Achieving Cultural Competency E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 467

Veröffentlichungsjahr: 2011

Beschreibung

Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals provides the necessary tools to meet the ever-growing need for culturally competent practitioners and trainees. Twenty-five self-study cases cover a variety of medical topics, including cardiovascular, pulmonary, neurology, oncology, hematology, immunology, and pediatric disorders. Actual scenarios that occurred in clinical settings help the user gain direct insight into the realities of practice today. Cultural factors covered within the cases include cultural diversity plus gender, language, folk beliefs, socioeconomic status, religion, and sexual orientation. This book is an approved CME-certifying activity to meet physicians' cultural competency state requirements. Get 25 pre-approved self-study American Dietetic Association credits at no additional charge when you purchase the book. Email [email protected] for further instructions.

Leseprobe

Contents

Contributors

Associate Editors

Achieving Cultural Competency:A Case-Based Approach to Training Health Professionals

Directions for Continuing Medical Education Credits

Overall Educational Objectives

Directions for Continuing Medical Education Credits

Completion Instructions

Select the case(s) for which you would like to receive CME credit.

Computer Requirements

Preface

Foreword

References

Acknowledgments

Introduction

The importance of cultural competency

Health disparities

Medical education

Using this book

Conclusion

References

Tools to Assess Cultural Competency Training (TACCT)

CASE 1 Ruth Franklin

Case Summary, Questions and Answers

References: Case 1

CASE 2 Carl Jones

Case Summary, Questions and Answers

References: Case 2

CASE 3 Maria Morales

Case Summary, Questions and Answers

References: Case 3

CASE 4 Maya Mohammed

Case Summary, Questions and Answers

References: Case 4

CASE 5 Jon Le

Case Summary, Questions and Answers

References: Case 5

CASE 6 Nadia Rosenberg

Case Summary, Questions and Answers

References: Case 6

CASE 7 Isabel Delgado

Case Summary, Questions and Answers

References: Case 7

CASE 8 George Dennis

Case Summary, Questions and Answers

References: Case 8

CASE 9 Mary Jones

Case Summary, Questions and Answers

References: Case 9

CASE 10 Priya Krishnamurthy

Case Summary, Questions and Answers

References: Case 10

CASE 11 Carlos Cruz

Case Summary, Questions and Answers

References: Case 11

CASE 12 Denise Smith

Case Summary, Questions and Answers

References: Case 12

CASE 13 Mae Ling Chung

Case Summary, Questions and Answers

References: Case 13

CASE 14 Earl Collins

Case Summary, Questions and Answers

References: Case 14

CASE 15 Irma Matos

Case Summary, Questions and Answers

References: Case 15

CASE 16 Eileen Clark

Case Summary, Questions and Answers

References: Case 16

CASE 17 Leslie O’Malley

Case Summary, Questions and Answers

References: Case 17

CASE 18 Juana Caban

Case Summary, Questions and Answers

References: Case 18

CASE 19 Alice Gregory

Case Summary, Questions and Answers

References: Case 19

CASE 20 Sunil Guha

Case Summary, Questions and Answers

References: Case 20

CASE 21 Pepper Hawthorne

Case Summary, Questions and Answers

References: Case 21

CASE 22 Alika Nkuutu

Case Summary, Questions and Answers

References: Case 22

CASE 23 Miguel Cortez

Case Summary, Questions and Answers

References: Case 23

CASE 24 Naomi Fulton

Case Summary, Questions and Answers

References: Case 24

CASE 25 Bobby Napier

Case Summary, Questions and Answers

References: Case 25

APPENDIX 1

APPENDIX 2

APPENDIX 3

Multiple Choice Questions

Case 1: Ruth Franklin: A 40-year-old African American woman with heart failure

Case 2: Carl Jones: A 48-year-old homeless Caucasian man with chest pain and lung cancer

Case 3: Maria Morales: A 57-year-old Mexican woman with type 2 diabetes

Case 4: Maya Mohammed: 15-year-old Arab American teenager with leukemia

Case 5: Jon Le: A 48-year-old Korean man with cerebral hemorrhage

Case 6: Nadia Rosenberg: A 53-year-old Russian woman with drug-resistant tuberculosis

Case 7: Isabel Delgado: A 47-year-old Dominican woman with hypertension

Case 8: George Dennis: A 35-year-old African American man with AIDS

Case 9: Mary Jones: A 2-year-old Caucasian girl with delayed speech development

Case 10: Priya Krishnamurthy: A 73-year-old South Asian Indian woman with a stroke

Case 11: Carlos Cruz: A 34-year-old Mexican man with sleep apnea and metabolic syndrome

Case 12: Denise Smith: A 41-year-old Caucasian woman with asthma

Case 13: Mae Ling Chung: A 22-year-old Chinese woman in an arranged marriage

Case 14: Earl Collins: A 73-year-old African American man with lung cancer

Case 15: Irma Matos: A 66-year-old Ecuadorian woman with type 2 diabetes and hypertension

Case 16: Eileen Clark: An 82-year-old African American woman with a stroke

Case 17: Leslie O’Malley: A 66-year-old Irish American man with breast cancer

Case 18: Juana Caban: A 21-year-old Puerto Rican woman who is pregnant and HIV-positive

Case 19: Alice Gregory: A 71-year-old African American woman with aortic stenosis

Case 20: Sunil Guha: A 32-year-old South Asian Indian man with metabolic syndrome

Case 21: Pepper Hawthorne: A 19-year-old Caucasian woman with a stroke

Case 22: Alika Nkuutu: A 24-year-old African woman with sickle cell disease

Case 23: Miguel Cortez: A 9-year-old Mexican boy with asthma

Case 24: Naomi Fulton: A 49-year-old African American woman with metabolic syndrome

