Betancourt, Joseph R. MD, MPH
Editor’s Note: This Commentary opens for discussion the issue of cultural competence training, an evolving element of medical education curricula that merits our attention. Are tomorrow’s physicians being adequately trained to provide optimal care to patients from ethnic, social, economic, or geographic backgrounds different from their own? Does (or should) cultural competence translate into improved health outcomes and reduction of disparities in health or health care? Do some approaches to teaching cultural competence oversimplify complex factors and encourage stereotyping groups of patients? The Commentary here sets the stage for three related papers in this issue that investigate these questions and others relating to implementing, assessing, or reforming cultural competence education. Please see the articles by Gregg and Saha on page 542, by Koehn and Swick on page 548, and by Lie, Boker, and Cleveland on page 557.
Two contemporary reports from the Institute of Medicine—Crossing the Quality Chasm1 and Unequal Treatment2—highlighted the importance of patient-centered care and cultural competence training as a means of improving the quality of health care for all and eliminating racial/ethnic disparities in health care. These recommendations are based on the premise that improving provider–patient communication is an important component of improving the quality of care generally, and addressing differences in quality of care that are associated with patients’ race, ethnicity, or culture more specifically. This month’s Academic Medicine revisits the issue of cultural competence and medical education with two articles—one by Gregg and Saha,3 one by Koehn and Swick4—that ask us to reconsider where the field is going, and one research report by Lie, Boker, and Cleveland5 that tells us whether faculty and students see eye-to-eye on whether its key principles are being taught.
There is no doubt that culture plays a large role in shaping each individual’s health-related values, beliefs, and behaviors. A recent study by Weissman et al. to which I contributed confirms this: our national survey of resident physicians in seven specialties (medicine, surgery, obstetrics–gynecology, psychiatry, family medicine, pediatrics, and emergency medicine) showed that nearly all thought it was important to consider the patient’s culture when providing care (with 96% of respondents indicating “moderately important” or “very important”).6 Moreover, many felt that poorly handled cross-cultural issues “often” resulted in negative clinical consequences, including longer office visits, patient noncompliance, delays obtaining informed consent, ordering of unnecessary tests, and lower quality of care. As an effort to provide physicians-in-training with the knowledge and skills to address cross-cultural challenges in the clinical encounter, curricula in “cultural competence” have emerged and been integrated into medical education.
The State of the Field
Previous efforts in cultural competence have aimed to teach about the attitudes, values, beliefs, and behavior of certain groups—the key practice “do’s and don’ts” for caring for a patient from a particular culture. Whereas in certain situations, learning about the health beliefs of a specific community can be helpful (e.g., the perspectives of a new immigrant group about postpartum care), when more broadly applied this approach can lead physicians to make assumptions about culture and oversimplify the fluidity of culture and the diversity within cultures. As such, there is no “manual” of how to care for patients from different racial, ethnic, or cultural groups; instead, a more effective approach is to learn a practical framework to guide inquiry with individual patients about how social, cultural, or economic factors influence their health values, beliefs, and behaviors. Rather than learning about individual cultures and their characteristics, this approach focuses on the issues that arise most commonly due to cultural differences, and how they may affect a physician’s interaction with any patient. It also includes the importance of curiosity, empathy, and respect, as well as an understanding of the patient’s social context, which is equally critical. Gregg and Saha3 here make the argument for this approach, and Koehn and Swick4 describe the importance and concrete application of this “transnational competence” to medical education. Luckily, these are not new concepts and have been argued previously, resulting in greater adoption of these principles among medical educators.7 Furthermore, these principles have now become the blueprint for teaching medical students throughout the country, although adoption of this approach is slow but steady.5,8,9
Cultural competence aims to bridge the “cultural distance”3 that exists between ourselves as providers and our patients. For some, the distance may be significant, manifested, for instance, by a patient who has a completely different understanding of hypertension than we as physicians do, and thus rejects what we have to offer by way of treatment. For others, the distance may be shorter, and based solely on slight but significant mistrust about the intentions of our efforts and recommendations. Cultural competence is an important building block of clinical care, an expansion of patient-centeredness, and a skill set that is central to professionalism and quality of care. It is not a panacea that will single-handedly improve health outcomes and eliminate disparities—nor is that its intention—but rather a necessary competency for all physicians who wish to deliver the highest quality care to all patients. For some patients who are culturally distant from us, our skill set in this area will make all the difference in the world; for others, to whom we are culturally closer, some of the tools and skills will still come to bear and make a marked difference that will lead to better health outcomes. The degree of distance makes no difference—the skill set and approach of cultural competence should equally and positively influence both circumstances, and as such also assist in the elimination of racial/ethnic disparities in health care.
