Cultural Competence

Viewpoint: Cultural Competence and theAfrican American Experience with HealthCare: The Case for Specific Content in Cross-Cultural EducationArnold R. Eiser, MD, FACP, and Glenn Ellis

Abstract

Achieving cultural competence in thecare of a patient who is a member of anethnic or racial minority is a multifacetedproject involving specific culturalknowledge as well as more general skillsand attitude adjustments to advancecross-cultural communication in theclinical encounter. Using the importantexample of the African American patient,the authors examine relevant historicaland cultural information as it relates toproviding culturally competent healthcare. The authors identify key influences,including the legacy of slavery, Jim Crowdiscrimination, the Tuskegee syphilis

study, religion’s interaction with healthcare, the use of home remedies, distrust,racial concordance and discordance, andhealth literacy. The authors propose thatthe awareness of specific informationpertaining to ethnicity and race enhancescross-cultural communication and waysto improve the cultural competenceof physicians and other health careproviders by providing a historical andsocial context for illness in anotherculture. Cultural education, modular innature, can be geared to the specificpopulations served by groups ofphysicians and provider organizations.

Educational methods should include bothinformation about relevant social grouphistory as well as some experientialcomponent to emotively communicateparticular cultural needs. The authorsdescribe particular techniques thathelp bridge the cross-cultural clinicalcommunication gaps that are createdby patients’ mistrust, lack of culturalunderstanding, differing paradigms forillness, and health illiteracy.

Acad Med. 2007; 82:176–183.

There has been much interest recentlyin preparing physicians to care forpatients from a variety of cultural andethnic backgrounds.1–3 Despite thisinterest, recent studies suggest that thisarea of medical education is the stillmost lacking.4,5 The population seekingprimary care consists of people fromvarying racial and ethnic backgrounds,with approximately 40% belonging toracial and ethnic minorities; by 2015, thisnumber will likely be over 50%.6 NewJersey is the first state to mandate culturalcompetence as a medical licensurerequirement, but others will soon followthis trend.7 The Institute of Medicinehas stated, on a national level, that cross-cultural training should have a significantrole in improving quality of care forminorities and eliminating racial andethnic disparities.8

One approach to improving the culturalcompetence of physicians focuses ongeneral attitudinal and organizationalshifts and the application of generalmethods for communicating acrossdifferent cultures.9,10 Kleinman et al9

pioneered this approach with the use ofopen-ended ethnographic-type questionsin cross-cultural physician–patientencounters. Others have advocated anapproach to cross-cultural educationbased on using specific backgroundinformation about patients.11

Although both of these approacheshave definite merit, we emphasize theimportance of the specific cultural andhistorical factors that influence the natureand outcomes of the clinical encounter.We also assert that specific knowledge ofthese factors is necessary for the optimalcross-cultural clinical encounter. In thisarticle we focus on the African Americanexperience as a paradigmatic example ofminority interaction with the Americanhealth care system. The fact thatphysicians themselves are increasinglycoming from varied ethnic backgroundsadds emphasis to the need for greatercultural education, as both patients andproviders are often ethnically distinct.Twenty-five percent of physicians

practicing in the United States areinternational medical graduates (IMGs),and many of them come from a variety ofcountries.12 In New York and New Jersey,IMGs comprise 40% of the physicianworkforce. Clinical communicationbetween patients and physiciansnecessarily crosses many differentcultural contexts, and effectivecommunication in a cross-culturalclinical encounter hinges on a physician’sability to bridge cultural divides. IMGswho were raised in other countries willnot generally be familiar with Americanhistory or cultural aspects, and thereforemay have some difficulty communicatingwith American patients. This, if anything,raises the need for cross-culturalcommunication education, even asAmerican medical graduates aresurely in need of it as well.

As just one example of health caredisparities between African Americansand Caucasians, recent studies indicatethat differences persist between thesetwo racial groups in terms of coronaryrefusion therapy and coronaryangiography.13,14 Caucasian patientswere more likely than African Americanpatients to undergo the potentiallylifesaving procedures such as coronary

Dr. Eiser is vice president, Department of MedicalEducation, Mercy Health System of SoutheasternPennsylvania, and professor of medicine andassociate dean, Drexel University College ofMedicine, Philadelphia, Pennsylvania.

