Extract
Of all of the forms of inequality, injustice in health care is the most
shocking and inhumane.—Martin Luther King Jr.In the context of our increasingly diverse society, culturally competent
care has emerged as an important educational discipline in the training of
physicians and is an essential component in the broader effort to address
disparities in health care. The unique nature of this content area, namely,
the ways in which it resonates on a deep level with our racial identities,
national history, and core values, requires that we approach it with humility,
enthusiasm, and persistence.
Of all of the forms of inequality, injustice in health care is the most
shocking and inhumane.—Martin Luther King Jr.
Of all of the forms of inequality, injustice in health care is the most
shocking and inhumane.—Martin Luther King Jr.
In the context of our increasingly diverse society, culturally competent
care has emerged as an important educational discipline in the training of
physicians and is an essential component in the broader effort to address
disparities in health care. The unique nature of this content area, namely,
the ways in which it resonates on a deep level with our racial identities,
national history, and core values, requires that we approach it with humility,
enthusiasm, and persistence.
In this article, we provide definitions for relevant terms such as cultural
competence. We also discuss why culturally competent care and education in
culturally competent care are essential to the medical profession and to our
society as a whole. We offer some hypotheses of the root causes of health care
disparities, concluding with total joint replacement as an accepted example of
a health care disparity in orthopaedics, and we present potential strategies
for the correction of this inequality.
Culture
The term culture is somewhat complex. Culture includes prevailing
patterns of human behavior characteristically associated with a given
language, thoughts, actions, customs, beliefs, and institutions of racial,
ethnic, social, or religious
groups1. For
example, a male Asian-American orthopaedic surgeon who is gay represents
multiple cultures; he is male, Asian American (representing one or a blend of
multiple ethnicities), an orthopaedist, and homosexual, and each of these
factors is important.
Competence
When discussing the complexities of cross-cultural communication, we use
the term competence in a broad sense. For our purposes, competence
refers to the possession of a fluid and evolving set of essential skills, not
a static state of achievement or mastery. Clinical competence refers to the
capacity to function effectively within the context of the beliefs, practices,
and needs presented by patients and their
communities1.
Cultural Competence and Culturally Competent Care
Cultural competence refers to the knowledge, skills, and attitudes
(and policies) that are required to work and communicate effectively with
individuals from cultural, ethnic, and racial backgrounds different from one's
own. Providing culturally competent care involves tailoring the delivery of
high-quality clinical care to meet the social, cultural, and linguistic needs
of the patient. Culturally competent care combines the principles of
patient-centered care with an understanding of the social and cultural
influences that patients bring to the medical
encounter2.
The Association of American Medical Colleges elaborated on this definition
of culturally competent care and identified four essential components of
culturally competent
care2: (1) an
awareness of self and one's value system, (2) an understanding of the concept
of culture and its role as a factor in health and health care, (3) a
sensitivity to cultural issues for each patien, and (4) an understanding and
ability to use specific methods to deal effectively with cultural issues in
interacting with individual patients, their families, members of the
health-care team, and the wider community.
Culturally Competent Care Compared with "Good" Patient
Care
It is quite common for a physician in discussions about this topic to
express the belief that he or she provides good care to all of his or her
patients. However, unconscious bias is believed to be an important
contributing factor to health care disparities.
What is the difference between culturally competent care and
"good" patient care? A practitioner who provides culturally
competent care considers factors relating to a patient's racial, ethnic,
religious, and socioeconomic background. Thoughtful cross-cultural
patient-doctor interactions might address issues such as the role of the
family and/or community in decision making, one's views on alternative
medicine compared with biomedicine, the level of trust in the medical
establishment, and shame or embarrassment in the discussion of sexual issues,
among others. While there are many practitioners who are sensitive to these
factors, every health care provider can improve his or her skills in this
area. Moreover, every health care provider has a responsibility to address,
and reduce, the current state of health care disparities in the United States,
some of which are associated with race and ethnicity.
Culturally competent care is an extension of good patient care because it
addresses racial, ethnic, religious, and socioeconomic factors, and it
improves health outcomes. During a recent symposium on culturally competent
care at the Annual Meeting of the American Orthopaedic Association (AOA) in
June 2006, the audience response system was
used3. The audience
was asked the following question: "Regardless of the patient's gender,
ethnic, or racial background, I feel that I can use the same approach
(courteous, friendly, approachable manner using simple words) to relate to all
my patients." Eighty percent of the audience either strongly agreed or
agreed with this statement. To provide the best health care possible,
physicians must individualize their care on the basis of the patient's
culture, wishes, and desires instead of using the same approach for every
patient. Thus, we must give the patient what he or she needs in regard to
medical information, treatment choices, and recommendations—not what
physicians think a patient needs solely on the basis of the medical problem.