Cultural Competence and Racial/Ethnic Disparities in Health Care
The field of cultural competence itself is in fact not new, and grew out of the realization decades ago that we live in a multicultural society that requires health professionals to be attentive to key cross-cultural factors that might affect the clinical encounter. It has, however, evolved significantly as a strategy to address racial/ethnic disparities in health care. This is because cultural competence is no longer seen as a set of skills necessary for physicians to care for immigrants, foreigners, and others from “exotic” cultures, but instead as a central tenet of patient-centered care, effective communication, and the need to be responsive and deliver quality care to all patients.
This new link to racial/ethnic disparities in health care is especially pertinent if we consider the important connection between communication, trust, and health outcomes. A recent telephone survey10 of close to 7,000 people inquired whether white, African American, Hispanic, and Asian American patients who had had a medical visit in the last two years had trouble understanding their doctor; whether they felt their doctor did not listen; and if they had medical questions they were afraid to ask. The survey found that 19% of all patients experienced one or more of these problems. However, whites experienced them 16% of the time, compared to 23% of the time for African Americans, 33% of the time for Hispanics, and 27% of the time for Asian Americans. Similarly, another telephone survey11 found that there is significant mistrust of the health care system among minority populations. Of the 3,884 individuals surveyed, 36% of Hispanics and 35% of African Americans (compared to 15% of whites) felt they had been treated unfairly in the health care system in the past based on their race and ethnicity. Perhaps even more alarming, 65% of African Americans and 58% of Hispanics (compared to 22% of whites) were afraid of being treated unfairly in the future based on their race or ethnicity. This highlights the fact that efforts to improve communication and trust between doctors and these racial/ethnic groups—under the umbrella of cultural competence—should contribute in part to the elimination of racial/ethnic disparities in health care. Cultural competence is not designed to draw attention away from, or address the larger factors that contribute to, racial/ethnic disparities in health, such as poverty, lack of education, the environment, and poor access to care, to name a few. Conversely, it allows the physician to understand this context and incorporate strategies to identify, address (including through the referral to social or other services), and incorporate these factors into his or her diagnostic and treatment strategy.
Evaluating Cultural Competence Instruction
The Association of American Medical Colleges’ Tool for the Assessment of Cultural Competence Training (TACCT) operationalizes the essentials of the field, including the importance of understanding both the rationale and context for the existence of cultural competence training and its key aspects, including cross-cultural skills. The study by Lie et al.,5 one of the first assessments of the TACCT, reveals that at one medical school, faculty and students generally see eye-to-eye on the cultural competence principles being taught. Furthermore, it seems the TACCT can be successfully implemented as both an assessment tool and a blueprint for curricular development. Interestingly, the findings of this assessment in some ways mirror the findings of our residency survey6 described above. The study by Lie and colleagues states that “evaluation of students’ skills and knowledge with respect to cultural competency was nonspecific; skills and knowledge were only indirectly assessed [and] no separate grade was given for students’ cultural competence in any instructional setting.” In our residency survey,6 approximately 21% of all residents reported that they were “rarely” evaluated on doctor–patient communication in general—and about 66% said they receive little or no evaluation on cross-cultural aspects of doctor–patient communication. Undoubtedly, this lack of evaluation sends a clear message to students and residents about the level of importance of cultural competence—if it is not evaluated, it must not be important.