Mr. Ellis is president, Strategies for Well-Being LLC,Yeadon, Pennsylvania.

Correspondence should be addressed to Dr. Eiser,1500 Lansdowne Ave., Darby, PA 19023; telephone:(610) 237-5620; fax: (610) 237-4762; e-mail:(aeiser@mercyhealth.org).

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revascularization or reperfusion. Severalfactors can influence such treatmentdifferences: physician bias, patientmistrust of physicians, reluctanceto undergo invasive procedures orpreventive testing, fundamentalistreligious beliefs, and insurance coverageand other economic influences.

The role of mistrust is one importantaspect in the African Americanexperience of medical care. AfricanAmerican history in the United Statesincludes a protracted period of slavery,post-Emancipation “Jim Crow”discrimination and persecution in theSouth, and an extended period ofsocioeconomic disadvantages duringghettoization in northern cities.15 Healthcare during these periods was oftenunavailable to African Americans, orthe quality and quantity of the care wasdeficient. Specific medically relateddiscrimination included hospital wardsegregation, which at one time wascommon,16 and the well-known U.S.Public Health Service–sponsoredTuskegee syphilis study in whichinformed consent was not used andindicated treatment was withheld withoutthe patients’ knowledge.17 This event wasrevealed through an investigative reportby the Atlanta Constitution Journaland was followed decades later with apresidential apology.18 Today, the study iswidely known in the African Americancommunity. The cumulative effect ofmany negative clinical and clinicalresearch experiences, of which Tuskegeeis only the best known, continues tofoster distrust of health care providersand the health care system within theAfrican American community.19,20 ManyAfrican Americans today, regardless ofsocioeconomic status, still carry lingeringmistrust as the result of this legacy ofmistreatment and lack of informedconsent.

The historical and cultural legacy ofdiscrimination against African Americansinfluences their socioeconomic status andaffects their health care interactions andclinical outcomes. African Americansreceive disparate care for a number ofconditions, including cardiac care,21,22

and most caregivers are oblivious to suchdisparate care differences.23 In additionto the discrimination that is prominent inAfrican American history, certain aspectsof the African American culturalhistorical experience are unique to this

particular group. Understanding thesecultural aspects is necessary in achievingthe optimal cross-cultural clinicalencounter between an African Americanpatient and a physician from a differentracial or ethnic background.

Religion and African Americans

Many African Americans have either areligious orientation or a viewpointgrounded in African American social andcultural history, which may emphasize aholistic approach to health and healthcare.24 Religion is a source of enormousemotional support for AfricanAmericans, and religious observance orreligiosity can, in many regards, correlatewith improved health outcomes.25

Religious and medical perspectives are,of course, different and could come intoconflict, though in general they need notbe contradictory. Furthermore, religiousbelief and practices may vary widelyamong individuals, even within thesame religion or specific denomination.Although most, if not all, religiousdenominations have memberships thatspan the racial spectrum, the AfricanAmerican religious experience brings aparticular intensity borne of the powerfulrole that Christian churches played in theAfrican American communities duringand after slavery, as well as in the civilrights movement.26 The church becamethe source of salvation for both body andsoul when often there was no otherinstitution available.27

Within the African Americancommunity, several distinctive groupsof churches can be identified,28,29

including mainstream Baptist orMethodist churches, messianic ornationalistic churches, conversionist (e.g.,Pentecostal) churches, and “spiritual”churches that emphasize magical contactwith the spirit world to improve physicalas well as spiritual states.29 As aprominent component of AfricanAmerican history and culture, religionhas a strong role in establishing AfricanAmericans’ health care attitudes andpractices. The spiritual churches alsorelate to African American faith healerswho provide consultations in individualas well as group settings as an alternativeto mainstream health care.30 Themainstream churches are less likely toencourage a fundamentalist religiousbelief. For African American women,

faith-based institutions provide a socialcontext whereby a new awareness ofhealth promotion can be possible.31,32

