By Christopher Guadagnino, Ph.D.
Joseph R. Betancourt, M.D., M.P.H., is director of The Disparities Solutions Center, program director for multicultural education, and a practicing internist at Massachusetts General Hospital.
PND: Why is cultural competency an important component of patient-centered care?
JRB: Over the last 10 to 15 years, a significant literature has emerged documenting several factors that make the issue of cultural competency particularly important. We know that our nation is becoming increasingly diverse, and social and cultural factors do matter in the clinical encounter. Issues of patient expectations of care, their health beliefs and their behaviors all may be apparent during the clinical encounter, and the literature supports the fact that it is important for physicians to be skilled to both ascertain what these issues are, and to be able to manage and negotiate them. A significant literature has also emerged in the area of racial and ethnic disparities in health care. This literature documents that patients, even with the same level of education or insurance, who may be of a different race or ethnicity, might receive a different quality of care. Minorities may receive lower quality of care than their white counterparts for some of the same conditions – for example, when they present to the emergency room with chest pain. The Institute of Medicine Report, Unequal Treatment, in which I had had the honor of participating, studied this issue for the better part of two years and found that communication between the doctor and the patient was one potential target area that would help us address these disparities. So, what we’ve seen over the last 10 to 15 years is a realization that we as physicians can build our skills in the area of communicating effectively across cultures, asking particular questions of our patients, and being able to negotiate in ways that we think will improve the outcomes for these patient populations.
PND: What is cultural competency, and what is its trajectory, from a policy standpoint?
JRB: This field basically is an expansion of patient-centered care – the need to be attentive to the health beliefs, values and perspectives of the patient. What has been absent in that discussion is particular attention to social and cultural factors, and that’s the gap that cultural competency hopes to fill. What cultural competency attempts to do is give the doctor a set of tools – questions and skills for negotiation – that they can incorporate into their history of present illness and shed light on what health beliefs a patient may have, what particular complementary or alternative medicine a patient might use, how a patient and their family might make decisions that may be culturally-based. Once that information is revealed, the physician could engage in a negotiation with a patient to improve outcomes. The set of tools and skills are built on a foundation of research: cross-cultural interviewing, medical anthropology, social psychology, patient-centered care. A melding of these different fields has built a set of questions that are taught, although it’s not completely standardized yet. We do know that, on the policy side, New Jersey has taken the lead on making the issue of cultural competency a requirement for licensure. We see about six to eight states that are engaging this issue as a significant policy movement. Like other fields, such as the patient safety movement, this field will become more standardized and I think will become an essential part of licensure. We are beginning to see questions in specialty board exams about racial and ethnic disparities and cross-cultural communication. Another area where this issue is being explored is risk management and prevention of malpractice, in which there is an understanding that building tools and skills in this area might be beneficial. There are certain medical malpractice companies across the country that are looking to give discounts for health care providers who have taken courses in patient-centered care, and hopefully soon in the area of cross-cultural communication.
PND: How does a physician strike a balance between being sensitive to the cultural background of their patients and treating each individual as a unique person without stereotyping them?
JRB: In years past, a lot of what was done in the area of cultural competence was what we called the manual-based approach, where you’d pick up a small text that would have five to seven key things you needed to know to take care of an Hispanic or African-American patient, for example. I’m Puerto Rican, myself, and I would often read these things and a lot of them didn’t apply to me or my family. A lot of them were stereotypical and I worried about that. It became clear to many people in the field that there’s no five-to-seven unifying facts that you could teach about any large racial, ethnic or cultural group. The way to walk the balance is to learn about a particular community and whether there are prevalent health beliefs and behaviors, but also to have a set of tools and skills to explore the particular social and cultural factors that impact that patient in front of you. As an example, if you’re taking care of an Hispanic patient, you may have read that Hispanics are fatalistic. That can be helpful, but it would be detrimental to make an assumption that all Hispanics are fatalistic. The better thing might be to assess whether that patient in front of you is fatalistic. For physician training, what we strive to do is increase awareness with particular clinical examples about how social and cultural factors impact clinical conditions, for example, how might a patient’s health belief about their hypertension dictate how they take their medications; or, how a patient’s understanding of their diabetes might dictate how they follow a physician’s recommendations. Once we establish that awareness among clinicians, we try to give them tools to ask patients questions such as, “In your culture, do you have any particular perspectives or practices around managing condition X?” or “Do you take any particular remedies for this condition?” or “In many cultures, people involve their family in decision-making. Do you involve family, or do you make decisions on your own?” These things don’t have to take a lot of time. We’ve built the curriculum in a way that really gives doctors “surgical-strike” questions that they use to shed light, say, on an issue of nonadherence.
