Many healthcare professionals who work to promote culturally competent medical practices take their definition of the term “

Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed

, which defined it as “a set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enables effective interactions in a cross-cultural framework.” The term, however, is thought to have been first used about a decade earlier, by psychologist Paul Pedersen. In his 1988 

Handbook for Developing Multicultural Awareness

, Pedersen developed a useful multicultural training model that was “an integration of awareness, knowledge, and skills.” It challenges educators to increase their awareness of and examine their own 

, acquire knowledge and “information that facilitates the development of an adaptable, non-stereotyping conception of family communications as well as the cultural, sub-cultural, and social dynamics of diverse groups,” and develop skills that will enable them to incorporate culturally sensitive methods and strategies that are reflected

Known as the Triad Training Model, this was Pedersen’s formula for achieving and teaching cultural competence. Although cultural competence can have an impact on a number of professions, the healthcare community stands to gain the most by incorporating these values into its day-to-day activities. In fact, many studies stress the importance of cultural competence as being vital to providing quality care. An example of this was demonstrated by the 

American College of Cardiology Foundation

, which in 2001 conducted hundreds of studies in cardiac care and concluded that “it is likely that a mix of patient, provider,

and health system factors contribute to disparities in care… such as the varying scope of insurance benefits, patient preferences, or the availability of high-tech cardiac equipment in hospitals.” Another, condition-specific example of this is seen in the well-documented 

racial disparities in diabetes care outcomes

, which include a higher prevalence of diagnosis and diabetes-related complications in minorities and, consequently, a higher rate of kidney disease, eye disease, and coronary artery disease. These are just two examples among many that reveal racial disparities in healthcare access and treatment outcomes, illustrating the importance and potential benefits of incorporating cultural competence training into medicine.

There are two ways in which an organization can improve its level of cultural competence: by hiring a company to conduct an assessment, or by obtaining the proper tools and conducting a self-assessment. Hospitals and healthcare facilities can contact the 

Center for Multicultural Competence in Healthcare Organizations

 (CMCHO), which conducts on-site, organizational surveys that review policies, procedures, clinical outcomes, and physician and employee perceptions, and then make a determination regarding the level of cultural competency at which the hospital is currently functioning. Following this assessment, the CMCHO suggests educational opportunities for the hospital to advance to the next level. Hospitals also have the opportunity to earn a “certification in cultural competency,” a process that includes hospital staff members, selected patients, and community members. Following initial certification, “post-survey measurement provides annual updates of hospital performance and regularly scheduled return visits every three years.” Additionally, an annual list of culturally competent hospitals is published in trade journals, peer-reviewed literature, and consumer magazines, providing incentive to be credited for their efforts. CMCHO is also available to clients for consultation regarding any “cultural competency development, maintenance, or enhancement opportunities” in areas such as administration, marketing, human resources, organizational development, and clinical care.

Organizations can also assess their own cultural competence by referring to online resources like the 

 (NCCC). Clinicians can go to the NCCC website and fill out the cultural competence healthcare practitioner

assessment (CCHPA) or the cultural and linguistic competence policy assessment (CLCPA). The CCHPA asks a series of

questions in the following areas: values and belief systems; life cycle events; cross-cultural communication; and empowerment/

health management. Users who would like to take the CLCPA need to register with the site, at which point they will be able to

download .PDFs pertinent to the assessment. Once the online questionnaires are complete, the program reviews the responses

given for each category and provides feedback, telling users what areas they should improve upon and providing library and online resources that can help improve certain areas of competency.

Another organization that focuses on improving cultural competency in healthcare is the 

 (CCHCP), which serves as “a bridge between communities and health care institutions to ensure full access to quality health care that is culturally and linguistically appropriate.” In addition to providing cultural competency training for healthcare providers and their staff and offering a “Bridging the Gap” medical interpreter training program, the CCHCP provides training in culturally and linguistically appropriate services (CLAs) assessment and implementation and assists in meeting Joint Commission on Accreditation of Healthcare Organizations ( JCAHO) requirements related to CLAs. The CCHCP also provide access to its

Resource Center, which has the latest research in health disparities, publications related to crosscultural health issues such as community profiles, community perspectives on barriers in healthcare, and medical glossaries in 24 languages.

