A different kind of competency

Juan Lopez, a Hispanic man with limited English proficiency, is admitted to your hospital with severe abdominal pain. You think he needs surgery, but he insists that the pain is the result of a hex, and requests treatment from a witch doctor. How do you respond?.


Juan Lopez, a Hispanic man with limited English proficiency, is admitted to your hospital with severe abdominal pain. You think he needs surgery, but he insists that the pain is the result of a hex, and requests treatment from a witch doctor. How do you respond?

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The Joint Commission recently posed this question to physicians and nurses at 60 U.S. hospitals and got a wide variety of responses. “Some of the responses were too horrifying to be laughable, but the bottom line was that none of these individuals wanted to cause harm. They were just stumped,” said Amy Wilson-Stronks, principal investigator for the commission's Hospitals, Language and Culture (HLC) project.

The pressure on physicians to correctly answer questions like this one—in both real and hypothetical situations—is growing. In addition to the Joint Commission project, hospital administrators, federal regulators and state licensing boards are currently looking at the ability of physicians and other health care providers to properly treat patients of different cultural backgrounds. Their methods for improving cultural skills and understanding vary widely and debate is heated about what kind of training is appropriate (if any), whether it has any impact on the cost and quality of care, and if there's enough evidence to justify making such training mandatory.

“On the one end, there are people that feel like this is the flavor of the month,” said Sunita Mutha, FACP, an associate professor of medicine at the University of California, San Francisco who trains physicians in cultural competency. “The other end of the spectrum is that this is the most important thing because this is all about communication and communication is what impacts medical errors, satisfaction, quality and adherence.”

Cultural what?

The debate on the subject even extends to its name. Although much of the research and legislation on the topic refers to “cultural competence,” most experts in the field dislike the word competence for its implication of a specific, achievable objective.

“A lot of people in the field have never been comfortable with the term cultural competence,” said Jacqueline (Voigt) Dieball, who is the cultural competency manager of the University of Michigan Health System. “One never really becomes 100% competent in this evolving field. We're not trying to imply that you can become competent.”

Cultural competency can be as simple as developing a rapport with your patient experts say
Cultural competency can be as simple as developing a rapport with your patient, experts say.

Cultural sensitivity, cross-cultural practice, cultural pluralism, patient-centered care—all of these terms are being used to describe the same basic goal of eliminating the barriers to health care that are caused by cultural differences.

The experts do agree, however, on what's driving the current interest in cultural competency. “If we look across the nation at the census data, there's been a marked increase in the number of people who have limited proficiency in English,” said Dr. Mutha. Cultural competency programs typically deal with both the language and cultural diversity that come with a growing immigrant population.

The effects of immigrant population growth are rippling throughout the medical community, most notably in emergency departments, obstetrics and pediatrics, she said. “The demographics are that the diversity of the pediatric population is way greater than the geriatric population because the birth rates are higher. This is not an issue that's going to go away.”

Dealing with this diversity will require more than hiring additional interpreters, according to Joseph R. Betancourt, MD, director of multicultural education at Massachusetts General Hospital and co-founder of a cross-cultural training business.

“Over the last 10 to 15 years, we've seen significant evidence emerge that social and cultural factors really matter in the clinical encounter,” he said. He and others pointed to an array of evidence, including the Institute of Medicine's Unequal Treatment report, which indicates that racial and ethnic minorities face disparities in health care, even when researchers control for insurance status, age and income.

Fixing the problem

With the reality of disparities acknowledged, the question becomes how to remedy them. Dr. Mutha, for one, believes that cultural competency training can help. Physicians can be taught how to have smoother, more effective interactions with a diverse group of patients, whether they speak a foreign language, believe in traditional remedies or follow particular dietary rules.

“It's getting people to be a little more self-reflective and also to recognize the unconscious biases that we may have. These are not conscious decisions that people are making,” she said. “The attitudes and awareness piece is often the most challenging.”

The knowledge piece of cultural competency education, however, can be the most controversial. Everyone agrees that physicians need to know how to work with translators or to understand that they might be biased, but there's debate over what these programs should teach about different cultures.

“The way that most cultural competency programs seem to be organized suggests that there's a fair chance that they contribute to stereotyping, which I think is the greatest possible danger you can have from an intervention in the cultural area,” said Arthur Kleinman, PhD, a professor of anthropology and psychiatry at Harvard University who has studied cultural competency education.

The problem is, as Dr. Mutha puts it, that “information is most useful if it's really specific.” As a physician who cares for a large number of Russian immigrants and deaf people, she is most interested in learning more about those cultures rather than generalities about cultural difference.

However, education about the traits of specific racial, ethnic or religious groups could lead physicians to make incorrect assumptions about everyone in those groups, worry critics of cultural competency programs. The textbook example of this sort of bad cultural competency training is the “cookbook” approach, which offers providers five useful facts about Puerto Ricans or Somalis, for example.

About 20 years ago, Dr. Kleinman was approached by an organization that wanted him to develop pocket cards for clinicians and house officers that would list an ethnic group, its core beliefs, and information on how to treat patients in that group. “I told them I wouldn't do it because I thought it was the problem, not the solution,” he said.

A perfect balance

Representatives of cultural competency programs argue that they have moved beyond those kinds of errors to a healthy balance between providing usefully specific information and avoiding stereotyping.