PND: Can you give some examples of these questions?
JRB: Sure. It’s important to remember that we all have culture, and these particular skills are going to be helpful for all patients, not just for minority patients, but they may be particularly helpful for those who are a greater distance from the Western medical model. There are a set of core cross-cultural issues that vary across cultures but are important hot-button issues for all patients, such as styles of communication – the stoic patient versus the very expressive patient; issues of mistrust that might be more prevalent among certain populations; issues of decision-making; sexual and gender issues; traditions, customs and spirituality – those are all issues that might play a role. Let me give you a clinical example. In my social history-taking, I will ask patients, “Are there any traditions or customs that might impact the care that I provide to you? For example, patients with certain religions won’t accept blood products if they needed a transfusion. Or some people may fast for a month while the sun is up. Do you have any customs like that that I should know about?” Issues like those may be particularly important, for example in the area of fasting, if you’re managing a patient who has diabetes. It would be really important, for example, for you to assess whether the patient was observing Ramadan and fasting for a month during daylight hours for you to be able to adjust their insulin regimen. Or, if a patient has congestive heart failure and has a particular tradition of eating salty foods – you might be able to discuss that with them or adjust their medications.
Clinicians should also ask about issues related to how a patient understands their condition, or what they expect as treatment. We see this a lot in patients who have conditions that are, for the most part, asymptomatic – hypertension is key among these. We see many patients who understand hypertension as a condition that is symptomatic. They feel like they know when their blood pressure is high, and that dictates when they take their medications. Being able to explore that with a patient, asking an open-ended question – “How do you understand your hypertension?” – might reveal a lot of very important information that might improve your ability to help them understand their condition and help them manage it. Those issues may be culturally-based. A person may be raised and have heard certain things about high blood pressure or diabetes or asthma that might lead them to manage their condition in a particular way.
PND: What role does discovering these issues play in promoting patient compliance?
JRB: Compliance is a huge issue. We’ve developed certain tools in the field to help screen for noncompliance among cross-cultural populations. We know that only about half of all hypertensives in the U.S. are at target. You as a physician might ask the patient, “Are you taking your medications?” and they may say, “Yes, yes, yes,” but they may be going home and taking the medications at different times, depending on how they feel, and may not really make that obvious to you. A simple question might get at the root of nonadherence: “You know, you’ve really had a tough time controlling your blood pressure. Before I go on and explain the pros and cons, and the evolution of hypertension, I want to get an understanding of how you view hypertension. What do you think makes your condition better or worse, and how do you think it should be treated?” By exposing the patient’s perspective in a very patient-centered way, you could then engage in a negotiation with them about how they can best address their hypertension, perhaps letting them know that, “Yes, your blood pressure can be higher in particular situations, but in fact, it’s higher than others almost all the time, and so medication will help it.” I think sometimes, as clinicians, we might be too quick to check “Patient noncompliant” or “Patient refusing” and not take the time to ask that second- or third-level question about the root of that nonadherence.
PND: When negotiating with patients over treatment recommendations, how should physicians strike a balance when cultural traditions clash with evidence-based treatment?
