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Wednesday, March 10, 2004

Cultural Diversity and Patient Safety

By Howard R. Epps, MD

An essential component of patient safety is the successful achievement of the objectives of a medical intervention. Compliance with any recommendation occurs most frequently when the physician and patient feel a shared partnership in the outcome. Effective communication concerning medical treatment increases the likelihood of adherence to recommendations.

Healthcare delivery involves a complex system of providers, support staff and ancillary services. The patient's role in the system is often overlooked. The patient's ability and willingness to adhere to a treatment regimen is critical for a successful outcome. Although medical care occurs in hospitals and clinics, a substantial portion of a patient's medical care takes place at home. The patient bears the responsibility of taking medications as directed or following the prescribed instructions.

Evidence suggests that patients are frequently noncompliant. Approximately 40 percent of patients fail to follow short-term or long-term treatment recommendations. Noncompliance occurs across a broad spectrum of socioeconomic groups, levels of education and backgrounds.1 This compromises the potential outcome of any treatment protocol or surgical procedure, irrespective of the skill or accuracy of the providers. Compliance requires an effective partnership with the patient and a complete understanding of the shared responsibility required for a successful outcome.

Researchers believe that there are two reasons for noncompliance: either the patient does not believe in the effectiveness of the treatment, or the patient cannot carry out the treatment due to its complexity.1 Care that lacks cultural competence exacerbates these problems.

Studies suggest that patient satisfaction is highest when patients and their physicians are culturally concordant. The ability to speak the language, or perhaps a sense of comfort that minority patients feel with a racially concordant physician may contribute to this finding.2 However, physicians of different ethnicity than their patients can successfully overcome cultural barriers that may hinder the physician-patient relationship.

To effectively communicate any treatment regimen with the patient, the physician must first establish rapport with the patient and then provide the patient with all the essential information.1 Recognizing and respecting a patient's cultural values help a physician establish rapport with patients of different backgrounds. Patients whose ethnicities are discordant with their physician appreciate genuine efforts to honor and respect their customs.2 A frequent barrier to cultural competence in communication is lack of knowledge of the patient's values.

The second contributor to noncompliance is lack of essential information. The patient must understand the risks, benefits and expectations of any treatment plan. Patients are more likely to comply with the therapy if they fully understand the rationale for the treatment.

Medical translators may be required to ensure that all information is properly conveyed and all questions are fully answered. If interpreters are not available, a member of the patient's family or one of the physician's office staff who is facile with both languages could help facilitate a free, open exchange of information between the physician and the patient. Here too, however, physicians should be aware of cultural mores. Using a family member who is young or a different sex than the patient may not be appropriate. Physicians also should be aware that family members, even if they are bilingual, may not have the vocabulary to express medical concepts.

A healthy physician-patient relationship contributes to a sense of shared responsibility for a patients care. Recognition and respect for cultural values fosters a healthy physician patient relationship and opens channels of communication. Informed patients are more likely to follow recommendations, and thus maximize the possibility that desired outcomes will be achieved.

Dr. Epps is a member of the AAOS Patient Safety Committee.


1. DiMateo M, Reiter R, Gambone J: Enhancing Medication Adherence Through Communication and Informed Collaborative Choice. Health Communication 1994;6(4):253-265

2. Ramirez A: Consumer-Provider Communication Research with Special Populations. Patient Education and Counseling 2003;50:51-54

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Last modified 01/March/2004