Published 5/1/2007
Elaine Fiedler

Increasing diversity sparks demand for cultural competency

Have you taken a good look at your patient population recently? If so, you’ve probably noticed that it’s a lot more diverse now than it was 10 or 15 years ago.

In part, the change is due to the nation’s shifting demographics. Currently, minorities make up about 32 percent of the U.S. population—up from 25 percent in 1990—and their numbers are continuing to increase. According to Census Bureau projections, minorities will comprise almost 35 percent of the U.S. population by 2010, 40 percent by 2025 and 50 percent by 2050.1 At least 10 million Americans speak little or no English, a number that experts believe is underreported.2

The increase in the number of African American, Hispanic/Latino, Asian/Pacific Islander, Native American, and immigrant patients reinforces the importance of improving your cultural competency. If you’re not already taking steps to address the differing backgrounds, beliefs, and healthcare practices of these patients, legislation may soon require you to do so.

Not a new idea
Although the concept of cultural competency is not new, each year brings additional—and more urgent—pressures to implement its practice. Learning cultural competency is becoming increasingly important for several reasons.

For example, reports of healthcare disparities between racial and ethnic groups continue and remain an issue of concern, as evidenced by the Institute of Medicine’s landmark study Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The study recommends learning how to care for minority patients as a way to reduce health disparities.

In addition, delivering culturally competent care helps reduce liability claims and patient dissatisfaction. “Communication competency is a patient care issue because doctors who successfully communicate with their patients experience better patient outcomes,” says Valerae O. Lewis, MD, a member of the Diversity Advisory Board.

“Communication also has a direct correlation with medical liability,” she says. “Doctors who get sued tend to be those who don’t communicate well with their patients.” By targeting linguistic challenges and trust issues, cultural competency helps to improve understanding between doctors and patients.

Increasingly, cultural competency is good for the bottom line. Physicians will need to welcome more minority patients to maintain or expand their practice, and minorities will favor doctors who recognize and respond to their needs.

New fronts for change
Pressure to practice culturally competent care is also coming from several directions. A recent report from the Joint Commission (previously the Joint Commission on Accreditation of Healthcare Organizations), based on a study of 60 hospitals, calls for national strategies to better serve diverse patients in American hospitals. The study shows inconsistent practices, with some hospitals having no resources or processes to meet linguistic or cultural challenges and others not using the resources they have.3

Medical residents are also expressing a need for cultural competency training. In one report, 96 percent of residents felt that cultural competency training was important, but one third to one half got little or no instruction.4

Increasing diversity is sparking public demand for quality health care for all segments of the population. National groups such as the Pew Health Commission, the Citizen Advocacy Center, the National Committee on Quality Assurance, and others are advocating cultural competency training.

In response, several proposals to mandate cultural competence training in medical education have been developed—and have passed in several sates. Under Senate Bill 144, doctors in New Jersey would be required to receive cultural competence training before they can obtain or renew a state medical license. In California, Assembly Bill 1195 mandates inclusion of cultural competency principles in continuing medical education courses. Washington State’s Senate Bill 6194 requires a course in multicultural health as part of basic education curriculum to train healthcare professionals. It also requires CME in multicultural health care.

More states will surely follow these trends and consider

mandating multicultural training in medical education. Some of the subjects covered in cross-cultural competency curricula include the following:

  • an overview of health disparities and their causes
  • linguistic and literacy issues
  • working with interpreters
  • obtaining informed consent
  • promoting communication and trust in the medical encounter
  • recognizing one’s own bias and stereotyping

The impact for orthopaedics
Racial and ethnic disparities in orthopaedic care are a continuing cause for concern. One study found that African Americans with long bone fractures were less likely to receive analgesics than Caucasians. Another study showed similar findings for Hispanic patients. Recent studies have also found that rates of total knee replacement vary, although osteoarthritis occurs in similar patterns across ethnicities. Racial disparities in total hip arthroplasty also appear to exist.

If minority patients are less likely to know someone who has had knee or hip replacements, they may have a greater distrust of the procedure. With cultural competency, orthopaedists could learn how to build trust and to reach out to patients with more information about orthopaedic procedures.5

AAOS resources
To help physicians and others learn how to cope with the changing patient population, the AAOS Diversity Advisory Board recently published its Culturally Competent Care Guidebook as a companion to the Cultural Competency Challenge CD-ROM.

The guidebook presents information on ethnic/cultural, gender-related, and faith-related topics, discusses trust issues, communication in patient encounters, family issues, physical examinations, religion, alternative medicine, and more, and includes tip sheets for the clinical setting. Participants can earn up to 6 AMA PRA Category 1 CME credits for both programs. Both the guidebook and the CD are available at no cost to AAOS members; place your order at www.aaos.org/diversity.

Harvard Medical School’s Culturally Competent Care Education Committee (CCCEC) has established an online resource center at www.hms.harvard.edu/cccec. The CCCEC was established and chaired (through June 2006) by Augustus A. White III, MD, an AAOS fellow and winner of the 2006 Diversity Award. The site is available to healthcare providers, educators, students, and others interested in cross-cultural care.

Elaine Fiedler is a healthcare writer who frequently focuses on diversity issues.


  1. US Census Bureau: http://www.census.gov/population/www/pop-profile/natproj.html
  2. Modern Language Association: http://www.mla.org/map_about#02
  3. Joint Commission Report: Hospitals, Language, and Culture: A Snapshot of the Nation.
  4. http://www.jointcommission.org/PatientSafety/HLC/
  5. Weissman JS, Betancourt J, Campbell EG, Park ER, et al: Resident Physicians’ Preparedness to Provide Cross-Cultural Care. JAMA, 294:1058-1067, 2005.
  6. Jimenez, RL and Lewis, VO, eds. AAOS Culturally Competent Care Guidebook, 2007.