Case 25: Bobby Napier: A 68-year-old Caucasian Appalachian man with type 2 diabetes

Answers

Case 1: The Case of Ruth Franklin

Case 2: The Case of Carl Jones

Case 3: The Case of Maria Morales

Case 4: The Case of Maya Mohammed

Case 5: The Case of Jon Le

Case 6: The Case of Nadia Rosenberg

Case 7: The Case of Isabel Delgado

Case 8: The Case of George Dennis

Case 9: The Case of Mary Jones

Case 10: The Case of Priya Krishnamurthy

Case 11: The Case of Carlos Cruz

Case 12: The Case of Denise Smith

Case 13: The Case of Mae Ling Chung

Case 14: The Case of Earl Collins

Case 15: The Case of Irma Matos

Case 16: The Case of Eileen Clark

Case 17: The Case of Leslie O’Malley

Case 18: The Case of Juana Caban

Case 19: The Case of Alice Gregory

Case 20: The Case of Sunil Guha

Case 21: The Case of Pepper Hawthorne

Case 22: The Case of Alika Nkuutu

Case 23: The Case of Miguel Cortez

Case 24: The Case of Naomi Fulton

Case 25: The Case of Bobby Napier

Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals

Index

This edition first published 2009, © 2009 by Blackwell Publishing Ltd

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Library of Congress Cataloging-in-Publication Data

Achieving cultural competency: a case-based approach to training health professionals/editors-in-chief, Lisa Hark, Horace DeLisser; senior editor, Gail Morrison.

p.; cm.

Includes bibliographical references.

ISBN 978-1-4051-8072-6

1. Transcultural medical care–Case studies. 2. Physician and patient–Case studies. 3. Medical personnel–Training of–Case studies. I. Hark, Lisa. II. DeLisser, Horace.

III. Morrison, Gail.

[DNLM: 1. Cultural Competency–Case Reports. 2. Ethics, Clinical–Case Reports. 3. Physician-Patient Relations–Case Reports. 4. Prejudice–Case Reports. W 21 A178 2009]

RA418.5.T73A24 2009

610.69’6–dc22

2008039954

Contributors

Associate Editors

Olivia Carter-Pokras, PhD

Associate Professor

Department of Epidemiology and Biostatistics

University of Maryland School of Public Health

College Park, MD, USA

Darwin Deen, MD, MS

Medical Professor

Department of Community Health and Social Medicine

Sophie Davis College of Biomedical Education

City College of New York, NY, USA

Desiree Lie, MD, MSEd

Clinical Professor of Family Medicine

Department of Family Medicine

University of California at Irvine, Orange, CA, USA

Ana Núñez, MD

Director of Women’s Health Education Program

Associate Professor of Medicine

Drexel University College of Medicine, Philadelphia, PA, USA

Debbie Salas-Lopez, MD, MPH, FACP

Associate Professor of Medicine

Division of General Internal Medicine

Vice Chair of Medicine

Lehigh Valley Hospital and Health Network, Allentown, PA, USA

Helen Abramova, MD, Postdoctoral Research Fellow, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Thomas A. Arcury, PhD, Professor and Research Director, Department of Family and Community Medicine Wake Forest University School of Medicine, Winston-Salem, NC, USA

Elena N. Atochina-Vasserman, MD, PhD, Senior Research Investigator, Division of Pulmonary, Allergy, and Critical Care Medicine University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Lisa Bellini, MD, Professor of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Clarence H. Braddock III, MD, MPH, Associate Dean for Medical Education Stanford University School of Medicine, Stanford, CA, USA

Fran Burke, MS, RD, Senior Clinical Dietitian, Department of Cardiovascular Medicine University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Olivia Carter-Pokras, PhD, Associate Professor, Department of Epidemiology and Biostatistics University of Maryland School of Public Health, College Park, MD, USA

Alexander J. Chou, MD, Instructor, Department of Pediatrics Memorial Sloan-Kettering Cancer Center, New York, NY, USA

April Coleman, Managing Editor University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Ronald G. Collman, MD, Professor of Pulmonary, Allergy, and Critical Care Medicine; Co-director, Penn Center for AIDS Research, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Nereida Correa, MD, MPH, Associate Clinical Professor of OB/GYN and Women’s Health, Albert Einstein College of Medicine, Bronx, NY, USA

Sonia Crandall, PhD, MS, Professor of Family and Community Medicine Wake Forest University School of Medicine, Winston-Salem, NC, USA

Hetty Cunningham, MD, Assistant Clinical Professor of Pediatrics Columbia University College of Physicians and Surgeons, New York, NY, USA

Horace DeLisser, MD, Associate Professor of Pulmonary, Allergy, and Spiritual Care Medicine; Assistant Dean, Cultural Competency University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Sharon Drozdowsky, MES, Industrial Hygienist, Consultation, Education and Outreach Services, Division of Occupational Safety and Health Washington State Department of Labor and Industries, Tumwater, WA, USA

Eric J. Gertner, MD, MPH, Associate Professor of Clinical Medicine Lehigh Valley Hospital and Health Network, Allentown, PA, USA

Indira Gurubhagavatula, MD, Assistant Professor of Sleep, Pulmonary, Allergy, and Critical Care, Medicine University of Pennsylvania School of Medicine, Veteran Affairs Medical Center of Philadelphia, PA, USA

Roy Hamilton, MD, MS, Assistant Professor of Neurology University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Lisa Hark, PhD, RD, Consultant, Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA

Scott Kasner, MD, Associate Professor of Neurology; Director Comprehensive Stroke Center University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Nadine T. Katz, MD, Associate Dean for Students; Associate Professor and Director of Medical Education, Department of Obstetrics and Gynecology and Women’s Health Albert Einstein College of Medicine, Bronx, New York, NY, USA

Amal Mohamed Osman Khidir, MD, FAAP, Assistant Professor of Pediatrics; Director, Pediatric Clerkship Weill Cornell Medical College in Qatar, Doha, Qatar

Lyuba Konopasek, MD, Associate Professor of Pediatrics (Education); Course Director, Medicine, Patients, and Society; Director, Pediatric Undergraduate Education Weill Cornell Medical College, New York, NY, USA

Elizabeth Lee-Rey, MD, MPH, Assistant Professor of Family and Social Medicine; Co-Director, Hispanic Center of Excellence Albert Einstein College of Medicine, Bronx, New York, NY, USA

Ryan Leonard, Research Assistant and Item Writer University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Desiree Lie, MD, MSEd, Clinical Professor of Family Medicine, Department of Family Medicine University of California at Irvine, Orange, CA, USA

Edgar Maldonado, MD, Assistant Clinical Professor of Medicine; Medical Director, Centro de Salud Latino Americano and Diabetes Institute Lehigh Valley Hospital and Health Network, Allentown, PA, USA

Mitchell L. Margolis, MD, Director of Clinical Pulmonary Medicine Veterans Affairs Medical Center of Philadelphia, Philadelphia, PA, USA

Gail S. Marion, PA, PhD, Professor of Family and Community Medicine Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA

Rica Mauricio, Former Health Education and Adult Literacy Program Coordinator and Researcher, Columbia University College of Physicians and Surgeons, New York, NY, USA

Steven R. Messé, MD, Assistant Professor of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Dodi Meyer, MD, Associate Clinical Professor of Pediatrics Columbia University College of Physicians and Surgeons, New York, NY, USA

Ana Núñez, MD, Director of Women’s Health Education Program; Associate Professor of Medicine Drexel University College of Medicine, Philadelphia, PA, USA

Sashank Prasad, MD, Instructor, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Noel B. Rosales, MD, Director, Cultural Effectiveness Initiative; Assistant Professor of Pediatrics Children’s Hospital of Philadelphia, Philadelphia, PA, USA

Lisa Rucker, MD, Associate Professor of Clinical Medicine Albert Einstein College of Medicine, Bronx, NY, USA

J. Eric Russell, MD, Associate Professor of Medicine Pediatrics University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Debbie Salas-Lopez, MD, MPH, FACP, Associate Professor of Medicine, Division of General Internal Medicine, Vice Chair of Medicine, Lehigh Valley Hospital and Health Network, Allentown, PA, USA

John Paul Sánchez, MD, MPH, Emergency Medicine Resident Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

Nelson Felix Sánchez, MD, Instructor, Department of Internal Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

Alexandra Schieber, Medical Student, New York University School of Medicine, New York, NY, USA

Nicholas E. S. Sibinga, MD, Associate Professor of Medicine (Cardiology) Albert Einstein College of Medicine, New York, NY, USA

Charles Vega, MD, FAAFP, Associate Clinical Professor of Family Medicine; Director, Program in Medical Education for the Latino Community University of California at Irvine, Irving, CA, USA

Susan E. Wiegers, MD, Professor of Cardiovascular Medicine University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals

Directions for Continuing Medical Education Credits

Duration: Maximum of 25 hours, each case should take 1 hour

Credit: Up to 25 AMA PRA Category 1 CreditsTM, each case is awarded 1 AMA PRA Category 1 CreditTM

Original Release Date: June 1, 2009

Last Review Date: January 5, 2009

Expiration: May 31, 2012

There is no commercial support for this activity.

Program Overview: Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals will provide the necessary tools to meet the ever growing need that health professionals in training and practice have to become culturally competent. A total of 25 self-study clinical cases will be presented on a variety of medical topics, including cardiovascular, endocrine, pulmonary, neurology, oncology, hematology, immunology, OB-GYN, and pediatric disorders. Learners will not only gain knowledge, but will have direct insight into real life, actual scenarios that have occurred in clinical settings. Cultural factors covered within the cases include cultural diversity plus gender, language, folk beliefs, socioeconomic status, health literacy, religion, and sexual orientation.

Intended Audience: This activity has been designed for physicians in training (interns, residents and fellows), practicing physicians and is also applicable to all medical disciplines and specialties and medical students.

Overall Educational Objectives

Upon completion of this activity, participants should be better able to:

1 Describe the language, culture, and behaviors of diverse individuals and their families.

2 Examine self-awareness and knowledge of the cultural factors that may affect interactions between patients and health care providers.

3 Employ skills to provide culturally effective and appropriate healthcare.

Accreditation: The University of Pennsylvania School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Directions for Continuing Medical Education Credits

Designation of Credit: The University of Pennsylvania School of Medicine designates this educational activity for a maximum of 25 AMA PRA Category 1 CreditsTM. Each case in this activity is designated for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosures: It is policy at the University of Pennsylvania School of Medicine for individuals who are in a position to control the content of an educational activity to disclose to the learners all relevant financial relationships that they have with any commercial interest that provides products or services that may be relevant to the content of this continuing medical education activity.

The staff in the Office of CME at the University of Pennsylvania School of Medicine and the peer reviewer, Zalman Agus, MD, have reported no relevant financial relationships with any commercial interests related to the content of this educational activity.

The faculty/editors listed below have disclosed that they have norelevant financial relationships with any commercial interests related to the content of this educational activity.

