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Published 9/1/2014
Ramon L. Jimenez, MD

Cultural Competence and Communication

Cultural Competent Care (CCC) is the ability to relate to or to care in a competent manner for someone who is different from you in race, ethnicity, socioeconomic status, religion, or political beliefs.

As part of the AAOS Communications Skills Mentoring Program, we use case scenarios to teach CCC. We give the caregiver typical identifying traits of certain races or ethnicities so that the caregiver can relate better to patients of those races or ethnicities and therefore care for them in a more culturally specific manner.

But when you stop and really think about it, this approach was somewhat naïve. For example, an “Asian” person may be from one of 52 different countries/cultures/ethnicities, each of which may have different languages and dialects as well as different customs and traits.

Instead of trying to pigeonhole patients into categories so that caregivers can treat them more competently, maybe it is better to treat all patients in a more general, equal way.

Perhaps a better approach would be to “humanize” the patient. To treat the patient with compassion and care. To treat the patient in the way the caregiver would want to be treated if he or she (or a family member) were wearing the patient’s shoes, moccasins, sandals, or huaraches. Caregivers who have been patients themselves—especially those who have been patients in a foreign country—understand this best.

Frankly, I make an effort to befriend every patient I encounter. I have relied on the artful use of self-deprecating humor to cross language barriers. Compassion does not mean a loss of professionalism. It may mean a couple of extra minutes, but it will pay off in the long run. Patients will realize that you made that extra effort initially; they will be careful not to monopolize your valuable time with mundane questions and they will gladly allow allied health professionals to take over.

Augustus A. White III, MD, PhD, the Ellen and Melvin Gordon Distinguished Professor of Orthopaedic Surgery and professor of medical education at Harvard Medical School, has recently published a wonderful and insightful book, Seeing Patients, which I highly recommend to everyone who cares for patients. Dr. White emphasizes the theme of unconscious bias. For example, we may believe that we are not biased against people who are obese, but in fact we may truly have such a bias.

Unconscious bias can quickly and easily be revealed through the implicit association test devised by Mahzarin R. Banaji, PhD, and popularized by Alexander R. Green, MD, MPH. The test is available on the web and only takes about 10 minutes to complete. The results may surprise you. It is important to be aware of your biases and to work around them. This can only help us to be better surgeons and to provide more competent care for patients.

Caregivers should adhere to two general principles when treating individuals from different cultures: respect the patient and listen to him or her. Most patients come from cultures that revere physicians as “men of knowledge and science” and are therefore very respectful. Many of these cultures, like the Hispanic/Latino, are patriarchal, so that what the doctor says, “Goes!”

As physicians, we must be sensitive to this and not fall into that trap. We must educate these patients about the necessity for them as patients to participate in shared decision making.

Listening is a very important component of effective communication and culturally competent care. That is the reason behind the relevance of “open-ended” questions. Listening shows respect.

Allow me to digress, because all too often people associate ethnicity with poverty. A common myth that circulates in the hospital hallways and doctors’ lounges is that poor patients present greater liability risks to physicians. A recently published article showed that poor patients in fact do not sue their doctors with greater frequency. In California, where I practice, Medicaid and Medi-Cal patients also have lower malpractice claims rates.

Poor patients do not have good access to the legal system and lawyers are not eager to take their cases (especially on contingency due to the lower economic return). So physicians should not be afraid to treat these patients or let ill-founded myths keep them from treating the poor.

I consider it an honor and privilege to be an orthopaedic surgeon. I have performed hundreds of total joint arthroplasties and surgical arthroscopies on grateful patients. However, the thrill of all those surgeries is matched by the satisfaction I receive from an effective good communication encounter with a patient. It is surpassed when that patient is from a different culture than I am. Then I know that I have used “new eyes,” unbiased eyes, to truly see him or her.

Ramon L. Jimenez, MD, is in private practice in Monterey, Calif., a past chair of the AAOS Diversity Advisory Board, and a mentor in the AAOS Communications Skills Mentoring Program.

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