Assessing Cultural Competency
In the ideal, the patient-provider relationship is smooth, easy, and full of trust. The imagery providers and hospitals often use is reflective of this ideal – smiling patients, providers with the warm but professional demeanor of a teacher speaking to a student, and well-lit surroundings. This is not the experience many of us can ever recall having, even when we do have a positive relationship with our providers. In the best of circumstances, our providers don’t always have as much time as we’d like to help explain something and, in the worst, we’re left feeling angry, talked down to, concerns dismissed, and so thoroughly frustrated, we don’t want to ever see a doctor again. These experiences shape the patient experience in similar ways to consumers approaching any other retail situation. The problem is the relationship between patient trust and engagement in care is far more consequential, often doesn’t allow for much choice, and even the smallest fracture in that trust can affect an individual patient for their entire lives – for communities, it can affect the health of generations.
Kaiser Health News recently covered the issue of assessing patient experiences and satisfaction and how issues of cultural competency are not being adequately measured to identify opportunities for improving patient experiences and even potentially tackling pervasive problems like implicit bias. Of particular note, author Rae Ellen Bichell pointed toward a Health Affairs study that evaluated clinician notes for coded language. The results of the study were remarkable with provider language using a negative frame toward Black patients at 2.5 times the rate white patients were described in a negative light. Digging into the nuances of how providers train to manipulate patient responses, how survey results published by the Centers for Medicare and Medicaid Services (CMS) only publish aggregate information rather delineated information which might identify an issue of disparate experiences, and how these surveys do not ask patients questions which would assess cultural competency, Bichell puts a fine point on the need to integrate cultural competency as a measure and tool of health equity. As Dr. Oni Blackstock pointed out earlier this year (and routinely does so in a fashion that providers everywhere should take note of), language matters and reflects how providers view their patients – necessarily reflecting how providers approach their patients’ needs.
These buzz words, “health disparities” and “cultural competency”, have been around for some time, picking up steam and attention as the Biden Administration set goals to address disparities further highlighted by the COVID-19 pandemic. Clinics and hospitals tend to offer “cultural competency” trainings, reviewing the needs of particular marginalized demographics. But these trainings tend to also be cursory, quick, and do not have a functional and effective tool to measure patient experiences. Lacking a complementary assessment tool, these trainings do little more than teach providers what slurs they cannot use when describing a patient, rather than ensuring patients are receiving the quality of care they deserve – the quality of care patients need in order to remain engaged in their own care.
Indeed, a common sentiment in assessing HIV and Hepatitis C programs, especially under the frame of stagnating metrics of success, is the notion that “these patients” are just harder to reach, keep in care. So much so that when reviewing various Ending the HIV Epidemic plans, there’s a very clear focus on testing and PrEP, with retention in care as a priority falling far behind despite scientific knowledge that undetectable equals untransmittable – successful engagement in care for people living with HIV is effective prevention. This frame necessarily puts the burden on patients to be engaged without acknowledging barriers to care and the very responsibility of providers (and their government funders) to assess what providers could do differently to earn the trust of patients.
As much noise been made of providers working to be more culturally competent in care, little has been done to measure that competency from the patient perspective. Lacking that data also leaves us blind as to identifying potential problems in provider approaches. Advocates and providers would do well to consider that “patient-centered” care means the patient perspective and experiences is the most key indicator as to if a patient is actually centered in care. Successful provider-patient relationships are the key to tackling medical mistrust and a critical tool in dismantling the systems that further health disparities.