IN LATE MARCH, New Jersey's Acting Governor Richard J. Codey signed legislation requiring that physicians take “cultural-competency training” in order to obtain a license or be relicensed by the State Board of Medical Examiners. The intent of the training, which will be mandatory for medical students and resident and practicing physicians, is to provide docs with a better understanding of the different health-related cultural beliefs and expectations patients bring with them to a doctor's practice, and how different diseases affect diverse populations. The legislation does not address how this training will be funded.
It is up to the State Board of Medical Examiners to implement the law, including the amount of training that will be required and what that training will consist of. Legislators in Arizona, Illinois, and New York are considering similar bills that would require cultural-competency training for medical students, residents, and physicians. California's Cultural and Linguistic Competency of Physicians Act of 2003, which set up a voluntary linguistic and cultural-competency program for physicians, may be bolstered if proposed legislation to make this type of training mandatory is passed. But one thing is certain: CME providers who develop cultural-competency education are going to face some pushback from physicians.
“It seems so misguided,” says Pennie Marchetti, a family physician who authors the MedPundit.blogspot.com weblog. “Perhaps its worst sin is that it assumes that all people of certain ethnic backgrounds behave and think so much alike that it's possible (or necessary) to make their behavior a subject for education.”
However, the disparity in the quality of healthcare provided to different populations has been established by reports from the Institute of Medicine and numerous studies, including the Agency for Healthcare Research and Quality's National Healthcare Disparity Reports for 2003 and 2004.
Robert Like, MD, MS, associate professor and director, Center for Healthy Families and Cultural Diversity, Department of Family Medicine, University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School, New Brunswick, N.J., says that changes are already taking place in medical schools and residency programs. “The American Association of Medical Colleges has introduced mandatory requirements, and the Accreditation Council on Graduate Medical Education also is pushing more of a focus on cultural-diversity issues as part of the need for increased professionalism and humanism in medicine,” says Like. He adds that there is an increasing global interest in multicultural medicine and cultural competency, citing as an example the European Union Amsterdam Declaration relating to the Migrant Friendly Hospitals initiative.
Robert Pallay, MD, associate director for practice initiatives and policy at Robert Wood Johnson Medical School's Center for Healthy Families and Cultural Diversity, says, “It's well-documented that the indigent and minority populations are not receiving the same quality of care as the mainstream population.” In addition, he says, the U.S. population is growing more diverse, “From what I've read, by 2050, well over half the population is going to be composed of [what we now call] minorities — they will be the majority of the population.”
Like believes the New Jersey legislation is necessary: “I think the fact that the legislation has taken off in New Jersey and now is being looked at in other states is testimony to the idea that current education is viewed as not doing the trick.”
But, Allen Roberts, MD, an emergency medicine physician in Fort Worth, Texas, likens mandatory cultural-competency training to the mandatory ethics training some states require. “Does anyone really think an hour of ethics CME is going to stop doctors from ripping off Medicare? No. And with some people there aren't enough hours in the day to make them behave ethically. While the overwhelming majority of doctors behave ethically every day, we'll make everyone take ethics classes and that way legislators can say they're doing something about unethical doctors. The same thing goes for cultural competency. It just makes a good sound bite for the politicians. It's hard as a medical community to put our foot down and say this is the wrong answer to the right question.”
But Pallay, who normally doesn't support mandates, says, “This is a mandate that I'm in favor of, and not just because I'm in this field. Most physicians feel that once they get in a one-on-one with a patient, they can take care of the problem. But this isn't true when it comes to treating people from other cultures.” In this case, he says, “in order to get where we need to go in medicine, we need to mandate that physicians learn about diversity and [gain] cultural competence. Otherwise docs don't give the best care, not because they don't want to do the right thing, but because they just don't know how to best handle someone from another culture.”