Helen Abramova, MD

Thomas A. Arcury, PhD

Elena Atochina-Vasserman,

MD, PhD

Lisa Bellini, MD

Clarence H. Braddock III,

MD, MPH

Frances Burke, MS, RD

Olivia Carter-Pokras, PhD

Alexander Chou, MD

April Coleman

Ronald G. Collman, MD

Nereida Correa, MD, MPH

Sonia Crandall, PhD, MS

Hetty Cunningham, MD

Darwin Deen, MD, MS

Horace DeLisser, MD

Sharon Drozdowsky, MES

Eric J. Gertner, MD, MPH

Indira Gurubhagavatula, MD

Roy Hamilton, MD, MS

Lisa Hark, PhD, RD

Scott Kasner, MD

Nadine T. Katz, MD

Amal Mohamed Osman Khidir,

MD, FAAP

Lyuba Konopasek, MD

Elizabeth Lee-Rey, MD, MPH

Ryan Leonard

Desiree Lie, MD, MSEd

Edgar Maldonado, MD

Mitchell Margolis, MD

Gail Marion, PA-C, PhD

Rica Mauricio

Steven R. Messé, MD

Dodi Meyer, MD

Gail Morrison, MD

Ana Nunez, MD

Sashank Prasad, MD

Noel B. Rosales, MD

Lisa Rucker, MD

J. Eric Russell, MD

Debbie Salas-Lopez, MD,

MPH, FACP

John Paul Sánchez, MD, MPH

Nelson Felix Sánchez, MD

Alexandra Schieber

Nicholas E. S. Sibinga, MD

Charles Vega, MD, FAAFP

Susan E. Wiegers, MD

Investigational and/or Off-Label Use of Commercial Products and Devices: The University of Pennsylvania School of Medicine requires all faculty to disclose any planned discussion of an investigational and/or off-label use of a pharmaceutical product or device within their presentation. Participants should note that the use of products outside FDA-approved labeling should be considered experimental and are advised to consult current prescribing information for approved indications.

The faculty members listed above have reported that there will be no discussion of investigational and/or off-label use of commercial products within the activity.

Completion Instructions

To receive CME credit for each case that you complete from this book, please visit the University of Pennsylvania Office of Continuing Medical Education website at: http://www.med.upenn.edu/cme/culture/Once on the site, you will be presented with the option to choose from two topics. The topic for this book is called “Achieving Cultural Competency Book Cases (Wiley-Blackwell 2009)”. After choosing this topic, you will be presented with a complete list of casesfrom this book.

Select the case(s) for which you would like to receive CME credit.

In order to access any of these cases, you must have an account on the CME Website (complementary).If you do not have an account, sign-up (click on member sign-up at the top of the page).If you have an account, log into the site with your e-mail address and password (click on log-in at the top of the page).Next, register for a particular activity (case) by using the link in the “Course Materials” box on the right. When prompted for an access code, enter: culturebook (Note: the access code is case-sensitive).Click on the “Get CME” link in the “Course Materials” box.You now need to complete the Post-Test.After successfully completing the Post-Test, with a score of 75% orhigher, you will be directed to the Evaluation.After completing the Evaluation, you will be able to view, print, or save a CME certificate verifying your credit for this activity.

Computer Requirements

Windows: Latest release of Safari, Internet Explorer 6/7 or Mozilla/Firefox.

Macintosh: Latest release of Safari or Mozilla/Firefox.

Plugins: Real Player

Contact Information: For CME-related questions, please contact the University of Pennsylvania School of Medicine, Office of Continuing Medical Education, at [email protected] or at 215-898-9750.

Preface

We are extremely proud of the first edition of Achieving CulturalCompetency: A Case-Based Approach to Training Health Professionals. We hope this book will provide the necessary tools to meet the evergrowing need that health professionals in training and practice have to become culturally competent. Twenty-five self-study cases are presented on a variety of medical topics in the areas of cardiovascular disease, pulmonary medicine, metabolic and endocrine diseases, obstetrics and gynecology, neurology, oncology, hematology, and pediatric disorders. Issues covered within the cases include cultural diversity plus gender, language, folk beliefs, socioeconomic status, religion, and sexual orientation. Learners will gain knowledge, and learn skills related to health disparities, community strategies, bias and stereotyping, communication skills, use of interpreters, and self-reflection as recommended by the AAMC’s Tools to Assess CulturalCompetency Training. Many health professionals have collaborated to write these cases that provide direct insights into real-life, actual scenarios that have occurred in clinical settings.

Culture is difficult to define and can easily be taken for granted. The pressures of modern medical practice are such that, as physicians treat their patients, they may tend to focus only on the medical issues, while neglecting the cultural heritage, beliefs, and values of their patients. Unfortunately, failure to consider and address these issues in the doctor–patient relationship may result in poor outcomes for individual patients, which may contribute to national healthrelated disparities for the entire society. We are pleased to be able to contribute this content and feel confident that, as physicians become more culturally competent, they will be able to provide better, more effective care to their patients. There is nothing more reassuring to patients than knowing that their health care provider respects and understands who they are as people, including the cultural factors that define them.

For this reason, the University of Pennsylvania School of Medicine, Office of Continuing Medical Education (CME) has recognized the importance of this material for physicians. The University of Pennsylvania School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Pennsylvania School of Medicine designates each case of this educational activity for a maximum of 1 AMA PRACategory 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Information about CME credits for this book can be found on pages xii and 219 and at the following Web site: http://www.med.upenn.edu/cme.

For more information about the University of Pennsylvania School of Medicine’s Cultural Competency Medical Education Program, visit http://www.med.upenn.edu/culture.

