Cover Story - March 2006
A woman who had recently immigrated from Asia underwent a
mammogram in The University of Texas M.D Anderson Cancer Center
mobile van in Houston. The screening detected a problem, and the
woman became upset when told of the findings.
"She believed she didn't have breast cancer before entering the
van," said Beverly J. Gor, EdD, program coordinator for the
cancer center's minority health research center. "Now she had it
and was convinced the screening was the cancer's cause instead of
recognizing that the problem had been found early and could be
Dr. Gor, who works with Houston's rapidly growing Asian-American
population, says a "physician must understand where his or her
patients are coming from in order for a treatment plan to be
successful. The woman in the mammography program may not have come
back for treatment had her fears about how she contracted breast
cancer not been addressed."
If doctors don't understand, she added, they "might ask the
patient to do things he or she doesn't understand or that counter
his or her already held beliefs about health. As a result, the
patient may ignore a treatment plan or not come back for a
follow-up. It's not that the physician has a bad patient, but that
there is a lack of understanding. The mammography patient's
misperception could have further compromised her health, especially
if she had chosen to not follow up with a physician out of fear
that treatment would cause more cancer," Dr. Gor said.
Cultural competency is one of those terms that can make you roll
your eyes. Ethnic differences and their impact on behavior is a
complex subject many folks often simply do not understand or are
afraid to explore, fearing they will be accused of insensitivity or
worse. Yet Texas physicians, facing increasingly diverse patients
as heretofore minority populations become the majority, need to
take cultural differences in account to help address mounting
concerns over racial and ethnic disparities in health care.
But dealing with a patient whose beliefs may be radically
different from yours or your other patients' doesn't have to be
impossible. For Paul Haidet, MD, MPH,
assistant professor at Baylor College of
Medicine, cultural competency is rooted in one word:
"The issue at hand is how we as individuals understand one
another and one another's perspective of things," said Dr. Haidet,
a staff physician at the
Michael E. DeBakey VA Medical Center inHouston. "
The key task for physicians is to establish a form of connection
with their patients during the 15 or so minutes they meet with
them. During that interaction, the physician is the driver of the
communication. I try to demonstrate to the patients that I
understand what issues are important to them because any treatment
plan will be influenced by those issues," he said.
The Dec. 1, 2005, issue of the
American Family Physician
says efforts directed toward more culturally relevant health
care enrich the patient-physician relationship and improve patient
rapport, adherence, and outcomes.
Unfortunately, a study in the Sept. 7, 2005,
Journal of the American Medical Association
) found that resident physicians say their preparedness for
delivering cross-cultural care lags well behind their preparation
in other clinical and technical areas.
The report explained that although residents perceived
cross-cultural care to be important, little clinical time was
allocated during residency to address cultural issues, and they
received little training, formal evaluation, or role modeling. The
report called for significant improvements in cross-cultural
education to help eliminate racial and ethnic disparities in health
The Issue of Understanding
Richard Paul Bartlett, MD, who has served as chief of staff
at the local hospital in the West Texas town of Crane, is very
aware of how cultural differences can contribute to health
barriers. A member of the statewide Health Disparities Task Force,
Dr. Bartlett is a minority Anglo in a mostly Hispanic community.
Although fluent in Spanish, he says being culturally competent is
much more than simply knowing a language.
"Cultural competency is understanding where a person is
coming from. It means treating patients and their families with
dignity and respecting their culture; these things need to be an
effort that is made and not just assumed. Physicians and their
staff need to make a constant effort to learn the diverse needs of
the populations they are serving."
The June 10, 1998,
says physicians must be aware of the cultural and psychological
biases of their patients and address them in culturally sensitive
ways. Using breast cancer as its example, the report said
physicians will more effectively promote behavior that may allow
early detection and treatment if they understand their patients'
fears and misconceptions about the disease.
The April 2003 issue of the
American Journal of Preventive Medicine
concurs with Dr. Gor. It says the quality of health care can be
compromised when a patient does not understand what the doctor is
telling him, the doctor does not speak the patient's language, or
the doctor is insensitive to cultural differences.
Adds Dr. Gor, who also is part of the task force, "Physicians
can look at the census to understand who is in their communities.
They can see what language groups are out there, which might lead
them to a nonprofit or community-based organization that can assist
them with communication needs. Health care professionals and their
staff should understand the demographics of the communities
they serve and be willing to make some modifications to improve
health care for the whole community."
Austin internist Abraham Delgado, MD, medical director for TMF
Health Quality Institute, believes physicians should not only be
aware of the cultural differences among their patients, they also
should consider their own backgrounds and the perceptions they
bring to the health care setting.