The same courteous, friendly approach to all patients may not be enough to
provide the best patient care. Dr. Valerae O. Lewis, who has been the
moderator of the Diversity Symposium at the Annual Meeting of the American
Academy of Orthopaedic Surgeons, coined a phrase that summarizes one of the
main tenets of culturally competent care, which is: "You may have to
treat patients differently to treat them equally".
The landmark Institute of Medicine report, Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care, found
considerable evidence that United States racial and ethnic minorities receive
a lower quality of health services and have worse health-status indicators
compared with white
Americans4.
Furthermore, the report asserts that there are differences in health care
status by race even when insurance status, income, age, and severity of
conditions are comparable. Minorities are less likely to be given appropriate
cardiac medications or to undergo cardiac bypass surgery, and they are less
likely to receive kidney dialysis or transplants. In contrast, they are more
likely to receive certain less desirable procedures, such as lower limb
amputations for diabetes and other conditions. The causes of disparities in
health care are highly complex; however, the Institute of Medicine report
suggests that these disparities may be caused in part by conscious and
unconscious bias on the part of the caregiver.
A small sample of care disparities described in the Institute of Medicine
report included the following:
In 1996, the average life expectancy was sixty-six years for black men and
seventy-four years for white men. Native American men in some regions of the
country can expect to live only into their mid-fifties.Whites are four times more likely than blacks to receive coronary artery
bypass graft surgery.Mexican American patients receive 38% fewer medications than white patients
after hospitalization for definite or possible myocardial infarction.Black women are less likely than white women to receive diagnostic testing
for breast cancer.Blacks, Hispanics, and Native Americans experience 50% to 100% higher rates
of illness and mortality from diabetes than do whites.The black population receives fewer total joint replacements than the white
population.Minority patients receive less pain medication for fractures than do
nonminority patients.
In 1996, the average life expectancy was sixty-six years for black men and
seventy-four years for white men. Native American men in some regions of the
country can expect to live only into their mid-fifties.
Whites are four times more likely than blacks to receive coronary artery
bypass graft surgery.
Mexican American patients receive 38% fewer medications than white patients
after hospitalization for definite or possible myocardial infarction.
Black women are less likely than white women to receive diagnostic testing
for breast cancer.
Blacks, Hispanics, and Native Americans experience 50% to 100% higher rates
of illness and mortality from diabetes than do whites.
The black population receives fewer total joint replacements than the white
population.
Minority patients receive less pain medication for fractures than do
nonminority patients.
Health care disparities have been noted for the following groups of
patients: women; elderly people; poor people; people with disabilities; obese
people; Asian Americans; blacks; Hispanics; Native Americans; immigrants; gay,
lesbian, bisexual, and transgendered individuals; some religious groups; and
prisoners. Currently, the best way to ensure that the highest-quality care and
the best health outcomes are received is to be a young, heterosexual,
physically fit, Protestant, white American man who works at a high-paying job
and has good health insurance. The urgency with which disparities in health
care need to be addressed is keenly felt when one imagines the number of
individuals who are right now in doctors' offices, emergency rooms, or
hospital beds about to receive inferior medical care.
The health research community is moving from a laundry list of diseases and
factors associated with health care disparities to more systematic,
theoretical approaches to conducting research in health care disparities that
attempt to understand how interactions of multiple, complex determinants
influence these disparities. One approach to understanding the complexity of
health care disparities is population-level research that examines why certain
racial and/or ethnic populations in the United States have higher rates of
disease than other populations, studying characteristics of populations rather
than characteristics of
individuals5.
Diseases cluster systematically in populations, not randomly among a
collection of individuals. Therefore, to find the causes of differences in
disease rates in populations, characteristics of populations need to be
studied. Social patterning contributes to the occurrence of disease. Because
social factors predict access to resources, they affect multiple disease
outcomes through multiple mechanisms and maintain an association with disease
even when health care is available.
Jenkins and Rowley proposed that many of the determinants of
population-level disparities are social, behavioral, cultural, economic,
historical, and political in
nature6. For
example, health care disparities as indicated by the infant mortality rate, a
key measure of community health, have not changed for over 100 years. Although
the rates of disease have declined dramatically over the years, the rate
ratio7, as an
indicator of the disparity, has not changed over that time-period
(Fig. 1).
However, an analysis of review articles on health care disparities
associated with various conditions suggested that three major factors account
for as much as 90% of these
disparities4.
