June 2000 Bulletin

Doctors coached on cultural competency

By Carolyn Rogers

More doctors than ever are finding that their patients come from ethnic backgrounds that are quite different from their own. Even in rural areas, it’s no longer unusual to see patients from Vietnam, Mexico or Africa. Physicians’ unfamiliarity with their patients’ cultural backgrounds, however, can lead to confusion, distrust and ultimately poor health outcomes.

Cultural competency training, some say, can help avert a myriad of cultural misunderstandings.

Certain health plans and provider networks see formal cultural competency training as a way of improving outcomes and boosting patient satisfaction. Plans such as Kaiser Permanente and Harvard Pilgrim Health Care are among the few to introduce their own training programs aimed at coaching doctors on everything from cultural stereotypes to the importance of gestures, eye contact, folk medicines and ethnic foods in medicine.

Since 1998, Harvard Pilgrim has offered a three-day diversity training course for Harvard Pilgrim affiliated providers as well as unaffiliated providers.

"About four or five years ago, we began to recognize that if we were going to be a culturally competent health care system, the patient-doctor relationship was a critical area we couldn’t ignore," says Barbara Stern, vice president of diversity at Harvard Pilgrim. "We needed something to help providers build the necessary skills."

Most of the doctors who have been coming to the $600 three-day course already have a good number of diverse patient populations, and are seeing patients that don’t speak English.

"They’re already immersed in some of the challenges; that’s what has motivated them to commit to a three-day course," Stern says. "Unlike the new residents coming out of medical school–who will have at least received some diversity training–we’re catching pro- viders who are already practicing and never got this kind of exposure when they were in medical school."

Stern says the three-day program, for which 20 1/2 Category1 CME credits are offered, has attracted a "good mix" of providers in terms of race, ethnicity and gender. Eighty percent of the participants are physicians.

"In this course, we tend to take the approach that every encounter is a cross-cultural encounter," Stern says. "We spend maybe a half a day talking about specific cultures. We’re not offering a lot of specific tips such as ‘Latinos or Russian immigrants do such and such.’ We’re here to give you a broad set of tools–stereotyping would be a mistake."

Course content is focused on building awareness, then goes beyond that to begin to build skills, Stern says. Participants engage in a skills-based activity on each day of the course.

For example, on one day standardized "patients" are brought in so the physicians can practice the art of bilingual interviewing with the guidance of trained medical interpreters. "Patients" are brought in another day to play the role of a patient with a particular medical problem. Each provider goes into a private room where he or she goes through a 20-minute patient encounter while being videotaped.

"At the end, we bring in a coach who offers feedback," Stern says "The patient also offers feedback as to how they experienced the encounter."

Another key component of the course is a community tour.

"We take the participants into a community–say, the Haitian community," Stern explains. "We bring them to a variety of places that will provide them with a better understanding of how Haitians live and deal with different issues. Participants are exposed to the particular group’s religious issues, diet, herbal remedies, etc. We also introduce them to leaders in the community who have valuable knowledge to share."

Much of the challenge in cross-cultural encounters, Stern says, is in creating the kind of relationship in which the patient will feel enough trust in the provider to listen and incorporate the suggestions that are made.

"We’re seeing that the physicians are walking away from the course with a much clearer understanding of approaches they can take in addressing their patients needs," she says. "It doesn’t work for them to go into the visit with a set agenda, or have one-way conversation, because the patient won’t automatically do what the doctor says. It’s really a negotiations process."

Cross Cultural Health Care Program (CCHCP), an independent not-for-profit Seattle-based group, also offers training to enhance health care providers’ cultural sensitivity.

‘Cultural competency’ has become a watchword in medicine, says CCHCP Training Manager Ira SenGupta.

CCHCP offers a wide variety of cultural competency services, such as training medical interpreters and assessing institutions, as well as training for physicians and other providers. Numerous health plans, hospitals and universities–such as Duke University Medical School and Kaiser Permanente–contract with CCHCP to provide diversity training for physicians and other providers. CME credit is typically offered to doctors who participate.

SenGupta offered six "compelling reasons" for cultural competency training:

  1. To respond to changing demographics and to emerging health beliefs that are different from the mainstream.
  2. To eliminate health disparities.
  3. To improve quality of service and health outcomes.
  4. To meet legislative, regulatory and accreditation requirements.
  5. To gain a competitive edge in the marketplace–more funding, more patients, better community partnerships.
  6. To decrease the likelihood of liability and malpractice claims.

"It’s not really about becoming culturally competent," SenGupta says, "but enhancing your competency–we’re always on that continuum. It’s about learning new ways of working with people– keeping up with the changing times and the patients’ needs."

Universities are also getting into the act. A majority of American medical colleges now teach courses in cultural competence.

"It’s not required across the board yet," says Joseph Betancourt, MD, associate director of the Center for Multicultural and Minority Health (CMMH), Weill Medical College of Cornell University, "but the AAMC and ACGME are working toward making it a mandated part of medical education in the next two years."

Dr Betancourt’s multicultural program, however, is ahead of the pack. The center opened in 1999 with four major initiatives: minority faculty and housestaff recruitment, multicultural health and health policy research, community outreach and cross-cultural education.

"The goal of our cross-cultural curriculum is to help physicians avoid cultural generalizations while improving their ability to understand, communicate with, and care for patients from diverse backgrounds," Dr. Betancourt says. "The skills learned through this curriculum can help promote communication and cooperation, improve clinical diagnosis and management, avoid cultural blind spots and unnecessary medical testing, and lead to a progressive depth of understanding between patient and physician."

While Cornell’s curriculum is primarily geared toward medical students and residents, the center occasionally is called upon to present a course to practicing physicians.

"These tools help physicians do what ‘good doctoring’ is all about," Dr. Betancourt adds, "listening, asking the right questions, and meeting the patients where they are."

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