At Boston University Medical Center, for example, a team of anthropologists has developed an online country guide that physicians can consult when looking for information on how to treat a patient from another culture. The guide provides links to multiple Web sites on each topic. “We look for every example we can find of pluralism and complexity within that country of origin. That's trying to avoid saying, ‘If someone is from this place, then they are…’” said Linda Barnes, PhD, a medical anthropologist and director of the project.

Teaching physicians to apply their training on an individual basis without stereotyping is a key component of cultural competency training, according to Ms. Wilson-Stronks. “The idea is really being open to hearing what the patient believes is going on with them in terms of their health, being aware of what they think is appropriate treatment. Have cultural norms in the back of your head, but don't apply them until the patient makes it clear that they believe in them,” she said.

The examples of patient beliefs that cultural competency trainers give—hexes, curses, witch doctors—are usually things that physicians would have trouble accepting as appropriate treatment, but that is actually the point of the lesson. “You don't have to believe everything that the patient believes, but you have to understand where they're coming from,” said Dr. Mutha.

Cultural competency programs use a variety of tools to increase this understanding—from email updates to group sessions with role playing to online training programs. The most important requirement is that programs be multifaceted and ongoing, according to Ms. Wilson-Stronks. “[The ideal programs] may have annual cultural competency training, but they incorporate this idea of cultural competence and patient-centered care into everything they are doing. They'll have policies and procedures that support the concept of cultural competence, and understanding and responding to the needs of the patient population will be a focus of strategic planning and resource allocation,” she said.

Mandated training

Of the entities that have mandated cultural competence training, California's policy conforms most closely to this multifaceted approach. A law enacted by the California state legislature in 2006 requires that all continuing medical education courses include curriculum on cultural and linguistic competency.

New Jersey and Washington have also passed laws requiring cultural medical education, and legislation is pending in Illinois, New York and Ohio. “New Jersey's probably the most stringent. They're just about to release regulations that would require six hours of training as a condition of licensure,” said Dr. Betancourt. “It's going to be a continuing issue as we go forward. People are looking at a combination of carrots and sticks.”

Whatever the incentives, Dr. Kleinman doubts that medicine will find a way to adequately account for patients' diverse cultures. “There are a variety of things that make it very unlikely that any serious approach to culture in medical care will ever be practiced on a routine basis, no matter how well it is taught. You have almost everything working against it,” he said.

He listed short patient visits, the cost-focused business model of medicine, and bureaucratization of the system as primary obstacles. He also expressed concern about the dearth of evidence proving that cultural competency training actually has an effect on patient outcomes.

“It's not that [the research] has failed. It just hasn't been done. I think medicine makes a totally rational request that such evidence be provided,” said Dr. Kleinman.

A 2005 review of cultural competence interventions, published in Medical Care, found that training improved the knowledge, attitude and skills of health professionals and increased patient satisfaction, but that there was little evidence that the programs affected adherence or outcomes. One study of pediatric asthma patients (in the July 2004 Pediatrics) did find a link between the cultural competence of health care organizations and appropriate use of preventive services.

Experts in the field can provide numerous examples of how cultural competence could potentially affect both cost and outcomes. “The ER is much more likely to order a CAT scan for somebody who has a pain in their head who they can't understand than somebody who they can have an articulate conversation with,” said Dr. Betancourt.

He also noted that recent research has shown that cross-cultural populations tend to have longer lengths of stay. “One might hypothesize that they may be due to difficulty getting informed consent or taking longer because you have to deal with family issues or other challenges,” he said.

Dr. Mutha believes that cultural competency training also could reduce errors. “A lot of hospitals when they do root-cause analyses, the cause that ultimately led to an error had to do with communication,” she said.

Future steps

Medical schools, at least, appear to have been convinced of the value of cultural competency. The Liaison Committee on Medical Education has added cultural competency education to its accreditation standards and schools have complied by adding cultural facets to their programs.

Part of Dr. Barnes' project in Boston is to educate medical students about diverse approaches to healing. Every year she takes a group of fourth-year medical students to meet traditional practitioners from different cultural communities including, for example, a local voodoo priest. “It blows every stereotype they ever had about a voodoo priest,” she said.

In addition to the efforts of med schools and residency programs, The Joint Commission is working on updating its standards in this area. Ms. Wilson-Stronks' hypothetical patient was part of a larger project to uncover current practices that hospitals have implemented for delivering care to diverse cultures, to assess hospital administrators' thoughts on cultural competency, and to determine the needs of health care organizations related to the issue. The first report from the HLC project, “Exploring Cultural and Linguistic Services in the Nation's Hospitals,” shares a “snapshot” of current practices and is available at jointcommission.org or by calling 630-792-5957. Ms. Wilson-Stronks' theme-based report, “One Size Does Not Fit All: Meeting the Needs of Diverse Patients,” is scheduled for release in late February or early March.

As for what happened to her hypothetical patient Juan Lopez after he asked for the witch doctor, “We did come across some nurses and some doctors who were definitely culturally sensitive,” Ms. Wilson-Stronks said. “Someone who was in that situation may say to the patient, ‘Oh, OK, I understand. Let me see what I can do to find a traditional healer who can help treat that problem. In the meantime, there are some other things that I believe are contributing to your pain that we can take care of here.’”