In addition to Christianity, Islam has hadan impact on African American historyand culture. It is estimated that 10% to20% of the slaves brought over fromAfrica were Muslims, and Islam hashad a growing presence in the AfricanAmerican community since the 1960s.33

Individuals who embrace the Islamicfaith are likely to define a good physicianas one who addresses issues of faith andspirituality as well as biological needs.It is reasonable to expect that AfricanAmerican Islamic patients expect someof these broader issues of faith andbelief—not merely biological issues—tobe addressed in the clinical encounter.34

If these issues are not addressed oracknowledged by the clinician, the resultcan be the patient’s mistrust of thephysician and noncompliance in themedical regimen. In our opinion, thisis likely to be true for patients of otherreligions as well.

A scientific medical approach does notpreclude a religious perspective, but itdoes qualify the domain of religion tosome extent with regard to some healthcare matters. Many health care providersas well as many hospitals have an overtlyreligious perspective or mission, yet theydeliver evidence-based medical care. Ingeneral, it should not be difficult forphysicians and other care providers toshow courtesy to patients’ religiousbeliefs without compromising evidence-based health care. In rare circumstancesof extreme belief, there may be directconflict between evidence-basedmedicine (EBM) and religious belief, andthis should be approached with tact aswell as community resources.

Many African Americans have adeep sense of spirituality, and thisspiritualism is intertwined withother aspects of their lives, includinghealth.29,30 Traditional AfricanAmerican folk beliefs concerning healthand illness focus on herbal remediesand magical aspects of illnesses thatinvoke spiritual components, includinghexes, roots, and divine displeasureof people or their offspring.35 Thehumoral theory of illness that datesback to antiquity and was codified byGalen found its way to the Americasand persists in Hispanic folk medicine

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culture.36 It also entered the AfricanAmerican health practices of theantebellum South.37 In this spiritual–magical schema, the allopathicphysician may have been viewed asinferior to an evangelist or spiritualist“gifted in the healing arts.”37,38 Thesebeliefs and practices were strongestin the South but made their wayto northern cities, includingPhiladelphia.39,40 This phenomenonis analogous with the burgeoningcomplementary medicine movementin the general population in recentdecades.41,42 The urge to have atheurgical or magicoreligious cure toillness perennially supersedes theemotionally colder approach thatscientific medical practice tends toentail.

However, a fundamentalist religiousbelief that God will cure illness withoutmedical treatment is associated with agreater than fourfold increased likelihoodof presentation with late stage of breastcancer among breast cancer patients.43,44

Similarly, the belief that “roots or spells”will cause or cure cancer has a fivefoldincrease in the likelihood of a patientpresenting with an advanced stage ofcancer.43 This study found that AfricanAmerican patients are more likely to havesuch a perspective. Another study showedthat African American women whobelieved in God as a controlling agentover health were less likely to obtainmammography and clinical breastexamination.44 These particular aspects ofreligiosity can complicate health care bydelaying appropriate interventions andmay contribute to presentation at a latestage of disease.

African American women were also morelikely than Caucasian women to considerbreast self-examination an effective formof early detection of breast cancer;however, self-examination is insufficientin this role because mammography andphysician examination are requiredfor appropriate screening.45 Such aninformation gap must be closed if clinicaloutcomes are to improve.

Religious beliefs and practices can affectpatients’ attitudes toward health care in anumber of ways. On one hand, patients’spiritual and religious participation tendsto correlate with better blood pressurecontrol in some studies of AfricanAmericans.46 Conversely, patients with

folk beliefs that “high-pertension” (assome of those surveyed referred to thecondition) is causally related to stress anda negative emotional state were lesslikely to comply with a regimen ofantihypertensives among AfricanAmerican outpatients in New Orleans.47

The president of the National MedicalAssociation when this article waswritten, Sandra Lynn Gadson, MD, anephrologist, related that in one case sheneeded a court order to dialyze a patientwith kidney failure, who was beingconfined by an alternative “minister”practicing faith healing.48 Dr. Gadson,herself an African American, noted thather own spirituality was a powerfulinfluence in her own life, yet it wascompatible with biomedical practice.Clearly, religious beliefs can vary greatly,and some improve health practiceswhereas others may delay importantmedical interventions.