Although the programs are generally instituted by healthcare organizations dedicated to improving institutional awareness of cultural issues, there are numerous factors that are directly related to the success of these programs. Ira SenGupta, MA, Executive Director of the Cross Cultural Health Care Program and past director of cultural competency programs, explains that the following circumstances and conditions are necessary for success: commitment from leadership to sustain the initiative, dedicated intent by an organization to provide culturally and linguistically appropriate services, a centralized program in which the organization is dedicated to organizing these services, trained medical staff language interpreters, a team of internal trainers who can sustain the training efforts of the organization, effective community outreach programs, and community engagement and presence on institutional boards and advisory committees.

Although it has been gaining momentum and popularity as a fashionable term in the healthcare industry, there are still many critics who maintain that putting too much stress on cultural competency and sensitivity misses the point a bit, and that it is more important that physicians concentrate on providing sound, evidence-based treatments that meet accepted standards of care. Asked about this contrary point of view, representatives at the NCCC countered by referring to the Institute of Medicine’s book titled 

Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences

, which states that racial and ethnic disparities in healthcare occur “in the context of broader historic and contemporary social and economic inequality;

many sources—including health systems, healthcare providers, patients, and utilization managers&mdash;may contribute to racial disparities in healthcare; and that bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.”

Representatives at the NCCC also stated that “if disparities and inequities could be solved by what is currently considered the

‘evidence-based treatments’ (a body of science that is seriously lacking in research that addresses cultural and biological

differences), then we would not be having this conversation, nor would the evidence continue to document the persistent

disparities in death, illness, and disability among specific racial and ethnic groups in the US.” In addition, SenGupta cites the

following reasons for providing cultural and linguistic services that are supported by research: access, quality, and cost of care;

risk management; federal requirements; and business sense.

There is plenty of evidence to suggest that culture is important in the clinical setting—it is crucial to diagnosis, treatment, and

care, and has been shown to shape health-related benefits, behaviors, and values; however, are there ways to improve how healthcare practitioners go about doing so?

Arthur Kleinman, MD, a psychiatrist at Harvard University, and Peter Benson, PhD, assistant professor at Harvard University,

both students of anthropology, explored the barriers to cultural competency in their 2006 article, “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It.” Published by the 

, a peer-reviewed open-access journal, the article discusses the problem of how cultural competency suggests that “culture can be reduced to a technical skill for which clinicians can be trained to develop expertise,” and how this creates the idea that isolated societies share all cultural meanings (ie, “Koreans believe this,” and “Americans believe this”). Kleinman and Benson also noted that another problem with incorporating cultural factors in the healthcare setting is that they are not always central to a case and may actually hinder a more practical understanding of the issue at hand. They also note that “cultural processes frequently differ within the same ethnic or social group because of differences in age cohort, gender, political association, class, religion, ethnicity, and even

, the two men came up with a different approach to incorporating culture into healthcare.

Kleinman and Benson contend that the best approach to making clinicians more culturally sensitive was to train them to perform social research from the native’s point of view by “appreciating and humanly engaging with their foreignness, and understanding their religion, moral values, and everyday practices.” They argue that this exercise in “mini-ethnography” is what really matters—understanding what is “really at stake for patients, their families, and, at times, their communities, and also what is at stake for themselves.” The reason for doing this is because cultural values may conflict with evidence-based clinical determinations (such as in the case studies referenced in their article). Cultural competency could become overbearing or even nonessential when dealing with a patient who identifies with more than one ethnic background. Clinicians should then be able to use this information in thinking through treatment decisions and negotiating with the patient. By doing this, the clinician can focus on “the patient as an individual, not a stereotype; as a human being facing danger and uncertainty, not merely a case; as an opportunity for the doctor to engage in an essential, moral task, not an issue in cost-accounting.”

Aside from demographic changes and health disparities, legislative, regulatory, and accreditation mandates will ensure that this area will continue to receive the attention it deserves. As SenGupta points out, the JCAHO, which accredits more than 15,000 healthcare organizations in the United States, has now teamed up with the National Committee for Quality Assurance and URAC (formerly known as Utilization Review Accreditation Commission) to combine standards into their accreditation

requirements. The NCCC sees a future in which “medical, health, and mental health professions’ academic training programs integrate core content on cultural and linguistic competency in all curricula and avoid having this content taught as a single course or elective.” As the push for cultural competence becomes more pronounced in the coming years, goals and implementation techniques are sure to evolve, and healthcare providers should be advised to embrace the addition of this knowledge, because, as Dr. Schyve put it, cultural competency is a “growing issue that is not going to go away.” 

Articles

FOCUS Multicultural Healthcare

Many healthcare professionals who work to promote culturally competent medical practices take their definition of the term "cultural competence"...