There is currently great interest in evaluating the effects of educational initiatives on health outcomes. Research on cultural competence is still at an early stage, and attempts are under way to determine its effects on outcomes. Given the evidence linking effective doctor–patient communication to improved health outcomes, many assume that education in cultural competence will have a positive effect on clinical indicators. It was this linkage that motivated the recommendations by the Institute of Medicine and other professional societies that patient-centeredness and cultural competence be considered linchpins of quality. As we strive to build links to health outcomes, the move to measure clinical competencies should provide a framework for evaluating cultural competence as well. But it is also important to place such evaluation in the context of the assessment of other educational initiatives designed to meet needs defined by the profession, such as training in palliative care, geriatrics, and genetics. In these domains, evaluation has thus far focused primarily on process measures, not health outcomes.
What the Future Holds
We must acknowledge that culture shapes the lens through which we each see and approach the world, and that we all belong to more than one culture (social, professional, or religious) that transcends simply our race, ethnicity, or country of origin. The concept of culture is complex, problematic, and frequently contested, yet this shouldn’t preclude physicians and physicians-in-training from striving to better prepare ourselves to understand and manage the multiple ways in which culture in the broadest sense manifests itself in the clinical encounter—including factors such as patients’ socioeconomic status. There is certainly no doubt that inattention to such factors—no matter the cultural distance between patient and physician—may limit our ability to deliver quality care to diverse populations.
As we look toward the future, one last bit of data from the residency survey is helpful here. Our study showed that few residents felt “very unprepared” or “somewhat unprepared” to treat patients from diverse cultures or from racial and ethnic minorities when asked in a general sense, although less than half responded that they were “well prepared” or “very well prepared.” Many more residents, however, felt unprepared to deliver care to patients with specific characteristics that are likely to arise in cross-cultural situations. For example, more than one out of five residents felt unprepared to treat patients with cultural issues involving health beliefs at odds with Western medicine, mistrust, or religious beliefs that affect care; users of complementary medicine; or new immigrants. Would we accept this low level of preparation for other key components of health care delivery?
At the end of the day, physicians need a practical set of tools and skills that will enable them to provide quality care to patients everywhere, from anywhere, with whatever differences in background that may exist, in what is likely to be a brief clinical encounter. Call it what you will, the field of cultural competence aims to quite simply assure that health care providers are prepared to provide quality care to diverse populations. Given the incredible and increasing diversity of this nation, skills beyond those that include knowing the best treatments for diabetes, and that also include the ability to communicate with and engage patients across cultures, are essential to the effective practice of medicine. If we are to be successful in achieving this end and truly being responsive to all patients we see, we must move past the semantics of the now-named field of cultural competence and instead focus our energies on assuring we are equipped to provide patients with the highest quality of care we have to offer, regardless of their race, ethnicity, culture, class, gender, language proficiency, or any factor that makes them “distant” from us.
1 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
2 Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press, 2002.
3 Gregg J, Saha S. Losing culture on the way to competence: the use and misuse of culture in medical education. Acad Med. 2006;81:542–47.
4 Koehn P, Swick HM. Medical education for a changing world: moving beyond cultural competence into transnational competence. Acad Med. 2006;81:548–56.
5 Lie D, Boker J, Cleveland E. Using the Tool for Assessing Cultural Competence Training (TACCT) to measure faculty and medical student perceptions of cultural competence instruction in the first three years of the curriculum. Acad Med. 2006;81:557–64.
6 Weissman JS, Betancourt JR, Campbell EG, et al. Resident physician’s preparedness to provide cross-cultural care. JAMA. 2005;294:1058–67.
7 Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130:829–34.
8 Betancourt JR, Green AR, Carrillo JE, Park ER. Cultural competence and health care disparities: key perspectives and trends. Health Aff (Millwood). 2005;24:499–505.
9 Green AR, Betancourt JR, Carrillo JE. The social history revisited: integrating social factors into cross-cultural medical education. Acad Med. 2002;77:193–97.