Cultural Competence — Marginal or Mainstream Movement?
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《新英格兰医药杂志》
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As the United States becomes increasingly diverse, physicians will see patients from a variety of sociocultural backgrounds on a daily basis. Culture plays a large role in shaping health-related values, beliefs, and behavior. With the aim of providing physicians with the knowledge and skills to address "cross-cultural" challenges in clinical encounters, educational efforts in "cultural competence" have emerged. This field is not new, but it has been reenergized during the past decade as a result of pronouncements by the Institute of Medicine and the American Medical Association, among other organizations, that cultural competence is necessary for the effective practice of medicine.
Yet the term "cultural competence" elicits varied responses from health care professionals, ranging from complete acceptance to outright derision. Many point to the lack of empirical evidence linking cultural competence to improvements in health outcomes and question whether it represents a marginal fad or has mainstream clinical applications and a direct correlation with high-quality care.
Culture is a pattern of learned beliefs, values, and behavior that are shared within a group; it includes language, styles of communication, practices, customs, and views on roles and relationships. We all belong to more than one culture, which may, for example, be social, professional, or religious; the concept goes beyond race, ethnic background, and country of origin. Culture shapes the way we approach our world and affects interactions between patients and clinicians.
Many have thought of cultural competence simply as the skills needed to address language barriers or knowledge about specific cultures. Although the former remains important, the latter is more problematic. Previous efforts in cultural competence have aimed to teach about particular groups — the key practice "dos and don'ts" for caring for "the Hispanic patient," for example. In certain situations, learning about a particular community can be helpful, but when broadly applied, this approach can lead to stereotyping and oversimplification of culture.
Cultural competence has thus evolved from the making of assumptions about patients on the basis of their background to the implementation of the principles of patient-centered care, including exploration, empathy, and responsiveness to patients' needs, values, and preferences. Culturally competent providers expand this repertoire to include skills that are especially useful in cross-cultural interactions.
Cultural competence has emerged as an important goal for very practical reasons. As the United States becomes more diverse, clinicians will increasingly see patients with a broad range of perspectives regarding health. Patients may present their symptoms quite differently from what we learned in our textbooks, they may have different expectations or thresholds for seeking care, and their beliefs will influence whether or not they follow our recommendations. In addition, effective provider–patient communication is linked to improved patient satisfaction, adherence to recommendations, and health outcomes.1 When sociocultural differences between patient and provider are not explored and communicated, patient dissatisfaction, nonadherence, and poorer health outcomes may result. Two recent reports by the Institute of Medicine2,3 have highlighted the importance of patient-centered care and cultural competence as means of improving communication and thereby improving quality, eliminating disparities, and achieving equity in health care.
Education in cultural competence has focused in part on methods for eliciting patients' understanding of illness and their condition (their "explanatory model"). Consider the case of a Hispanic woman with hypertension whose blood pressure had been difficult to control for more than two years. A workup had ruled out secondary causes, and she had received various antihypertensive medications. Finally, an exploration of her perception of hypertension revealed that although she said she took her medication every day, she believed she knew when her blood pressure was high and therefore took it at different times of the day and sometimes not at all. Asking this patient about her understanding of the cause of hypertension clarified her perspective. This discussion provided an opportunity for reeducation and negotiation about medication.
Or consider the case of an elderly Italian woman whose son asked her surgeon not to inform her that she had metastatic colon cancer. A culturally competent clinician discovered that the son thought it would "kill" his mother to know the truth. This scenario is common in many cultures, but decision-making and truth-telling processes vary from family to family. Exploring the reasons for and consequences of this preference for secrecy leads to negotiation and an ethically appropriate compromise whereby the patient may be informed of her condition in a way that is agreed on by the family.
It is also important to determine patients' perception of biomedicine and whether they use complementary, alternative, or folk medicine. In response to the proper inquiry, a Chinese man with limited English proficiency who was treating his asthmatic daughter with herbal remedies (in addition to her prescribed inhalers) explained that this tradition had been passed down for generations. Once the herbal treatment was revealed, the appropriate use of inhalers could be reviewed and reemphasized. In such cases, effective communication may require interpreters, and clinicians must be trained in their use.
(Figure)
Education in cultural competence also aims to increase clinicians' awareness of disparities in health care and their understanding of the effects of race and ethnic background on clinical decision making. Such education also addresses mistrust in the clinical encounter — for example, that expressed by a 64-year-old black man who was reluctant to undergo cardiac catheterization because of a relative's bad experience and memories of the Tuskegee Syphilis Study. Key steps in building trust include acknowledging patients' concerns, orienting them to the doctor's decision-making process, noting that many patients are mistrustful of the health care system, and offering reassurance.
Interactive, case-based sessions that highlight clinical applications are the ideal methods for teaching cultural competence. When used selectively as the clinical scenario dictates, the skills acquired from such sessions can help illuminate the patient's values, beliefs, and behavior.
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. For now, however, it may make more sense to focus on process measures, as we have done with other educational initiatives designed to meet emerging needs of the medical profession.
Cultural competence is not a panacea that will single-handedly improve health outcomes and eliminate disparities, but a necessary set of skills for physicians who wish to deliver high-quality care to all patients. If we accept this premise, we will see cultural competence as a movement that is not marginal, but mainstream.
Source Information
From the Department of Medicine, Harvard Medical School; and the Institute for Health Policy, Massachusetts General Hospital — both in Boston.
References
Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on patient-doctor communication. Cancer Prev Control 1999;3:25-30.
Committee on Quality Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press, 2001.
Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, D.C.: National Academies Press, 2003.(Joseph R. Betancourt, M.D)
As the United States becomes increasingly diverse, physicians will see patients from a variety of sociocultural backgrounds on a daily basis. Culture plays a large role in shaping health-related values, beliefs, and behavior. With the aim of providing physicians with the knowledge and skills to address "cross-cultural" challenges in clinical encounters, educational efforts in "cultural competence" have emerged. This field is not new, but it has been reenergized during the past decade as a result of pronouncements by the Institute of Medicine and the American Medical Association, among other organizations, that cultural competence is necessary for the effective practice of medicine.
Yet the term "cultural competence" elicits varied responses from health care professionals, ranging from complete acceptance to outright derision. Many point to the lack of empirical evidence linking cultural competence to improvements in health outcomes and question whether it represents a marginal fad or has mainstream clinical applications and a direct correlation with high-quality care.
Culture is a pattern of learned beliefs, values, and behavior that are shared within a group; it includes language, styles of communication, practices, customs, and views on roles and relationships. We all belong to more than one culture, which may, for example, be social, professional, or religious; the concept goes beyond race, ethnic background, and country of origin. Culture shapes the way we approach our world and affects interactions between patients and clinicians.
Many have thought of cultural competence simply as the skills needed to address language barriers or knowledge about specific cultures. Although the former remains important, the latter is more problematic. Previous efforts in cultural competence have aimed to teach about particular groups — the key practice "dos and don'ts" for caring for "the Hispanic patient," for example. In certain situations, learning about a particular community can be helpful, but when broadly applied, this approach can lead to stereotyping and oversimplification of culture.
Cultural competence has thus evolved from the making of assumptions about patients on the basis of their background to the implementation of the principles of patient-centered care, including exploration, empathy, and responsiveness to patients' needs, values, and preferences. Culturally competent providers expand this repertoire to include skills that are especially useful in cross-cultural interactions.
Cultural competence has emerged as an important goal for very practical reasons. As the United States becomes more diverse, clinicians will increasingly see patients with a broad range of perspectives regarding health. Patients may present their symptoms quite differently from what we learned in our textbooks, they may have different expectations or thresholds for seeking care, and their beliefs will influence whether or not they follow our recommendations. In addition, effective provider–patient communication is linked to improved patient satisfaction, adherence to recommendations, and health outcomes.1 When sociocultural differences between patient and provider are not explored and communicated, patient dissatisfaction, nonadherence, and poorer health outcomes may result. Two recent reports by the Institute of Medicine2,3 have highlighted the importance of patient-centered care and cultural competence as means of improving communication and thereby improving quality, eliminating disparities, and achieving equity in health care.
Education in cultural competence has focused in part on methods for eliciting patients' understanding of illness and their condition (their "explanatory model"). Consider the case of a Hispanic woman with hypertension whose blood pressure had been difficult to control for more than two years. A workup had ruled out secondary causes, and she had received various antihypertensive medications. Finally, an exploration of her perception of hypertension revealed that although she said she took her medication every day, she believed she knew when her blood pressure was high and therefore took it at different times of the day and sometimes not at all. Asking this patient about her understanding of the cause of hypertension clarified her perspective. This discussion provided an opportunity for reeducation and negotiation about medication.
Or consider the case of an elderly Italian woman whose son asked her surgeon not to inform her that she had metastatic colon cancer. A culturally competent clinician discovered that the son thought it would "kill" his mother to know the truth. This scenario is common in many cultures, but decision-making and truth-telling processes vary from family to family. Exploring the reasons for and consequences of this preference for secrecy leads to negotiation and an ethically appropriate compromise whereby the patient may be informed of her condition in a way that is agreed on by the family.
It is also important to determine patients' perception of biomedicine and whether they use complementary, alternative, or folk medicine. In response to the proper inquiry, a Chinese man with limited English proficiency who was treating his asthmatic daughter with herbal remedies (in addition to her prescribed inhalers) explained that this tradition had been passed down for generations. Once the herbal treatment was revealed, the appropriate use of inhalers could be reviewed and reemphasized. In such cases, effective communication may require interpreters, and clinicians must be trained in their use.
(Figure)
Education in cultural competence also aims to increase clinicians' awareness of disparities in health care and their understanding of the effects of race and ethnic background on clinical decision making. Such education also addresses mistrust in the clinical encounter — for example, that expressed by a 64-year-old black man who was reluctant to undergo cardiac catheterization because of a relative's bad experience and memories of the Tuskegee Syphilis Study. Key steps in building trust include acknowledging patients' concerns, orienting them to the doctor's decision-making process, noting that many patients are mistrustful of the health care system, and offering reassurance.
Interactive, case-based sessions that highlight clinical applications are the ideal methods for teaching cultural competence. When used selectively as the clinical scenario dictates, the skills acquired from such sessions can help illuminate the patient's values, beliefs, and behavior.
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. For now, however, it may make more sense to focus on process measures, as we have done with other educational initiatives designed to meet emerging needs of the medical profession.
Cultural competence is not a panacea that will single-handedly improve health outcomes and eliminate disparities, but a necessary set of skills for physicians who wish to deliver high-quality care to all patients. If we accept this premise, we will see cultural competence as a movement that is not marginal, but mainstream.
Source Information
From the Department of Medicine, Harvard Medical School; and the Institute for Health Policy, Massachusetts General Hospital — both in Boston.
References
Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on patient-doctor communication. Cancer Prev Control 1999;3:25-30.
Committee on Quality Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press, 2001.
Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, D.C.: National Academies Press, 2003.(Joseph R. Betancourt, M.D)