Spotlight On... Cultural Competence Assessment and Training

If modern connective technology is changing the face of contemporary medicine in the United States, then the nation’s shifting demographics are changing its voice as well. In 1990, approximately 31.8 million Americans spoke something other than English as their primary language; around 14 million had what is called limited English proficiency (LEP; defined as a limited ability to listen to, speak, read, and/or write in English). By the year 2000, the number of US residents with LEP had increased by 50%, to 21 million; 45% of turn-of-the-millennium Americans spoke one of more than 150 non-English languages at home.

Given that the percentage of healthcare providers who are fluent in 150+ languages is rather small, the result of these demographic changes is a constantly increasing proportion of patients who are unable to communicate clearly with their physicians, with consequent difficulties including reduced or nonexistent access to healthcare benefits and services (including

Medicare/Medicaid), the complication of the diagnostic process, reduced subjective satisfaction for all parties, and—potentially&mdash;the violation of the patient’s civil rights.

One solution for overcoming these challenges is to employ interpreters in the healthcare setting. However, haphazardly assigning interpreters with no medical training or knowledge apart from fluency in a particular language carries its own hazards. An interpreter who knows the language and dialect of a patient but isn’t comfortable or familiar with medical terminology in either English or the patient’s language may struggle to communicate key diagnostic questions or treatment instructions. An interpreter who doesn’t understand the patient’s cultural background may be unable to appropriately communicate the true meaning

, “addressing language barriers can influence medical outcomes by improving access and the quality of services provided, reducing medical errors, and increasing patient adherence with care regimens.” In many cases, it can also be a legal necessity, with roots dating back to the 1964 Civil Rights Act. From the Act’s Title VI, Section 601: No person in the United States shall, on the ground of race, color, or national origin, be excluded

from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.

Four decades of case law have confirmed an interpretation of this statute, under which providers receiving federal funds must make accommodations for patients with LEP. At minimum, says the US Office of Civil Rights (OCR), providers must make available language services at no cost; these services must be sufficient to “ensure that the LEP person is given adequate information, is able to understand the services and benefits available, and is able to receive those for which he or she is eligible.”

Programs attempting to comply with this provision—and violating Civil Rights legislation passed in 1964 is generally bad business and bad medicine whether or not one is receiving federal funds&mdash;are encouraged to conduct a thorough self-assessment, develop a written policy, and train staff on its execution. The OCR’s 

 offers advice on specific approaches to this problem, including the hiring of bilingual staff members, the use of contract interpreters or community volunteers, and the use of telephone interpreter lines like 

. The latter alternative may be particularly useful in providing rapid response. However, a telephone-based interpreter may not always be available (in case of equipment failure, for example) or may be unfamiliar with the terminology specific to a given practice; such services should never be relied upon as the only language-assistance option.

Also required under Title VI: the translation of written materials routinely provided to patients in English into all languages commonly encountered in regular practice. Specifically, compliant practices should translate all materials into languages spoken by 10% or 3,000 members of the likely patient population, translate vital materials (such as consent or benefit enrollment forms) into languages spoken by 5% or 1,000 members of the likely patient population,\ and provide notice in other languages of the right to receive competent oral translations.

From the Very Long Acronym Department On December 22, 2000, the Federal Register published a new set of national standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS), created by the US Department of Health and

Human Services’ Office of Minority Health (HHSOMH).

gov/assets/pdf/checked/executive.pdf) include three types of

standard: (1) Mandates, which are required for all recipients

of federal funds; (2) Guidelines, which accrediting

agencies are encouraged to adopt as standards; and (3)

Recommendations, which are considered strictly voluntary.

Of the CLAS Standards, four deal directly with the issue

of patients with LEP; all are mandates. These standards

(numbers 4-7) are quoted in the box below. The first

CLAS Standard summarizes the philosophy underlying the

entire group: Healthcare organizations should ensure that

patients/consumers receive from all staff members effective,

understandable, and respectful care that is provided

in a manner compatible with their cultural health beliefs

The OMH offers a practical guide to compliance with

assets/pdf/checked/CLAS_a2z.pdf. Key recommendations are

summarized on the next page; readers are encouraged to

• An initial self-audit is critical; providers are advised

to study the evolution of their own patient demographics

Practices should assess whether they can handle

incoming telephone calls, whether diverse reading

materials in the waiting room are available, whether

signage describing office policy is translated, and

so forth. The AAFP website links to “I-Speak” language

flashcards, which allow quick identification of

• Institutions are advised to employ an on-staff interpreter

for each language group from which they see

• Other language groups may be handled via medical

interpreters hired on an “as needed” basis, bilingual

staff members who are certified and have completed

specific training, or telephone services.

