Even limited training improves communication with patients from other cultures

May 25 2005

Simple classroom lectures about different religious holidays, such as the Muslim tradition of fasting during Ramadan, or Spanish language lessons focused on common medical terms really work to help physicians and nurses connect with patients from different cultures and improve patient satisfaction, according to a pair of reports from Johns Hopkins researchers.

But the latest study, published in the journal Academic Medicine, still falls short of showing any direct link between such training and the improvements in health of cultural and racial minorities.

"Far more rigorous testing is needed to prove that the training does more than just facilitate better interactions between caregivers and patients," says study co-lead investigator Eboni Price, M.D., M.P.H., a senior clinical research fellow in the Welch Center for Prevention, Epidemiology and Clinical Research at The Johns Hopkins University School of Medicine.

The Hopkins analyses are believed to be the first detailed review of steps taken by academic medical institutions to address cultural differences with patients, since a series of national reports from the Institute of Medicine (IOM) brought about mandatory cultural competency training of health professionals in 2004. The IOM reports called for training as a key tool in reducing racial disparities in health status between minorities and whites.

"Communicating with a physician or nurse from a different ethnic background, someone with different traditions or who speaks a different language, is a growing fact of life for many Americans," says study co-lead investigator and internal medicine specialist Mary Catherine Beach, M.D., M.P.H., an assistant professor of medicine, and health policy and management at Hopkins' Welch Center, School of Medicine and Bloomberg School of Public Health. "While more than one quarter of the general population is from black, Hispanic or Asian descent, the vast majority of physicians are white."

According to Beach, racial inequities in health status persist, in part, because of a failure in communication and lack of trust between the physician and the patient - it is a bigger problem than the ability to speak the same language and extends into perceptions of cultural differences, where the patient can feel underappreciated or misunderstood by physicians or nurses.

"We know, for example, that over a broad range of medical conditions and clinical settings, the diagnostic tests performed, and the quality of diagnosis made and treatment options offered are lower for black Americans and other minorities than they are for whites," she says. "All health professionals have a duty to provide good care to patients so that they feel good about their relationship, trust the medical advice provided and want to show up for their next appointment."

In a related study, published in the journal Medical Care in April, the Hopkins team found that cultural competency training significantly improved health care providers' knowledge of patients' different cultures and also improved patients' satisfaction with their physician. However, insufficient evidence was found to prove that training improved how patients took their medicines or followed their physician's advice, or that training improved the health status of patients or saved money.

The researchers reviewed the findings from 34 studies on cultural competency, grading the research for methodology and quality of evidence. The studies were culled from more than 4,000 on the subject of cultural competency produced since 1980, when data first became available. Only the studies with the most rigorous results, ranked first by quality of evidence - with results measured both before and after training - were included in the final analysis.

More than half, 19 of 34, confirmed that knowledge improved. Fourteen studies evaluated patient attitudes and found that trained physicians were judged by their patients as more likely to have listened, shown concern for their problem and been respectful. Indeed, patients were more likely to rank their physician as "more friendly" after training. In another study, nurses were more likely to expand their number of friends from other minority groups after training. Hispanic patients were also more likely to better communicate with their physician or nurse after the provider had taken just 20 hours of language training.

According to Beach, the evidence confirmed two things: It can take very limited amounts of training to get a significant improvement, and that training helped the physician get the patient to "open up" and provide more information to the physician.

Three studies attempted to evaluate patient outcomes, whether or not the patient's health actually improved because the physician or nurse was trained, but only showed improvements in patient satisfaction with the provider. Only one of these evaluated adherence to medication prescriptions, which was insufficient for drawing conclusions; no study measured the financial costs and savings of training.

In the latest analysis, the Hopkins team assessed the quality of the research as a determination of how cultural competency training works.

"Now that medical schools have to provide cultural competency training, we decided to critique the evidence that training makes a real difference to physicians, nurses and patients, and how well the research stands up to tough criticism," says Price.

Price and her team subjected the studies to a process of elimination, selecting only those with sufficient information for a comprehensive critique of methodology. Chosen studies needed to be written in English, have original data available, involve some type of training that was evaluated and measurable, and specifically target a group of physicians or nurses, with a goal to impact minority health. The researchers ended up with 64 studies that could be critiqued for methodology, including 34 from the first group.

Each study was then assessed for its strengths and weaknesses. Of particular interest to the researchers were flaws in methodology, such as inaccurate descriptions of the participants, their selection and their training, and lack of objective evaluation of results. Assessments also had to be blinded to prevent any bias from skewing outcomes. Poor use of statistical analysis was also a factor in the assessment.

The researchers found that a majority of the articles had flaws in data collection: Less than one-third provided enough information about participants and the training used so that other researchers could duplicate the study. Only eight of 64 compared trained participants to a similar group of participants, called a control group, who did not receive any training. Only 27 used objective evaluations, such as a written test, while most studies used unreliable self-evaluations to gather results. Excluding unusuable or biased data is common in research, but must always be explained, yet only 14 studies explained why particular sets of data were not included in the final analysis.

"Our evaluation of the research shows that training is clearly having an effect, that physicians and nurses are learning more about the cultures of their patients," concludes senior study author Lisa Cooper, M.D., M.P.H., an associate professor of medicine, epidemiology, and health policy and management at Hopkins' Welch Center, School of Medicine and Bloomberg School of Public Health. "Researchers and educators who perform the training will have to work more closely to implement more effective, methodologically sound studies to determine the full impact and value of cultural competency training."

Funding for these analyses, which took place from November 2002 to October 2003, was provided by the United States Department of Health and Human Services' Agency for Healthcare Research and Quality.

Other investigators in this research were Tiffany Gary, Ph.D.; Karen Robinson, M.Sc.; Aysegul Gozu, M.D.; Ana Palacio, M.D., M.P.H.; Carole Smarth, M.D.; Mollie Jenckes, M.H.S., R.N.; Carolyn Feuerstein, B.A.; Eric Bass, M.D., M.P.H.; and Neil Powe, M.D., M.P.H., M.B.A.