By increasing their cultural competence, orthopaedists can improve their ability to communicate effectively with patients from backgrounds other than their own.


Published 5/1/2009
Jennie McKee

5 tips for boosting your cultural competence

Experts offer advice for better communication with your patients

According to Valerae O. Lewis, MD, many physicians take their communication skills for granted—but shouldn’t.

“Conscious awareness of one’s communication habits requires considerable work and energy,” said Dr. Lewis. “And yet, it can make such a difference.”

Dr. Lewis noted that cultivating cultural competence—awareness of and sensitivity to patients’ cultures, ethnic backgrounds, genders, and beliefs—is essential to good communication.

“Providing culturally competent care can have a favorable impact on patient behavior, outcomes, and satisfaction,” said Dr. Lewis, “and can therefore also reduce the incidence of malpractice lawsuits.”

Dr. Lewis and other faculty members of an instructional course lecture held at the 2009 AAOS Annual Meeting—Daryll C. Dykes, MD, PhD; Norman Y. Otsuka, MD; and Ramon L. Jimenez, MD—explored ways that orthopaedists can enhance their cultural competence. The following five tips can help improve your interactions with African-American, Hispanic/Latino, and Asian-American patients, as well as with patients from other backgrounds.

Tip 1: Follow the “Golden Rule,” when appropriate.
It isn’t always appropriate to treat patients how you would want to be treated, as advised by the “Golden Rule.”

“It’s important to acknowledge differences,” said Dr. Lewis. “We sometimes need to treat people differently to treat them equally.”

For example, said Dr. Otsuka, people in many Asian cultures are reserved, ask few questions, and respect authority figures. He recommends using open-ended statements such as, ‘Please tell me about your problem in your own words.’

It’s also important to remember that some patients, such as Asian-Americans born outside the United States, may be more comfortable with formal communication.

“Greet elders first, and address everyone by using their title and last name,” said Dr. Otsuka. “Watch out for inadvertent ‘signs of contempt,’ which include crossing your legs, leaning on a table or desk, or pointing your foot.”

Dr. Dykes said that African-American patients should also be addressed with formal titles. He also cautioned against using the terms ‘you,’ and ‘you people.’

“Be friendly, but not overly familiar with Hispanic/Latino patients,” advised Dr. Jimenez.

“Asking about their country of origin is a good icebreaker.”

Tip 2: Understand community demographics.
Simply because a patient checks “African-American,” “Asian,” or “Hispanic/Latino” on an intake form doesn’t mean that he or she shares cultural, social, religious, linguistic, socioeconomic, and physical characteristics with others who check the same box.

African-Americans born in the United States, for example, may have very different attitudes and expectations than more recent immigrants.

“Historically, African-Americans came to the United States from the west coast of Africa as part of the slave trade,” explained Dr. Dykes. “Since 1860, growth in the U.S. population of people of African descent has come about primarily through birth. Recent immigrants have come from countries such as Egypt, Ethiopia, and Ghana.”

The Hispanic/Latino population is exploding and expected to make up 25 percent of the U.S. population by 2040, said Dr. Jimenez. The terms “Hispanic” and “Latino” are not synonymous, he explained.

“Hispanic” refers to the people and culture of Spain, although it has evolved to include the Spanish-speaking nations of the Americas. “Latino” usually refers to people from the countries of Latin America, including Mexico, Puerto Rico, the Dominican Republic, Cuba, and Central and South America.

According to Dr. Otsuka, Asian-Americans, who make up 5 per­cent of the U.S. population, are a diverse group of people from 50 different countries who speak 100 different languages/dialects. “Asian-Americans are as diverse as European-Americans,” he said.

Dr. Otsuka noted that although a significantly higher percentage of African-Americans and Hispanic/Latinos are uninsured compared to the general U.S. population, 82 percent of Asian-Americans have health insurance compared to 86 percent of the general population.

Tip 3: Watch for healthcare disparities and common conditions.
Studies have shown that healthcare disparities affect all minorities, said Dr. Jimenez.

“For example,” he said, “Hispanic/Latino patients do not receive total joint replacements at the same frequency as Caucasian patients. These disparities have been attributed to the lack of access to the healthcare system, lack of access to patient education, and not being offered the opportunity.

“Latino patients also have an increased prevalence of type 2 diabetes mellitus and its deleterious effects on the lower extremities” continued Dr. Jimenez. “So, foot and ankle surgeons should have a heightened awareness of this condition in both preoperative and postoperative phases of treatment.”

“Asian-Americans have an increased risk of osteoporosis because of diets low in calcium and a high rate of lactose intolerance,” said Dr. Otsuka “They also react differently to some medications. For example, diazepam has a high risk of toxicity in Asian-Americans, who metabolize the drug poorly. Orthopaedists should also be aware that between 30 per­cent and 60 percent of Asian-Americans use herbal medicine that can affect coagulation.”

Dr. Dykes noted that African-Americans are more susceptible to conditions such as hypertension and sickle cell anemia.

“If not addressed,” added Dr. Lewis, “these conditions can affect the outcome and postoperative course of the orthopaedic patient.”

Tip 4: Involve the family—or not.
Dr. Dykes noted that African-Americans may live together in family clusters, which provide important support and resources. Several generations may live under one roof. He recommends that orthopaedists ask African-American patients if they want family members to be involved in hearing medical information or assisting them in making medical decisions.

Dr. Jimenez said that Hispanic/Latino patients, particularly recent immigrants and first-generation individuals, are still influenced by the paternalistic medicine practiced in their native countries.

“You must be aware of the circumstances and attitudes about health care that these patients bring with them to your office,” he said.

Tip 5: Don’t discount spirituality.
When faced with an illness, said Dr. Dykes, many African-American patients turn to their families, neighbors, friends, and churches.

“Orthopaedists should inquire about religious beliefs,” he said. “Patients’ religious beliefs are tied to how they handle the diagnosis of a disease—especially cancer.

“African-American patients may be suspicious of your diagnosis, may seek another opinion, or may pray for healing and intervention from a higher power,” he continued.

Dr. Jimenez added that many Hispanic/Latino patients’ health beliefs are culturally determined rather than based on scientific facts.

“You must be sensitive to the differences and avoid stereotyping,” he said. “If you combine this with compassion as a physician and good communication skills, you will be very successful at delivering culturally competent care.”

Jennie McKee is a staff writer for AAOS Now. She can be reached at

For more information
To learn more tips for delivering culturally competent care, visit and order a free copy of the Culturally Competent Care Guidebook and CD-ROM edited by Drs. Lewis and Jimenez. Look for the guidebook and CD-ROM to become available for free online access later this year.

If you’d like the AAOS to hold an interactive “grand rounds” training seminar on culturally competent care at your residency program, please contact or Maureen Geoghegan, AAOS marketing manager, at (847) 384-4164.