How cultural competence helps physicians improve outcomes and achieve value-based financial incentives
Ashley Bose, M.D., a family physician in Edinburg, Texas, has lived in the Rio Grande Valley nearly her entire life. She says cultural immersion helps her better understand and address the unique health needs of Spanish-speaking patients, who make up about 93% of her patient population.
For example, Bose knows that mental health carries a big stigma in many cultures. Sometimes even saying the word “depression” can be taboo. Spanish-speaking patients may instead focus on their physical symptoms, in which case Bose mirrors that language to make them feel more comfortable. “It’s a big issue in Hispanic cultures and certain Asian cultures as well,” she says. “Mental health doesn’t exist. It’s the whole concept of, ‘Keep going and you’ll be fine.’ ”
Dona E. Cooper-Dockery, M.D., an internist in McAllen, Texas, says she also is mindful of cultural differences in her medical practice. For example, when providing nutritional counseling to Hispanic patients, she focuses on how to make healthy tacos rather than healthy pasta dishes. When treating Muslim patients, she tries to avoid physical contact between health care workers and patients of the opposite gender.
The connection between cultural competence and value-based care
It is all part of a growing movement to provide culturally competent care, says Sherri D. Onyiego, M.D., Ph.D., FAAFP, medical director at Equality Health, which provides technology, services and support for value-based care. “Cultural competency is defined as the ability of providers to integrate a patient’s race, ethnicity, cultural background, language, sexual orientation and other factors into the way they deliver care,” she says.
Culturally competent care is not only good for patients — it may also help physicians achieve value-based financial incentives, says Suganya Karuppana, M.D., a family physician in Phoenix. “You’re not going to achieve lower A1C and decreased (emergency department visits if patients don’t trust you and follow your recommendations,” she says.
Cooper-Dockery agrees. “As we provide culturally competent care, we increase trust, patient satisfaction and patient (adherence),” she says. “This increases quality, promotes positive outcomes and reduces health care disparities.”
In addition, cultural competency helps providers in another way: patient referrals. “When you build trust, patients will want to come back,” says Karuppana. “They’ll also spread the word and tell their friends.”
Bose agrees. “We can do a lot of social media marketing, but it’s really the ‘word of mouth’ that is truly our marketing base.”
Strategies to provide culturally competent care
With culturally competent care, the goal is to embed culture into care delivery. “It’s important not to frame culturally competent care as a checklist of things to do,” says Karuppana. “In my mind, it’s a way of being.” Providing culturally competent care is not a one-and-done task, she adds. It is something providers and staff must repeat consistently over time to build trust.
Consider these strategies to promote culturally competent care in your medical practice.
1 Survey your patients.
What are patients’ cultural needs, and what can you and your staff do to better serve the community? How can you improve the experience for all patients and especially those who may be from marginalized groups?
For example, consider asking these questions: Did the clinician or health care team communicate with you in your preferred language? Did the clinician or health care team help you understand your diagnosis and treatment plan? “The patient voice is really important and critical to all of this,” says Onyiego.
“Oftentimes, the patients are the ones who teach us and thus guide our thoughts into making the correct diagnoses and effective treatment plans,” Cooper-Dockery says. “This can only be done if the health care provider connects with the patients linguistically, socially and culturally.”
2 Ensure staff mirror the patient community you serve. “Patients want to identify with the practice, whether it’s culturally, linguistically or socially,” says Cooper-Dockery. “This is very important.”
It is also about hiring people who see the value in cultural competence and who have the capacity to provide it, says Onyiego. “This is something practices need to think about as they bring on staff who are going to be charged with talking to people in some of their most vulnerable moments,” she adds.
3 Accommodate preferred languages. For example, Karuppana uses an interpreter service in her practice. To identify each patient’s preferred language, staff ask patients to point to their country of origin on a map or their country’s flag on a chart. She tries to avoid using a patient’s family members as interpreters. “Sometimes family members can feel uncomfortable with doing direct translation of what the provider is trying to say, and they may alter what’s being said,” she says. “Providers who don’t speak that language wouldn’t know what’s actually being delivered to your patient. You need a clear and safe communication method with your patient.”
At Cooper-Dockery’s practice, all staff are required to be fully bilingual in English and Spanish. Cooper-Dockery learned sign language so she could communicate with patients who are deaf.
“Putting in the effort to learn the language is helpful,” says Bose, who tries to communicate in Spanish and contracts with an on-demand interpreter. “Patients appreciate that you try. That sets the tone for the visit.”
It is also important to understand another linguistic factor: preferred terminology within a community, says Onyiego. She provides the example of patients who identify as lesbian, gay, bisexual, transgender or queer. “Health care providers need to speak to this community using language that’s appropriate and that makes those patients want to continue to engage in care,” she adds.
4 Invest in training and education. Everyone in the medical practice plays a role in making the visit more inviting and inclusive. “Everyone also needs to hear the same message about cultural competency,” says Onyiego. “Then you need to invest in retraining on an ongoing basis.”
5 Do not make assumptions. Physicians cannot understand everything about a particular culture based on a single training or experience, says Karuppana. “Even if you take my country of origin — India — there are so many different practices in different regions within the same country,” she says. “You can’t say you understand Indian culture if you’ve gone to India or have a single Indian friend. Learn from your patients about their cultural practices and values.”