Horace DeLisser, MD, Lisa Hark, PhD, RD and Gail Morrison, MD

Foreword

Clarence H. Braddock III, MD, MPH, FACP

In the early 1980s, there was increasing recognition of the powerful challenge that our health care system was facing in providing highquality care to increasingly diverse populations. As a result, the term “cultural competence” entered the language of health professions education in the late 1980s. Based on the work of Cross and others, many authors began to articulate frameworks for defining cultural competence (1). Yet cultural competence was slow to emerge as an important fixture in health professions education.

A large part of this slow progress was the ongoing debate on defining cultural competence. Is cultural competence the knowledge of the unique traditions, health beliefs, and health of a defined population? Is it a set of communication skills to better understand the unique health needs and beliefs of any patient? Is it more of an attitude—a stance—in which the physician shows the humility and curiosity to explore the patient’s background and allow what is learned to inform diagnosis and treatment? In reality, cultural competence is all these things. This recognition has stymied many educators seeking to develop curricula to address the challenge.

In 2000, the Liaison Committee for Medical Education, the organization that sets and applies accreditation standards for U.S. Medical Schools, added a standard for teaching about the role of culture in clinical practice:

“The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. Medical students should learn to recognize and appropriately address gender and cultural biases in health care delivery, while considering first the health of the patient” (2).

In 2003, the Institute of Medicine (IOM) published its landmark report, Unequal Treatment. This publication cataloged the growing body of evidence of the vast extent of disparities in health care in the United States. The IOM recommended that health care profession education include specific training in cultural competence. These two strong statements drew attention to a previously overlooked area of education and training, and many educators began to scramble to find ways to teach cultural competence (3).

The cause of cultural competence education took a major step forward with the publication by the Association of American Medical College’s Tools for Assessing Cultural Competence Training (TACCT) in 2005. Developed by a national expert panel of educators in this area, TACCT provides a framework of broad domains of cultural competence and 42 specific learning objectives for use in constructing a robust cultural competence curriculum (4).

Currently, the majority of health professions schools, postgraduate training programs, and health care systems are working to meet the goal of preparing a workforce who can deliver high-quality and culturally and linguistically appropriate care to all. The remaining challenge in cultural competence—and it is not a small one—is developing meaningful and effective strategies to teach cultural competence. There are a few Web-based resources, most notably the National Consortium for Multicultural Education for the Health Professions the University of Pennsylvania School of Medicine and the University of Alabama at Birmingham Web sites, but precious few textbooks or guides to teaching and learning in this area, until now (5–7). Hark and DeLisser’s Achieving Cultural Competency: A Case-BasedApproach for Training Health Professionals is a fabulous addition to the growing list of resources for teaching. The authors have assembled a rich resource, with contributions from many of the top educators in cultural competence in the United States.

This book fills an important niche, providing a rich and diverse set of cases for teaching and learning. By mapping the learning objectives of the cases to the TACCT, the authors and their contributors have added incredible value. The authors have masterfully molded their years of combined experience into a usable guide to case-based education in cultural competence. Now educators seeking to add curriculum on a particular TACCT domain or set of learning objectives can select high-quality materials for the kind of teaching that embraces principles of adult learning: experiential and case-based teaching (See pp. xxix and Appendix 3).

Achieving Cultural Competency: A Case-Based Approach for TrainingHealth Professionals will undoubtedly become a fixture in the libraries of faculty in health professions schools who are charged to develop, expand, or augment their curriculum in cultural competence. I’m certain that the originators of the cultural competence movement would be gratified to see the kind of high-quality attention this topic is now receiving in health professions education.

Clarence H. Braddock III, MD, MPH, FACP

Associate Professor of Medicine

Associate Dean for Medical Education

Stanford University School of Medicine

Director, National Consortium for Multicultural Education for Health Professionals.

References

1. Cross T.L., Bazron B.J., Isaacs M.R., et al. Towards a culturally competent system of care:A monograph on effective services for minority children who are severely emotionally disturbed. Georgetown University Center for Child Health and Mental Health Policy, CASSP Technical Assistance Center, Washington DC, 1989.

2. Liaison Committee for Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree, 2007.

3. Smedley B.D., Stith A.Y., Nelson A.R. Unequal Treatment: Confronting Racialand Ethnic Disparities in Health Care. Institute of Medicine (U.S.): Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. The National Academies Press, 2003.

4. Association of American Medical Colleges. Cultural Competence Education for Medical Students. 2005. Available at: http://www.aamc.org/meded/tacct/start.htm.

5. National Consortium for Multicultural Education for Health Professionals. Available at: http://culturalmeded.stanford.edu.

6. University of Pennsylvania School of Medicine’s Cultural Competency Medical Education Program and Resources. Available at: http://www.med.upenn.edu/culture.

7. Cultural Competence Online for Medical Practice (CCOMP). A Clinician’s Guide to Reduce Cardiovascular Disparities, especially hypertension, University of Alabama at Birmingham. Available at http://www.c-comp.org.

Acknowledgments

We gratefully acknowledge the National Heart, Lung, and Blood Institute at the NIH for providing a K07 Academic Award to the University of Pennsylvania School of Medicine for the development of our Cultural Competency Medical Education Program and the cases in this book.

Dr. Horace DeLisser would like to thank his wife, Opal, for her ongoing love, patience, and support throughout his professional career. He would also like to thank his parents, Oswald and Eileen, for their love and his sons, Horace Jr. and Jason, for all they have done to make their parents proud.

Dr. Lisa Hark would like to thank her children, Jamie and Brett, for their loving support and inspiration. She would also like to thank her parents, Diane and Jerry, for being the best parents anyone could ever have.

Both Drs. DeLisser and Hark dedicate this book to all the patients who have taught them the importance of listening better and how their cultural backgrounds influence so many issues related to medical care.

