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Caring Across Cultural Divides
Faced with an increasingly diverse patient population, Community Physicians decided it needed to rethink the way its clinicians delivered care.

Good JobThe 40-ish Filipino woman sitting across from Barbara Cook appeared nervous, constantly cracking her knuckles and shifting in her chair. It was her first visit to Johns Hopkins Community Physicians at White Marsh and she hadn’t seen a physician—even for a routine gynecologic examination—in 12 years.

That set off alarm bells for Cook, a family medicine doctor, who is president of the primary care practice.

The woman had a pulse rate of 120, her blood pressure was high, and she looked agitated and worried. Yet Cook’s attempts to draw information from her proved fruitless. “I just couldn’t break through,” Cook recalls. “She didn’t know me, I’m not of her culture, and she was so afraid about what might be wrong with her. As hard as I tried, I never could get that look off her face—a deer caught in headlights.”

That experience earlier this month brought home to Cook the importance of cultural competency training, which can give clinicians and staff the skills to understand societal differences that may pose barriers to effective health care delivery. Community Physicians has embarked on what Cook calls a “robust plan” to help deal with the group’s increasingly diverse mix of patients.

Community Physicians’ challenge is in many ways a microcosm of that faced by all of Johns Hopkins Medicine as it embarks on an organization-wide push to improve diversity. Hopkins leaders have recognized that staying atop the field of medicine requires that they recruit, retain and promote more women, underrepresented minorities and people of otherwise diverse backgrounds. In the hope of reducing racial and socioeconomic disparities in health care outcomes, the initiative also aims to develop a workforce that is culturally sensitive and more representative of the patient population.

To help her penetrate the cultural barrier with the Filipino patient, Cook called her medical assistant, Maria Hale, who is from the Philippines. Hale spoke with the patient in their native Tagolog, eased her fears and explained the need for lab tests and a thorough examination on a second visit. “The lady left so much calmer,” Cook says. “I have every reason to believe she will come back because we had someone who could reach out to her in her own language and reassure her.”

Such reassurance is crucial for health care providers in a polyglot society. “The ability of clinicians to bridge cultural gaps, to see someone else’s perspective, to understand where people are coming from, is becoming increasingly important,” asserts Mary Catherine Beach, an assistant professor in the Department of Medicine and a recognized expert on patient-centered care and cultural competency. She is acting as a consultant on JHCP’s diversity initiative.

Beach’s studies show that cultural competency training significantly improves providers’ knowledge of social differences. This leads to more openness with patients and improved patient satisfaction. Even limited training for care providers, she found, helps them get patients to open up.

“Our clinician group and our practice administrators need formal work in cultural competency,” Cook observes. “It’s clear to me that I can’t necessarily use my white, Anglo-Saxon, Protestant perspective to understand where that lady from the Philippines is coming from.” Cook says health care workers need to develop different cultural skills by paying attention to body language and subtle signs, asking more questions and probing patients’ beliefs and understandings.

Women from the Middle East, for instance, may resist removing their head coverings, or their husbands may insist on accompanying them. Patients from some cultures may not feel comfortable unless they are examined by clinicians of the same sex.

At the urging of Hopkins Health System President Ron Peterson, Community Physicians in June created its own diversity committee with three goals: increased diversity throughout the organization, improved patient experience through cultural competency training, and a better work climate.

For JHCP clinicians, cultural competency training began at the annual Medical Group Retreat on Nov. 16, where Robert Like, director of the Center for Healthy Families and Cultural Diversity at the Robert Wood Johnson Medical School in New Jersey, was the guest speaker. Like’s talk was part of six hours of diversity training for clinicians and administrators at the retreat.

The Diversity Committee is reviewing additional training resources for the clinicians as a follow-up to the retreat. In addition, they are working on a separate cultural competency program for medical assistants and front-office staff.

Another diversity plan involves training pediatricians to identify and support gay or lesbian teens who have hidden their sexual preferences from others. “These situations create a lot of conflict and emotional issues,” Cook says. “We want to provide competent care to them in that milieu.”

Cook also has set up a focus group for underrepresented minority clinicians to examine their perceptions of the barriers to advancement and professional satisfaction at JHCP.

Community Physicians’ overall diversity figures are encouraging, although some of its 15 offices have a racial mismatch between clinicians and the patient population. Forty-seven percent of JHCP employees are non-Caucasians and 87 percent are women. Non-Caucasians make up 43 percent of the clinical group: 17 percent are African American, 16 percent are Asian and 2 percent are Hispanic.

That last number troubles Cook, who is one of only four JHCP clinicians fluent in Spanish. The practice, whose clinicians call on Johns Hopkins International to provide translators when necessary, is now advertising for office staff fluent in two languages. It’s a priority Cook feels she owes those patients.

 “We also have very few front-desk employees who speak Spanish,” she notes, “which makes it challenging to assist Spanish-speaking patients who call to make an appointment, refill a prescription or need help on an urgent issue. Who is going to field those calls?”

 
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