Roberts does admit that some types of cultural-competency training could be useful. “I was first exposed to patients whose nation of origin was the Philippines when I was in the Navy as an intern. I had to see several patients before I realized that when they say, ‘Doctor, I feel dizzy,’ it has nothing to do with vertigo or lightheadedness. ‘I feel dizzy’ is just the way that culture expresses, ‘I don't feel good.’ That's a cultural-competency aspect that's useful to know. Is that something a required course is going to teach you? Maybe, maybe not. Too much of CME doesn't require you to learn, or understand, or even agree with what they're saying. It's like serving a sentence; you do your time, then you go home. One thing this new law will do is to provide an excellent market for cultural-competency seminars, educators, and CME classes.”
Robert Centor, MD, an academic general internist with a Southeastern medical school, said on his blog, Med-Rants.com, that cultural-competency training just isn't practical. “Cultural competency sounds so good. Most physicians try to understand their patients. Cultural competency gives the sense that we will better understand our patients' needs.” But, he adds, “How do we develop a curriculum that works for all physicians? Some physicians have exposure to many Latinos. But Mexican culture differs from South American culture, which differs from Cuban culture. How do we balance all those issues? Certainly Minnesota physicians have different cultural-competency needs than Hawaiian physicians. Those in urban practice have different cultural-competency needs than rural physicians. We have a different culture in the South than in the West. How do we provide a course that really helps practice?”
Some also worry that this type of training will backfire. As one person who commented on Centor's blog wrote, “What's the difference between cultural competency and cultural stereotyping? Are they both not ways of telling us that a patient who is Laotian/Jewish/Chinese/Indian can be expected to have this or that attribute, or that she will like/dislike this or that behavior or activity? What ever happened to taking patients one at a time?”
Like agrees that the worry that this type of training could increase stereotyping and overgeneralization is a legitimate one. “I unfortunately have experienced diversity training programs and educational materials that are very problematic. While it may be helpful to have some general guidelines and descriptive information about different ethnic and sociocultural groups, in the end, you have to look at every individual as an individual. Every encounter is a cross-cultural encounter.”
Like also believes that cultural-competency training is possible, but that it will not be attained through a “cookbook approach to care. We have to see this as different from other types of CME courses,” he says. “It has to be a process of how we continue to learn about the diverse populations we're caring for as well as our own personal and professional biases, values, beliefs, and behaviors — I don't think taking a one- or two-hour course is going to be effective. The question is, how do we bring this into the ongoing training that other physicians and care providers are already getting?” In addition, he believes that it should extend to all those involved in healthcare, including nurses, dentists, physical therapists, pharmacists, psychologists, social workers, and other allied health professionals. “We also have to look at the organizations and systems in which we work and to reduce institutionalized barriers to providing culturally and linguistically appropriate services. Although the legislation is helpful as an incremental step, I think it needs to go much further in regard to affecting other constituencies in healthcare.”
Because it was unknown at press time what exactly the mandated training will be in New Jersey, it is difficult to predict how it will play out with physicians and their patients. Will cultural competency be woven into existing CME on various disease states? Will the required training instead consist of stand-alone courses on the medical and communication challenges of different populations? And who's going to pay for it? Physicians? Hospitals? Managed Care? Pharma?
Like adds, “I would have preferred an incentivized approach to an unfunded mandate. On the other hand, this could be an opportunity to develop programs that make a difference. CME itself isn't going to solve the problem of disparity in healthcare, but it is one critical piece of the puzzle.”
Robert Like, MD, MS, associate professor and director, Center for Healthy Families and Cultural Diversity, Department of Family Medicine, University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School, New Brunswick, N.J., uses this mnemonic in his clinical practice:
ETHNIC: Explanation (The doc should elicit the patient's explanation of the problem.), Treatment (What has the patient already used to treat the condition, including herbal and other nontraditional treatments?), Healers (Who else has the patient has seen for treatment?), Negotiation (What kind of help does the patient want?), Intervention (pharmacological, psychological, social, spiritual, educational), Collaboration (Who does the doc need to work?)
Source: Levin, SJ; Like, RC; and Gottlieb, JE. ETHNIC: A framework for culturally competent clinical practice. In Appendix: Useful clinical interviewing mnemonics. Patient Care 2000; 34(9):188-189.
For a comprehensive compendium of cultural competency-related resources, visit Medical Meetings' Web site: mm.meetingsnet.com.