Introduction

Olivia Carter-Pakras, PhD and Horace DeLisser, MD

The importance of cultural competency

Over the last 50 years, increased non-European immigration, globalization, changing sexual norms, and the aging of the American population have resulted in a much more culturally diverse country with respect to race, ethnicity, age, religion, sexual identity and orientation, and beliefs about illness and health. As a result, health care providers are likely to encounter patients who will be culturally different from them. These cultural differences affect both patients’ and providers’ health beliefs, practices, and behaviors and influence their expectations of each other. Lack of awareness about cultural differences can make it difficult to achieve high-quality care. Miscommunication may result, and the provider may fail to understand why the patient does not follow instructions. For example, why the patient takes a smaller dose of a prescribed medicine (because of a belief that Western medicine is “too strong”); or why the family, rather than the patient, makes important decisions about the patient’s health care (because major decisions are made by the family as a group in the patient’s culture). Likewise, the patient may reject the provider (and the entire U.S. medical system) even before any one-on-one interaction occurs because of nonverbal cues that do not fit expectations.

Thus in the context of the provider-patient relationship, culturalcompetence refers to the health care provider’s ability to work effectively with individuals from different cultural and ethnic backgrounds. Despite our similarities, fundamental differences among people arise from nationality, ethnicity, and culture, as well as from family background and individual experiences. Cultural competency refers to the ability to understand the language, culture, and behaviors of other individuals and groups, and to make appropriate recommendations. It also includes an awareness of one’s own cultural influences as well as personal biases and prejudices. Cultural competency has been described as a “set of congruent behaviors, attitudes, and policies that come together in a system, agency or profession that enables that system, agency or profession to work effectively in cross-cultural situations” (1). This definition of cultural competency identifies systems, agencies, or professions as potential points of intervention. However, other definitions of cultural competency primarily address individuals within systems and pay less attention to other factors associated with social inequity.

Although varying definitions of culture exist, what is common to these definitions is the view that culture is a set of shared values, beliefs, patterns, and communication styles that characterize the social life of a group or society (1–11). Importantly, culture is not a static entity but rather a fluid and ever-changing set of values, knowledge, and beliefs and a learned behavior. By acknowledging, recognizing, and accounting for cultural issues, health care providers can deliver effective and appropriate care for patients in a variety of inpatient and outpatient settings.

Cultural sensitivity, which is a necessary component of cultural competence, means that health care professionals make an effort to be aware of the potential and actual cultural factors that affect their interactions with patients. It also means that they are willing to design and implement culturally relevant and specific programs and materials and to make related recommendations. The terms cultural competence and culturally effective health care are sometimes used synonymously.

Health disparities

Cultural competence has implications beyond the individual provider-patient relationship. Despite steady improvements in the overall health of the U.S. population, racial and ethnic minorities as a whole continue to experience disproportionately higher morbidity and mortality rates than nonminorities. For example, African Americans and Hispanic Americans (and to a less well-documented extent, Native American, Alaska Natives, Asian Americans, Native Hawaiians, and other Pacific Islanders) receive less medical care in general and fewer intensive care procedures compared to white patients (12–14). This pattern has been found in the use of hightechnology interventions, such as angioplasty and coronary artery bypass surgery, and for medical and surgical procedures as well as the treatment of chronic conditions, such as diabetes. Men have higher prevalence of coronary heart disease, yet women die at higher rates. African American women have lower prevalence of breast cancer, yet die at higher rates. The reasons for these racial and ethnic disparities are complex and include multiple interconnected social and economic factors (12–15). In contributing to the elimination of these disparities, health professional students and providers must understand the underlying forces driving and maintaining these health disparities.

Differences in access to health care and differences in the quality of care received unquestionably contribute to health disparities. Timely use of personal health services to achieve the best health outcomes or health care access can be measured by (a) entry into the health care system, (b) structural barriers (e.g., transportation, ability to schedule appointments, and specialist referrals), (c) patient perceptions (e.g., patient-provider communication and relationships, cultural competency, health literacy, and health information), and (d) health care utilization (i.e., routine, acute, and chronic care, and avoidable hospital admissions).

While explanatory models for health disparities acknowledge the role of socioeconomic factors, they often include “culture” as a separate but related underlying factor (16–17). Freeman suggests that “poverty is reflected through the prism of culture…culture may augment or diminish poverty’s expected effects” (16). Poverty or social and economic location within a society, combined with geopolitical context, shapes a racial, ethnic, or cultural group’s access to social resources such as health care access and quality. Several views have been proposed on the role of culture in explaining health disparities. Some consider culture as a central or a significant predictor of health; some view it as having some role that is not yet clear, and others view it as a contextual variable that may promote or enhance the use of health services (18–25).

Although the National Healthcare Disparities Report does not specifically mention the role of bias and stereotyping, racial and ethnic bias and stereotyping by health care providers are thought to make significant contributions to health care disparities (12–14). Cultural competency training at all levels of professional education can play an important role in addressing racial and ethnic bias and stereotyping by health care providers.

