Many of the nation's newest doctors don't feel prepared to deal with the increasing cultural diversity of their patients, according to two Commonwealth Fund-sponsored reports appearing in recent issues of the Journal of the American Medicine Association and Academic Medicine.
Residents also receive mixed messages about the importance of cultural sensitivity in communicating with patients, according to two of the report's authors, Joseph Betancourt, M.D., and Joel Weissman, both of Harvard Medical School.
On one hand, residents are told it's important to develop cross-cultural communication skills, but on the other hand, they receive little training, mentoring or evaluation regarding such skills, Betancourt and Weissman said.
"It's not about learning as much as you can about a specific culture, it's about learning universal approaches that you can use whether you're a white Anglo Saxon Protestant physician treating a Haitian American or a Haitian American physician treating a white Anglo Saxon Protestant," said Weissman, lead author of the JAMA report.
According to the JAMA report, 25% of 2,047 residents surveyed in 2003 said they were not prepared to provide care to new immigrants or to patients whose health beliefs were at odds with Western medicine. Some 24% said they lacked the skills to identify relevant cultural customs that impact treatment, and 20% said they weren't prepared to treat patients whose religious beliefs affect care.
Perhaps most telling, about 66% of residents said they received little or no evaluation on cross-cultural aspects of physician-patient communication. By specialization, the percent who complained about inadequate evaluation ranged from about 40% for family medicine and psychiatry to about 80% for surgery, obstetrics and gynecology, and emergency medicine.
"Evaluation sends a message that these concepts and approaches are to be taken seriously," Weissman said, although he added, "We're not saying graduate medical education is going into the trash heap, we're saying there's room for improvement."
Read the JAMA abstract.
In the Academic Medicine study, focus groups and interviews with 68 residents found that in the absence of formal instruction on evidence-based best practices, residents developed on-the-job "coping skills," such as use of visual cues to overcome language barriers and use of eye contact to show empathy or build trust.
Some coping skills were inappropriate, the authors said -- for example, using any hospital staff member who could be grabbed in the hallway to help with translation, or delaying procedures until someone could be found to better explain treatment options in order to obtain informed consent.
"They got the job done, but not in an optimal way," Betancourt said.
Read the Academic Medicine abstract.
Cultural variations in communication include use of first or last names, eye contact and touch, and residents need to learn how to identify each patient's comfort level, he said.
Two Institute of Medicine reports, Crossing the Quality Chasm and Unequal Treatment, point out that improving cross-cultural communication could be used to reduce persistent healthcare disparities associated with race, ethnicity and culture, the authors noted.
The need for cross-cultural communication skills is growing, Betancourt and Weissman said. For example, rural areas in Alabama, Arkansas and Northern California are seeing large increases in their Latino populations. Urban areas also are becoming increasingly diverse. Detroit, for example, has a growing Muslim community and Massachusetts now has a large Cambodian population, the authors said.
The researchers findings, the JAMA report concluded, "highlight a potential overemphasis on technical competence relative to interpersonal skills."