The State of New Jersey Board of Medical Examiners (NJBME) has recently added new requirements for cultural competency training for physicians. This training obligation is based on Georgetown University and University of Pennsylvania studies, which were published in the New England Journal of Medicine. The studies, along with similar published works, detail disparities in the provision of healthcare. They produce documented proof that referrals for specific types of care, especially cardiac, are not made available to women and blacks as often as they are to Caucasian men.[1]

The NJBME stresses the importance of cultural competence and notes that few medical schools currently include it in their curriculum; therefore, special training is now required for physicians’ relicensure if they did not receive cultural competency training in medical school.[2]

The movement to cultural competence is part of a modification of healthcare practice toward patient-centered care. Instead of focusing primarily on disease or injury, the patient-centered process looks at the patient as a complete entity. That is, the patient is seen as a person who has a disease or injury, rather than concentrating on a disease or an injury which happens to occupy a body.

The complete person is best defined within an understanding of the person’s culture. Weston and Brown quote Cassell’s description of culture in the following statement:

Culture defines what is meant by masculine or feminine, what clothes are worn, attitudes toward the dying and the sick, mating behavior, the height of chairs and steps, attitudes toward odors and excreta, where typewriters sit and who uses them, bus stops and bedclothes, how the aged and the disabled are treated. These things, mostly invisible to the well, have an enormous impact on the sick and can be a source of untold suffering. They influence the behaviour of others toward the sick person and that of the sick toward themselves. Cultural norms and social rules regulate whether someone can be among others or will be isolated, whether the sick will be considered foul or acceptable, and whether they are to be pitied or censured.[3]
 

O’Connor notes that the health professions often view culture and ethnicity as the same thing, yet all people are culturally defined no matter what background they come from.[4] In addition, an ethnic person should not be lumped into a generic group with identical qualities as everyone else in that group; that is simply not an accurate representation.[5] She explains, “Medical problems have emotional, psychological, aesthetic, religious, interpersonal, and practical dimensions that differ across cultures and belief systems and that impel certain kinds of action and constrain others” and “moral mandates and ethical convictions differ cross-culturally.”[6]

Understanding how the patient’s disease or injury fits into their life, family, social relationships, and work helps a physician communicate more effectively with the patient. It means that fewer clues are missed and that decisions made with the patient on the care plan improve the likelihood the plan will be followed by the patient. Adherence to the care plan is important, as any physician knows; so the physician needs to spend some time finding out what care plan the patient will, or can adhere to, by finding out about their culture and their current circumstances.

A simple example of this might be a physician who is treating a female patient in her mid-twenties for a back injury. The physician advises bed rest during the day along with medication and physical therapy. If the physician does not take into account that she has four children under the age of five and no friends or family to help her, then he may be unhappy with her lack of adherence to his orders. However, if that same woman belongs to a culture which has close bonds with extended family, the physician may find his patient to be more likely to follow his orders.

To be more culturally aware, a physician must not only take the training that the NJBME requires, but should look for other opportunities to increase understanding of the differences between cultures.

Immigrants who come from other cultures also are accustomed to other health systems. The American healthcare and reimbursement system is complex and technology-based. We know that this system is often more than a little intimidating to people who have been in the states for generations and are fluent in Americanized English. Imagine the difficulty our system represents to a recent immigrant!