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volume 75, no. 6 345

A Case for Diversity, Cultural Competency and Ending Disparities in the 21st-Century Medical Practice

Sonja Boone, mD

aS practicing physicians, we are constantly juggling complicated factors and asking ourselves difficult questions. What is the accepted gold standard of medicine for this patient? Will the patient participate in and adhere to the prescribed treatment regimen? What is achievable for this case? We want to provide the best possible health outcome for each patient. add in the current environment of uncertainty with regard to the affordable Care act (aCa) and the unstable health system in general, and the balancing act becomes even more tenuous.

let’s examine yet another aspect of practice that we must reconcile daily—patient diversity and cultural competency. The 2010 u.S. Census Bureau population statistics predict that by 2050, the current percent of Caucasians will decrease from 65% to 46%. Invariably, the term “minority” will no longer be applicable, and “majority” will have different connotations.1 addition- ally, there will be broader insurance coverage for ameri- cans through the aCa, and funding for Community Health Centers will increase by eleven billion dollars over five years (doubling funding over the past years), as the american population becomes more diverse.2

Throughout the medical literature, particularly within the past 10 years, the terminology used in many studies and subsequent journal articles may have caused confu- sion. There is increasing use of the terms: diversity, dis- parities, health literacy and cultural competency. These terms can have different meanings depending on the

author, publication and, of course, context. Sometimes the terms are used interchangeably, and they are often used in error. nevertheless, the terms diversity, dispari- ties, health literacy, cultural competency, and equity in health care in the context of health care and health-care delivery can be defined as follows:

• Diversity in health care usually refers to the pro- vider work force and how those providers reflect the diversity of patients served with regard to gender, racial, ethnic, cultural, sexual orientation, language, education, living with a disability, so- cioeconomic status, or veteran status and religious background.

• Disparities in health care describes the gap identi- fied in the health outcomes of minorities when compared with nonminorities; e.g., due to long- standing racial bias and unequal care, minori- ties experience poorer outcomes in every health category and often have less access to care.3

• Health literacy refers to patients’ ability to obtain, process and understand health information and services needed to safely care for themselves; e.g., low health literacy is associated with medical mis- understandings and errors, increased hospitaliza- tions and poorer health outcomes.

• Cultural competency in health care is delivering care in a manner that is respectful of and sensitive to the patient’s background and health beliefs.

• Equity in health care describes the ideal state we are striving for as systems and processes are redesigned and as providers are educated in cultural differ- ences and trained in linguistically competent care (culturally competent communication) in order to eliminate disparities in health care and provide quality care to all people.

Sonja Boone, mD, american medical association, Di- rector of Physician Health and Healthcare Disparities, Feinberg School of medicine at northwestern university, Department of medicine; Faculty (adjunct), Chicago, Il; office #: 312-464- 5530; Fax #: 312-464-4111; email: [email protected]

special section on health equity

ConneCtICut meDICIne, june/july 2011346

Based on a shared understanding of the aforemen- tioned terms, it would be beneficial to review the terms “race” and “ethnicity.”

Race can be defined as a continuously evolving social construct used to categorize individuals into groups that have typically been based on the physical characteristics (e.g., skin color, hair texture or other distinctive charac- teristics, etc.) of an individual or their ancestors.

ethnicity refers to cultural groups that have been typi- cally defined by a common language, religion, nationality or heritage.

Providers, patients, health systems and social deter- minants of health within community environments all contribute to disparities in health care. Barriers to culturally competent communication involve language, cultural idiosyncrasies, communication style, personal- ity and sometimes a lack of consideration for the pa- tient’s needs and preferences. even when all parties are native-born and speak english, there can be significant language barriers. The average american reads at an eighth-grade level; however, the reading level of printed and orally communicated health information is often at the 12th-grade and postcollege graduate level. Therefore, a holistic, patient-centered approach to communication is essential in practice and needs to be a cornerstone in the education of all clinicians as we strive to develop a more equitable health-care system. Putting the patients’ need to understand first and ensuring that they have the opportunity to recount in their own words what they have been told about their health-care issues and plans are essential first steps in eliminating disparities and improving quality of care.

The above approach leads to a very simple point—the 21st-century practice of medicine requires an awareness of diversity, enhanced communication through cultural competence, acknowledgement of health literacy chal- lenges for all patients and a daily commitment to elimi- nating disparities with every patient encounter.

There are many organizations working toward the elimination of disparities in the united States. one such organization is the Commission to end Health

Care Disparities (CeHCD), established in 2004 by the american medical association (ama), the national medical association (nma), and the national Hispanic medical association (nHma) in response to the Iom’s Unequal Treatment Report.3 The CeHCD has expanded as an organization of organizations representing physi- cians, nurses and allied health-care professionals who are dedicated to helping eliminate racial and ethnic disparities in health care by focusing on four major areas: 1) educating and training physicians, nurses and allied health-care professionals on disparities and cul- tural competency; 2) Increasing work-force diversity in medical and allied health-care professions; 3) advancing policy and advocacy initiatives that improve the quality of care provided to minority and multicultural populations and health outcomes; and, 4) Improving the collection of data and research in order to identify and eliminate health-care disparities. For more information, visit www. ama-assn.org/go/enddisparities.

The imperative to learn more and raise awareness about solutions that will end health-care disparities is a focus of many regulatory, pharmaceutical and nonprofit health- care organizations. now is the time for medical societies and associations to elevate this issue to the same level as quality and patient safety. In doing so, practicing physi- cians and physicians-in-training cultivate the perspective that each and every patient encounter can indeed change the system and be a powerful and sustainable force for achieving equity in health care.

REfEREnCEs 1. Kaiser Family Foundation: http://www.census.gov/popula-

tionprojections 2. andrulis DP, Siddiqui nj, Purtle jP, Duchon l:Patient Protec-

tion and Affordable Care Act of 2010: Advancing Health Equity for Racially and Ethnically Diverse Population. available from http://www.jointcenter.org/publications_recent_publica- tions/health/patient_protection_and_affordable_care_act_ of_2010_advancing_health_equity_for_racially_and_ethni- cally_diverse_populations.

3. Institute of medicine Report: unequal treatment: confront- ing racial and ethnic disparities in health care. Washington, DC. the national academies Press. 2002. www.iom.edu/ Reports/2002/unequal-treatment-Confronting-Racial-and- ethnic-Disparities-in-Health-Care.aspx.

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