At times, belief in God may beaccompanied by a reduction inmedication compliance. For example,Polzer and Miles49 found that strongspirituality in African American diabeticpatients was correlated with self-management of the disease and greaternoncompliance with a diabetic regimen.Religious beliefs may at different timesexert differing effects, positive ornegative, on the delivery of effectivehealth care. The challenge in realizingimproved health outcomes amongAfrican Americans is to maximizethe positive influence of faith whileminimizing the negative influence.

Delay in diagnosis of breast cancer is anexample of correlation between religiosityand an increased probability of latediagnosis. A “true believer” who isawaiting divine intervention may have aworse outcome than a patient who seeksallopathic medical attention at the firstsigns of disease. Clinicians must beattuned to this possibility andrecommend an approach that permitsfaith to support the patient withoutimpeding evidence-based evaluation andtreatment. Physicians can explain to theirpatients who adhere to African Americanreligious and cultural traditions that faithcan be compatible with timely medicalinterventions. Physicians can refer tothe many examples wherein faith andmedical approaches are pursuedconcurrently, such as by the many faith-based medical institutions, as well as by

medical practitioners like Dr. Gadson,the president of the National MedicalAssociation, and many other clinicianswho embrace religious faith whilepracticing EBM. Physicians who expressrespect for patients’ religious beliefs whileproviding the latest in EBM are likely tobe most positively received in cross-cultural clinical encounters. In oneauthor’s (ARE) practice, a rare,previously invariably fatal infection(cryptococcemia) was effectively treatedwhen the patient’s faith group waspermitted to pray at the bedside and thelatest medical management was applied.50

This act of respect and acknowledgementof the religious and cultural beliefs of thepatient facilitated the cooperation thatwas necessary for the application of thecomplicated and difficult medicaltechnology that the patient required.One cannot state that the praying at thebedside altered the clinical outcome,but it did improve mutual respect andcommunication between the physicianand the patient, and it may haveimproved the patient’s frame of mind.Physicians can also demonstrate respectof their patients’ cultural and religiousneeds by permitting them to discusstreatment options with their clergy andfamily before making decisions abouttreatment.

Home or Natural Remedies

Home or natural remedies are commonlyknown and are used by AfricanAmericans, particularly among theelderly. Turning to an herbalist forremedies is a part of the AfricanAmerican cultural history dating back tothe time of slavery, and in Africa beforeslavery.51 Indeed, it is difficult to separateAfrican herbal medicinal usage fromAfrican religions, including those of Igbo,Yoruba, and other traditions.52 AfricanAmericans were often deprived ofstandard medical treatments duringslavery and for some time thereafter. Asa result, a common practice in the pastamong African Americans was to try thehome herbal remedies before accessingmedical institutions that were ofteninhospitable or, in many instances,unavailable. For example, an ailingperson may have tried Epsom saltingestion and apple vinegar for acathartic effect to “cleanse” the body ofillness. Root or faith healing is a traditiondating back to African origins that wasnurtured during slavery and has endured

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to current times. It is not uncommonthat an African American today has trieda home remedy before seeking medicaltreatment. Traditionally, the familymatriarch was the source of knowledgeof roots and home remedies, and thisknowledge was considered part ofdomestic expertise and was passed downfrom the matriarch to her daughters.53

One study reveals that elderly AfricanAmericans with osteoarthritis are morelikely than elderly Caucasian patients toperceive that traditional remedies areefficacious and are less likely to seekjoint-replacement therapy.54

One author (GE) was the proprietorof a health food and herbal store locatednear the hospital of the University ofPennsylvania during the 1990s. It washis personal experience that AfricanAmerican patients routinely went to thestore directly from a physician’s officeor clinic to seek an herbal remedyalternative to the physician’s prescribedtreatment. Often, the patients would notinform the physician that they weretaking the herbal remedy instead of or inaddition to the prescribed medication. Aclinical study in North Carolina foundthat African Americans and AmericanIndians were 81% and 76%, respectively,more likely to use food home remediesthan Caucasian study participants.55