Socioeconomic status accounts for >30%, racism may account for =30%, and
culture accounts for just under 30%. Genetics and biological differences
account for the remaining 10% of these disparities.
The association between health status and socioeconomic status is well
established. The linear relationship between income and health suggests that,
even at the higher ends of the economic spectrum, income is a predictor of
health—the higher the income, the better the health. Education provides
the resources to make maximum use of health care services through an increased
ability to communicate needs and increased social power to ensure that those
needs are met. Desirable occupations and financial position allow persons to
avoid stressors that influence the disease burdens experienced by those who
have fewer resources.
Racism by health care providers has historically been supported through the
pseudoscience of the classification of living organisms. In the eighteenth
century, in addition to physical factors such as skin color, facial
characteristics, and hair texture, races were considered to be characterized
by temperament and psychological traits. Above all, this concept of race
connoted that groups could be arrayed on a scale from biologically inferior to
biologically superior, and racial differences in health outcomes were
acceptable. Historical attitudes about the inferiority and superiority of
certain "races" remain influential, despite evidence from the
human genome project that humans can be neither genetically nor biologically
classified by race. Racism, on both institutional and individual levels,
continues to influence health status.
A major part of the contribution of culture to health care disparities is
the acceptability of health care, which is often confused with increasing
access to health care. However, given the widespread availability of health
care today, the greater issue is not accessibility of health care but
acceptability of health care. Minority patients may have access to
health care but not to health care that they find acceptable nor to health
care that is accepting of them. This is a major factor leading to a delay in
seeking health care and in creating a perception of the lack of availability
of health care.
While genetics is an important factor, it is a small one. The distribution
of genetic factors is so similar among different racial and ethnic groups that
it accounts for very little of the health disparities across populations.
Additionally, the American focus on race tends to obscure our thinking on the
implications of genetics as an indicator of health status.
Patient-Provider Relationship
Patient care can suffer when the health care practitioner is not culturally
competent. While many practitioners are aware of the influence of cultural
factors in the medical encounter, there is clearly a need for additional
education in this area. During the symposium at the Annual Meeting of the AOA
in June 2006, the audience was asked the following question: "During the
last twelve months of your practice, how often have you personally experienced
an incident where the doctor-patient relationship suffered because of your
lack of knowledge about a patient's cultural or ethnic
background?"3
Sixty-two percent of the audience acknowledged having had such an experience,
with 26% overall stating they had experienced three or more such incidents
during the last twelve months.
The health care provider must be aware that sociocultural differences
between patient and provider influence communication and clinical decision
making. Evidence suggests that patient-provider communication is directly
linked to patient satisfaction, adherence to treatment recommendations, and
subsequently to health outcomes and malpractice
claims8-10.
When sociocultural differences between patient and provider are not
appreciated, explored, understood, or communicated in the medical encounter,
patient dissatisfaction, poor adherence to treatment plans, poorer health
outcomes, and racial and/or ethnic disparities in care may
result11. Education
in culturally competent care is an approach to improving patient-provider
communications.
A study in 2000 found that positive communication behaviors by the
physician increased a patient's perceptions about physician competence and
were associated with decreased malpractice claim
intentions12. As
such, one can deduce that patient-physician encounters that have been
influenced and improved by education in culturally competent care result in
fewer malpractice claims.
Furthermore, most medical and surgical teams are multicultural, and
education in culturally competent care contributes to team harmony, quality of
work life, and fewer errors. This concept applies not only to how physicians
relate to one another but also to how physicians relate to allied health
professionals, other caregivers, and colleagues of other cultures.
Humanitarian, Ideological, Nationalistic, and Global Rationales
The rationale for culturally competent care includes humanitarian,
ideological, nationalistic, and global concerns:
Humanitarian reasons: We care about all patients.Ideological reasons: As stated in the Preamble to the Declaration of
Independence, "We hold these truths to be self-evident, that all men are
created equal, that they are endowed by their Creator with certain unalienable
Rights, that among these are Life, Liberty, and the Pursuit of
Happiness."Nationalistic reasons: A healthy nation is stronger and more
competitive.Global reasons: A strong healthy nation enhances global health.
Humanitarian reasons: We care about all patients.
Ideological reasons: As stated in the Preamble to the Declaration of
Independence, "We hold these truths to be self-evident, that all men are
created equal, that they are endowed by their Creator with certain unalienable
Rights, that among these are Life, Liberty, and the Pursuit of
Happiness."
Nationalistic reasons: A healthy nation is stronger and more
competitive.
