Q&A with Robert Like, MD, MS

MDNG spoke with Robert C. Like, MD, MS, Professor and Director of the Center for Healthy Families and Cultural Diversity, Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, to discuss his efforts to improve cultural competency in healthcare.

As the director at the Center for Healthy Families and Cultural Diversity, what role do you play in maintaining the goals of the Center?

I’m a family physician with a background in medical anthropology and, as the director at the Center, have been involved in providing training and technical assistance for more than 20 years to groups of healthcare professionals—physicians, nurses, and other allied health professionals—as well as hospitals, managed care plans, ambulatory practices, academic medical centers, community groups, governmental agencies, and other entities who are interested in improving the quality and safety of care provided to our increasingly diverse populations. The Center has given more than 450 invited workshops, seminars, grand rounds, and conference presentations to a wide variety of health and human services professionals, both in the United States and abroad. Topics addressed have included eliminating racial and ethnic disparities in health and healthcare, culturally competent patientcentered care, caring for patients with limited English proficiency, addressing cross-cultural health literacy challenges, and becoming a culturally competent healthcare organization. In the past, the Center has received funding to carry out multi-method research and evaluation relating to the effectiveness of cultural competency training. I also have collaborated on educational projects with colleagues in the European Union, Israel, and Australia.

Can you explain the importance of addressing the problems related to poor cultural competency within healthcare?

The patients that my colleagues and I care for come from many ethnic, racial, and socio-cultural backgrounds. In order to provide patient-centered, family-focused, community-oriented care, we need to better understand both our patients’ health beliefs and practices, as well as how our own professional and personal attitudes, beliefs, and values can impact clinical encounters. By doing so, we hopefully can do a better job of developing a therapeutic alliance and caring for patients with illnesses like cardiovascular disease, cancer, diabetes, and depression, as well as providing appropriate health promotion and disease prevention services. Published research from organizations like the Institute of Medicine, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Robert Wood Johnson Foundation has shown that not only do people from different backgrounds have unequal access to care, but they also have disparities in health outcomes and in healthcare itself. One approach to help reduce these disparities in care is to provide cultural competency training and link this to ongoing quality improvement and patient safety interventions in healthcare organizations.

What are some misconceptions physicians might have regarding culturally competent care?

There are a number of things I frequently hear; for example, “Isn’t this just political correctness [PC] run amuck?” For me, PC is more about being professionally and personally caring with all of my patients. I also hear people say, “Well, how do you expect me to learn about every different population on the planet?” This, of course, is not feasible, nor even the goal of cultural competency training. The real issue is, are there clinical interviewing skills and approaches that can help us learn more about what is meaningful to each and every person we see so that we don’t create stereotypes or practice “cookbook” medicine, but instead can individualize care? There are certainly many challenges in everyday practice that come up, given that clinicians are very busy struggling with financial pressures, increased paperwork, numerous regulations, and other competing demands. So, the challenge becomes, “How can my office staff and I make practical use of this information and improve the quality of care provided to our patients?”

Do you think you and your colleagues have been successful in your efforts to raise physicians’ awareness and make them more conscious of maintaining a culturally aware practice?

I believe that demographic change; market forces; quality improvement and patient safety initiatives; legislative, accreditation, and regulatory activities; and educational efforts are increasing healthcare professionals’ awareness about the importance of providing more culturally responsive and effective services to our increasingly diverse population. Influential national organizations such as Centers for Medicare & Medicaid Services, the Joint Commission, and National Committee for Quality Assurance are also beginning to make use of the Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care in some of their assessment and evaluation programs. The development of cultural competence is an ongoing journey, and people are beginning to “walk the talk.” There is much work left to do, however, especially in the areas of healthcare policy, reimbursement, and systems reform in order to support and sustain these nascent activities over the long-term.

In your opinion, what is the most interesting research being done in this area now?

Thanks to federal and private foundation funding, cultural competency is increasingly being investigated at the clinical, organizational, and systems levels. Researchers are actively studying whether the delivery of culturally and linguistically appropriate services helps to reduce racial and ethnic disparities for different medical and mental health problems. They are also evaluating the effectiveness of quality improvement and patient safety interventions in healthcare settings serving diverse populations. This research is making use of both quantitative and qualitative methods and is increasingly being done in collaboration and partnership with communities. I personally believe that clinical cultural competence training, while important and necessary, will not be sufficient. We must also significantly transform the healthcare organizations and systems we work in. The current interest in developing “patient-centered medical homes” is an example of one very promising initiative that merits further study. Two additional topics that are also increasingly attracting the attention of researchers are: 1) patient safety/risk management concerns related to caring for people with limited English proficiency, low health literacy, and/or other communication challenges, and 2) making the business case for cultural competence as well as the potential impact of pay for performance and other reimbursement strategies on disparities in health and healthcare.

What role does healthcare technology play in regards to cultural competency?