"There is a culture of medicine that people are introduced to
when they train in health care. Physicians, nurses, and other
health care professionals learn a way of looking at the world that
is part of their training. It is an influence. For example, this
country has a very high-tech view of medicine; technology is part
of the culture. At some point, physicians will find themselves
trying to bring the benefits of this technological culture to
patients who may not be familiar with that particular view of
Armin D. Weinberg, PhD, director of the Baylor College of
Medicine Chronic Disease Prevention and Control Research Center,
says it is a mistake to assume that cultural competency is relevant
only to race or ethnicity. Physicians also should take into
consideration such cultural concerns as literacy, language,
economics, and geography, he says.
While culture competency programs such as those offered by the TMF
Health Quality Institute and American Academy of Family Physicians
The Road to Cultural Competency
") can be valuable, Dan Bustillos, JD, PhD, a health disparities
fellow at Baylor, warns that cultural competency cannot be taught
in just an afternoon lecture.
"There is growing concern that cross-cultural competency is now
being seen as only a skill set, that a good practitioner will
simply master it. But just because you memorize that a person from
a particular background will act a certain way does not guarantee
he or she will do so. It's important that physicians remember that
each of their patients is different culturally, just as they are
Jacquelyn Johnson-Minter, MD, MPH, a TMF clinical advocate and
physician consultant for tuberculosis clinics
inHarrisCounty, agrees. "As physicians, we learn there
is no 100 percent in medicine because we are all different. Even if
I've read all the literature that said 99 percent of these patients
will prefer this, I may have the 1 percent in front of me who
doesn't. Yes, they are part of a larger group, but how they
interact in a health care setting or in a crisis may be very
different than what you might expect."
A Simple Question
Dr. Haidet practices what he preaches in communicating with his
patients by asking them one simple question. Their response may
alter how he implements a treatment plan.
"I ask my patients, 'What do you think is going on?' or 'What's
worrying you most about this?' I always take the extra 20 seconds
to ask that sort of question. Often the diagnosis stays the same,
but how we set up the treatment plan and how I present future
information can change because of that answer."
He says many times the patient says "something that I never
would have anticipated. Patients come from all walks of life. And
they come from all sorts of backgrounds. And these backgrounds set
up their expectations for an illness and how they can treat it.
There is no way to screen for that, the only thing you can do is
take the moment to say, 'Tell me your understanding of what is
going on here.'"
American Family Physician
report suggests physicians use body language and speak slowly and
directly to the patient, using short sentences and a normal tone of
voice. It says patients, often feeling embarrassed, might nod their
head in agreement even if they don't comprehend what the physician
"I convey to my patients that we are a team trying to solve a
health problem," Dr. Johnson-Minter said. "Showing patients that
you are concerned about understanding them and about being
understood is the key. Physicians cannot be afraid to admit they
did not understand a patient the first time around. A solution can
materialize if both parties are working toward it."
Dr. Gor says interpreters are invaluable and acknowledges that
physicians often feel most overwhelmed by language barriers. She
advises them to acknowledge a patient's culture, then to assess how
well they are communicating with the patient. If they cannot cross
the language barrier, she suggests exploring community
"Some communities are fairly well organized and have
organizations or religious centers that can provide health
translators," Dr. Delgado said. "For years, physicians have relied
on family members, especially children, for translation. But it's
been shown that children may not be the best translators. In many
cultures, having children know a lot about their elders can be
considered very inappropriate. A child might be uncomfortable
discussing certain medical conditions. You can have a less than
ideal, sometimes very unsatisfactory, interaction if you rely on
Dr. Bustillos says even having a translator present does
not guarantee smooth communication. He points out that although a
translator may be fluent in Spanish, it could be Mexican-based
Spanish, which will sound quite different to someone from Spain or
Cuba. Although someone may speak another's language, it is not a
guarantee they know anything about that person's culture.
"An optimal situation is to have a trained medical translator, a
trained culture broker, a person that deals with these sorts of
interactions on a daily basis. What cultural competency should be
at its core is awareness that differences exist, the awareness that
there is a potential for misunderstanding in a dialogue, then from
there we should try to overcome these misunderstandings by using
whatever means are available to us," he said.
Dr. Delgado reiterates that developing trust, communication, and
understanding between people makes a difference in patient care. He
believes physicians who are culturally educated about their
patients provide better treatment.
"Communication can decrease the risk of malpractice. It improves
medical care and decreases the chance that medical errors will be
made. One can definitely make a medical case for the importance of
can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385;
by fax at (512) 370-1629.
The Road to Cultural Competency
To train physicians to care for diverse populations, the U.S.
Department of Health and Human Services Office of Minority Health
commissioned the Cultural Competency Curriculum Modules. The
modules are grounded on principles outlined in the National
Standards for Culturally and Linguistically Appropriate Services
(CLAS) in Health Care and are a first step in giving health care
professionals training in cultural competency.
