States mandate cultural awareness to address bias
States mandate cultural awareness to address bias
New Jersey first to put law on the books
The Institute of Medicine (IOM) in 2002 issued a report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare," that concludes that bias, prejudice, and stereotyping on the part of health care providers may result in differences in care. Now, more states and accrediting bodies are taking steps to require clinicians to become more culturally aware — the success of which will be measured later, rather than sooner, experts say.
"Unequal Treatment was a 700-page compilation of studies saying there’s unconscious racism in the United States. So, now the question comes down to Can you influence those feelings in an adult?’" says Margaret Kirkegaard, MD, MPH, pre-doctoral program director for Midwestern University’s Chicago College of Osteopathic Medicine.
New Jersey: New educational requirements
In March, New Jersey became what medical leaders say is the first state to pass a law that ties physicians’ licenses to their efforts to become culturally attuned to their patients.
The new law was sparked by findings such as the IOM report and a federally funded study conducted by Georgetown University, University of Pennsylvania, and the Rand Corp. that indicated physicians are far less likely to refer blacks and women than white men with identical complaints of chest pain to heart specialists for cardiac catheterization.
"Cultural awareness and cultural competence are essential skills for providing quality health care to a diverse patient population," the law, created under state bill S144, states. Despite the importance of cultural competency suggested by the studies, only a fraction of medical schools in the United States provide formal training in cultural competence, although more and more are adding programs and integrating cultural education into existing curricula.
New Jersey’s law requires each medical school in the state to include instruction in cultural competency, focusing on race and gender disparities, to be developed in consultation with the Association of American Medical Colleges or other recognized reviewer of medical school curricula. Completion of the instruction is required for a diploma, and physicians already practicing who did not receive cultural competency instruction are required to obtain cultural competency training as a condition of re-licensure within three years of the act’s passage.
According to S. Manzoor Abidi, MD, president of the Medical Society of New Jersey, even though the law has been signed into effect by the governor, it won’t go into effect in practice until the state board of medical examiners adopts regulations to implement the training requirement. As yet, he says, the specific criteria in terms of time, content, and scope of the training "are subject to negotiation through rule making."
The medical society "will work with members and the [board of medical examiners] to formulate meaningful criteria and training that will effectuate the laudable purpose of the act — providing quality health care to a diverse patient population," says Abidi.
A good start
Kirkegaard says, even if the effects of cultural competency training aren’t seen immediately, making it part of medical school curricula and continuing medical education (CME) is a good first step.
"Cultural competency training is the educational response to the problem of health disparity in the United States," she says. Her institution has had a "strong curriculum" in cultural competency for three years, she says, and during that time the strengths and weaknesses of the program have emerged.
"There is a deep-seated health disparity in the U.S. on the basis of race, ethnicity, gender, and obesity," Kirkegaard explains. "So if we teach people culturally competency, it will reduce the disparity.
"Now, there’s no data to show it yet," she continues, "but there’s some intermediate information that patients feel more comfortable [with physicians who have received cultural competence training]."
A 2003 study by researchers at Johns Hopkins University1 indicated that patients who saw physicians of their own race were more satisfied with their visits, and that physicians spent a bit more time with patients of their own race.
At Chicago College of Osteopathic Medicine, cultural competency is integrated into different levels of the curriculum, rather than presented as a separate course or module, Kirkegaard explains. One thing the school realized as the program has progressed is that students are not the only ones who could benefit from the training.
"We realized that we were looking at the students, but we also had to look at the faculty and the campus, at the hidden curriculum,’" she says. "We have a long way to go, still. You’re trying to affect change in a deep-seated issue."
Cultural competency programs don’t assume that the physician or student is racist. But because everyone has developed, beginning in early childhood, perceptions and biases and awareness of his or her own culture, anyone can make wrong assumptions based on culture, Kirkegaard explains.
First, there is an individual’s own cultural awareness — what he or she knows and believes about his or her own culture, and what is correct and incorrect.
Then, there are the beliefs we develop about cultures that are different from our own.
"Here’s a completely made-up example," Kirkegaard says. "In my experience, ginger ale is a perfectly good remedy for an upset stomach. But what if a patient comes in and says dandelion juice is her remedy for an upset stomach? That would seem as strange to me as ginger ale would seem to her, and neither has a medical basis — they’re just personal beliefs."
Stereotyping other cultures
Another facet of our cultural knowledge is what we know or believe to be the attributes of other cultures — which gestures and practices are synonymous with other cultures, which gestures and practices might be offensive to people of certain cultures, etc.
"There is a concern that that can lead to stereotyping," says Kirkegaard, because a physician might make an assumption based on his or her cultural knowledge that turns out to be wrong.
"We were working with a Hispanic patient in one class, and we asked if she had religious beliefs that impacted her health, and she said she did," she recalls. "We all assumed she was Catholic, but she is Seventh-Day Adventist."
Kirkegaard says that at her school, the focus is not on memorizing facts about different cultures, but about developing the ability to adapt and understand the culture of others and encouraging student physicians to ask every patient what his or her understanding is about what’s happening and what the patients’ expectations are.
Other states considering legislation
Arizona, California, Illinois, and New York are following suit. Each is considering cultural competency requirements for physicians and medical students. The only proposal thus far that specifies a required amount of CME is New York’s, which proposes a 16-hour CME requirement for cultural competency training for recertification.
California has had a law on the books for about two years, but changes have been proposed to change cultural and linguistic competency training from voluntary to mandatory. The California Medical Association, which backed the law calling for voluntary training in 2003, has come out in opposition to the proposed change.
A bill in committee in the Illinois state senate would create a voluntary program to teach foreign language and cultural understanding, with the hope that a physician would become proficient in at least one language other than his or her own, and would develop understanding and awareness of cultural influences on the delivery of health care.
Reference
- Cooper LA, Roter DL, Johnson RL, et al. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med 2003; 139:907-915.
Sources
- S. Manzoor Abidi, MD, President, Medical Society of New Jersey, Lawrenceville. Phone: (609) 896-1766.
- Margaret Kirkegaard, MD, MPH, Pre-Doctoral Program Director, Midwestern University, Chicago College of Osteopathic Medicine. E-mail: [email protected].
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