Health care providers, physicians, andothers need to understand the role ofhome remedies in the social history ofAfrican Americans and how that roleinfluences the current context of aclinical counter today. If the providersshow some understanding and respect forthese traditions, even without endorsingthem, it can help in caring for AfricanAmericans by gaining their respect andtrust. Minority groups’ skepticism aboutevidence-based medicine can be bridgedby creating trusting relationshipsgrounded in physicians’ understanding ofparticular aspects of the minority culture.

Distrust and Race

We note that distrust of institutionsand authority figures is rooted in theAfrican American history of racialdiscrimination, including slavery, post-Emancipation persecution, and persistentracial discrimination.56 Boulware et al57

have demonstrated that AfricanAmericans were less likely to trust theirphysicians and hospitals than Caucasians

were. The Tuskegee syphilis study isfrequently cited for this distrust andundoubtedly contributes to it, as do morerecent instances of racial bias in healthcare.19,20 Distrust itself contributes toracial disparity in health outcomes. Trustin a physician has been shown to increasethe likelihood of compliance with amedical regimen, despite cost pressuresand other influences.58,59 Patients withlower levels of trust were less likely tocomply with a medical regimen fordiabetes.60 Furthermore, the quality ofpatient–physician communication maybe lower when Caucasian physicians treatAfrican American patients. According toJohnson et al,61 physicians were moreverbally dominant and less engaged inpatient-centered communications whendealing with African Americans. Inanother study, African Americans wereless trusting of Caucasians regardingmedical research participation.62 Thisdistrust of medical intervention,illustrated by African Americans’ uneasewith cross-cultural physician–patientcommunication and medical researchparticipation, also applies to invasivebut effective clinical practices. AfricanAmerican veterans were significantly lesslikely to accept a recommendation forcarotid endarterectomy in VA systemhospitals.63 In this study, AfricanAmerican patients were more likelyto express a high aversion to such anintervention and fewer African Americanpatients received the intervention,though all patients had a carotid stenosisof at least 50%.

Within the African Americancommunity, a patient’s distrust ofinstitutions and physicians may actsynergistically with fundamentalistreligious beliefs to cause him or her todelay seeking medical treatments in favorof trying faith healing or herbal remediesfirst. Clearly, there exists an opportunityfor African American religious andcommunity leaders to affirm to theircommunity members the value ofevidence-based medical care and itsconcordance with religious beliefs.Although there may be some religiousbeliefs that are incompatible withevidenced-based medical practice, mostare not. We suggest in this regard theperspective that “God helps those whohelp themselves to preventive care andtimely medical intervention,” though werecognize that all religious leaders maynot agree with this proposition.

Distrust of physicians occurs amongCaucasians and African Americans aswell as other ethnic groups. Surveysreveal a somewhat higher rate ofdistrust of physicians among AfricanAmericans.64 Physicians can mediateracial differences by showing emotionalsupport for their patients and involvingother health care providers (nurses,social workers, therapists, dietitians) ofvarious ethnicities in the patient’s care.Respectful, emotionally supportivedialogue can help overcome racialbarriers.

Racial Concordance

African American patients rated theirencounters with physicians morerewarding and participatory when thephysician was also African American.However, only 22% of respondentsexpressed a preference for an AfricanAmerican physician, but those who didwere more likely to express satisfactionwith a racially concordant physician.65

The Commonwealth Fund’s HealthCare Quality Survey found that AfricanAmericans were more likely to rate theirphysicians as excellent if the physicianwas also African American.66 Raciallydiscordant clinical dyads were found tobe less likely to engage in a participatorycommunication process.61 It is unlikely inthe foreseeable future that most minoritypatients will be treated by raciallyconcordant physicians, given the differingpatient and physician demographics.African American physicians account forless than 4% of the medical profession,whereas African Americans account forapproximately 13% of the population,67 sothe majority of African Americans will seenon-African American physicians. Theability to cross cultural and ethnic dividesis an essential component of the 21st-century physicians’ “toolkit.” Moreover,today physicians themselves come fromdiverse ethnic backgrounds, makingcross-cultural clinical dialogue inevitable,and all physicians should work toimprove their cultural competence.