Global reasons: A strong healthy nation enhances global health.
Figure 2 presents several
dynamic and reciprocal relationships; some are hypothetical or theoretical,
and others are evidence-based. Education in culturally competent care seeks to
improve outcomes for patients who currently experience disparate health care.
Such education can be expected to improve cross-cultural patient-physician
interactions and relationships.
Fundamental Principles of Medical Professionalism
A key factor in the consideration of the rationales for culturally
competent care comes from "Medical Professionalism in the New
Millennium: A Physician Charter"; this charter is the product of a
collaboration that began in 1999 among the American Board of Internal Medicine
Foundation, the American College of Physicians Foundation, and the European
Federation of Internal
Medicine13. In it,
the principle of social justice is cited as one of three fundamental
principles to which all medical professionals can and should aspire. According
to this principle, "The medical profession must promote justice in the
health care system, including the fair distribution of health care resources.
Physicians should work actively to eliminate discrimination in health care,
whether based on race, gender, socioeconomic status, ethnicity, religion, or
any other social category."
This charter was published simultaneously in 2002 in both the Annals of
Internal Medicine and The Lancet. The American Board of Internal
Medicine reproduces and circulates this document annually. The AOA has
officially adopted this physician charter.
Limitations of Education in and Practice of Culturally Competent
Care
It is important to acknowledge that while education in culturally competent
care is an essential component in addressing the problem of health care
disparities, there are factors that contribute to the problem that this
approach does not address. As asserted by Gregg and Saha, culture alone does
not explain health behaviors, and sensitivity to culture alone does not
address health care
disparities14.
Rather, culture is one of several factors that contribute to health care
disparities; the impact of social and economic factors must also be
considered.
Arthritis is the most prevalent chronic condition affecting people in the
United States. It is a leading cause of disability, which disproportionately
affects older and minority populations. Several studies have revealed glaring
racial and/or ethnic disparities in the number of patients who receive a total
joint replacement. For example, a study by Wilson et al., which was based on
annual Medicare data on procedures done from 1980 to 1988, revealed that white
women received 64.8% of the total knee arthroplasties and white men received
30.9%, which is in contrast to blacks who received 3.5% and black men who
received 0.8%15.
Ten years later, a study by Skinner et al., which was based on data from 1998
to 2000, demonstrated that the rate of total knee arthroplasty per 1000 was
5.97 for white women, 5.37 for Hispanic women, and 4.84 for black
women16. The rate
was 4.82 for white men, 3.46 for Hispanic men, and a dismal 1.84 per 1000 for
black men. The considerable racial disparity is concerning; the reasons for it
are complex and multifactorial, including, as previously discussed,
behavioral, cultural, economic, historical, and political factors.
In their 2003 study, Skinner et al. demonstrated geographic differences in
the United States with regard to the rate of total knee arthroplasty among
Medicare
patients16. They
concluded that higher degrees of residential racial segregation and low income
were associated with large differences in arthroplasty rates. Better stated,
in areas with less residential segregation and higher income, the rate
difference was less. Cultural factors have also been studied and shown to be a
major barrier to certain groups receiving total joint replacement. Figaro et
al., in a study of ninety-four black patients in New York City, attempted to
assess the preference for arthritis care among urban
blacks17. They
stated that a common assertion among these patients is: "I don't want to
be cut." They hypothesized that the beliefs and experiences of blacks
may be an important underlying cause of the underutilization of total knee
arthroplasty. There was a strong preference for natural remedies, a perceived
negative expectation of surgery, a strong belief that God will control all,
and a strong preference for continuing in their current state and foregoing
relationships with specialists. Figaro et al. concluded that educational
programs in cultural sensitivity that address the negative perceptions of
surgery might improve the attitudes and beliefs of black patients about
arthritis and its surgical treatment and thus ultimately lead to appropriate
clinical use of total joint arthroplasty
A strategy for correcting the disparity in the rate of total joint
arthroplasty among different racial and/or ethnic groups has to occur on
several levels. First, at the societal level, the fundamental social and
economic inequities must be addressed. Second, at the health care delivery
level, health care should be accessible and acceptable to all patients
regardless of race and/or ethnicity. Third, at the patient level, people who
are candidates for total joint arthroplasty should understand the real medical
risks and benefits of the procedure so that they can make an informed
decision. Finally, at the physician level, physicians must provide
patient-centered care that is respectful of, and responsive to, individual
patient preferences and needs. The physician should consider patient values,
and the cultural competency of the physician will help in addressing those
values. One cannot provide patient-centered care without also providing
culturally competent care.