The National Council on Interpretation in Health

whose mission is to “promote culturally competent

professional healthcare interpreting as a means to support

equal access to healthcare for individuals with

[LEP].” The Council addresses unresolved issues surrounding

the use of interpreters in a healthcare setting

in a series of working papers accessible through its

site. According to the paper “The Role of the Health

Care Interpreter,” by Maria-Paz Beltran Avery, PhD,

the most critical of these issues concerns the definition

and limitations of the interpreter’s role (

NCIHC_PDF/TheRoleoftheHealthCareInterpreterAnEvolving

“If meaning rather than literal conversion is the

goal,” asks Avery, “should the interpreter also convey

the emotional tone and affective content of the message?”

Historically, the interpreter has focused on being a

mechanical operator, and providing straightforward interpretation

without editorializing; should the contemporary

interpreter instead serve as an advocate for patient rights?

Should the interpreter be considered a full member of the

healthcare team? “When I arrive and find that the family

is waiting and the doctor is not yet ready, I visit with [the

family] in the waiting room,” one community interpreter

told Avery. “This way I can learn many things about them...

it helps me do a better job when we meet with the doctor.”

Developing a relationship like this with the patient and

his/her family can enable the interpreter to provide true

“cultural translation,” assisting the doctor in understanding

the patient more clearly, as opposed to pure linguistic translation.

However, says Avery, this sort of assertive “cultural

brokering” can reduce the quality of the translation and

increase complications if not handled carefully.

Related problems are associated with the use of friends,

family, and minor children as interpreters in a pinch. The

OCR notes that the use of such persons could constitute a

breach of confidentiality. Moreover, “such untrained individuals

often [have] little or no understanding of medical

concepts or terminology,” says Avery. Meanwhile, many

patients may be uncomfortable discussing sensitive medical

matters around close family and be less than perfectly open

In the end, opines Avery, “the interpreter cannot

remain a passive, uninvolved party. There are times when,

because of the cultural distance between the parties, the

interpreter may have to serve as a cultural bridge. Fidelity

to meaning may require the use of metaphors as well as

negotiated explanations of concepts that do not necessarily

If modern connective technology is changing the face of contemporary medicine in the United States, then the nation's shifting demographics are changing its voice as well.

A Failure to Communicate: Caring for Patients with Limited English Proficiency

spoke with Robert C. Like, MD, MS, Professor and Director of the 

Center for Healthy Families and Cultural Diversity

, Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, to discuss his efforts to improve cultural competency in healthcare.  

As the director at the Center for Healthy Families and Cultural Diversity, what role do you play in maintaining the goals of the Center? 

I’m a family physician with a background in medical anthropology and, as the director at the Center, have been involved in providing training and technical assistance for more than 20 years to groups of healthcare professionals—physicians, nurses, and other allied health professionals&mdash;as well as hospitals, managed care plans, ambulatory practices, academic medical centers, community groups, governmental agencies, and other entities who are interested in improving the quality and safety of care provided to our increasingly diverse populations. The Center has given more than 450 invited workshops, seminars, grand rounds, and conference presentations to a wide variety of health and human services professionals, both in the United States and abroad. Topics addressed have included eliminating racial and ethnic disparities in health and healthcare, culturally competent patientcentered care, caring for patients with limited English proficiency, addressing cross-cultural health literacy challenges, and becoming a culturally competent healthcare organization. In the past, the Center has received funding to carry out multi-method research and evaluation relating to the effectiveness of cultural competency training. I also have collaborated on educational projects with colleagues in the European Union, Israel, and Australia.  

Can you explain the importance of addressing the problems related to poor cultural competency within healthcare? 

The patients that my colleagues and I care for come from many ethnic, racial, and socio-cultural backgrounds. In order to provide patient-centered, family-focused, community-oriented care, we need to better understand both our patients’ health beliefs and practices, as well as how our own professional and personal attitudes, beliefs, and values can impact clinical encounters. By doing so, we hopefully can do a better job of developing a therapeutic alliance and caring for patients with illnesses like cardiovascular disease, cancer, diabetes, and depression, as well as providing appropriate health promotion and disease prevention services. Published research from organizations like the 

Agency for Healthcare Research and Quality

Centers for Disease Control and Prevention

Health Resources and Services Administration

 has shown that not only do people from different backgrounds have unequal access to care, but they also have disparities in health outcomes and in healthcare itself. One approach to help reduce these disparities in care is to provide cultural competency training and link this to ongoing quality improvement and patient safety interventions in healthcare organizations.  