Bridging the Gulf

Cultural competence in the clinicalsetting indicates that the physician issensitive to the individual patient’s needsand establishes rapport across ethnicdifferences. Establishing interpersonalrapport with a patient by identifying andrelating to his or her personal humanity

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has been described in the context ofnarrative ethics.68,69 Physicians needs tocomprehend the “patient’s story,” notmerely detect the disease and treat it.Such a more narrative approach can alsohelp bridge cultural differences andimprove clinical communications ingeneral.

Demonstrating humility and mutualconcern can also be effective in thisregard, although the former is not acommon physician characteristic.Bridging the cultural gap requires thenon–African American physician to reachout to the African American patient toestablish an individual rapport thattranscends historical distrust of medicalinstitutions. The physician can establishsuch a rapport by making an effortto observe, learn, and practicethe techniques of cross-culturalcommunication. For example, although itmay be necessary, referring to insurancecoverage does not build trust between thephysician and the patient. When possible,it is preferable for the physician to leavethis aspect of interaction to his or hersupport staff to avoid the appearance thatself-interest is guiding the physician–patient interactions. A patient’sperception of a physician’s self-interestcan also be one of the causes for mistrust.

List 1 summarizes techniques we suggestin this article for bridging the gulf incross-cultural clinical communication.

Health Illiteracy

The prohibition against educatingAfrican American slaves has seriouslyimpacted on the long-term literacy ofcertain components of the AfricanAmerican population.24 Health illiteracyis a common hindrance to optimalhealth care and is more frequent in lowersocioeconomic groups.70 Amongethnically and racial diverse patients,43% report difficulty understandinginformation in the clinical encounter.Among patient with chronic illness, threequarters have limited literacy. Lowliteracy in diabetic patients was associatedwith worse glycemic control andincreased rates of retinopathy andblindness.

One of the authors (ARE) was partof an Agency for Healthcare Researchand Quality–sponsored researchcollaboration that developed andevaluated a multimedia computerprogram for diabetes education in low-literacy minority populations.71 Thisprogram was developed with the conceptthat racial and ethnic concordanceenhance communication of information.The study demonstrated that theprogram increased perceivedawareness of susceptibility to diabeticcomplications, especially among thosewith low literacy. Other studies revealthat health illiteracy increases medicalcosts and reduced efficiency of services.72

Thus, improving health literacy can

conceivably improve outcomes andreduce costs if it is culturally sensitive.

Certified health educators areinfrequently African American (10%)and only a minority (34%) of healtheducators are community based.73 Hence,there are relatively few African Americanhealth educators to provide raciallyconcordant health education. Healtheducators can educate patients aboutself-care, communicate with health careproviders, and advocate for patients withreduced health literacy.74 Federalfunding of community-based ethnicallysimilar health educators may beefficacious and cost-effective if it isshown to improve compliance andavoid late-stage disease.

Cultural Competence of HealthCare Providers and Cross-CulturalEducation

Betancourt75 delineated a usefulframework of cross-cultural medicaleducation that noted three approachesto or components of such education:promoting awareness of attitudes,including self-reflection; knowledgeof cultural issues; and developing theethnographic skills in a clinical setting tounderstand the cultural context of illnessfor a given patient.

