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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
Kundhal KK, Kundhal PS. Cultural Diversity: An Evolving Challenge to Physician-Patient Communication. JAMA. 2003;289(1):94. doi:10.1001/jama.289.1.94