What are some misconceptions physicians might have regarding culturally competent care? 

There are a number of things I frequently hear; for example, “Isn’t this just political correctness [PC] run amuck?” For me, PC is more about being professionally and personally caring with all of my patients. I also hear people say, “Well, how do you expect me to learn about every different population on the planet?” This, of course, is not feasible, nor even the goal of cultural competency training. The real issue is, are there clinical interviewing skills and approaches that can help us learn more about what is meaningful to each and every person we see so that we don’t create stereotypes or practice “cookbook” medicine, but instead can individualize care? There are certainly many challenges in everyday practice that come up, given that clinicians are very busy struggling with financial pressures, increased paperwork, numerous regulations, and other competing demands. So, the challenge becomes, “How can my office staff and I make practical use of this information and improve the quality of care provided to our patients?”  

Do you think you and your colleagues have been successful in your efforts to raise physicians’ awareness and make them more conscious of maintaining a culturally aware practice? 

I believe that demographic change; market forces; quality improvement and patient safety initiatives; legislative, accreditation, and regulatory activities; and educational efforts are increasing healthcare professionals’ awareness about the importance of providing more culturally responsive and effective services to our increasingly diverse population. Influential national organizations such as 

 are also beginning to make use of the Office of Minority Health’s National Standards for 

Culturally and Linguistically Appropriate Services

 (CLAS) in Health Care in some of their assessment and evaluation programs. The development of cultural competence is an ongoing journey, and people are beginning to “walk the talk.” There is much work left to do, however, especially in the areas of healthcare policy, reimbursement, and systems reform in order to support and sustain these nascent activities over the long-term.

In your opinion, what is the most interesting research being done in this area now? 

Thanks to federal and private foundation funding, cultural competency is increasingly being investigated at the clinical, organizational, and systems levels. Researchers are actively studying whether the delivery of culturally and linguistically appropriate services helps to reduce racial and ethnic disparities for different medical and mental health problems. They are also evaluating the effectiveness of quality improvement and patient safety interventions in healthcare settings serving diverse populations. This research is making use of both quantitative and qualitative methods and is increasingly being done in collaboration and partnership with communities. I personally believe that clinical cultural competence training, while important and necessary, will not be sufficient. We must also significantly transform the healthcare organizations and systems we work in. The current interest in developing “patient-centered medical homes” is an example of one very promising initiative that merits further study. Two additional topics that are also increasingly attracting the attention of researchers are: 1) patient safety/risk management concerns related to caring for people with limited English proficiency, low health literacy, and/or other communication challenges, and 2) making the business case for cultural competence as well as the potential impact of pay for performance and other reimbursement strategies on disparities in health and healthcare. 

What role does healthcare technology play in regards to cultural competency? 

This is an important subject area that people are just beginning to take a look at. Electronic health records (EHRs), for example, are being used by some healthcare organizations to collect patients’ ethnicity, race, and primary language data in ongoing quality improvement and patient safety initiatives involving diverse populations. The appropriate stratification and analysis of this data can permit clinicians, administrators, and researchers to look for potential disparities in health outcomes and healthcare utilization and develop strategies to address these. The problem is that most medical EHRs, to my knowledge, don’t have specific fields in place yet for race, ethnicity, and primary language, unless they’re specially customized. It is important for practices with EHRs that want to address health disparities issues and provide more culturally and linguistically appropriate care to make sure that they have the ability to collect and access the necessary information. Having centralized information is also very helpful in improving access to care for patients with limited English proficiency that need interpreters or translation assistance when they go to a hospital, ambulatory clinic, pharmacy, laboratory, or other site in the service delivery system. When physicians prescribe medications or provide patient education materials, it’s important that this be done in a language that patients understand and the EHR could help. The emergence of new face-to-face, telephonic, and video interpreting technologies is also proving to be extremely valuable. One of the more controversial topics is the collection of racial, ethnic, and primary language data from patients. If we’re going to reduce disparities in healthcare experienced by different population groups, it’s important to know who they are. National efforts are underway via the 

 (HRET), which has developed a helpful race, ethnicity, and language data collection toolkit. The toolkit helps to train staff on how to collect this information in a more sensitive way so that people self-identify rather than being arbitrarily assigned to a category by looking at someone’s name or appearance and guessing. The 

, with funding from the Robert Wood Johnson Foundation, has also developed an educational DVD and related resources to assist hospital admissions and clerical staff on how to collect this information. 

