Cultural Competence in Clinician Communication

After completing this article, readers should be able to: Note: A clarification has been posted.Some have suggested that cultural competence cannot be taught or learned and that some clinicians are just more sensitive than others when it comes to issues of cultural differences. Indeed, in some instances, we preach to the choir, if you will, regarding attitudes toward cultural competence. However, certain skills can be imparted to help all clinicians, regardless of their attitudes. As Dr Joseph Betancourt concludes, we would not accept substandard competence in other areas of clinical medicine, and cultural competence should not be an exception.(1)Certain skills can be acquired, practiced, and honed on the journey of becoming a more culturally competent clinician. This article reviews the evolution and benefits of cultural competence in pediatric practice and gives examples of questions that can be asked to provide more comprehensive care to the patient and his or her family.Cultural competence can be assessed via several methods. For example, evaluations or satisfaction surveys from patients, families, and staff, otherwise known as 360-degree evaluations, in a busy pediatric practice can provide useful feedback that prompts change in behavior. Observation, one of the best tools for evaluating clinician behavior, can be performed by using either standardized or real patients. Observed role-playing with standardized patients can provide clinicians with formative feedback to improve their interviewing skills. Observation of interactions with actual patients or unidentified standardized patients, similar to the observation model used in education, captures actual clinician behavior when functioning under pressure.The Institute of Medicine issued its landmark report about health disparities in 2002, referencing inequities in adult health-care services. Pediatrics is a part of the health disparities landscape, with many health outcomes being complicated by childhood poverty. Classic examples of pediatric health disparities include differences in immunization status, care of asthma, and prevalence of teen pregnancy. Although the terms “health disparities” and “cultural competence” often are used interchangeably, cultural competence is one vehicle, along with increased access, insurance coverage, and others, that can improve health outcomes through improved communication and increased trust and understanding between patient and clinician.Culture is defined as patterns of human behavior inherent in the lives of a racial, ethnic, religious, or social group. Some social groups can be defined by age, generation, ableness, body image, and mental illness, for example. Characteristic behaviors can include thoughts, language, customs, beliefs, and institutions. For example, adolescents are their own culture (subculture), characterized by how they communicate, how they wear their clothes, the types of music to which they listen, and what they value.Some of the variance across cultural groups can be affected by immigration, family structure, educational attainment, and socioeconomic status. The importance of educational attainment as an influence on socioeconomic status cannot be overstated and is highly predictive of health outcomes for children.Cultural competence, therefore, is an acknowledgment and incorporation of the importance of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs on the part of clinicians and health-care systems. Some clinicians state that they interact with all patients in the same manner. Indeed, being culturally competent implies that clinicians not treat patients the same, given the cultural dynamics each brings to the encounter.Cultural competence is a concept that has come to medicine slowly, although it has been discussed in the nursing and psychology literature extensively. Cultural competence terminologies have evolved over the past 2 decades from cultural awareness to cultural sensitivity to cultural competence. Other terms, such as cultural effectiveness and cultural humility, are used currently. Regardless of the term used, the principles of cultural competence may be recognized most often when they are absent. These principles include empathy, curiosity, and respect, with which comes a heightened understanding and appreciation of the social context of the patient.The term cultural competence is used in this article because it is a familiar term to most clinicians, although it falsely implies that some endpoint can be reached. The exact opposite is true, however; no one ever becomes “competent.” Cultural competence is a process, built upon by asking questions of the patient, family, and oneself.Clinicians today are practicing in the midst of a rapid change in the demographics of the pediatric population of the United States. New York is one of several states that has stood apart in terms of patterns of immigration over the past century. The immigrant child population is the fastest growing portion of the child population. In contrast to the white European and English-speaking immigrant populations that migrated to the United States in the early 20th century, families from the Caribbean, Africa, and Asia constitute significant immigrant groups today.Noteworthy is the growing Hispanic population. Immigrants from Mexico and Central America who are settling and raising their families in the United States, similar to other immigrants, are looking for greater economic opportunities or seeking safety from the conflict of war. It is estimated that by the year 2020, Hispanic adolescents will constitute the largest minority youth population and that approximately 40% of all youth will belong to a minority group.Given the change