Culturally competent care: Address your patients’ humanity

Introduction

Twenty years ago I wrote an article on the value of culturally competent medical care. I had just become aware of the concept at that time and wanted to express my thoughts on the issue. Following publication of the article, I received five letters from male readers saying they were as sensitive as anyone in the care of different ethnic groups and women — and then two of them went on to express that only men should be orthopedic surgeons.

As a result, I turned to Augustus A. White lll, MD, PhD, for some refinement and additional thinking in this area. It seems appropriate that 20 years later, I have asked my friend Gus to share his thoughts with all of us in this 4 Questions interview on culturally competent care and what he has added to his knowledge in this topic through the writing of his new book, Seeing Patients: Unconscious Bias in Health Care.

Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: How would you define culturally competent care?

Augustus A. White III

Augustus A. White III, MD, PhD: I believe the question can best be answered with several definitions. One is that culturally competent care is care in a situation wherein both the caregiver and the patient have humanized one another, or at least the caregiver has humanized the patient.

When the caregiver humanizes the patient, that caregiver has interacted with, communicated with or in some positive way engaged the patient’s fundamental humanity. This means that the patient recognizes that the doctor cares about him or her as an individual human being.

Another way culturally competent care can be described is care in which the doctor possesses a set of attitudes, skills and knowledge which allows him or her to give the same quality of care to a patient of a different gender, culture, or ethnicity that he or she gives to one of his or her own gender, culture or ethnicity.

A third way of looking at culturally competent care is to think of it as patient-centered care in which the quality of care is not compromised by conscious or unconscious bias on the part of the caregiver due to the patient’s gender, race, ethnicity, religion, socioeconomic status, age, body type, sexual lifestyle or nationality.

Jackson: What are some of the disparities that currently exist in health care in our country?

White: African-Americans experience an infant mortality that is almost two and a half times that of white infants. The life span for African-Americans on average is 7 years less that for white Americans. African-Americans are more likely to be castrated as a treatment for prostate cancer than white Americans. Surgeons do not operate on African-Americans as often for equally operable lung cancers.

White and minority women with heart disease receive less bypass surgery than men. Women receive less prescriptive cardiac medication after a heart attack than men. It takes more time for emergency services to transport women to the hospital with heart attacks.

Hispanic Americans with heart disease receive less bypass surgery than non-Hispanic white Americans. Hispanic Americans do not receive basic recommended health care services for which they are eligible at the same rate as majority whites. These include: mammograms, pap smears, colonoscopies, cardiovascular screenings, flu vaccines and diabetic screenings.

Gay, lesbian, bisexual and transgendered communities are prone to high rates of suicide, alcoholism and tobacco use, and are at special risk for a variety of serious and sometimes fatal illnesses that often times go unnoticed in primary care examinations.

In addition, elderly patients are not being treated with the degree of attention, consideration and dignity that younger patients are given.

Jackson: What are some examples of these disparities in orthopedics?

White: Compared with whites, African-Americans experience lower rates of hip and knee replacements. Diabetic blacks are more often amputated than diabetic whites.

Among all women, women with osteoarthritis of the knees are less likely to receive joint replacements than men.

Hispanics and African Americans in emergency rooms receive less pain medication for long bone fractures. Mortality after a hip fracture is greater among African-Americans than Caucasians.

Jackson: What practical suggestions can you offer to all of us to help us be more culturally sensitive when interacting with our patients?

White: First, recognize that we all have conscious and subconscious biases. Also, we must acknowledge the fact that there are extensive examples for disparate health care in our society. Much of this is based on the lack of culturally competent care capabilities on the part of physicians, nurses and various therapists. There are overwhelming statistics in support of this assertion. The most notable and comprehensive of which is Smedley and colleagues’ 2002 Institute of Medicine report.

It is important to recognize that motivated by our professionalism and our humanitarianism, we can improve on this situation. I respectfully submit that being culturally competent is an important part of our professional and societal responsibility. Cultural competence is not an easy capability to develop; nevertheless, we owe it to our patients to achieve this competency.

Here are some suggestions that we trust will be helpful:

• When treating patients of a culture different from our own, we will do well to learn something of their prevailing practices and preferences. We want to respect and recognize these preferences in a nonjudgmental way. We also want to learn not to stereotype and assume that each individual we identify being as from a given culture will necessarily have all of the practices and preferences that we’ve learned about. In other words, we don’t want to stereotype any individuals by ascribing to them characteristics that they do not in fact possess. The prevailing preferences that we want to be aware of for any given culture we frequently treat will be ideas about pain, disease, treatment, appropriate indications and situations of familiarity, preferred practices for examination and sighting of various body parts.
• It is not practical that we can aspire to have a kind of in-depth knowledge comparable to that of a cultural anthropologist for all the numerous cultures we may encounter. However, for the major cultures that comprise our practices, some knowledge of prevalent concerns of a patient that are different to our own culture will greatly improve and facilitate our patient care.
• The endeavors on our part to gain the knowledge and experience to make us comfortable and effective with the major cultures in our practice will accrue a tremendous benefit to our patients, our community and ourselves. Last but not least, let’s learn the not so difficult skills of utilizing the services of an interpreter.

We can also facilitate, synergize with, support and enhance our cultural competence by addressing the immediate environment in which we practice; including our practice staff and the actual physical facilities. First of all, it is helpful if the composition of the staff reflects the composition of the patient clientele. Also, some cultural sensitivities and concerns in the training and orientation of the practice personnel makes an immense contribution to cultural competence. In regards to the physical plant, pictures or paintings in the waiting room and the examining rooms as well as magazines, care should be taken to make sure that these things address the interest of the patients.

Finally, the CLAS guidelines (National Standards for Culturally and Linguistically Appropriate Services in Health Care) compromise a useful “cookbook” to enhance the cultural capabilities and competence of a given practice. It can be accessed at http://www.omhrc.gov/assets/pdf/checked/finalreport.pdf.

References:

• Dykes DC and White AA III. Getting to equal: strategies to understand and eliminate general and orthopaedic healthcare disparities. Clin Orthop Relat Res. 2009;(467):2598–2605.
• Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academics Press, 2002.
• White AA III. The Orthopaedic Forum: Alfred R. Shands, Jr., Lecture: Our Humanitarian Orthopaedic Opportunity. J Bone Joint Surg (Am). 2002; 84(3): 478-484.

• Augustus A. White III, MD, PhD, the Ellen and Melvin Gordon Distinguished Professor of Medical Education and professor of orthopedic surgery at Harvard Medical School, can be reached at Landmark East 2N07, 401 Park Drive, Boston, MA 02215; 617-998-8802; e-mail: augustus_white@hms.harvard.edu.

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