Conversations in Cultural Competency

Managing cultural differences in healthcare

Culture is a complex concept. It includes people’s beliefs, values, behaviors, and ways of understanding their world. In medicine, managing cultural differences—including customs—is essential to providing high-quality health care. One challenge is that patients may not realize they have customs that could jeopardize their wellness. Culture is largely invisible to people who share it. But to outsiders, the customs and ways of life of different cultures are often obvious—and sometimes strange. Here's an example from my own experience:

Manage Chronic Disease with the EFST Model for Cultural Competence

How can clinicians help ease the stress of chronic disease? Recent healthcare news stories published in The New York Times draw attention to the incredible burden of serious illness and chronic disease on critically sick patients. Not only are they physically uncomfortable and often fighting for their lives—they are also baffled by a confusing healthcare system and swamped by medical bills. Now imagine adding a language barrier to the mix! The challenges of serious illness are compounded when there are cross-cultural issues at play. Quality Interactions' EFST Model is designed to help clinicians uncover and address these issues and provide culturally-sensitive care to all patients with chronic disease.

In the 1990s, before I started my second year of medical school at University of California, San Diego (just 30 minutes north of the Mexican border) I made a decision that would change my life. The second-year curriculum allowed for a number of elective courses. We were supposed to select from a catalogue of options—radiology, advanced anatomy, medical ethics, and many others. Most students chose two per semester. I chose one that spanned the entire year: Medical Spanish.

This content was originally presented as part of our live learning event, "Expanding the Role of Interpreters in a Value-Based System," by Dr. Alexander Green. View the recorded event here.

As a primary care physician, I take care of a large Spanish-speaking population, among other culturally and socioeconomically diverse patients. I’m fluent in medical Spanish and communicate directly with my Spanish-speaking patients. But regardless of whether I’m speaking Spanish or working with a medical interpreter, visits with limited English proficiency (LEP) patients always leave me with a worried feeling in the pit of my stomach. I’m keenly aware that most healthcare takes place outside of the doctor’s office, and this is where LEP patients fall through the cracks. I wonder, “Did Mrs. Ramirez really understand how to prep for her colonoscopy next week?” or “Was Mr. Luan actually convinced that he needs to take the medication I prescribed for his diabetes?”

Address the patient, speak clearly, avoid jargon, and check for comprehension

If you’re a healthcare provider who works with some of the 25 million limited English proficient (LEP) patients in the U.S., you know how important interpretation is to successful patient outcomes. Poor communication increases the chance of medical errors with any patient, and LEP individuals are especially vulnerable in this regard.

How should important medical decisions be made?

If you've grown up in the U.S., you're probably familiar with the concept of a patient's "right to know." American culture holds that patients are entitled to be fully informed in their own medical care, including the decision-making process. In some cultures, however, autonomy in decision-making is not the norm. For many people, it is essential to involve (or even defer to) others, particularly family members, in important health decisions. In such families, it's common to look to an authority figure (determined by gender, position in the family, or level of acculturation) as the primary decision-maker within the group. In some cases, these families may wish to exclude the patient from decisions in order to avoid what is perceived as undue stress. This can cause friction between health providers, patients, and their relatives.

Medical Residents Lack Comprehensive Training in Cultural Competency

A report from the Accreditation Council for Graduate Medical Education (ACGME) presents data from medical residency and fellowship programs, which shows that clinical learning environments (CLEs) vary widely in their application of strategies to address healthcare disparities. Among other findings, the data demonstrate a lack of comprehensive training in cultural competency.

Perceived discrimination, based on race, gender, and other factors, causes patients to distrust the healthcare system and medical practitioners. They are then less likely to seek treatment, and less likely to follow through on medical advice. In response to a recent study on this topic, Quality Interactions co-founder Dr. Joseph Betancourt published an editorial in the Journal of General Internal Medicine (JGIM).The study, by Nguyen et al., found that rates of perceived discrimination in healthcare declined among black patients between 2008 and 2014. While this could be promising news, Dr. Betancourt argues that it is not time to celebrate yet.

Health literacy describes one's ability to obtain and understand the medical information needed to make informed healthcare decisions. This includes the ability to understand medical explanations of symptoms and illnesses; follow directions for medications, tests, and procedures; and ask relevant questions.