Although CLAS standards are primarily directed at health care
organizations, physicians and other health care professionals are
encouraged to use them to make their practices more culturally and
The TMF Health Quality Institute is promoting the modules, which
offer Texas primary care physicians the opportunity to earn up to 9
free continuing medical education hours. Primary care practices
that participate in the project also can receive consultation to
implement CLAS standards and a 3-percent (up to $1,000) premium
reduction from Texas Medical Liability Trust. Physicians and other
health professionals can sign up for free online at
or by calling call TMF at (866) 439-8863.
Another resource is the Intercultural Cancer Council's
pocket guide, "
Cultural Competence in Cancer Care: A Health Care Professional's
Passport." It helps health care professionals better assess,
diagnose, and treat cancer patients of various cultural
backgrounds. Call (713) 798-4617 or log on to
The American Academy of Family Physicians (AAFP) offers a
cultural competency program as well, which includes handbooks to
address the importance of cultural competence in health care
delivery. For more information, contact Kaiser Permanente at (510)
271-6663 or log on to the AAFP Web site at
Back to article
Physicians who receive financial reimbursement under Medicaid or
Medicare must comply with a federal law that requires them to
notify patients who speak limited English about their right to
language-assistance services and, if needed, provide interpreters
at no cost to the patient.
For more information, log on to the Texas Health and Human
Services Commission Civil Rights Office Web site at
or call (888) 388-6332.
How to Improve Your Cultural Competency
- Do not necessarily treat the patient the same way you would
want to be treated. Culture determines the roles for polite,
caring behavior and will formulate the patient's concept of a
- Begin by being more formal with patients born in another
culture. In most countries, a greater distance between caregiver
and patient is maintained through the relationship. Except when
treating children or very young adults, it is best to use the
patient's last name when addressing him or her.
- Do not be insulted if the patient does not look you in the
eye or ask questions. In many cultures, it is disrespectful to
look directly at another person (especially one in authority) or
to make someone "lose face" by asking him or her questions.
- Do not make assumptions about the patient's ideas about how
to maintain health, the cause of illness, or the means to prevent
or cure it. Adopt a line of questioning that helps determine some
of the patient's central beliefs about health, illness, and
illness prevention. Allow the patient to be open and honest.
- Do not discount beliefs not held by Western biomedicine.
Often, patients are afraid to tell Western caregivers they are
visiting a folk healer or taking an alternative medicine because
they have been ridiculed in the past.
- Do not discount how beliefs in the supernatural may affect
the patient's health. If the patient believes the illness has
been caused by
(bewitchment), the evil eye, or punishment, he or she is not
likely to take any responsibility for the treatment. Belief in
the supernatural may result in the patient's failure to either
follow medical advice or comply with the treatment plan.
- Inquire indirectly about the patient's belief in the
supernatural or use of nontraditional cures. Say something like,
"Many of my patients from _____ believe, do, or visit ______. Do
- Try to ascertain the value of involving the entire family in
the treatment. In many cultures, medical decisions are made by
the immediate or extended family. If the family can be involved,
the patient will more likely comply with the treatment.
- Whenever possible, incorporate into the treatment plan the
patient's folk medication and folk beliefs that are not
contradicted. This will help the patient develop trust in the
treatment and help assure that the treatment plan is
Available on the American Medical Student Association Web site
Tips for Small Practices
An April 2005 Commonwealth Fund field report
surveyed health care practices to assess how physicians adapt
their practices to treat patients with limited English proficiency.
Eleven site visits and seven phone interviews took place at health
care settings with 10 or fewer clinicians. Promising initiatives
used by the physicians include the following.
Language Access Planning
Small practices are developing written language plans, as suggested
by the U.S. Department of Health and Human Services. These plans
identify language needs and propose strategies for meeting those
needs. Physicians are monitoring patient satisfaction as they
continue to evaluate and expand their language services. This may
be as simple as patient-charting notations or more formal patient
Bilingual Midlevel Practitioners
A limited supply of bilingual physicians, along with heavy
competition to hire them, has motivated some practices to focus on
recruiting and hiring bilingual midlevel staff who perform multiple
roles, including language-assistance tasks. For example, persons
with conversational proficiency in a second language may provide
services at the front desk (e.g., answering phones and scheduling
appointments), while those with medical proficiency may interpret
for patients during medical or clinical visits.
Particularly in communities with heavy demand for services in a
particular language, physicians may hire full- or part-time on-site
interpreters. Physicians may also consider interpreters who are
available to work on contract. Potential sources for hiring such
interpreters include area hospitals, state or local agencies,
refugee resettlement sites, community-based organizations, or
commercial entities. Physicians are increasingly taking steps to
improve the competency of bilingual staff who interpret for
patients. On-the-job training is offered in some practices by
bilingual midlevel practitioners and office administrators, who
also may assess language skills during the hiring process and
evaluate new staff in training. A growing number of practices are
seeking to minimize their reliance on family or friends of patients
as interpreters. Where family members are still being used, some
physicians attempt to have a trained interpreter sit in during the
medical encounter or follow up with the family within 24 hours to
verify the patient's condition.