in the cultural makeup of the United States, clinicians are being challenged as never before to provide cross-cultural care that is sensitive, effective, and able to meet the needs of the patient and family. Cross-cultural care requires that clinicians be open and seek to understand the various dynamics of the patient-clinician encounter, such as variations in the perception of illness, diverse belief systems around health, differences in help-seeking behaviors, and preferences in approaches to health care. Therefore, cultural competence is not a question of “doing the right thing.” Rather, it is an important vehicle for achieving patient satisfaction, patient safety, and improved health outcomes.One of the first challenges in achieving culturally competent practice is acknowledgment that medicine is its own culture, often at odds with the cultural orientation of patients. Western medicine puts a high priority on concepts such as individualism, emphasizing that the individual has control over his or her health. Western medicine also endorses the following: diseases have specific causes, there is one system of care to address the disease, and patients adapt to the system. Pediatric clinicians may have particular assumptions about family dynamics and how families mobilize on behalf of their children to make health-care decisions.In contrast to the culture of Western medicine, patients’ cultural norms may demonstrate more community than individual orientation, conceptualize circumstances as being beyond their control, see disease as a result of misfortune or imbalance, and use other treatments in combination with or to the exclusion of Western medicine. To bridge this gap, the onus is on the clinician to ask questions that uncover such orientations to health and illness so they can be integrated into the caretaking of the patient and family and negotiated, if possible, when making health-care decisions.As mentioned, cultural competence involves empathy, curiosity, and respect. Although being aware of the history, health beliefs, and practices of a particular cultural group can provide a foundation for understanding, such knowledge must be balanced carefully to avoid stereotyping and to accommodate diversity within groups. Resources such as Working with an Interpreter: Stronger Outcomes Tips at www2.massgeneral.org/interpreters/working.asp and additional sites (listed at the end of the article) cover general information regarding various racial and ethnic groups. In addition to these broad guidelines, there is an important role for asking questions to acknowledge and create deeper understanding of how the many layers of culture interact within the individual patient and family to influence health care.Before beginning the process of engaging with the patient, clinicians must have an idea of their own sensibilities, an awareness that comes with self-reflection. Five key goals should be sought in this process of becoming culturally competent: Cultural competence is not only an orientation to employ when the patient speaks a different language or looks different from the clinician; it should be engaged with every patient. Some of the most surprising instances of cultural “disconnects” occur with patients and families who look like their clinicians. Regardless of shared race, ethnicity, or cultural identification, we may not have the same values, perspectives, or choices as our patients.Given the challenges in everyday practices, how do clinicians negotiate across cultures with families? First steps are to recognize individual biases in a particular situation. Are we able to sidestep the bias or do we need to refer? If we can sidestep the bias, how do we create time and space to reassess that bias and its origin? How do we organize these efforts for the office team? With self-reflection, can we change how we engage with patients and families?Patients may hesitate to offer their beliefs and fears, which can be overcome through respectful questioning (Table 1). Clinicians can save time during the encounter by having the patient help set the agenda for the visit and, therefore, meet his or her needs. Bridging a gap by recognizing the role of complementary and alternative medicine may shed more light on a patient's explanatory model for health or illness. The next three examples, all of which are real, are designed to highlight how asking or not asking such questions can help or hinder a patient-clinician interaction.A 17-year-old African American girl comes in for a scheduled health supervision visit. While performing a psychosocial assessment, you note that she appears agitated. After some time, she states that she wants oral contraceptives.This is a case of asynchronous agendas. The patient's agenda was very well-defined, basically to avoid becoming pregnant. Asking questions that were more in the realm of a psychosocial history revealed that her two older sisters were adolescent parents and that she was eager to avoid the same outcome. She was seeking birth control at this visit and had specific ideas about what method she wanted and why. Questions to elicit the patient's agenda such as “How can I be most helpful to you?” at the beginning of the visit could have set the context for and increased the patient's satisfaction with the visit.A 15-year-old white girl and her mother come in for consultation regarding general body aches and sleep disturbance. The patient has seen various specialists, and results of evaluations have been benign. The mother has consulted family members, friends, and neighbors regarding what could be wrong with her daughter. In particular, the girl's aunt seems to have had substantial input regarding potential causes and nonmedical treatments for the girl's problems.The