Lavizzo-Mourey and Mackenzie76 haverecommended including culturalsensitivity and knowledge of differences

List 1Cultural Competence and the Care of the African American Patient: PracticalSuggestions and Applications

Ethnic social historyRacial con/discordance Home remedies Health illiteracy Religion

• Learning about AfricanAmerican history (slavery,reconstruction, Tuskegeestudy instance of humanexperimentation withoutconsent, discrimination in20th century in hospitalsettings, current racialdisparities in healthservices)

• An experiential componentthrough theatricalperformances and/orsimulation workshopsis recommended

• Greet respectfullythrough bodylanguage, choice oflanguage, and personalgreeting

• Avoid inappropriatefamiliarity butencourage friendlydiscourse and becognizant of andacknowledge thepatient’s emotions inclinical encounters

• Be aware that homeremedies may be usedin addition toprescribed treatmentsor prior to seekingmedical treatment

• Avoid disparagingcomments regardingalternativemedication; calmlyinform patient thatsome home remediesmay be harmful andprovide specific riskswhen known

• Communicate insimple, directlanguage; write downand diagramif possible

• Use others (nurses,health educators, etc.)to better communicatein the vernacular that isfamiliar to a patient ofa particular ethnicity

• Delineate theboundaries betweenevidence-based medicaltreatment andfundamentalist beliefsand explain outcomedifferences asappropriate

• Show respect forreligious beliefs,permitting observationof religious practice,even in the hospital asthe setting permits

• Encourage patients toengage clergy in asupportive role

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among subpopulations in medicationresponse as a part of medical quality.We hold that cultural competenceencompasses a variety of differentcompetencies, some knowledgebased and others more rooted incommunication styles based on culturalawareness.

Some, out of concern that it mightlead to stereotyping, have discouragedthe knowledge approach to culturalcompetence training.77 Others haveargued that cultural humility is superiorto cultural competence because the lattersuggests the “detached mastery of a . . .finite body of knowledge.”78

We contend that ignorance is not blissand that cultural and even historicalknowledge is needed to informphysicians’ sensitivity and permit anethnographic approach to cross-culturalcommunication. More specifically,physicians, nurses, and other health careproviders need to be better informedregarding the history, sociology, andcultural–religious aspects of minoritypatients, including African Americans.Cultural competence requires learningspecific information, including the role ofreligion in health-related decision makingand effects of historical racism that mayrender an African American patientreluctant to seek needed medical care.Self-reflection regarding personal,institutional, internalized, and subtleforms of bias is an important part ofcultural competence in general. Culturalcompetence training requires bothgeneral attitudinal approaches as well asspecific advice based on cultural aspectsof minority life.

Such cultural competence educationshould be modular and tailored for theethnic and racial minorities that arepresent in the community servedby specific health care providers.Individualized cultural information andawareness can be taught in the settings ofgraduate and undergraduate medicaleducation, as well as continuing medicaleducation (CME) as states are beginningto add CME to the regulatory mandate.Computer-based cultural competencyeducation can be useful and can includevideo streaming, but should be inaddition to live interactive workshops.

An experiential component of culturalcompetence education is importantinasmuch as didactic material is

inadequate in communicating theemotive content of some historical andcultural information, events, attitudes,and values. Works of cultural andhistorical context from the world ofperforming arts, such as Joan MyersBrown’s Philadanco dance companyperforming Tally Beaty’s “SouthernLandscape,” which depicts the brutalrepercussions of Reconstruction eventsinvolving African Americans 79 arecapable of communicating viscerallyacross differing cultures. Such culturalworks, if recorded and replayed forphysicians-in-training, could helpprovide an experiential component ofcultural histories of African Americanpopulations and provide such traineeswith greater cultural awareness.

Experiential workshops using actorscan have a strong emotional as well ascognitive impact on physicians-in-training. For example, one author(GE) participated in a workshopdemonstrating ethnic issues in medicalethics consultation.80 In such workshops,individuals simulate clinical ethicsconsultation and elicit interaction thatincludes cross-cultural dialogue. Seminarparticipants receive observer feedback ontheir interaction. This type of experientialeducation could become a standard partof undergraduate and graduate medicaleducation.