Telephone Language Lines
Some practices are developing ways to make interpreters via
telephone accessible to both physicians and patients. Some
practices have placed speaker phones in examination rooms. Some
physicians carry cell phones with speakers that can be easily
exchanged between doctor and patient.
When evaluating the need for translated materials, many practices
make extensive use of existing materials. They use translated
materials offered by various organizations, Web-based materials
from federal and state governments, and materials downloaded from
health departments in other countries such as Taiwan. Some
practices also use bilingual staff, contract interpreters, local
hospitals, and faith-based organizations to translate
Many small practices seek funding from various sources, including
federal, state, and local governments; foundations; and nonprofit
Case Studies in Cultural Competency
Reevaluating Ethics and Values From a Different Cultural
An adolescent, unmarried girl in Saudi Arabia was taken to a
hospital for an unrelated spinal problem when her American doctors
discovered that she was pregnant. Two of the doctors, familiar with
the gender expectations of young women, knew that the pregnancy
would bring great dishonor to the family and that punishment could
bring death to the girl. They arranged for her to have an abortion
in a neighboring country. They told her parents that treatment for
the spinal problem was only available in this other country.
A third doctor, who had been in Saudi Arabia only a short time,
felt that he could not be a part of this deception. The other two
doctors urgently convinced the third doctor that the girl would be
in serious danger if her pregnancy was revealed to her family. The
third doctor reluctantly agreed to say nothing.
At the last minute, as the girl started to board the plane, the
doctor uncontrollably felt he could not go through with what he
felt was an ethical violation of truth-telling and told the father
the girl was pregnant. The father immediately grabbed the girl and
left with her. Several weeks later, the third doctor ran into the
girl's brother and asked about her condition. The boy shook his
head and explained that the girl was dead. The family's honor had
been restored. The distraught doctor left Saudi Arabia.
- What were the conflicting values about which the three
- Did the third doctor make a mistake by telling the family or
did he just do what he felt was ethically imperative?
- How might reexamining his ethics have helped the doctor make
a better decision?
- As the physician, what would you have done? How would you
justify your actions?
Caring for Patients From Different Cultures: Case Studies From
2nd ed.Philadelphia,Pa:UniversityofPhiladelphiaPress; 1997.
Family Relationships, Truth-Telling
Mrs. Lee was a 49-year-old Cantonese-speaking woman who had
immigrated years ago from China to the United States. She lived
with her husband and youngest son, Arnold, age 22. Studies revealed
that Mrs. Lee suffered from lung cancer that had metastasized to
her lymph nodes and adrenal glands. Arnold did not want Mrs. Lee's
diagnosis known to her. Eventually, the cancer spread to her
Her physician, knowing her poor prognosis, suggested a DNR to
her son, who refused to even discuss the possibility with his
mother. Arnold felt his role as son and family member meant he must
protect his mother from "bad news" and loss of hope. He believed
telling her the dim prognosis would be cruel and cause unnecessary
stress. Though futile, the son insisted that all heroic methods be
used, including a ventilator, to save his mother's life. He accused
the house staff and physician of racism and threatened litigation.
As a family member, he considered himself, not the doctors or
patient, responsible for his mother's treatment.
- Had you been the physician, what would you have done?
- Try to see Arnold's point of view. What might he have been
- How did cultural differences in the telling of bad news,
treatment limits, and the role of family differ between provider
- How did Mrs. Lee's age and her son's sense of responsibility
to the family affect her care?
- What might have been some culturally competent options for
the house staff?
- How do the ethics of "informed consent" and autonomy fit into
the beliefs of Mrs. Lee and her family?
Source: Muller JH, Desmond BD. Cross-cultural
medicine - a decade later: ethical dilemmas in a
cross-cultural context - a Chinese example.
West J Med
Conflicts About Disability, Right to Refuse Treatment
A Hmong child was born with a clubfoot. Doctors felt the foot would
cause social embarrassment and make walking difficult. They
recommended an operation to reshape the foot. The family believed
the foot was a blessing, a reward for ancestral hardships.
Because the family believed "fixing" the foot would bring shame
and punishment to the family and Hmong community, they refused
treatment. The family went to the Supreme Court to defend their
right to refuse treatment. They won.
- What do you think should have happened in the court case?
- In this case, the operation did not involve life or death.
But what if it had?
Source: Harry B.
Developing Cultural Self-Awareness
. In: CASAnet Library: Cultural Competency. Available at:
These case studies are available on the American Medical
Student Association Web site at