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  • Practice Perfect

    Improve Cultural Competence in Your Practice

    By Laura B. Kaufman, Contributing Writer
    Interviewing Andrew G. Iwach, MD, Rohit Varma, MD, MPG, and Lynn H. Baskett, MBA

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    A serious eye condition has brought a new patient to your office. He comes from a culture more than half a world away, and though his beliefs, customs, and native language differ from yours, you must provide vital details to help him preserve his vision. How do you communicate this information as effectively as possible?

    There is a growing need for ophthalmologists and their staff to be attuned to the cultural perspective of the patient. “You may have all the skills in the world, but if you can’t communicate with the patient, it can be much more than a source of disappointment,” said Andrew G. Iwach, MD, executive director of the Glaucoma Center of San Francisco. “Patients may not understand outcomes. They may not comply with instructions.”

    And that can create long-term problems. “It’s part of our job to educate patients about what’s going on with them. Don’t shortchange them. It has a negative impact on how they accept our care and, ultimately, the outcome,” said Rohit Varma, MD, MPH, professor and chairman of ophthalmology and visual sciences and associate dean of strategic planning at the University of Illinois College of Medicine. 

    Why Cultural Sensitivity Matters

    It improves outcomes. As the U.S. population becomes increasingly diverse, the importance of developing cultural competency skills continues to rise. “Because vision loss can often be reduced with regular comprehensive eye exams and timely treatment, there is an increasing need to implement culturally appropriate programs to detect and manage eye diseases,” Dr. Varma said.

    The CDC Office of Minority Health & Health Disparities has documented a sustained correlation between race and ethnicity and health disparities among U.S. populations. Cultural competency is a key element in closing that gap in health care, according to the U.S. Department of Health and Human Services Office of Minority Health (http://minority The bottom line: Health care that is respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients can improve health outcomes.

    It’s the law. Title VI, part of the landmark Civil Rights Act of 1964, which prevents discrimination, requires physicians to make their best attempt at communicating with patients who speak a language other than English, Dr. Iwach said. The government obliges any health care provider who receives federal funding to communicate effectively with all patients—or risk losing that funding. There could be other legal consequences if a patient does not fully understand your explanations and directions, he said. “For instance, informed consent is a very commonly challenged item.” 

    How to Build Sensitivity

    Raise general awareness. Dr. Iwach chaired a “Beyond Language Differences” seminar at the 2007 Annual Meeting, with a panel of physicians of different ethnic backgrounds. “Cultural competency is not meant to represent a complete understanding of each culture. Rather, the goal is to be aware and to appreciate and accept differences,” he said. “It is understanding that patients of diverse cultures and belief systems may perceive health and illness differently and, thus, respond differently to symptoms, diseases, and treatments.”

    For instance, several studies have evaluated whether Muslim glaucoma patients are willing to use their drops during the month of Ramadan. In one study of 190 patients, only 34.2 percent indicated that they would be willing to use their drops during the fasting hours; the remainder believed that using their drops would constitute breaking the fast.1

    Find training. One way to raise awareness is individual training. Dr. Varma suggested starting with ( This online resource was designed specifically for MDs, physician assistants, nurses, and other providers. It provides vignettes and demonstrations of how to change behavior, and it offers CE/CME credits. Each practice member can assess his or her own cultural competency and start to build and improve, Dr. Varma said.

    Alternatively, if you practice under the umbrella of a larger institution, see if it offers any training in cultural competency. Lynn H. Baskett, MBA, vice president and executive director of the Community Health Alliance at John Muir Health, a not-for-profit integrated health system in Concord, Calif., led her organization to enhance cultural competency with a strategic plan on an institutional level.

    Take personal responsibility. Ms. Baskett added that individuals can take steps to increase their personal knowledge of, awareness of, and sensitivity to the cultural complexity of interactions. For instance, she said, it’s important to avoid generalizations and stereotypes, to value the cultural preferences and practices of others, and to remember that there is more than one right way to accomplish something.

    “It’s as though our DNA is our hardware, and culture is our operating software. Everyone really is different,” she said. “When we don’t demonstrate cultural understanding, our unconscious biases, assumptions, and expectations can have an impact on all of our interactions.”

    How to Avoid Common Mistakes

    In treating patients from minority groups, MDs and staff often make several common mistakes.