Medical education

Cultural competence is now recognized by various governmental and accreditation agencies as essential for improving patients’ health status and access to health care and for eliminating disparities in health care delivery. Health care system interventions to increase cultural competence can include programs to recruit and retain staff who reflect the cultural diversity of the community, use of interpreter services or bilingual providers, cultural competency training for health care providers, use of linguistically and culturally appropriate health education materials, and culturally specific health care settings (23). Health may be improved through these approaches because patients gain trust and confidence in accessing health care, and health care providers increase their ability to understand and treat a culturally diverse clientele. The effectiveness of these interventions can be assessed through intermediate outcomes and health outcomes. Examples of professional, governmental, and accrediting organizations recognizing the importance of cultural competency include the following:

(1) Association of American Medical Colleges (AAMC) Liaison Committee on Medical Education (LCME). Standards for accreditation of medical education programs leading to a medical degree in the U.S. and Canada require that medical students and faculty demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments (26). Medical schools are now required to document development of skills in cultural competence, indicate where in the curriculum students are exposed to such material, and demonstrate the extent to which the objectives are being achieved. Medical school instruction must stress the need for students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on their health. Clinical instruction is to include demographic influences on health care quality and effectiveness, such as racial and ethnic disparities in the diagnosis and treatment of diseases. Most importantly, self-awareness among students regarding any personal biases in their approach to health care delivery is to be addressed. The AAMC’s recently published Tool for Assessing Cultural CompetenceTraining (TACCT) is a comprehensive guide of objectives for the development of cultural competency and health disparities curriculum for undergraduate and graduate medical education (27, 28) and is shown in the introduction and Appendix 3.

(2) Accreditation Council for Graduate Medical Education (ACGME). In 1999, ACGME identified six core competencies for physicians: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (29). The fourth competency requires interpersonal and communication skills resulting in effective information exchange and collaboration with patients, their families, and other health professionals. The fifth competency, professionalism, includes “sensitivity to a diverse patient population.” Health care organizations and health professional training programs are therefore beginning to develop cultural competence initiatives. Many organizations are getting social and legal pressures to do this from different segments of the population.

(3) The Department of Health and Human Services’ Officeof Minority Health. In 2001, the Office of Minority Health released the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards) to guide health care organizations and individual providers in providing culturally effective health care (30).

(4) State Cultural Competency Training requirements. In 2005, New Jersey became the first state to require cultural competency training for physicians as a condition of licensure. More recently, Washington, California, New Mexico, and Maryland have passed legislation mandating or strongly recommending cultural competency training. A number of states are considering similar legislation (see http://www.thinkculturalhealth.org/cc_legislation.asp for a current update).

Using this book

Individuals working with different ethnic and cultural groups can become more culturally competent by advancing through three main stages: developing awareness, acquiring knowledge, and developing and maintaining cross-cultural communication and negotiation skills. Achieving Cultural Competency: A Case-Based Approach to TrainingHealth Professionals is self-instructional, with case vignettes and questions, followed by case discussions. Twenty-five cases are presented in the areas of general medicine, cardiology, pulmonary medicine, hematology/oncology, neurology, pediatrics, endocrinology, and obstetrics and gynecology. Learners will not only gain knowledge, but have direct insight into real-life scenarios that have occurred in clinical settings.

The cases focus on how age, gender, socioeconomic position, race/ethnicity, sexual orientation, immigrant status, language, religious and spiritual practices, and folk beliefs and practices can affect the doctor-patient relationship. For example, the age of the patient may influence how the patient uses his/her time with the physician and/or how the patient is perceived by the physician (Case 21). Patients who are very young or very old may require the assistance of others in obtaining information and providing care (Case 10). The doctor-patient relationship may be negatively affected when the physician makes superficial judgments about patients based on stereotypes of a racial, ethnic, or socioeconomic (Cases 2, 11, 24, 25). A lack of patient empowerment, as a response to perceived higher status of the physician, may pose a barrier to building rapport, and result in an inability to question the physician’s recommendations, or an overly trusting, dependent patient. A patient’s perceptions of entitlement (i.e., deserving of special treatment), and whether the patient is rich or poor, can also negatively affect the doctor-patient relationship.

Ability to pay is considered the leading barrier to accessing health care. Financial constraints may result in poor health care due to lack of preventive care and/or later presentation for care. A patient may lack a primary care physician, be unable to pay for appropriate diagnostic tests and treatments (e.g., prescription medications), and/or depend on unreliable or expensive sources of transportation (Case2). The daily experience with poverty, partner violence, drug use, poor housing, prostitution, and toxic environments impact not only the access to care, but also the patient’s ability to prevent disease and its complications.

A patient’s health literacy, associated either with low educational attainment or with a lack of understanding of health issues, can negatively affect the patient’s ability to understand a diagnosis or participate as an active partner in developing and carrying out a treatment plan (Case9). Health literacy can be unassociated with overall literacy and should be explored with all patients. Lack of reliable information (whether due to lack of money to pay for it, or lack of education to know whether and how to use it) can lead to an inability to understand or put into action the information provided. Individuals without ready access to a computer, or education or knowledge on how to use resources available at a library, may find it difficult to obtain needed information about self-care, illness, treatment, and resources.

Patients of the opposite gender as their physician may not feel comfortable discussing issues related to sexuality or sexual dysfunction. Gender discordance between the patient and the provider may affect the physician’s ability to take a sensitive and thorough sexual history, and patients may prefer the same gender for OB/GYN and urology providers (Cases 4, 13). Gender bias in diagnosis and treatment may result in underconsideration of heart disease with females, overuse of cardiac catheterization with males, or presumption of males as perpetrators of partner violence and abuse (Cases 17, 21).

Stigma and the potential for discrimination serve as obstacles for lesbians and gays seeking appropriate health care (Cases 8, 12). Screening for interpartner violence with gay and lesbian patients is often overlooked and unattended. Establishing comfort and trust between the patient and the physician (i.e., the physician conveys and the patient feels that it is safe to disclose sexual orientation and sexual practices) is key to good doctor–patient communication.