JRB: We shouldn’t let the perfect be an obstacle to the good. Obviously, if you have an individual in front of you, and you want to gradually build their trust and get them to buy into what you’re offering, it may require some negotiation up front. I don’t think that is necessarily at odds with evidence-based medicine. We engage in this type of work every day, where a patient may accept a mammogram but may be refusing a colonoscopy and a pap smear. You don’t want to shun a patient because they refuse two out of three. You obviously try to get the mammogram, then try to work with them on the importance of health promotion and disease prevention, and over time negotiate with them and try to secure those other two important screenings. What we’re trying to accomplish with the concept of negotiation is that it’s much better to keep the patient in care and chip away at these issues over time, especially given some of the recent research about the importance of a medical home and patients developing a relationship with a clinician. What we’re trying to avoid is having a patient say, “I feel uncomfortable. I didn’t feel that that doctor understood me, so I’m not going to follow-up.” That’s the worst-case scenario, and negotiation provides a door to keeping people engaged in the care, gradually leading to the evidence-based standards.
PND: From a practical standpoint, how serious an obstacle is the time burden of a typical 15-minute clinical encounter to doing this right?
JRB: Without a doubt, time is a challenge. In our 15-minute patient visits, it’s challenging to do anything well. Clearly, this is an added dimension that poses an additional challenge. All that being said, asking some of these questions – asking about a patient’s health beliefs, getting at their understanding – might, in fact, save time in the clinical visit. Too often, we’ll sit and explain things to a patient using the medical model and take up a lot of those 15 minutes speaking our medicalese, when in fact a cross-cultural patient-centered question might reveal a patient’s perspective quicker, put you in a position to negotiate faster, and use your time more effectively. Now, I’m not trying to be pollyannaish or naEFve about this. I clearly think that this is an issue that we need to be careful about, but I do think that some of the better curricula around the country is cognizant of that practical challenge and tries to give providers key questions that they could use, in an as-needed fashion, that could help them save time. Also, this type of work should be done with an eye towards continuity – you don’t necessarily need to do it all in one visit. Effective communication actually saves time and makes the visit generally more efficient and higher quality. In fact, some health insurers are offering pay-for-performance incentives for completion of cultural competency training, including Blues plans in Florida and Massachusetts, Aetna, as well as several larger employer groups around the country – such as Marriott, which understands that a quarter to a third of their employee base may be from ethnic minority groups.
PND: What tools are there to deal with language barriers?
JRB: There’s no doubt about it, when seeing a patient with a language barrier in the absence of an interpreter, your ability to get a good history is significantly limited. But there’s also no doubt that that visit will likely take more time. We’ve seen a significant movement toward the use of tools such as telephone interpreters in the doctor’s office that could provide that service for you. Hospitals are developing professionally-trained interpreter services that they can use with their patients. In the individual doctor’s office, some type of telephonic interpreter service is probably the most effective. Payment issues are being worked out, as health plans, hospitals and others are trying to figure out how to appropriately compensate for these types of encounters. You could imagine a doctor needing to use a language line and footing the bill him- or herself all the time. I don’t think that’s necessarily tenable.
PND: How do physicians go about getting cultural competency information and training?
JRB: There are a variety of tools out there. I and my colleagues have been working in the area of e-learning as a quick, effective mechanism to improve cross-cultural communication. We’ve developed a Web-based program called Quality Interactions that is a practical, case-based, applied approach to cross-cultural communication, and offers continuing medical education credit. There are a variety of other individuals who have developed training modules in this regard. We’re seeing more and more in the area of e-learning because it’s an easy modality and there’s significant evidence to support the fact that it’s is a very effective teaching tool. Hospitals are also bringing in experts to do training for clinicians. Some of the professional societies are doing this as well – I know the American Academy of Orthopaedic Surgeons has developed some DVDs in this regard. It could be as simple as clinicians Googling “cross-cultural care” or “cultural competence” and looking at potential options, and also checking their profession societies or their state boards to see what’s available out there. Physicians do need to be discriminating about the type of learning that they engage in – work that’s built by clinicians and individuals who’ve walked in their shoes. Programs that have a proven track record are important as well – that the tools and skills are in fact practical, not preachy, and give the individual clinician a chance to learn and apply them in a clinical setting. I would hope that clinicians don’t see the issue of cultural competence or cross-cultural education as a burden, but instead, an opportunity to improve their capacity to deliver high-quality care to any patient they see regardless of their background.