%AE-RGB.png?width=215&height=62&name=PRA-MMI-Logo%C2%AE-RGB.png)](https://www.norcal-group.com?hsLang=en-us)   - [About](https://norcal-group.com/about) - [About Us](https://norcal-group.com/about) - [Coverages](https://norcal-group.com/state) - [Claims](https://www.proassurance.com/report-a-claim/) - [Resources](https://www.norcal-group.com/resources) - [HIPAA Resources](https://proassurance.com/hipaa) - [Website Accessibility](https://proassurance.com/accessibility) - [Pay](https://www.norcal-group.com/pay) ## [Resource Library](https://www.norcal-group.com/library?hsLang=en-us) # Cultural Bias and Inflexibility Impedes Communication and Contributes to Poor Outcomes July 5, 2017 - [Tweet](https://twitter.com/share) In this interaction, a patient’s ethnic background and limited English proficiency obstructed her care. Instead of taking steps to facilitate communication, the physician continued only with his established treatment plan and methods, failing to appreciate the value of the patient’s contribution to or understanding of her care. This contributed to the physician failing to treat the patient fairly and a poor outcome. ## ![doctor-talking-to-hispanic-mother-and-daughter](https://files.norcal-group.com/hubfs/doctor-talking-to-hispanic-mother-and-daughter.jpg)Allegation *Failure to diagnose an impending myocardial infarction* ## Case File ### Four Basic Principles of Medical Ethics5 1. **Beneficence** — acting for the patient’s good 2. **Nonmaleficence** — doing no harm 3. **Autonomy** — recognizing the patient’s values and choices 4. **Justice** — treating patients fairly A 66-year-old female patient with a past history of diabetes mellitus, hypertension, and vascular disease presented to an internist complaining of a cough and wheezing. The patient had immigrated to the United States from Ecuador several years earlier, and she spoke mainly Spanish. She lived with her son, who had been in the U.S. longer, spoke English fairly well, and worked as a computer technician. The son had sometimes come to medical visits with the patient in the past, but he did not come to this visit. The internist diagnosed sinusitis and attempted to convey to the patient, without using an interpreter, that she should take acetaminophen, rest, and drink fluids. This physician had a very strong and often-expressed view that people who come to the U.S. should learn to speak English. His grandparents had emigrated from Italy, and the physician liked to point them out as an example of people who had quickly adopted the language of their new country and successfully assimilated to American culture. He had repeatedly said he did not agree with spending his practice’s money on interpreters. If patients wanted interpreters, they could hire their own or use family members, this internist believed. He had expressed this view to the patient and her son at some past visits. A week after this visit, the patient was significantly worse, and her son took her to the emergency department of the local hospital. Her examination in the emergency department revealed bilateral wheezing. A chest x-ray showed left lower lobe consolidation. Labs taken in the emergency department included elevated blood glucose, slightly elevated white blood cell count and abnormal CPK and troponin levels. The patient was admitted to a general medical floor with a diagnosis of pneumonia, and a nephrology consult was ordered. The patient’s internist was her attending physician. He did not use a language interpreter while she was in the hospital. For the first two days of the hospitalization, the patient’s status seemed to be improving: her respiratory symptoms and kidney function were better. However, the patient then developed shortness of breath and nausea. The internist ordered furosemide and an antiemetic. Repeat labs still showed an elevated CPK level. The next day the patient had continuing nausea and shortness of breath, and her internist ordered a 100% NRB (non-rebreather) mask and intravenous theophylline. The patient developed respiratory and metabolic acidosis. That evening, at about 11 p.m., the patient had a cardiac arrest. She was resuscitated but remained minimally responsive in the intensive care unit (where she was transferred). Her son withdrew medical care two days later. The patient’s son subsequently brought a lawsuit against the internist alleging failure to monitor cardiac status and failure to diagnose and treat an impending myocardial infarction, which led to the patient’s death. The son testified in deposition that his mother’s care was further compromised by the internist’s lower level of vigilance toward the care of a Latina patient. The son’s deposition testimony included his recollection of the physician’s statements that immigrants should learn English and that patients