Cultural Competence

The term cultural competence has a variety of definitions, but perhaps the most relevant for physician assistants (PAs) is Betancourt’s 2002 definition:

Cultural competence in health care describes the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs.

This definition refers to a system , recognizing that no one individual can achieve the level of care needed without the integrated support of an organization in which diversity is understood and valued. Each of us can strive through our own actions and reactions to improve both our individual encounters and, to the extent we are able, the system in which we practice. This chapter focuses primarily on the individual with the understanding that we must also work with our clinical and ancillary teams to create a context that is welcoming to all.

Introduction to Culturally Competent Practice

The single overarching goal of culturally competent practice is to reduce medical errors by improving patient–provider communication. Communication, of course, is a two-way process, and errors can occur in either direction. For example, a provider may encounter a patient who uses a wheelchair and has slow speech who the clinician assumes to be intellectually challenged. Similarly, a financially stressed patient may encounter a clinician who appears to be of a higher social and economic stratum and assume the clinician has no understanding of the challenges of poverty. Either of these assumptions may be made fairly automatically and with little or no conscious thought, and either can lead to significant barriers in communication, regardless of the accuracy or inaccuracy of the assumption.

Assumptions about others are often based in stereotypes, categories of traits that are connected in our understanding. Stereotypes range from fairly innocuous, such as the assumption that a blue collar worker is more likely to bowl than play golf, to detrimental, such as the idea that a black man is more violent than a white man. In either case, the stereotype is based on an unsubstantiated association of unrelated traits. Stereotypes are universal and normal but can lead to bias, a consistent shift (positive or negative) in thoughts and behavior that is not substantiated by facts.

In the clinical setting, PAs and other clinicians must often make rapid judgments with regard to diagnostic and treatment decisions. Such decisions may be colored by incomplete or inaccurate assumptions based in stereotypes. Because these rapid thought processes are subconscious, their occurrence cannot generally be consciously controlled, but this does not mean we are powerless.

If the clinician is aware of the effect of personal bias on decision making, he or she can check any assumptions by eliciting further information from the patient. Errors in patient understanding of the illness and its treatment can be reduced by eliciting the patient’s understanding of the illness and expectations of care during the encounter. In addition, the clinician can ask about social or cultural factors that may potentially influence patients’ decision making during an encounter. Checking assumptions during the patient encounter helps the clinician to remove stereotypes, allowing the patient to be seen more as an individual than a member of a group (with all its attendant associations). A framework for eliciting the patient’s understanding and cultural context is Kleinman et al.’s explanatory model :

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  What do you think has caused your problem?

  
  
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  Why do you think it started when it did?

  
  
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  What do you think your sickness does to you? How does it work?

  
  
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  How severe is your sickness? Will it have a short or long course?

  
  
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  What kind of treatment do you think you should receive?

  
  
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  What are the most important results you hope to receive from this treatment?

  
  
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  What are the chief problems your sickness has caused for you?

  
  
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  What do you fear most about your sickness?

The busy practitioner may not have time to get all this information in a single visit, but incorporating just a few of these questions into your standard clinical history can help resolve errors in communication. The following three questions will usually allow the clinician to evaluate whether or not further discussion of the interaction between personal and cultural beliefs and the understanding and management of illness should be explored:

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  What do you think your sickness does to you? How does it work?

  
  
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  What kind of treatment do you think you should receive?

  
  
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  What are the most important results you hope to receive from this treatment?

Although obtaining a good understanding of the patient’s view of health and disease may be crucial to building rapport and improving communication in a primary care setting or other ongoing patient–provider interaction, it may not be possible in the context of emergent care. The emergency department (ED) is, however, a place where it is critical that subconscious bias and stereotyping be avoided so that it does not influence clinical decision making. The most rapid way to circumvent bias and improve the patient–provider interaction is through perspective taking. Perspective taking is instantaneous; the clinician merely takes a moment to picture him- or herself in the patient’s shoes, seeing the situation through the patient’s eyes. The patient can no longer be seen as “other,” and stereotypes fall away. The effect of perspective taking is not equal across clinicians or situations, but with practice, it can become a tool that is both quick and easy.

The basics of culturally competent practice are summarized in Box 24.1 . To clarify the processes involved in improving the interaction between patient and provider, we will delve further into the rationale behind the need to reduce communication barriers and some background into the psychology behind their operation.

Rationale

To fully understand the importance of culturally competent practice and the steps outlined earlier, we must explore how perceived differences between individuals affect clinical decision making and, ultimately, contribute to health care disparities. Disparities in health and in health care are related to a complex web of factors. The landmark Institute of Medicine report in 2003, “Unequal Treatment,” determined that although disparities in health care are influenced by many elements outside of the clinician’s direct control, including the operation of health systems and legal and regulatory factors, they are largely attributable to discrimination, bias, and stereotypes on the part of health care practitioners. Bias and stereotypes are largely subconscious and can lead to errors in clinical decision making. Outward discrimination is less common but can occur without intent. For example, choosing to locate a clinic far from a bus route may discriminate against those without cars even though no discrimination was intended.

The reduction of health care disparities is a key goal of incorporating cultural competence into patient care. Obviously, not all disparities in patient care are related to communication, but the improvement of communication, both conscious and subconscious, can go a long way toward resolving at least one cause of disparities. Communication also involves creating a welcoming atmosphere.

Bias and Stereotyping

The term stereotype was coined by Walter Lippman, a journalist, in 1922 and refers to a printing plate made to duplicate a particular type of page. He used it to refer to the tendency of people to form mental images based on preconceptions that members of a particular group are alike in certain ways. These mental images make it easier to associate another person with something that conforms to the stereotype than with something discordant. In other words, congruent associations are automatic, and incongruent associations are just a little slower. The entire process is subconscious and is based in our culture, the images we see every day, and the world around us, not in our own logical thoughts or beliefs. Over the past few decades, the process of stereotyping has been evaluated through multiple techniques. Since the advent of computers, the easiest method has been to simply measure the time it takes to associate two items, words, or pictures. This process is repeated with random allocation of right and left, positive and negative associations on a wide variety of subjects. You can test your own automatic associations at Harvard University’s Project Implicit, https://implicit.harvard.edu/implicit . Keep in mind that this is not a test of your values but of the way your world pulls you to automatically respond. It should be used to increase your awareness of the potential for stereotyping so that you can focus your efforts on interrupting the process through further assessment both of your patient and of your own thoughts and feelings.

Bias and stereotyping are important in clinical care because they have been shown to influence diagnosis and management in a discriminatory way. The association between a negative automatic association and reduced quality of care has been shown in computer-based patient scenarios and in patient care. Misperceptions can lead to misdiagnoses and inadequate or inappropriate treatment.