States, CME incorporating cultural competency training

Reducing disparities is one goal as education for practicing physicians begins to take off.

By Myrle Croasdale, AMNews staff. July 16, 2007.

Physicians agree that health care disparities exist, but what is unclear is how much individual physicians contribute to why black heart attack patients get less-aggressive treatment than those who are white or why male diabetic patients have lower death rates than females.

A growing number of state legislatures and health plans see physicians as an integral part of narrowing such disparities. So physicians can expect to see cross-cultural care become an increasing part of their continuing medical education curriculum.

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"This is not a passing trend," said Tawara D. Goode, director of the National Center for Cultural Competence at Georgetown University in Washington, D.C. "In the last five years, I have seen a much greater emphasis on this in terms of addressing health disparities."

At least two states -- California and New Jersey -- have mandated cultural competency CME, and a third -- Ohio -- is considering it.

California is on the leading edge. As of July 2006, all CME there must contain clinically relevant cultural and linguistic information, such as how symptoms may present themselves differently in men versus women or how management of a disease should be adjusted for specific cultural groups.

"It's only a matter of time until other states adopt something like this," said Alecia Robinson, MPH, project administrator for California's cultural and linguistic competency program, which is being run through the Institute for Medical Quality, a subsidiary of the California Medical Assn. "What happens in California often translates to the rest of the U.S."

This gives added importance to the efforts she and the other stakeholders are making to create meaningful change in California's CME standards, she said. Their goal is to help CME providers find ways to weave meaningful cultural and linguistic information into every topic taught.

To do this, the Institute for Medical Quality has a two-year $243,261 grant it is using to offer workshops, large events and Internet resources. They highlight examples of good cultural and linguistic competency training, best practices in this area and relevant data, journal articles or demographic information that can be linked to the clinical topic.

While California has put the onus on CME providers, New Jersey has put the burden directly on physicians. In 2005 New Jersey made cultural competency CME a licensing requirement, though the rule is not expected to go into effect until 2008.

Ohio could be next. A bill introduced in that state this year also would make cultural competency CME a licensing requirement.

Hoping to improve patient outcomes, health plans are investing in cultural competency CME as well.

For example, in June, WellPoint announced it had an online tool for physicians seeking cultural and linguistic resources and training. Aetna, Blue Cross and Blue Shield of Florida and Blue Cross and Blue Shield of Massachusetts also offer physicians CME on this topic, said Joseph Betancourt, MD, MPH, who helped develop the CME product the plans are using.

So far, more than 3,000 physicians and other health care professionals have taken this particular course. Though there are no results at this time whether patient outcomes have improved, pretest and posttest scores show large gains in participants' understanding of cross-cultural medical issues, Dr. Betancourt said. After taking the course, several physicians also have commented, "I didn't know how little I knew."

A lack of mentors

Physicians need this training, Dr. Betancourt said. In a 2005 Journal of American Medical Association survey he co-authored, one-third of the residents reported they lacked physician role models who could demonstrate effective cross-cultural care.

According to the JAMA survey, most residents lacked confidence in the area of cultural competency. They did not feel that they had the skills to handle such situations as a patient with a deep mistrust of the health care system or one whose beliefs were at odds with Western medicine.

Based on the JAMA research, Dr. Betancourt recommended in a May Commonwealth Fund report that residencies teach and formally evaluate residents' cultural competency skills. At the same time, programs need to train faculty, he said.

"We understand this is an emerging field, and a fair number of physicians are behind the curve," he said. "They may not realize how important it is and feel they don't have the time to learn and apply the skills."

While doctors may consider culturally competent medicine important, they may not be aware that there are specific skills that can help, he said. "In a general sense, physicians feel if you express concern and listen, that should do the trick."

While CME focuses on the physician, Goode, with the National Center for Cultural Competence, said efforts to create culturally competent doctors should be done in tandem with changes in health care systems and organizations where doctors work.

"To be culturally and linguistically competent in an institution that does not support you with resources isn't enough," Goode said.

Cultural competency applies to the health care system at large, she said, and without systemwide change, disparities in care will remain.

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