in his practice were responsible for getting their own interpreters. The son said that is why he usually came with his mother to her appointments, although his work schedule sometimes prevented him from accompanying her. He also said that he had at several times talked to his mother about changing doctors, but the internist’s office location was convenient for her, and she was generally reluctant to alter any arrangement that she had become familiar with in the U.S. Expert reviewers criticized the internist for not admitting the patient to a critical care floor, not ordering a heart monitor, not following up on the elevated CPK level, and for delaying in treating the patient’s worsening respiratory and metabolic symptoms. They also faulted the physician for not having used language interpretation services to better communicate with the patient in his office and at the hospital. The experts believed the physician did not meet the standard of care and that his failure to act on the elevated CPK level caused harm to the patient; therefore, the case was settled. ## Discussion ### More Information About Medical Ethics and Physician-Patient Encounters - [Closed Claim Case Study: Patient Demand for Unconventional Care Presents an Ethical Dilemma for Physicians](https://www.norcal-group.com/library/patient-demand-for-unconventional-care-presents-an-ethical-dilemma-for-physicians?hsLang=en-us) - [Closed Claim Case Study: When Patients Refuse Treatment: Medical Ethics Issues for Physicians](https://www.norcal-group.com/library/when-patients-refuse-treatment-medical-ethics-issues-for-physicians?hsLang=en-us) - [Closed Claim Case Study: Personal Relationship With a Patient Leads to Below Standard Care](https://www.norcal-group.com/library/personal-relationship-with-a-patient-leads-to-below-standard-care?hsLang=en-us) - [Closed Claim Case Study: Patient Confidentiality: Understanding the Medical Ethics Issues](https://www.norcal-group.com/library/patient-confidentiality-understanding-the-medical-ethics-issues?hsLang=en-us) - [Closed Claim Case Study: Medical Ethics Issues with Shared Decision-Making in Patient Encounters](https://www.norcal-group.com/library/medical-ethics-issues-with-shared-decision-making-in-patient-encounters?hsLang=en-us) - [Closed Claim Case Study: Improper Informed Consent Leads to Allegation of Negligent Supervision](https://www.norcal-group.com/library/improper-informed-consent-leads-to-allegation-of-negligent-supervision?hsLang=en-us) - [Closed Claim Case Study: Ethical Dilemmas with Disclosing Medical Errors](https://www.norcal-group.com/library/ethical-dilemmas-with-disclosing-medical-errors?hsLang=en-us) The main medical ethics principle that fits this case is *justice*. The patient’s ethnic background was a barrier to her receiving proper care when it should not have been. An important tenet in medical ethics is that “the sick should be cared for regardless of race, religion, gender or nationality.”1 In this case, poor care was exacerbated by communication problems as well as by ethnic bias and lack of cultural sensitivity in health care delivery on the part of the physician. Jonsen and colleagues point out that today, biases against various ethnic groups “may be less explicit but still present.” They write that “many studies reveal that racial and cultural minorities receive lower quality of care.”1 As these authors exhort, “It is ethically important that these biases be identified and eliminated from clinical decisions.”1 ## Medical Liability Risk Management Recommendations ### Interactions with Patients of Diverse Ethnic Backgrounds and Those who Speak Languages Other than English - Be sensitive and alert to cultural differences between you and your patients. This content originally appeared in the NORCAL Group Risk Management publication, *Claims Rx*. Many releases are available for download in the [*Claims Rx* Directory](https://www.norcal-group.com/claimsrx?hsLang=en-us). Policyholders will also find instructions for obtaining CME credit for select releases. ## References 1. Jonsen AR, Siegler M, Winslade WJ. *Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine*. 7th ed. New York, NY: McGraw Hill; 2010:118. 2. 45 C.F.R. 80.3 *et seq*. 3. Youdelman M. [Can the care be high quality if the communication is not?](http://journalofethics.ama-assn.org/2007/08/pfor1-0708.html) *Virtual Mentor*. 2007;9(8):559-565. (accessed 7/5/2017) 4. U.S. Department of Health and Human Services. [Think Cultural Health: Advancing Health Equity at Every Point of Contact](https://www.thinkculturalhealth.hhs.gov). (accessed 7/5/2017) 5. Beauchamp TL, Childress JF. Part II: moral principles. *Principles of Biomedical Ethics*. 7th ed. New York, NY: Oxford University Press;2012:99-288. 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