THE ROLE OF CULTURAL
COMPETENCY IN MEDICAL
EDUCATION
Maria A. Marzan, MPH, Associate
Director, Introduction to Clinical Medicine
Program, Albert Einstein College of
Medicine
CULTURAL COMPETENCY?
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Multicultural Society
Multilingual
Importance of physician-patient care
International/public health impact
Racial and ethnic disparities in health care
access and health outcomes
DISPARITIES IN HEALTH for
Minority Populations
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Decreased Access
More uninsured and underinsured
Decreased quality of care
Poorer outcomes of care
Largest Ethnic Minority Populations in
the U.S.
AFRICAN AMERICANS
HISPANIC/LATINO
ASIAN & PACIFIC ISLANDERS
AMERICAN INDIANS & ALASKA NATIVES
RACIAL/ETHNIC DISPARITIES
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African-American
medicare recipients
less likely to get renal
transplants
Latino patients with
leg fractures got less
pain medication
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Women and AfricanAmerican simulated
patients were less
likely to get cardiac
testing
Minority lung cancer
patients less likely to
get surgery
NON-FINANCIAL BARRIERS
TO CARE
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Health care workforce issues
Patient educational level
Racial bias and discrimination
Immigration issues
Language barriers
Socio-cultural Barriers to Health care:
Multilevel
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Organizational - leadership and workforce
issues
Structural - complex, funding issues,
language issues, bureaucratic systems
Clinical level – the medical encounter
Provider-patient communication
and decision making
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Evidence suggests that provider-patient
communication is directly linked to patient
satisfaction, adherence and health outcomes
Ineffective communication in the medical
encounter may lead to patient dissatisfaction,
non-adherence, poorer health outcomes, and
subsequently, racial and ethnic disparities in
healthcare.
Conceptual Approaches to CrossCultural Medical Education
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A Focus on Attitudes:Cultural/Sensitivity
Awareness Approach
Focus on Knowledge: The
Multicultural/Categorical Approach
Cross-Cultural Approach
Cross-Cultural Approach
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Tools and Skills for providers
Process-oriented instruction (patient’s
explanatory model, assess patient’s social
context, provider-patient negotiation)
Care of Diverse populations by crosscultural interviewing
Practical approach for clinical years undergraduate, graduate and continuing
medical education (CME)
CROSS-CULTURAL ISSUES IN
HEALTH CARE
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Language (including illiteracy, health literacy)
Socio-economic barriers to access are greater in
minority and immigrant groups
Educational differences
Diverse health and disease belief systems
Alternative and complementary medicine beliefs
and practices vs. traditional medicine
Religious differences
Power and privilege
ETHNIC: A FRAMEWORK FOR CULTURAL
COMPETENCE
E: Explanation
What do you think may be the reason you have these symptoms?
What do friends, family, others say about these symptoms?
Do you know anyone else who has had or who has this kind of problem?
Have you heard about/read/seen it on TV/radio/newspaper? (If patient cannot
offer explanation, ask what most concerns them about their problems).
T: Treatment
What kinds of medicine, home remedies other treatments have you tried for
this illness?
Is there anything you eat, drink, or do (or avoid) on a regular basis to stay
healthy? Tell me about it.
What kind of treatment are you seeking from me?
H: Healers
Have you sought any advice from alternative/folk healers, friends or other
people (non-doctors) for help with your problems? Tell me about it?
N: Negotiate
Negotiate options that will be mutually acceptable to you and your patient and
that do not contradict, but rather incorporate your patient’s beliefs.
I: Intervention
Determine an intervention with your patient. May include incorporation of
alternative treatments, spirituality, and healers as well as other cultural
practices (e.g. foods eaten or avoided in general, and when sick).
C: Collaboration
Collaborate with the patient, family members, other health care team
members, healers and community resources.
Cultural Competency - Current
Mandates and the Future
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AAMC
LCME
Legislation (NJ, CA - Bills pending)
National Board of Medical Examiners
Professional Licensure
Malpractice Insurers (discounts)
Bronx County
Total Population ………………………...1,332,650
WHITE………………………………………..398,003
BLACK/AFRICAN AMERICAN……...……475,007
American Indian & Alaskan Native …….…...11,371
ASIAN…………….……………………………40,120
Native Hawaiian/ Other Pacific Islanders…….1,383
HISPANIC or LATINO……………….…….329,724
White Persons, Non-Hispanic/Latino..……....77,042
Source:US Census Bureau 2000
CULTURAL COMPETENCE
A set of academic and interpersonal skills that allow
individuals to increase their understanding and
appreciation of cultural differences and similarities
within, among, and between groups. This requires a
willingness and ability to draw on community-based
values,traditions,and customs and to work with
knowledgeable persons of and from the community in
developing targeted interventions, communications
and other supports.
Source:Office of Minority and Women's Health, HRSA, NIH
CULTURE
The shared values, traditions, norms,
customs, arts, history, folklore, and
institutions of a group of people that
are unified by race, ethnicity,
language, nationality, or religion.
Source:Office of Minority and Women's Health, HRSA, NIH
CULTURAL DIVERSITY
Differences in race, ethnicity,
language, nationality, or religion
among various groups within a
community is said to be culturally
diverse if its residents include
members of different groups.
Source:Office of Minority and Women's Health, HRSA, NIH
ETHNIC
Belonging to a common group, often
linked by race, nationality, and
language with a common cultural
heritage and/or derivation.
Source: Office of Minority and Women's Health, HRSA, NIH
Glossary of Key Terms
Culture
The shared values, traditions, norms, customs, arts, history,
folklore, and institutions a group of people that are unified
by race, ethnicity, language, nationally or religion.
Cultural Competence
A set of academic and interpersonal skills that allow
individuals to increase their understanding and appreciation
of cultural differences and similarities similarities, among,
and between groups. This requires a willingness and ability
to draw on community based values, traditions, and customs
and to work with knowledgeable persons of and from the
community in developing targeted interventions,
communications, and other supports.
Cultural Group
A group of people who consciously or unconsciously share
identifiable values, norms, symbols, and some ways of living
that are repeated and transmitted from one generation to
another.
Source:Office of Minority and Women's Health, HRSA, NIH
Glossary of Key Terms - continued
Cultural Diversity
Differences in race, ethnicity, language, nationality, or religion
among various groups within a community is said to be
culturally diverse if its residents include members of different
groups.
Cultural Sensitivity
An awareness of the nuances of one’s own and other cultures.
Culturally Appropriate Demonstrating both sensitivity to cultural differences and
similarities and effectiveness in using cultural symbols to
communicate a message.
Ethnic
Belonging to a common group, often linked by race, nationally,
and language with a common cultural heritage and/or
derivation.