With comprehensive training programs in cultural competence still in
development, the commonsense approach to cultural competence is a good place
to start as an initial and immediate step. Namely, apply the "Double
F" criterion to all patients—treat them all as if they are family
or friends10. The
need for formal education in culturally competent care, whether it occurs in
medical school, residency, and/or established clinical practice, is necessary
because of numerous emerging efforts and changes in policy. Such initiatives
are occurring within federal, state, and local government agencies, as well as
in various organizations engaged in the education, credentialing, licensing,
and professionalism of physicians.
Education in culturally competent care as a means of addressing health care
disparities is essential for the health and well-being of the nation. There is
considerable evidence that there are disparities in the health care status of
racial and ethnic minorities in the United States and in the medical care
provided to those populations. The causes of health care disparities are
highly complex and multifactorial, and they include socioeconomic status,
racism, culture, as well as genetic and biological differences. Culturally
competent care and education in culturally competent care are important
approaches to addressing the problem of health care disparities. Studies have
shown that there are alarming differences in the provision of total joint
arthroplasty along racial
lines15,16.
The reasons for this are complex and require a multifaceted response,
including the provision of culturally competent care. Reducing health care
disparities is an ambitious aspiration, but it is achievable. There are
specific steps that practitioners must take to increase their knowledge and
improve their cross-cultural skills. Together, we can provide the highest
quality of care to all patients and reduce the poor health outcomes
experienced by many individuals in our society.
Cross TL, Bazron BJ, Dennis KW, Isaacs
MR. Towards a culturally competent system of care: a monograph on
effective services for minority children who are severely emotionally
disturbed: Volume I. Washington, D.C.: Georgetown University Child
Development Center; 1989.
1989
White AA III, Hill JA, Mackel AM, Rowley
DL. Symposium 5: Importance of cultural competence in orthopaedics: its
effect on outcome and healthcare disparities. Presented at the 118th
Annual Meeting of the American Orthopaedic Association; 2006 Jun
23; San Antonio, TX.
2006
Smedley BD, Stith AY, Nelson AR,
editors. Unequal treatment: confronting racial and ethnic disparities
in health care. Washington, D.C.: National Academy Press;
2003.
2003
Rose G. Sick individuals and sick
populations. Int J Epidemiol.
2001;30:
427-34.30427
2001
[PubMed][CrossRef]
Jenkins W, Rowley DL. Personal
communication. July 2005.
2005
Centers for Disease Control and
Prevention, National Center for Health Statistics.
National vital statistics system, 1915-1997.
.
Accessed 2006 Jan.
http://www.cdc.gov/nchs/nvss.htm
Eisenberg JM. Sociologic influences on
decision-making by clinicians. Ann Intern Med.
1979;90:
957-64.90957
1979
[PubMed]
Stewart M, Brown JB, Boon H, Galajda J,
Meredith L, Sangster M. Evidence on patient-doctor communication.
Cancer Prev Control.
1999;3:
25-30.325
1999
[PubMed]
White AA 3rd. Our humanitarian
orthopaedic opportunity. J Bone Joint Surg Am.
2002;84:
478-84.84478
2002
[PubMed]
Betancourt JR, Carrillo JE, Green AR.
Hypertension in multicultural and minority populations: linking communication
to compliance. Curr Hypertens Rep.
1999;1:
482-8.1482
1999
[PubMed][CrossRef]
Moore PJ, Adler NE, Robertson PA.
Medical malpractice: the effect of doctor-patient relations on medical patient
perceptions and malpractice intentions. West J Med.
2000;173:
244-50.173244
2000
[PubMed][CrossRef]
Medical Professionalism Project. Medical professionalism in the new
millennium: a physicians' charter. Lancet.
2002;359:
520-2.359520
2002
[PubMed][CrossRef]
Gregg J, Saha S. Losing culture on the
way to competence: the use and misuse of culture in medical education.
Acad Med. 2006;81:
542-7.81542
2006
[PubMed][CrossRef]
Wilson MG, May DS, Kelly JJ. Racial
differences in the use of total knee arthroplasty for osteoarthritis among
older Americans. Ethn Dis.
1994;4:
57-67.457
1994
[PubMed]
Skinner J, Weinstein JN, Sporer SM,
Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee
arthroplasty among Medicare patients. N Engl J Med.
2003;349:
1350-9.3491350
2003
[PubMed][CrossRef]
Figaro MK, Russo PW, Allegrante JP.
Preferences for arthritis care among urban African Americans: "I don't
want to be cut". Health Psychol.
2004;23:
324-9.23324
2004
[PubMed][CrossRef]