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States increasingly requiring cultural competency courses to improve patient care
Understanding ethnic backgrounds and cultural taboos can lead to better medical outcomes.
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An increasingly diverse patient population is raising awareness of the need for cultural competency care education for medical schools and physician re-licensure in certain states.
In 2002 New Jersey, for example, passed legislation requiring all medical school curriculums to include at least one cultural competency course, “designed to address the problem of race and gender-based disparities in medical treatment decisions.” In addition, all New Jersey medical students must now complete at least one cultural competency course to receive a diploma. Out-of-state physicians and those applying for re-licensure must document at least 16 hours of cultural competency training.
New Jersey won’t be the only state for long. Arizona and New York are considering legislation that will also require at least one cultural competency course at each medical school and the successful completion of a cultural competency course to achieve a diploma.
In California and Illinois, legislators are considering cultural and linguistic competency acts, which will require not only cultural competency courses, but foreign language courses as well. Illinois officials describe these courses as “a foreign language at the level of proficiency that initially improves their ability to communicate with non-English speaking patients” and “understanding and application of the roles that culture, ethnicity and race play in diagnosis, treatment and clinical care.”
If passed, the California law will take effect on July 1.
Why cultural competency?
In New Jersey, legislators referred to a 1999 study in the New England Journal of Medicine that found a patient’s race and sex independently influence how physicians manage chest pain. Physicians reported lower mean estimates of coronary artery disease probability for women than men (64.1 ± 19.3% vs. 69.2 ± 18.2%). And logistic-regression analysis indicated that women were less likely than men, and blacks less likely than whites, to be referred for cardiac catheterization.
“As we see the world and as we see the United States becoming increasingly diverse, our patient populations are becoming increasingly different,” Ramon Jimenez, MD, American Academy of Orthopedic Surgeons (AAOS) Diversity Committee chairman told Orthopedics Today.
Specifically, orthopedics has not kept up with the increasing diversity of the general population. For example, 14% of the U.S. population is Latino, while only about 2.4% of orthopedic surgeons are Latino, said Jimenez, who is also an Orthopedics Today editorial board member. What is more, African Americans represent about 12% of the population, but only about 3% of the orthopedic surgeon population.
Orthopedic surgeons should have some knowledge of their patients’ different ethnic backgrounds, in part because it can lead to better outcomes, Jimenez said. He presented the example of “a 50-year-old Latino male who has all the clinical signs, symptoms and MRI evidence of a ruptured disc with impingement on the nerve roots and other significant problems.”
“If a surgeon is just not aware and is not practicing culturally competent care for this Latino individual, and then says, well, you have all the signs and we have all the evidence that you have a blown disc and you need to have surgery. And if possible, you need to have a lumbar epidural injection and you'll be out of work for three months ... and then moves on, the patient may seemingly acknowledge what the surgeon is presenting, but leave and never return.”
In this case, Jimenez explained, if the surgeon had been practicing cultural competency, he would have addressed the underlying issues that are common with Latino male patients: the patient’s role as the only family provider, his innate fear of surgery and his “machismo spirit” that may prevent him from admitting that fear. “This patient has not been served well and neither has the doctor,” Jimenez said.
Are you culturally competent?
Speaking the language is helpful, but not absolutely necessary, Jimenez said. Instead, physicians need to address a minority patient’s views of medicine, as well as his or her attitudes toward medications, authority, death and surgery, Jimenez said.
Offering other examples, he said, a Hispanic woman generally cannot give consent to surgery without her husband’s approval and a physician typically should not be alone with a Muslim woman patient. And although Jimenez said he typically asks all patients for permission before examination, he stresses asking permission of Muslim and Indian patients. Physicians may also find that some Native Americans and Alaskan Natives use rituals, herbals and invasive techniques, such as poultice dressing on a postop wound or for needling a joint.
“If you are aware, curious, compassionate, sensitive ... you will practice culturally competent care,” Jimenez said. “You will retain patients and get more patients.”
Programs and mentoring
AAOS and other medical groups have developed programs and materials that aim to expose physicians to cultural competency care. The AAOS offers seminars on how to talk to and give better care to patients, as well as a CD-ROM with 18 case studies that test a physician’s cultural competency.
“We have a mentoring program that’s available with about 350 mentors across the United States and we matched them with about 280 to 300 or so medical students,” Jimenez said. “Those mentors are, for the most part, culturally competent and at least aware of it and will impart this knowledge to those students.”
As for physicians who have been in practice for a long time, Jimenez said it is important for them to always know their population and keep up with it. “If their population is changing and they don’t act positively to it and change themselves, and if they don’t perceive a need for culturally competency care, then they probably won’t change,” he said. “But if they do perceive a need and they want to know how best to treat their patient populations, then this information [and these programs] are for them also.”
For more information:
- Schulman K, Berlin J, Harless W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med. 1999;340:618-626.