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msJAMA
January 1, 2003

Cultural Diversity: An Evolving Challenge to Physician-Patient Communication

JAMA. 2003;289(1):94. doi:10.1001/jama.289.1.94

North America's demographic profile has undergone significant changes in the last 30 years. In the United States, the number of immigrants has nearly tripled since 1970, increasing from 9.6 million to 26 million.1 The proportion of blacks in the US is projected to increase from 12.8% in 2000 to 14.7% in 2050. Other ethnic groups are expected to have similar increases in the US population by then.2 Widespread immigration has increased population diversity in many communities. As a result, physicians can expect to care for patients from varied ethnic backgrounds during the course of their careers.

The cultural and ethnic backgrounds of patients can shape their views of illness and well-being in both the physical and spiritual realm and affect their perceptions of health care as well as the outcome of their treatment.3 Consequently, clinicians should be skilled at eliciting and understanding the cultural values of their patients. Clinicians should also be able to work with patients' cultural values in the context of conventional medical practices and the physician's own beliefs. Cultural competence extends beyond cultural awareness or sensitivity and may be defined as the ability to use cultural knowledge effectively in cross-cultural situations.4,5

Among the challenges presented by caring for culturally diverse patients is diversity in symptom presentation, reflecting culturally mediated understandings of illness and therapy. Certain illnesses are stigmatized in different cultures. Consequently, patients may present symptoms that are acceptable within their own cultures. For example, the diagnosis of clinical depression is stigmatized in many Asian cultures, and patients with depressive illness may report only physical symptoms such as fatigue and weight loss.6

Culture can also mediate patients' perceptions of illness causation and treatment. A study of Latinas and Anglo-American women in southern California found that Latinas were more likely to attribute breast cancer to "sinful" behaviors (eg, alcohol and drug use) than were the other groups.7 Similarly, a study of Hispanic home health attendants in the Bronx, NY, found that 58% believed that surgical treatment of breast cancer would cause it to metastasize. Such beliefs may prevent women with breast cancer from undergoing early curative procedures, such as a local lumpectomy.8 These examples highlight the importance of the cultural context in which patients interpret health and illness.

Formal cultural training has been found to improve the cultural competence of health care practitioners.9,10 However, Flores et al recently found that only 8% of US schools and no Canadian schools had formal courses on cultural issues.11 They also found that only 35% of US medical schools addressed the cultural issues of the largest minority groups in their respective states.

Dogra et al evaluated the implementation of a cultural diversity program in their undergraduate medical curriculum using a questionnaire before and after the program.9 After this intervention, the investigators found a significant increase in positive attitudes toward, and knowledge about, different cultures.9 However, little research exists to show whether improvements in attitudes and knowledge about other cultures translates into clinical skills or better outcomes.

Educational interventions can help physicians in training to develop specific cultural competency skills.3 These skills include use of interpreter services and community health workers, and the inclusion of family and community members in discussions to fully understand the dynamics of a patient's symptoms. Other approaches that may help clinicians include learning about cultures common to their region through immersion rather than study, coordinating care with traditional healers, and using culturally appropriate health promotion techniques.3

References
1.
US Centre for Immigration Studies.  Census Bureau Population Survey for March 1998. Los Angeles, Calif.
2.
Day JC. Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050US Bureau of the Census Current Population Reports, publ. no. P25-1130. Washington, DC: US Government Printing Office; 1996.
3.
Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? a review and conceptual model.  Med Care Res Rev.2000;(57 suppl):181-217.
4.
Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally DisturbedWashington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center; 1989.
5.
Tirado MD. Tools for Monitoring Cultural Competence in Health CareSan Francisco, Calif: Latino Coalition for a Healthy California; 1996.
6.
Dein S. ABCs of mental health: mental health in a multiethnic society.  BMJ.1997;315:473-476.
7.
Chavez LR, Hubbell FA, McMullin JM, Martinez RG, Mishra SI. Understanding knowledge and attitudes about breast cancer: a cultural analysis.  Arch Fam Med.1995;4:145-152.
8.
Morgan C, Park E, Cortes DE. Beliefs, knowledge, and behavior about cancer among urban Hispanic women.  J Natl Cancer Inst Monogr.1995;18:57-63.
9.
Dogra N. The development and evaluation of a programme to teach cultural diversity to medical undergraduate students.  Med Educ.2001;35:232-241.
10.
Culhane-Pera KA, Reif C, Egli E, Baker NJ, Kassekert R. A curriculum for multicultural education in family medicine.  Fam Med.1997;29:719-723.
11.
Flores G, Gee D, Kastner B. The teaching of cultural issues in US and Canadian medical schools.  Acad Med.2000;75:451-455.
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