August 2000 • Volume 6 • Number 8
Contemplating cultural competency
Zainab Kalokoh, right, a recent immigrant from Sierra Leone, cradles her son, Ibrahim Sesay, while Kim Bullock, M.D., confirms acute otitis media.
Cues for care
If this mother and baby from Sierra Leone were your patients, information about that nation could prove helpful in your evaluation and treatment:
- Adult literacy rate is 33 percent.
- Infant mortality rate is 129 per 1,000 births.
- Life expectancy for males and females is 34 years.
- English is the official language, but most people speak Krio.
- Rice is a staple food, but malnutrition is wide-spread among children.
- Extreme poverty affects two-thirds of the population.
- Government-provided health care is considered inadequate.
- Citizens have a limited knowledge of nutrition and preventive care.
- Common illnesses include anemia, gastrointestinal disease, malaria and tuberculosis, and the HIV infection rate is high.
- Civil war in 1998 and 1999 inflicted terrible atrocities on the population.
Source: CultureGrams, 1305 N. Research Way, Orem, Utah
Kim Bullock, M.D., center, and second-year medical student Africa Wallace, left, discuss Andrew Epps' dislocated shoulder at Providence Hospital in Washington, D.C.
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BY SHERI PORTER
The results of a 1997 census survey won't surprise you if cultural competency is an issue on your personal radar screen: One in every 10 persons living in the United States is foreign-born.
Today's immigration rates are fast approaching the peak rates of the 20th century, reached between 1901 and 1910 when 8.8 million immigrants were admitted. Recent U.S. immigrants hail predominantly from Asian, Latin American, African and Caribbean nations. Currently, in seven states, more than 20 percent of residents do not speak English at home.
So if you're an FP who's been dodging the topic, America's changing demographics may prod you to examine your own cultural proficiency.
Why should you care? For a variety of reasons, says FP Kim Bullock, M.D., of Washington, D.C., who has written and lectured extensively on the topic. "Unless your comfort level is such that you know how to communicate -- even if it's not linguistically -- with people from different cultures, you are really stuck, professionally as well as personally," Bullock says.
Bullock makes a compelling case for upgrading cultural awareness because doing so will:
- help eliminate health care disparities among ethnic groups;
- improve the quality of health care and outcomes;
- help FPs gain a competitive edge in the marketplace;
- meet accreditation mandates; and
- decrease their liability and malpractice claims.
As an assistant clinical professor in Georgetown University Medical Center's Department of Family Medicine, Bullock wants the residents and medical students on her watch prepared to face the challenges of America's burgeoning diversity. She points out current demographic data and shares journal articles highlighting health care disparities among minority groups. She wants to impress upon them the impact that cultural competency will have on their practices.
"It used to be that you could choose to practice in an area that was very homogeneous -- small-town America. Well increasingly, there are fewer and fewer small-town Americas, where there's a real homogeneity to the entire population," Bullock says.
To help assess patients, Bullock, who is also assistant director of Providence Hospital Emergency Department in Washington, takes a cultural history right along with a medical history. "We ask questions related to religion, vocation, social history and family history, so that we can put that together as part of the picture when we're creating a management plan for the patient," Bullock says.
She insists that practitioners don't need extensive clinical knowledge or experience with ethnic groups to become culturally competent. "Most people think it requires a lot of expertise and training -- but there are some universal applications that we use every day with patients," she says. Good communication skills, appropriate use of interpreters and effective body language are good starting points.
"The increased number of malpractice cases doesn't necessarily have to do with a mistake or negligence; a large percentage of those have to do with communication errors," Bullock says. Try allotting more time for patients with communication limitations -- those not proficient in English, those with low literacy levels or even the hearing-impaired.
"What's important to all of us is our cultural background," says Bullock. "Our beliefs, our traditions, our history, our background -- that's what makes us who we are, and unless we as FPs are asking about that, we are missing a part of our patients that is critically important."
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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