Cultural Competency Training in the Garden State: A Q&A with Debbie Salas-Lopez, MD

In 2005, the New Jersey Legislature passed a law requiring the New Jersey Board of Medical Examiners (NJBME), “in consultation with the Commission on Higher Education, to prescribe requirements, by regulation, for physician training in cultural competency.” These requirements were adopted in their final form in April of this year. This essentially means that physicians who were licensed in New Jersey on or before June 29, 2007 (and podiatrists licensed on or before October 30, 2007) must comply with the new cultural competency training requirements before their next license renewal. As outlined on the New Jersey Division of Consumer Affairs website (www.njconsumeraffairs.gov/bme/ press/cultural.htm), the specific topics that must be covered in an accredited CME program on cultural competency in order to meet the Board of Medical Examiners’ requirements are as follows:

1. A context for the training; common definitions of cultural competence, race, ethnicity, and culture; and tools for self assessment.
2. An appreciation for the traditions and beliefs of diverse patient populations, at multiple levels—as individuals, in families, and as part of a larger community.
3. An understanding of the impact that stereotyping can have on medical decision making.
4. Strategies for recognizing patterns of healthcare disparities and eliminating factors influencing them.
5. Approaches to enhance cross-cultural skills, such as those relating to history-taking, problem solving, and promoting patient compliance.
6. Techniques to deal with language barriers and other communication needs, including working with interpreters.

Might other states follow New Jersey’s lead and enact their own cultural competency training rules for physicians? To find out more about the origins of this law and the lessons others seeking to implement similar requirements might learn from the experiences of the policy makers, physicians, and legislators behind it, we spoke with Debbie Salas-Lopez, MD, MPH, FACP, Chief of the Division of General Internal Medicine, Interim Chair of Medicine Lehigh Valley Hospital and Health Network.

Dr. Salas-Lopez is a co-author of Cultural Competency in New Jersey: Evolution from Planning to Law, which “outlines New Jersey’s journey of cultural competency legislation, from planning to law.” Dr. Salas-Lopez and her co-authors noted that “New Jersey’s experience can serve as a blueprint for other public health agencies seeking to develop a cultural and linguistic competency state agenda to improve minority health through legislation.”

What was the driving force behind the New Jersey legislation?

The legislation in NJ was sparked by the nationwide demand for culturally and linguistically appropriate services and its correlation to improving quality of care. In 1999, the DHHS [Department of Health and Human Services] issued the CLAS [Culturally and Linguistically Appropriate Services] standards as a guiding document for all hospitals and academic health centers. The Association of American Medical Colleges, Accreditation Council for Graduate Medical Education, and The Joint Commission were also on board with their own statements and regulatory guidelines. Legislating what had already been sanctioned as needed was the next step. Senator Wayne Bryant and others were the key legislators who championed the bill through our New Jersey Legislature.

What kind of physician feedback have you gotten in response to the new requirements?

I have received nearly unanimous agreement that cultural and language-appropriate services are needed. What has been more difficult to elicit is agreement on what constitutes enough training. Currently, the Board of Medical Examiners has issued a requirement of 6 CME credit hours. This was met with some resistance—some thought it was too much, while other national leaders thought it may not be enough, particularly since [becoming a culturally competent provider] is considered to be a journey. Now that it is done, most would agree that they want to comply. NJBME has also made it plausible to generate these credits in a variety of settings such as Web-based activities, conferences, grand rounds, and seminars.

How is it decided what constitutes acceptable and adequate training in cultural competence?

The NJBME [New Jersey Board of Medical Examiners] will be happy to assist those who have questions regarding cultural competency training requirements. The details of what is acceptable and adequate are still being worked out. We will be relying on state and national experts as consultants in this area.

How does New Jersey compare to other states when it comes to the broader issue of cultural competency?

NJ is ahead of the curve and is actually the first state in the country to enact this type of legislation. Others have since followed suit with CME requirements, such as California, Washington, and New Mexico.

Is there a way to gauge the effectiveness of these requirements?

Assessing cultural competency training effectiveness is not as clear-cut as other program assessments. However, when framed under quality of care, one could assess effectiveness based on patient outcomes. For example, are diabetics who are treated by language-concordant providers (or designees) likely to have better HgBA1Cs? Are they more likely to return to follow up with their primary care providers? Are they more likely to have lower rates of obesity? It is already known that we can reduce medical errors such as appropriate prescription adherence when we meet language and cultural needs, and we can improve patient satisfaction. There remains more research to be done, but the inherent nature of the new paradigm of patient-centered care and the medical home will hopefully help reduce and eventually eliminate this gap.

As cultural competency training programs and requirements are enacted in states across the US, it is only natural to speculate on how this will affect healthcare in the coming years. Perhaps Dr. Salas-Lopez’s colleague, Theresa Barrett, MS, CMP, CAE, Deputy Executive Vice President of the New Jersey Academy of Family Physicians, best summarizes the potential impact of having culturally competent healthcare providers. She asserts that “Cultural competency is absolutely a part of the future of healthcare. We are a multicultural nation. It is the skill and ability of the physicians in eliciting relevant information from their patients about their health in a manner that is culturally sensitive and recognizes that each person is a unique individual, with unique, culturally diverse perspectives which shape their view of their health, that is going to have an impact on improving outcomes for all patients.”