AAOS Bulletin - October, 2006

Addressing the black-and-white issue

Communicating with African-American patients takes empathy and understanding

The African-American man with an injured leg sits across from the orthopaedic surgeon. He says he is in pain, and is afraid his leg will have to be amputated. The surgeon knows that will not be necessary, and ignores the remark, telling the patient he will need to take further tests. The patient reacts suspiciously and refuses to cooperate. Is this an example of disparity in health care, a lack of cultural understanding between blacks and whites or a standard interaction between physician and patient?

Why it matters
Patient safety, satisfaction and successful outcomes rely on understanding both a patient’s medical and cultural needs. Black Americans—whether from the Caribbean, Central or South America, Africa or America—continue to confront challenges and disparities in health care compared to white (Anglo- or Euro-pean-) Americans. African-American men are less likely to receive an analgesic for their pain than white men, and they are more likely to have their limbs amputated. They also tend to have a general distrust of medical care and are skeptical of being asked to participate in clinical research studies.

“African-American patients wait longer for diagnoses, receive less aggressive treatment and are undertreated for pain,” says orthopaedic surgeon Valerae O. Lewis, MD. “Racial and ethnic disparities exist even when insurance, status, income, age, education and severity of conditions are comparable.”

Poor communication is a major reason for these disparities. By improving their communication with African-Americans and other minority patients, orthopaedists can improve diagnoses, patient cooperation and treatment outcomes.

“Some doctors walk in with a patriarchal attitude, don’t want to take the time, or are just apathetic,” says Diversity Advisory Board Chair Ramon L. Jimenez, MD. “Others have good intentions, but don’t communicate them. Cultural competence is all about communication. If you don’t communicate, it doesn’t matter what your intentions are.”

Dr. Jimenez urges orthopaedists to change their approach to minorities through the practice of “culturally competent care,” which he defines as the combination of attitudes, skills and knowledge that allows health care providers to better understand and take care of patients whose cultural backgrounds are different than their own.

Many people would agree that culturally competent care for African-American patients—or any cultural/ethnic group—should be an end in and of itself. But it is also the means to an end—better health care for all patients.

“Good orthopaedic surgeons want to deliver the best care they can to all of their patients,” says Dr. Jimenez. “The best method for physicians to improve understanding between cultures is to inculcate compassion, sensitivity, curiosity and awareness.”

Empathy and engagement are the most important elements of culturally competent care, he adds.

Steps toward understanding
Fortunately, cultural communication skills can be improved. The best place for physicians to start is within—by taking a good look at themselves and taking the following steps:

  • Take stock of your own attitudes, biases and stereotypes.
  • Recognize that more differences exist within a group than between groups.
  • Be aware of the role that your own cultural group’s values plays in how you approach patients.
  • Become more aware of how your nonverbal communication might affect patients. Is it insulting or confusing?
  • Ask how you might have contributed to any of the conflicts you experience.
  • Have as many face-to-face encounters with “diverse” patients as possible. The more encounters, the more knowledgeable and adept you will become.


The issue of respect is extremely important in interactions between white doctors and African-American patients. This past spring, a Washington Post/Kaiser/Harvard survey found that when white men and black men were asked if they are treated with less respect than other people, twice as many black men said they were.

By showing genuine interest in and respect for African-American patients during a consultation, doctors can pave the way for improving overall quality of care. Orthopaedists who are polite, show consideration, appear unhurried and set a friendly tone can find common ground with their patients. Ask nonjudgmental, open-ended questions, and never be afraid to ask questions if something is unfamiliar or confusing to you. As you show a willingness to listen, patients will more likely respond in greater depth, leading to fewer misunderstandings and ultimately fewer errors.

As Dr. Lewis outlines in “Cultural Competence and the African-American Patient,” (available online at www.aaos.org/diversity), physicians can take the following steps to improve patient consultations:

  • Recognize that many African-American patients are extremely wary of the health care system—for good reason. The infamous Tuskegee study, which deliberately withheld treatment from syphilitic black men in the name of science, went on for decades—well into the 1970s. Other cases of racist medical treatment continue to be reported.
  • Recognize that African-Americans are a diverse group. They vary in physical features as well as socioeconomic levels. Recent immigrants come from various African and Caribbean areas with different cultures, religions and languages.
  • Always use titles, such as Mr., Mrs., Ms., Dr., Pastor or Reverend. Never use first names unless the patient invites it.
  • Let patients choose where they want to sit. Showing consideration for personal space is another way of conveying respect.
  • Look patients in the eye; it is a sign of respect and helps gain trust. But do not be surprised if patients listen without making eye contact themselves.
  • Allow patients to tell their stories in their own way.
  • Avoid using the term “you”—as in “you people.”
  • Call patients personally to give test results. It takes time, but helps build trust.
  • Pay attention to the patient’s religious or spiritual beliefs and how they may influence their feelings about disease or pain.
  • Never make assumptions about a patient’s intelligence based on their dialect or use of language. Instead, watch for nonverbal cues, listen carefully, speak clearly and without jargon, and ask the patient to repeat information and instructions to verify comprehension.

“If you open up your arms, word gets out, and you’ll have a more successful practice,” Dr. Jimenez says. “You’ll also be able to face yourself in the mirror.”

If you need another reason to fine tune your cultural communication skills, legislation tying a doctor’s “cultural competence” to medical licensing has already passed in California and New Jersey. Advocates are working to introduce similar legislation in Illinois, Texas, Michigan and Arizona, Dr. Jimenez adds.

Communicate welcomes suggestions about future topics. E-mail your suggestions to the Bulletin at aaoscomm@aaos.org

Cultural Competency Challenge

What is the most important thing an orthopaedic surgeon can do to begin practicing culturally competent care? “Practice empathy and engagement,” Dr. Jimenez says. “Also, take the AAOS Cultural Competency Challenge! It’s an excellent learning tool.”

The Cultural Competency Challenge is a free, enjoyable and educational tool that tests your ability to effectively communicate with, and treat, an ethnically diverse patient population. Developed by the AAOS Diversity Committee, the CD helps gauge your “cultural care IQ” through 18 patient cases and 90 multiple-choice questions. It also makes a great teaching tool for residents and medical students. To take the “Challenge” today, visit www.aaos.org/diversity or order a free CD from AAOS Customer Service—(800) 626-6726 or custserv@aaos.org

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