clinician in this case had to negotiate with more people than actually were present in the room at the time of the visit. Being respectful and listening to the ideas of the family were important to establishing rapport with this family. Questions such as “Have you used nonmedical remedies or treatment for your problem?” can help open the door to a comprehensive conversation about how patients help themselves.Such an approach also gave the clinician a sense of the family's interest in complementary and alternative medicines, demonstrated the clinician's openness to such considerations, and allowed the clinician to steer them toward appropriate alternative treatments. Some of the therapies that were proposed and accepted by the family included melatonin/valerian root for sleep disturbance, peppermint for stomach upset, and yoga for general conditioning. Also, continued biofeedback therapy, in which the family already was engaged, was encouraged. Asking about and coordinating care with complementary and alternative medicine clinicians or traditional healers in the community can be validating to a family and encourage a nonmutually exclusive approach to a health condition.A Chinese father brings in his 9-month-old son for a health supervision visit. The baby has been doing well, but the baby's grandparents have been pressuring the father to start feeding the child eggs. The clinician summarily tells the father that eggs are not recommended until 12 months of age because of the risk of food allergies. She suggests that the father use her as the scapegoat with the grandparents for adhering to this recommendation.This case encompasses the issue of who advises parents about their child's health. Although pediatric clinicians see themselves as the pillars of prevention and health, many other influences affect the daily lives of children, such as grandparents. In this case, the clinician missed an opportunity to inquire about the cultural importance of eggs to this Chinese family's diet. Questions such as “Tell me why this is important to you and your family” open a dialogue to increase understanding of a family's explanatory model for health. Instead, this clinician closed the conversation with no guarantee that the father is in agreement with the recommendation or that the father will disclose the family's health beliefs in the future.The social context of patients can affect their health and presentations. Poverty is one of the most significant barriers to health and access to health care. Table 2 highlights questions regarding resources, change in environment, social supports, and literacy, which can open the dialogue. Understanding of such social factors can increase the clinician's appreciation of the challenges encountered by patients and compensate for them in counseling and treatment. The following four actual patient cases demonstrate this focus.A 7-year-old boy has just been diagnosed as having attention-deficit/hyperactivity disorder. His mother is eager to have him on medication because of the pressure she is getting from his school. Unfortunately, she has switched jobs and is in between insurance plans. The out-of-pocket cost for a 30-day supply of stimulant medication would be $200 for the month between this visit and when the mother might have her new insurance plan.The clinician in this case was able to determine that finances were an issue for this family and would affect the family's ability to purchase medication. In light of this situation, frank discussion of how much the family could afford was possible. The mother agreed to the idea of purchasing the medication for 2 weeks until she met her next pay period. The ability to consult social workers or community health workers who can perform outreach to a family can increase access to services as well as increase understanding of the challenges families may face.A 12-year-old girl who has sickle cell disease and emigrated from Jamaica is having adjustment reaction issues and conflict with her mother. The mother, who now is an illegal alien, has had a dramatic change in her earning potential compared with their middle class lifestyle in Jamaica. The family emigrated for better health care for the girl.As is common for many immigrant children, this patient was between two worlds. She was mourning the loss of the life she had in Jamaica while being confronted daily with the unpredictability of her family life in a new country. Her mother had to work jobs that paid “under the table,” which sometimes meant that her mother needed to move away for months at a time, leaving the patient with other family members. Questions such as “Tell me what brought you to this country” and “What was life like for you in your country?” elicit information about place and family of origin, changes in socioeconomic status, and acculturation. As in this case, just letting the patient/family tell their story can answer many critical questions.A 19-year-old African American man is dealing with the second recurrence of his cancer. He is admitted to the hospital. Both parents are vigilant and at the bedside. Various family and church members come to pray for him. The number of visitors becomes more of an issue as the patient develops neutropenia and requires isolation.It was clear that this family's spirituality was very important. They were connected to their church and appreciated the prayers that the congregation had said for them. Spirituality also was important to this young man. He had taken on many active roles in the church, including maintaining the church property and helping some of the more elderly parishioners. These parishioners, in turn, visited him for the sake of on of to and of the patient. 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