What the Heck is Cultural Competence?

I stumbled across this old post about Washington trying to pass a bill mandating continuing education for physicians on cultural competence. They just did it again in the legislative session that ended. Again the bill died, but not the one mandating education on suicide prevention.

Suicide prevention is a wonderful thing, but I will be obligated to spend six hours of my valuable time learning about something I bet I do better than 99% of the doctors in this state. I’m not being cocky, it’s just that we have very few psychiatrists around and I have had to upgrade my psychiatric, pharmacology and counselling skills.

The sad part is that it will not help suicide prevention because CME is superbly badly suited to the skill required. So here is the old post.


Washington State has chosen to address the cultural competency of their physicians and providers.

While this is laudable in purpose, an effort to assure cultural competence is difficult to implement well. On the face of it, additional training seems the logical response to a deficit in cultural competence. Unfortunately, continuing medical education and training has never been demonstrated to effectively change the practice patterns of physicians, so there is no reason to believe it will work here.

One could try to increase the diversity of the physician supply, but my experience is that whereas this may improve the satisfaction of people with similar ethnic and cultural backgrounds, it does not address the competence of physicians dealing with a diverse group of patients. Foreigners of any given ethnicity are no better able to deal with other ethnicities than a plain vanilla white American boy.

Moreover, the way cultural competence is presented can be dangerous, the way many well-intentioned efforts succumb to the law of unintended consequences. For example I recently received a brochure from The Joint Commission (aka JCAHO) which represents different ethnic groups and their usual beliefs and behaviors about illness.

Many of the ‘facts’ presented are truisms and platitudes that only hold for some people in any given population. Not every Hmong rubs coins on their childrens’ backs and not every Latina mother thinks about cold and hot illnesses. These beliefs are typical of ordinary people and thus much more dramatically influenced by socio-economic status within the culture that by the culture itself. It is tantamount to calling an Asian smart or an African athletic. Whether or not the statement hold true in the aggregate, the seed of prejudice (i.e. pre-judging) lies in assuming that the person in front of you shares those attributes.

Perhaps there is a different way to assure cultural competence, but also to address the underlying issues for poor communication between physicians and patients. Physicians are taught interpersonal and communication skills in medical school and residency, but the training is uneven and inconsistent between programs. To deal with every person on a psychosocial continuum is to see them as a unique collection of ethnic, cultural, social, family personal, biological and genetically determined experiences that need to be peeled away layer by layer without assumption, judgment or bias. Culture rightly become a focus, but only of one of several factors which shape the interaction.

In the cognitive specialties, like the primary care specialties, the ability to provide satisfactory care without excessive investigation is the key to assuring low-cost, high-quality health outcomes.

I would propose we completely and utterly abandon cultural competence (by the way, I am convinced Washington State is using “competency” in a grammatically incorrect way) as the framework for how we approach patients and replace with a broader psychosocially defined “communication competence concept.” These can be taught through the current channels with an IOM-driven effort to influence curricula via ACGME and the AAMC. In other words, use current channels to support a broad communication-skills agenda rather than a narrow-focus of cultural competence.

Some resources can be found at HRSA, Joint Commission (aka JCAHO) and the ANM.