Accepting the Challenge

The challenge of achieving culturallycompetent medical care in amulticultural society requires severaldifferent skill sets. Specific knowledgeof minority communities’ culture andhistory is crucial to the cross-culturalclinical encounter. The authors havepointed out some of the key featuresof that knowledge with regard to theliterature on African Americans’interaction with health care. Beliefsystems, especially religious ones, havea unique and complex relationship tohealth care. This needs to be taken intoconsideration for all patients, butespecially for minorities. Health literacyis a crucial aspect of being an informedconsumer of health care, and providersalso need to be aware that there arebarriers to this. We recommend thatcultural and historical information fordifferent ethnic minority groups becompiled and that physicians andphysicians-in-training have both

experiential and informational trainingon the appropriate cultures and ethnicgroups that characterize their patients.These methods need to be furtherevaluated by methodologicallyvigorous studies. It is reasonable toexpect that efforts in this regard will, atleast in part, reduce disparities in healthoutcomes.81

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Teaching and Learning MomentsDeath, Quietly?

“Do you think about dying?”

Perched beside his hospital bed, sheplaced her hand firmly on his wiltedshoulder, a gesture that caused theyoung man to peer up at her with hiswide, fragile eyes. She had said thatword—the word; it was for just thatreason that she’d been invited into theroom.

“Yes, I think I’m scared to die.”

She continued to sit beside him,feeling increasingly awkward in theconfines of the small room, althoughshe knew that the best thing she coulddo was to silence her own discomfortand pay several moments of quietrespect to the young man’s humbleresponse. They sat looking at eachother, each knowing the weight ofthose words, and then she pushed alittle further.

“What are you hoping for?”

He cast his eyes downward, the frightsweeping across his face, tears wellingin his eyes. Her hand squeezed hisshoulder and they sat together, hecrying, she trying not to. Nevertheless,it was apparent in his repeatedattempts to catch his breath andanswer her question that he wanted totalk about it. Before he could, thevoice of his father broke the silence.

“Doc, you need to stop—now,” heinterjected, filling the small room withthe kind of uncomfortable tension thateveryone had tried to avoid.

In my three years of medical school,this was the first time I had ever been

included in a discussion about death,and I now understood the reasons whymedical students are routinely left out ofsensitive family meetings (too private,too emotional, too intense). Instead, weare assigned to follow healthier patients.We receive little training in breaking badnews, and, even when we do witnessdeath, there is rarely the opportunity todiscuss it. The topic of death often sitsquietly at the periphery of the medicalschool curricula.

The following day, the physician, whohad permitted me to witness the tensemeeting with the young patient andhis family, pulled me aside. Sheexplained that she’d gone back theprevious night to visit with the youngman and his family once they had timeto calm down. She admitted howawkward she’d felt as she reenteredhis room, but also how surprised shewas when his family ultimatelythanked her.

“You could see it—with everything outon the table, there was this ‘Ah, whata relief, now we can talk about theimportant things’ kind of feeling.”

Interestingly, as uncomfortable as I hadfelt in the moments after the outburstby the patient’s father, once thephysician and I debriefed about theexperience, I slowly felt that rawfeeling in my stomach beginning torecede. By introducing me head-on tothe emotionally charged world ofdeath, my teacher had paradoxicallyquieted some of my fears.

For all the charged emotion that hadinitially coursed through the cramped

hospital room (perhaps because of allof the emotion), in the end, the youngman, his family, and his physician hadnot allowed the words of death tostand silently at the periphery, to gounspoken. Having then said theimportant things, having talked abouthis hopes and his priorities, deathfinally arrived.

In the wake of this patient encounter, Iremain grateful to my teacher forallowing me to gain knowledgethrough this highly personal andsensitive experience. However, it was arare opportunity. I desperately believethat we must try to take more time toinclude medical students in thedealings of death.

When the time comes for me to finallyspeak with my first dying patient, evenwith this experience in mind, I mayfalter. Perhaps that is the nature of aprocess that is so final—there is noroom for rehearsal. But at least byallowing medical students to hear thewords and see the emotions, it willmean that as future doctors we willhave the confidence and compassionto address the issues surrounding apatient’s impending death.

Acknowledgments

All identifying names and events have beenchanged or removed.

James A. Feinstein

Mr. Feinstein is a fourth-year medical student,University of Pennsylvania School of Medicine,Philadelphia, Pennsylvania.

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