Culturally Competent Family Medicine: Transforming Clinical Practice and Ourselves
Am Fam Physician. 2005 Dec 1;72(11):2189-2190.
The subject of cross-cultural medicine is an enormous one, and the article by Juckett1 in this issue of American Family Physician provides a succinct overview of the nation’s changing demographics, racial and ethnic health disparities, and selected traditional health care beliefs and practices in Latino, Asian, and black cultures.
The article emphasizes the importance of physicians maintaining a curious, caring attitude; understanding one’s own ethnocentrism and biases; eliciting the patient’s perspective about health and illness; respecting differences in verbal and nonverbal communication; working with qualified interpreters when language barriers exist; and developing a therapeutic alliance with patients. Juckett correctly reminds us that significant heterogeneity exists within all populations, and that physicians must avoid stereotyping and generalizations. It is dangerous to simply memorize “facts” about different racial, ethnic, and sociocultural groups. Instead, a skills-based approach that includes mutual respect, building trust, the cross-cultural interview, and negotiation is recommended.
Cultural competence is defined as a system’s ability to provide care to patients with diverse values, beliefs, and behaviors. This includes tailoring delivery of care to meet patients’ social, cultural, and linguistic needs. The ultimate goal is a health care system and workforce that delivers the highest quality of care to patients of all races, ethnicities, cultural backgrounds, and languages.2
The discipline of family medicine has taken the lead in emphasizing the importance of providing high-quality, culturally responsive, patient-centered care to persons of all backgrounds. The American Academy of Family Physicians (http://www.aafp.org) and the Society of Teachers of Family Medicine (http://www.stfm.org/corep.html) have published guidelines related to culturally competent care. Cultural proficiency also is one of the key elements in the Future of Family Medicine Report.3
A variety of resources provide practical cultural competency tools to assist busy family physicians in their daily work. For example, physicians can use the George-town University National Center for Cultural Competence’s Promoting Cultural and Linguistic Competency: Self-Assessment Checklist for Personnel Providing Primary Health Care Services4 to perform an initial evaluation of their practices, and then follow up with more detailed organizational assessments linked to improved performance. Interviewing tools such as the LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate),5 BATHE (Background, Affect, Trouble, Handling, Empathy),6 ETHNIC (Explain, Treatment, Healers, Negotiation, Intervention, Collaboration),7 and ESFT (Explanatory model, Social risks, Fears about medication, understanding Treatment)8 models can facilitate communication during cross-cultural encounters. A growing number of excellent continuing medical education programs also are available, including AAFP’s Quality Care for Diverse Populations video and CD-ROM (http://www.aafp.org/x13887.xml), and the Office of Minority Health’s free e-learning course—A Family Physician’s Practical Guide to Culturally Competent Care (http://cccm.thinkculturalhealth.org).
Federal, state, and local initiatives to improve cultural competence in health care are on the rise.9 Legislation requiring cultural competency training has been approved in New Jersey and is under consideration in several states (i.e., Arizona, California, Illinois, and New York).10 The business and quality case is being made for eliminating health disparities and developing cultural competency.11,12
Public and private sector initiatives include:
The Office of Minority Health’s recommendations on national standards for culturally and linguistically appropriate services in health care
Web site: http://minorityhealth.hhs.gov
The Liaison Committee on Medical Education and Accreditation Council for Graduate Medical Education requirements for medical schools and residency training
The Commission to End Health Care Disparities
A host of multicultural initiatives also are underway in Canada, Europe, and Australia.13
As we continue to care for an increasingly diverse population, it is critical to cultivate “cultural humility” and to develop collaborative partnerships with patients, families, and communities to learn about different perspectives, needs, and assets; address any cross-cultural ethical issues and value conflicts that arise; and provide culturally responsive and effective services.14–17
ROBERT C. LIKE, M.D., M.S., is professor in the Department of Family Medicine and director of the Center for Healthy Families and Cultural Diversity at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick.
Address correspondence to Robert C. Like, M.D., M.S., University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, New Brunswick, NJ 08903 (e-mail: firstname.lastname@example.org). Reprints are not available from the author.
1. Juckett G. Cross-cultural medicine. Am Fam Physician. 2005;72:2267–74.
2. Betancourt JR, Green AR, Carrillo JE. Cultural competence in health care: emerging frameworks and practical approaches, field report. New York: Commonwealth Fund, 2002. Accessed online September 19, 2005, at: http://www.cmwf.org/usr_doc/betancourt_culturalcompetence_576.pdf.
3. Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med 2004;2(suppl 1):S3–32. Accessed online September 19, 2005, at: http://www.annfammed.org/cgi/content/full/2/suppl_1/s3.
4. Sutton M. Cultural competence. Fam Pract Manag 2000;7:58–60. Accessed online September 19, 2005, at: http://www.aafp.org/fpm/20001000/58cult.html.
5. Berlin EA, Fowkes WC Jr. A teaching framework for cross-cultural health care. Application in family practice. West J Med. 139:934–8.
6. Stuart MR, Lieberman JA. The fifteen minute hour: practical therapeutic interventions in primary care. 3d ed. Philadelphia: Saunders, 2002.
7. Levin SJ, Like RC, Gottlieb JE. Useful clinical interviewing mnemonics. Patient Care. 2000;34:188–9.
8. Betancourt JR, Carrillo JE, Green AR. Hypertension in multicultural and minority populations: linking communication to compliance. Curr Hypertens Rep. 1999;1:482–8.
9. Betancourt JR, Green AR, Carrillo JE, Park ER. Cultural competence and health care disparities: key perspectives and trends. Health Aff (Millwood). 2005;24:499–505.
10. Pelletier S, ed. N.J. mandates cultural-competency training. Medical Meetings, June 1, 2005. Accessed online August 2, 2005, at: http://meetings.com/cmepharma/cme/meetings_nj_mandates_culturalcompetency/index.html.
11. Brach C, Fraser I. Reducing disparities through culturally competent health care: an analysis of the business case. Qual Manag Health Care. 2002;10:15–28.
12. National Business Group on Health/Office of Minority Health. U.S. Department of Health and Human Services. Why companies are making health disparities their business. The business case and practical strategies, 2003. Accessed online September 19, 2005, at: http://www.omhrc.gov/cultural/business_case.pdf.
13. McBride G. The coming of age of multicultural medicine. PLoS Med 2005;2:e62. Accessed online September 19, 2005, at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069660.
14. Tucker CM, Herman KC, Pedersen TR, Higley B, Montrichard M, Ivery P. Cultural sensitivity in physician-patient relationships: perspectives of an ethnically diverse sample of low-income primary care patients [Published correction appears in Med Care 2003;41:1330]. Med Care. 2003;41:859–70.
15. Barr DA, Wanat SF. Listening to patients: cultural and linguistic barriers to health care access. Fam Med. 2005;37:199–204.
16. Culhane-Pera K. Healing by heart: clinical and ethical case stories of Hmong families and Western providers. Nashville: Vanderbilt University Press, 2003.
17. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved. 1998;9:117–24.
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