Individual worldviews and belief systems (i.e., the meaning and significance of illness) of patients and physicians are shaped by the cultures in which they were raised and currently reside (Cases 3, 5,7,13,15,20,22). Issues of trust/distrust due to historic racism (e.g., Tuskegee Study) and intergroup conflicts can negatively affect the doctor-patient relationship (Cases 1, 16). Racism on the part of the patient or physician may diminish the physician’s ability to gather and/or interpret information about the patient and assure effective treatment and management (Cases1,19). For example, a young black man or woman presenting to the emergency department with pain while in a sickle cell crisis may be presumed to be a drug seeker (Case22). Communication and interpersonal styles of communication that differ by culture may contribute to misunderstanding, misdiagnosis, or failure to develop rapport (Cases 7, 23). Values and traditions that conflict with mainstream “American” practices (e.g., female genital mutilation, objecting to an evaluation by provider of the opposite gender due to social norms, providing proof of virginity, seeking alternative therapies, and using euphemism to describe a terminal diagnosis) may affect the doctor–patient relationship.

Some of the meaning and significance of illness is shaped by the religious or spiritual traditions in which patients or their physicians are raised and/or currently practice (e.g., how a patient and family respond to death and dying) (Cases 10, 14, 17). Patient values and traditions stemming from religious/spiritual beliefs may conflict with those of their physician or health care system (e.g., end-of life decisions, abortion, organ donation, and therapeutic practices such as use of blood products). Physician comfort and willingness to cooperate with certain patient practices can enhance the ability of the physician to establish rapport and build trust with the patient (e.g., patient’s unwillingness to disrobe for physical examination, or patient’s request to participate in or condone religious/spiritual practices such as asking the physician to pray with them) (Case 25). Some beliefs or practices may require or prohibit certain behaviors that can affect the patient’s health or treatment (e.g., the challenge for diabetics of fasting during the Muslim holiday of Ramadan) (Case 4).

Verbal and nonverbal language differences between patients (and their families) and caregivers can diminish their ability to acquire accurate and timely information and provide care. Professional medical interpretation is needed in all places of care delivery since patients who speak English as a second language may not fully comprehend interviews or instructions in English (Cases 6, 10, 11, 23). Nonverbal language is also culturally based communication: assumptions cannot be made regarding the meanings attached to familiar actions (e.g., proximity, body language, gestures, and eye contact) (Case 22).

Patients may question the competence of foreign-born (immigrant) physicians or other health care providers due to pronounced accents, differences in cultures, and educational systems perceived as inferior (Case 19). The doctor–patient relationship may also be challenged by the expectations and experiences an immigrant patient brings to the encounter, and by the level of understanding and comfort the immigrant has of American culture (e.g., patients ’lack of empowerment in the country of origin and concerns for safety especially with health care providers) (Cases 6, 22). The reason for immigration (e.g., economic opportunity or refugee status) and immigrant status may play important roles in the ability to access needed services. Immigrants who are living with undocumented family members, or who are undocumented themselves, delay presentation of symptoms and use fewer medical services (Case 23). Many immigrants work for smaller employers who do not provide paid leaves to attend medical appointments. Employment as seasonal workers can also prevent continuity of care and/or compliance with treatment. Given these issues, it is not surprising that the average lifespan of a male immigrant agricultural worker is 47 years as compared to a comparable white male.

Conclusion

In summary, health professionals in training and practice have been and will continue to be challenged to take care of patients and their families from many different ethnic and cultural groups who may live in the U.S. on a full- or part-time basis. Developing skills in cultural competency is an evolving process and it takes time, experience, and a commitment to listening and respecting patients and, above all, appreciating their perspective. It is our hope that Achieving Cultural Competency: A Case-Based Approach to Training HealthProfessionals will help with this process. Developed by a multidisciplinary team of medical educators experienced in cultural competency and health disparities education of medical students, physicians, and other health care professionals, this book of cases is the first of its kind.

Olivia Carter-Pokras, PhD

University of Maryland School of Public Health

College Park, MD, USA

Horace DeLisser, MD

University of Pennsylvania School of Medicine

Philadelphia, PA, USA

References

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Tools to Assess Cultural Competency Training (TACCT)

CASE 1

Ruth Franklin

A 40-year-old African American woman with heart failure

Susan E. Wiegers, MD and Horace DeLisser, MD

University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Educational Objectives

Explain how perceived racial differences and stereotyping by physicians may impact the patient–physician relationship.Review the health-related issues such as obesity that may be viewed differently by various racial and ethnic groups.Identify several factors that may lead to poor adherence to prescribed medications.Describe an approach for engaging a colleague whose behavior demonstrates cultural insensitivity.

TACCT Domains: 1, 3, 6

Case Summary, Questions and Answers

Mrs. Franklin is a 40-year-old African American woman who came to see Dr. Cox, a cardiologist, for management of congestive heart failure. She had seen another cardiologist in the group (Dr. Moore) 3 months earlier who had told her, “There is nothing wrong with you that losing 50 pounds won’t cure.” [She is 5’4” and weighs 235 lbs (BMIhas been overweight for all of her life.] This comment greatly angeredMrs. Franklin and so she did not follow-up with Dr. Moore.

1 What factors may have contributed to Mrs. Franklin’s anger?

The insensitivity of Dr. Moore would certainly have provided sufficient reason for Mrs. Franklin to be angry. Clearly, it would have been better if Dr. Moore had addressed her need for weight loss in a more tactful and thoughtful way. However, it is important to recognize that Mrs. Franklin’s past experiences with the health care system as an African American may shape the significance she might ascribe to Dr. Moore’s comments and the intensity of her reaction. That is, Dr. Moore’s comments are seen not as the mere words of a tactless individual, but are taken as another clear expression of a system that is hostile to African Americans. For Mrs. Franklin, the physician’s behavior becomes part of a list of racially motivated mistreatments (real or perceived) she has experienced that are carried forward into her relationships with other physicians.