Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients

The 2002 Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, brought into stark focus the issues of inequities based on minority status in health care services. The IOM report concluded that, “Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare” (1). Persons in racial and ethnic minority groups were found to receive lower-quality health care than whites received, even when they were insured to the same degree and when other health care access-related factors, such as the ability to pay for care, were the same (1). Clients in minority groups were also not getting their needs met in mental health treatment (2, 3). The IOM report was a primary impetus for the cultural competence movement in health care.

Cultural competency emphasizes the need for health care systems and providers to be aware of, and responsive to, patients’ cultural perspectives and backgrounds (4). Patient and family preferences, values, cultural traditions, language, and socioeconomic conditions are respected. The concepts of cultural competence and patient-centered care intersect in meaningful ways. The IOM’s Crossing the Quality Chasm (5) document defines patient-centered care as “providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” (p. 3). Both patient centeredness and cultural competence are needed in striving to improve health care quality (6, 7). To deliver individualized, patient-centered care, a provider must consider patients’ diversity of lifestyles, experience, and perspectives to collaborate in joint decision making. Patient-centered care has the potential to enhance equity in health care delivery; cultural sensitivity may likewise enhance patient-centered care (6). Indicators of culturally sensitive health care identified in focus groups of low-income African-American, Latino American, and European American primary care patients included interpersonal skills, individualized treatment, effective communication, and technical competence (8). The U.S. Office of Minority Health has set national standards for culturally and linguistically appropriate health care services (9). The Principal Standard is that health care must “provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs” (p. 1).

Five key predictors of culture-related communication problems have been identified in the literature: cultural differences in explanatory models of health and illness, differences in cultural values, cultural differences in patients’ preferences for doctor–patient relationships, racism and perceptual biases, and linguistic barriers (10). Physicians are often poorly cognizant of how their communication patterns may vary with respect to the characteristics of the individual they are treating (11). This unconscious preconceptualization is termed implicit bias, which refers to the attitudes or stereotypes that affect understanding, actions, and decisions in an unconscious manner (12). All people experience these—even those who strive to maintain a multicultural orientation and openness to diversity. Health care providers must openly reflect on and discuss issues of the patient’s culture, including ethnicity and race, gender, age, class, education, religion, sexual orientation and identification, and physical ability, along with the unequal distribution of power and the existence of social inequities, to effectively coconstruct a treatment plan that is patient centered and culturally sensitive.