How can private-practice physicians, hospitals, and other healthcare organizations become more culturally competent? 

There are already many excellent practice improvement frameworks and strategies that have been developed by groups such as the 

National Initiative for Children’s Healthcare Quality

. The goal is to provide care that is more patient-centered, effective, timely, efficient, and equitable. These were the pillars of quality care recognized in the Institute of Medicine’s “Bridging the Quality Chasm” report. As our population becomes more diverse and we experience cultural and language challenges, we must strive to make quality improvement itself more culturally and linguistically competent. This will require practices to carry out “organizational cultural competency selfassessments,” and fortunately a number of excellent tools are available that can be helpful (eg, 

). Inviting patients and families to actively participate in the process of defining what quality of care looks like from their perspective by becoming members of quality improvement teams is another innovative strategy being employed by some practices. There are also efforts underway in which physicians and staff are working closely with local communities, faith-based organizations, and advocacy groups to better understand what people’s healthcare priorities are and to collaboratively design interventions that are evidence-based, effective, and mutually acceptable. I think what we can do is integrate the best and promising practices from the cultural and linguistic competency field into our many excellent national, state, and local quality improvement and patient safety efforts. We need to become a “learning community of practices” that engages in ongoing critical reflection designed to improve clinical practice and patient outcomes. 

Would further study of cultural competency in medical school and during post-graduate training be beneficial? Would it help alleviate some of the problems? 

I believe it will make a big difference. In fact, the Liaison Committee on Medical Education already has a mandatory cultural diversity accreditation requirement for medical schools and the Association of American Medical Colleges (AAMC) has developed a 

Tool for Assessing Cultural Competency Training

. The Accreditation Council for Graduate Medical Education has also called for a “a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse population,” as well as “sensitivity and responsiveness to patients’ culture, age, gender, and disabilities,” in their Professionalism outcomes-based competency requirement for residency training programs. In a recent issue of the 

 was published that provides recommendations for teaching medical students, residents, and practicing physicians about racial and ethnic disparities in health and health care. Specific curricular topics that should be addressed include: “1) examining and understanding attitudes, such as mistrust, subconscious bias, and stereotyping, which practitioners and patients may bring to clinical encounters; 2) gaining knowledge of the existence and magnitude of health disparities, including the multifactorial causes of health disparities and the many solutions required to diminish or eliminate them; and 3) acquiring the skills to effectively communicate and negotiate across cultures, languages, and literacy levels, including the use of key tools to improve communication." Finally, at the level of policy and legislation, there are several states that have already passed or are considering bills requiring cultural competency training for physician licensure through continuing education as well as educational initiatives for other healthcare professionals (Graves DL, Like RC, Kelly N, and Hohensee A. “Legislation as Intervention: A Survey of Cultural Competence Policy in Health Care.” 

2007; 10(2):339-361). These efforts, unfortunately, are currently unfunded mandates, and it remains to be seen how they will be planned and implemented, the quality and relevance assured, and their impact and effectiveness evaluated. These important issues need to be addressed, and I’m sure there will be many lessons learned.

Disclaimer: The opinions expressed in this article are those of Dr. Robert Like and not necessarily the opinions of the Center for Healthy Families and Cultural Diversity/Department of Family Medicine/UMDNJ-Robert Wood Johnson Medical School or any other organizations with which he is affiliated. 

Health Resources and Services Administration: Health Literacy 

A Physician’s Practical Guide to Culturally Competent Care 

Quality Interactions: A Patient-Based Approach to Cross-Cultural Care 

Resources to Implement Cross-Cultural Clinical Practice Guidelines for Medicaid Practitioners 

Self-Assessment Checklist for Personnel Providing Primary Health Care Services 

Should Your Practice Collect Patients’ Race & Ethnicity Data?

Telephone Interpreting in Health Care Settings: Some Commonly Asked Questions 

MDNG spoke with Robert C. Like, MD, MS, Professor and Director of the Center for Healthy Families and Cultural Diversity, Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, to discuss his efforts to improve cultural competency in healthcare. 

December 2007

Spotlight On... Cultural Competence Assessment and Training

A Failure to Communicate: Caring for Patients with Limited English Proficiency

Q&A with Robert Like, MD, MS