Cultural Competence, Physician Education, and the Fight to Reduce Healthcare Disparities

Tawara D. Goode, MA, is an assistant professor in the Department of Pediatrics, Georgetown University Medical Center in Washington, DC. She serves on the faculty of the Georgetown University Center for Child and Human Development (GUCCHD) and has degrees in early childhood, special education, and human development. She is also the director of the National Center for Cultural Competence (NCCC), an organization that seeks to increase the capacity of healthcare and mental healthcare programs to design, implement, and evaluate culturally and linguistically competent service delivery systems to address growing diversity, persistent disparities, and to promote health and mental health equity.

A big focus right now is linking cultural and linguistic competence to quality of care and patient safety and the concept of patientand family-centered care. Another area that we are excited about is measuring cultural and linguistic competence both at a physician level and at the practice and healthcare systems level.

What has been your experience in terms of physician acceptance of cultural competence education? Have you encountered resistance from physician groups?

There is [some] resistance. However, if I look back over the last five years, at a minimum, there’s been a much greater degree of interest by physicians overall. I don’t think it’s by coincidence; I think that some have experienced changes in the demographic makeup of the patients to whom they provide healthcare. I think that we are also seeing a greater emphasis on this in terms of legislative, regulatory, and accreditation involvement. For instance, three states—New Jersey, Washington, and California—have enacted legislation requiring cultural and linguistic competence as part of medical education and/or licensure. That has prompted a higher degree of emphasis on cultural and linguistic competence. At the physician training level, the LCME (Liaison Committee on Medical Education) has mandated cultural competency content and other diversity training be included in the curricula for medical students who are currently being trained. The Joint Commission has convened a national advisory group to look at its standards and determine the extent to which The Commission can better integrate issues of culture, language, and health literacy into their accreditation process. The National Quality Forum recently released voluntary standards, a framework and preferred practices for measuring and reporting cultural competency. I would say that some physicians don’t have the interest, but policy and accreditation, to some extent, have also been driving this.

What factors have lead to the increased focus on cultural competence in healthcare?

I think there are multiple factors that are impacting this. I think that some of the things we’ve seen are the result of champions who feel very strongly that cultural and linguistic competence is indeed an approach—not the only approach but one approach for addressing racial and ethnic disparities that we see in health and mental health. That has been a strong motivating factor. We are getting more evidence of this; two colleagues and I had a paper published by the Commonwealth Fund that looked at the evidence base for cultural and linguistic competence in healthcare.

We as a nation have disparities that have been entrenched, and many are looking for a variety of ways in which we can alleviate these disparities. Cultural and linguistic competence has shown proven efficacy in addressing some aspects of disparities, not necessarily in morbidity and mortality, but in certain screening and education interventions and in other short-term and midterm goals in terms of health.

I think physician education in this area is critical at multiple levels, not just at the practice level. We’re looking at the physicians who may be policy makers and administrators, such as physicians who may be heading large hospital systems. Our view of cultural competence encompasses multiple levels within any setting: policy making, administration, healthcare delivery at the practice level, the community, and also obviously at the effects on patients and family. We don’t want to put this all on the solo practitioner or physician practice; instead we want to really look at this in the context of moving a whole system and healthcare organization forward.

What are some of the challenges facing efforts to reduce healthcare disparities and deliver better care to these underserved populations? To what extent does physician resistance play a role?

I think that when we talk about physician resistance, we have to characterize and better define this. Healthcare disparities and health disparities are two different but interrelated issues. I think that some physicians feel that the evidence base on the role of cultural and linguistic competence in reducing disparities is strong enough. I am just speculating here, but some physicians may not see cultural competence as directly relevant to what they do. Some physician associations, like the American Academy of Pediatrics, have been champions of cultural and linguistic competence for a while. Interest in these topics is being generated and looked at in a number of different arenas. I see the momentum growing; I’m not saying I want to downplay the resistance—it is real—but I think there are clearly more people on board now than there were before. I like to look at it from that perspective. When you talk about physician resistance, it’s a really complex topic and it may turn physicians off instead of focusing on a way forward and a way to grow.

What is the relationship between cultural competence and efforts to reduce health disparities?

Cultural and linguistic competence is one thing, but then disparities are something different. To be able to show that cultural and linguistic competence—applying those principles within a clinical setting and in communities, and engaging communities and that sort of thing—is a key strategy and approach to addressing disparities.

What have been the most promising developments in efforts to promote cultural competence?

We’re very excited in the area of measuring and assessing cultural competence. We have developed a number of checklists. It’s pretty amazing when you look at the number of people who have used the checklists and asked to reprint them in journals or books or use them in training. This goes from checklists to our online cultural competence healthcare practitioner assessment, and most recently we’ve created a CME program. We used the lessons that we learned from one of our online self-assessment instruments and applied this knowledge to create a highly specialized CME program that looks at disparities, particularly mental health disparities, and addresses how to incorporate cultural linguistic competence into the diagnosis and treatment of depression. In many patients who are receiving care, especially for chronic diseases, mental health concerns may go unaddressed and unnoticed in a primary care setting. I think this whole notion of measuring and assessing cultural and linguistic competence is at the forefront of what’s to come. People want to be able to measure this; they want to be able to quantify it. Although we’ve looked at measuring cultural competence from the provider perspective, we feel it is also important to measure it from the patient perspective. These are the areas that we are currently working on and will continue to work on.

As you mentioned, some states are ahead of the curve in this area. Are other states making progress in enacting cultural competency requirements?

We conducted for a major foundation an environmental scan of 14 states that have either introduced or enacted legislation that would require cultural or linguistic competence in training and/ or licensure for physicians. There were some very interesting outcomes from that study in terms of where states are and how they are going about trying to push this legislation forward. When we completed the study, three states had already introduced and enacted this legislation (California, New Jersey, and Washington). Other states were following suit, with some more successful than others in their initial efforts.

So, cultural and linguistic competence training is just the first step? What other approaches hold promise?

We look at cultural competence not as a discrete process but as something that people commit to in terms of continuous learning. I may understand and be familiar with a particular patient population, but then the demographic in my neighborhood changes with new folks coming in. That means I have to go back and learn some more things. So we look at this as an ongoing developmental process that health professionals commit to as part of their delivery of care.

Another important area that we have been working in is leadership. Cultural competence can’t be realized just at an individual physician level; it has to be an integral aspect of a healthcare system, practice, or organization. We have over the last 18 months conducted what is called a “community of learners” for leadership to advance and sustain cultural and linguistic competence. We have to ensure that there is leadership with the energy, knowledge, and skills to guide the difficult work of advancing and sustaining cultural and linguistic competence. We need leadership to address this at multiple levels within a system or organization. This includes the front desk staff, physician champions, folks on the board recognizing how important this is, and community leaders. I think that that is a very important aspect, not just for our work, but for work in the future.