    Mind the language barrier. “In the next couple of decades, non-Hispanic whites will be the minority in many of the largest states,” said Dr. Varma, who directed the Los Angeles Latino Eye Study (LALES), the most comprehensive epidemiologic analysis of visual impairment in Latinos conducted in the United States. For instance, U.S. Census figures show that 43 percent of Californians speak a language other than English at home. The largest populations of non-English speakers are in California, Florida, New York, and Texas.

    When patients who do not speak English seek care, health care providers may view them as being less educated than English-speaking patients and, thus, unable to navigate the health care system, Dr. Varma said. “There can be a sense of making decisions for the patient, which is a paternalistic view. In the vast majority of medical care, there are always options and alternatives.”

    Dr. Varma added, “When patients are not English speaking, there may be a sense from practitioners of, ‘I’ll just decide what we should do.’ That is a cop-out. We are all pressed for time, but it is important to take that time.”

    Avoid making assumptions. It is human nature to assume that people from the same culture are all the same and that differences between cultures are superficial, Ms. Baskett said. When you see patients, beware of your assumptions, she said, and remember that your experience is not the same as theirs.

    Ask questions. People have their own view of what disease is and what to do about it, Ms. Baskett said. “You can ask, ‘What do you feel is going on, what do you think we should do?’”

    Validate the patient’s perspective. Instead of correcting a patient, it’s more productive to reinforce and validate his or her perspective, Ms. Baskett said. “You can say, ‘I understand your concern about your health. I really want to work with you so that we can make this the least-uncomfortable cure [for you and cause as little inconvenience to your family] as possible. I would appreciate it if you’d be open to some new things; here is why I think you should try them.’”

    Ten Tips for Better Cultural Relations

    Did you know that in some ethnic groups, the oldest son may play the key role in making decisions about an older person’s care? Are you aware that in certain cultures, asking direct questions is perceived as disrespectful—or that patients from some groups may not be comfortable offering up personal information during an office visit? These and other cultural differences may derail your best efforts to provide high-quality care.

    To avoid these pitfalls, Drs. Iwach and Varma provided the following suggestions:

    1. Begin by being more formal. It is best to use the patient’s last name.

    2. Do not feel insulted if a patient fails to look you in the eye.

    3. Do not feel insulted if a patient asks questions about treatment. Conversely, be aware that a patient’s failure to ask questions may be a sign of respect for you and that it may have no bearing on whether the patient has—or hasn’t—understood your explanations and directions.

    4. Ask questions to ascertain the patient’s beliefs about health or illness prevention.

    5. Ascertain the value of involving the family.

    6. Be aware that patients may see you while also seeking treatment from a traditional healer. Do not try to change a patient’s benign beliefs. Most folk medical practices are not harmful and do not interfere with biomedical therapy. Moreover, pursuing two forms of therapy actually may increase patient compliance.

    7. Inquire indirectly about the patient’s beliefs, for example, “Many of my patients from your region believe xx. Do you?”

    8. Be aware of what happens when people from different cultures interact. It can push both parties out of their comfort zones and cause tension. You need to make the extra effort at communicating.

    9. Avoid sounding confrontational when you talk about compliance. For instance, Dr. Varma said, “You can say, ‘Oh, you didn’t take your eye drops,’ and then follow up by reiterating, in a respectful way, ‘It is very important; please use these drops.’”

    10. As with other patients, be open and able to bond.

    A New Era

    There’s no question that cultural competency is on the rise. “We are at a much better place than two decades ago,” Dr. Varma said. “When we bring in our new medical residents, they have to go to Los Angeles County Hospital, where the vast majority of patients are Hispanic. Everybody has to learn Spanish. New physicians have already been exposed to cultural competency in school. Younger physicians are much more culturally aware and competent, and they are more aware of their own attitudes.” 

    Moreover, graduating physicians themselves are a more diverse group. “Overall, we as a nation are becoming much more culturally competent, and we are becoming a bigger melting pot. We have to learn how to navigate. That’s a good thing, a healthy thing,” he added.

    And the increasing diversity of the U.S. population will necessarily have an impact on medical research and treatment, Dr. Varma pointed out. “As we go into the next decade, we will see unique eye diseases from various racial and ethnic groups. We need to begin from research and science and have a good handle on those diseases and treatment. For many years, much research has been based on non-Hispanic whites … and responses and courses of disease may differ among groups. It’s going to be increasingly important.”


    Ms. Baskett and Dr. Iwach report no related financial interests. Dr. Varma has received NIH funding to study Latino and Chinese populations as well as children of non-Hispanic white cultures.


    1 Kumar N, Jivan S. Ophthalmology. 2007;114(12):2356-2360.