This is an important subject area that people are just beginning to take a look at. Electronic health records (EHRs), for example, are being used by some healthcare organizations to collect patients’ ethnicity, race, and primary language data in ongoing quality improvement and patient safety initiatives involving diverse populations. The appropriate stratification and analysis of this data can permit clinicians, administrators, and researchers to look for potential disparities in health outcomes and healthcare utilization and develop strategies to address these. The problem is that most medical EHRs, to my knowledge, don’t have specific fields in place yet for race, ethnicity, and primary language, unless they’re specially customized. It is important for practices with EHRs that want to address health disparities issues and provide more culturally and linguistically appropriate care to make sure that they have the ability to collect and access the necessary information. Having centralized information is also very helpful in improving access to care for patients with limited English proficiency that need interpreters or translation assistance when they go to a hospital, ambulatory clinic, pharmacy, laboratory, or other site in the service delivery system. When physicians prescribe medications or provide patient education materials, it’s important that this be done in a language that patients understand and the EHR could help. The emergence of new face-to-face, telephonic, and video interpreting technologies is also proving to be extremely valuable. One of the more controversial topics is the collection of racial, ethnic, and primary language data from patients. If we’re going to reduce disparities in healthcare experienced by different population groups, it’s important to know who they are. National efforts are underway via the Health Research Education Trust (HRET), which has developed a helpful race, ethnicity, and language data collection toolkit. The toolkit helps to train staff on how to collect this information in a more sensitive way so that people self-identify rather than being arbitrarily assigned to a category by looking at someone’s name or appearance and guessing. The New Jersey HRET, with funding from the Robert Wood Johnson Foundation, has also developed an educational DVD and related resources to assist hospital admissions and clerical staff on how to collect this information.

How can private-practice physicians, hospitals, and other healthcare organizations become more culturally competent?

There are already many excellent practice improvement frameworks and strategies that have been developed by groups such as the Institute for Healthcare Improvement, the National Quality Forum, and the National Initiative for Children’s Healthcare Quality. The goal is to provide care that is more patient-centered, effective, timely, efficient, and equitable. These were the pillars of quality care recognized in the Institute of Medicine’s “Bridging the Quality Chasm” report. As our population becomes more diverse and we experience cultural and language challenges, we must strive to make quality improvement itself more culturally and linguistically competent. This will require practices to carry out “organizational cultural competency selfassessments,” and fortunately a number of excellent tools are available that can be helpful (eg, MedQIC Cultural Competency website). Inviting patients and families to actively participate in the process of defining what quality of care looks like from their perspective by becoming members of quality improvement teams is another innovative strategy being employed by some practices. There are also efforts underway in which physicians and staff are working closely with local communities, faith-based organizations, and advocacy groups to better understand what people’s healthcare priorities are and to collaboratively design interventions that are evidence-based, effective, and mutually acceptable. I think what we can do is integrate the best and promising practices from the cultural and linguistic competency field into our many excellent national, state, and local quality improvement and patient safety efforts. We need to become a “learning community of practices” that engages in ongoing critical reflection designed to improve clinical practice and patient outcomes.

Would further study of cultural competency in medical school and during post-graduate training be beneficial? Would it help alleviate some of the problems?

I believe it will make a big difference. In fact, the Liaison Committee on Medical Education already has a mandatory cultural diversity accreditation requirement for medical schools and the Association of American Medical Colleges (AAMC) has developed a Tool for Assessing Cultural Competency Training. The Accreditation Council for Graduate Medical Education has also called for a “a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse population,” as well as “sensitivity and responsiveness to patients’ culture, age, gender, and disabilities,” in their Professionalism outcomes-based competency requirement for residency training programs. In a recent issue of the Annals of Internal Medicine, an important article was published that provides recommendations for teaching medical students, residents, and practicing physicians about racial and ethnic disparities in health and health care. Specific curricular topics that should be addressed include: “1) examining and understanding attitudes, such as mistrust, subconscious bias, and stereotyping, which practitioners and patients may bring to clinical encounters; 2) gaining knowledge of the existence and magnitude of health disparities, including the multifactorial causes of health disparities and the many solutions required to diminish or eliminate them; and 3) acquiring the skills to effectively communicate and negotiate across cultures, languages, and literacy levels, including the use of key tools to improve communication." Finally, at the level of policy and legislation, there are several states that have already passed or are considering bills requiring cultural competency training for physician licensure through continuing education as well as educational initiatives for other healthcare professionals (Graves DL, Like RC, Kelly N, and Hohensee A. “Legislation as Intervention: A Survey of Cultural Competence Policy in Health Care.” Journal of Health Care Law and Policy 2007; 10(2):339-361). These efforts, unfortunately, are currently unfunded mandates, and it remains to be seen how they will be planned and implemented, the quality and relevance assured, and their impact and effectiveness evaluated. These important issues need to be addressed, and I’m sure there will be many lessons learned.

Disclaimer: The opinions expressed in this article are those of Dr. Robert Like and not necessarily the opinions of the Center for Healthy Families and Cultural Diversity/Department of Family Medicine/UMDNJ-Robert Wood Johnson Medical School or any other organizations with which he is affiliated.

Additional Resources:

• Health Disparities Collaboratives Health Resources and Services Administration: Health Literacy
• A Physician’s Practical Guide to Culturally Competent Care
• Quality Interactions: A Patient-Based Approach to Cross-Cultural Care
• Resources to Implement Cross-Cultural Clinical Practice Guidelines for Medicaid Practitioners
• Self-Assessment Checklist for Personnel Providing Primary Health Care Services
• Should Your Practice Collect Patients’ Race & Ethnicity Data?
• Telephone Interpreting in Health Care Settings: Some Commonly Asked Questions