Doctors Need to Learn Cultural Competency in a Changing Healthcare World

November 20, 2008

The demographics of the United States are shifting rapidly. According to the Census Bureau, minorities currently constitute approximately 32% of the U.S. population.

The demographics of the United States are shifting rapidly. According to the Census Bureau, minorities currently constitute approximately 32% of the U.S. population. Projections say that percentage will increase to 35% by 2010, 40% by 2025, and 50% by 2050.

“It’s not very far off where there will be no majority culture,” says Richard O’Brien, MD, FACP, a professor at Creighton University. “We’ll all be minorities.”

That change is increasing the diversity of patients seen by physicians and other health professionals. It’s also increasing the challenges of providing effective healthcare.

Change brings frustration

Robert Schwartz, MD, chair of the Department of Family Medicine and Community Health at the University of Miami Miller School of Medicine, has seen the impact of the cultural divide taking place in south Florida. He says that older Caucasian physicians who didn’t take the time to learn Spanish as their patient populations were changing are now frustrated.

“Older populations have left the community and been replaced by younger Hispanics,” explains Schwartz. “Physicians are challenged, not just from a language perspective, but also understanding the culture and the nature by which people from other countries approach healthcare. The culture differs from Cuba to Venezuela to Columbia to Brazil, as do the expectations of the healthcare system and their physicians.”

Ramon Jimenez, MD, senior consultant for Monterey Peninsula Orthopaedic and Sports Medicine Institute in Monterey, Calif., and a spokesperson for the American Academy of Orthopaedic Surgeons, says the old mantra of treating all patients the same doesn’t work any more. He credits a colleague with coining the phrase, “you may have to treat patients differently in order to treat them equally.”

“You have to treat [patients] the way they want to be treated, not the way you think they ought to be treated,” says Jimenez. And, he adds, there are financial complications if you don’t.

Financial impact

Jimenez explains that if physicians don’t treat patients with culturally competent care, they risk alienating patients not only from themselves, but from the healthcare system as a whole. “They may choose to vote with their feet and walk away from healthcare until there is an emergency of some sort,” says Jiminez, “thereby incurring increased costs.”

Schwartz concurs. “If a doctor can’t meet both the language and the cultural criteria for patients, they’ll walk. Language is an important issue, but sometimes it’s secondary to a patient’s willingness to have faith in their physician. If a physician doesn’t pay attention to the cultural component of the interaction, that patient won’t come back.”

Recognizing the need for cultural competence training, several states—New Jersey, California and Washington, among them—have passed or are considering legislation requiring doctors to receive such training before they can obtain or renew a state medical license. Some of the topics covered in cultural competence training include an overview of health disparities and their causes, working with interpreters, and recognizing one’s own bias and stereotyping.

Says Jimenez, of the pending legislation, “Either do it, or it will be done to you.”

Making changes

Sheila D’Nodal, MD, is chief diversity officer and vice president of Ambulatory Services at New York’s South Nassau Communities Hospital. She says that the key first step for physicians looking to become more culturally in tune with their patients is awareness, followed by education to understand the possible pitfalls in dealing with different cultures, and hiring staff who can communicate across cultural barriers.

“Ninety-five percent of the data you need to make a diagnosis is in the [patient] history,” says D’Nodal, explaining that asking the right questions is the key to obtaining an accurate history. “Now, how do you do that if you’re not communicating? If you don’t understand the reservations that a [person from a certain] culture might have? That’s the beginning, and you can get there by hiring staff that is multi-cultural. But first you have to be aware, and I think there’s a blind spot there for physicians.”

Jimenez says that a few years ago when he first began lecturing on the importance of culturally competent healthcare, the message was about as welcome as the scratching of fingernails on a chalkboard. But, he adds, times are changing.

“More [healthcare professionals] are realizing that you have to be aware of how to treat people who are different than you,” he says. “And as an orthopaedic surgeon, I have to be able to relate to colleagues too; to an anesthesiologist from a different culture. They may have beliefs that could affect the way they practice. It’s not all standard. You can hide in a shell and pretend the world is not different, but you’re going to lose.”

Ed Rabinowitz is a veteran healthcare writer and reporter. He welcomes comments at edwardr@frontiernet.net.