According to the Health Resources and Services Administration (HRSA) in Bethesda, Md., cultural competence refers to a set of academic and interpersonal skills that allows individuals to increase their understanding and appreciation of cultural differences and similarities within, among and between groups. What that boils down to, says Louis W. Sullivan, M.D., president of the Morehouse School of Medicine (MSM) in Atlanta, is that the practice of medicine is ultimately a social transaction. "We need to consider patients' psychology, history, the community they live in and their economic circumstances to give the best possible outcome," Dr. Sullivan says. "If there is impaired communication, the compliance may not be very good because the patient has no understanding. The patient has to believe you understand the situation. You have to earn the patient's trust."

In March 1991, MSM and the New America Wellness Group, a division of Chicago-based True North Communications Inc., conducted a multiethnic healthcare study. They discovered that the widening gap in healthcare between people of color and white America is not solely due to economics, but to the lack of culturally relevant care. Some of the more significant findings involved the differences between how minorities view healthcare as compared to how white people perceive it. For example, 61 percent of Hispanics felt it was important to have a doctor of the same ethnicity as opposed to 28 percent of blacks who believed the same thing. Also, blacks were less likely to accept that there is a cause-and-effect relationship between diet and health.

A growing number of individuals and institutions are finding that a person's culture often affects the way he or she approaches medical care. Minorities are more likely to seek attention from those who understand their values, traditions and customs. Because the number of racially and ethnically diverse healthcare professionals is not keeping up with America's rising minority population, more people are calling for cultural-competence training in the medical field. With broad-based programs, it would become commonplace for all healthcare workers to be knowledgeable about other cultures, not just their own. By doing so, proponents of cultural competence hope to encourage more minorities to seek professional services and to follow medical advice, thereby eliminating the gaps in quality healthcare.

Several projects already have been started, including The Initiative to Eliminate Racial and Ethnic Disparities in Health, led by the U.S. surgeon general and the Department of Health and Human Services (DHHS). The government has earmarked $400 million for the plan, which aims to improve the overall health of the nation by getting rid of the disproportion that exists between white people and minorities. DHHS predicts that by the middle of the 21st century, blacks, Hispanic Americans and Asian Americans will represent the majority of the population. To amend the nation's health outlook, medical professionals will need to keep up with the demand of diverse patients by learning to meet their specific needs in regard to language, culture and beliefs.

As cultural competence becomes a bigger issue, more groups are forming to help healthcare professionals and institutions generate change. The National Center for Cultural Competence in Washington, D.C., for instance, was created by DHHS at the Georgetown University Child Development Center. The foundation gathers information on the topic and offers recommendations for executing programs. It also employs cultural-competence consultants, who implement and provide training and technical assistance to organizations. Another initiative is HRSA's Cultural Competence Workgroup, which focuses on making the issue part of senior staff training. The American Medical Association (AMA) also targets the subject in its Cultural Competence Compendium. This resource serves as the foundation for developing initiatives and changes that will help physicians provide individualized care that respects the multiple cultures of their patients.

When it comes to cultural-competence training, healthcare professionals will have more options in the future. Elena Rios, M.D., president of the National Hispanic Medical Association in Washington, D.C., says there are already a few medical centers where physicians can go to receive special training in certain cultures. As the issue continues to grow, she expects more places to offer cultural-competence instruction. In fact, she feels such progress is imperative if the United States wants to continue to be proud of its healthcare system. "We have to take care of all Americans," Dr. Rios says. By becoming more aware of different cultures, individuals in the medical professions can help prod minorities to seek help when they need it. "People don't want to go to a place where they don't feel comfortable," Dr. Rios observes. "Realistically we have to train others. There are not enough Hispanic doctors out there."

Because language is one of the biggest barriers between caregivers and minority patients, the demand for translators is growing, especially in rural areas. In the years to come, interpreters will find more and more opportunities in the medical field. Dr. Rios says that Hispanic people in particular are more likely to trust those who speak their ethnic tongue. "It's not only immigrants, but even second or third generations feel more comfortable speaking in the Spanish language," she explains.

Most advocates of cultural competence recognize that it is impractical to expect every healthcare professional to know everything about every culture. Instead, Dr. Sullivan suggests that students and medical personnel gather a basic understanding of major cultures. While training programs and college courses will help, Dr. Sullivan believes the most important learning tool is experience. The medical profession is different than most because what needs to be learned often goes beyond the classroom. To practice medicine successfully, Dr. Sullivan says, healthcare providers need to develop intimate relationships with patients - and that means knowing about their cultures. "They should look around the community," Dr. Sullivan advises. "They should see what other groups are there other than the ones they are familiar with. What are their customs? Visit their institutions and talk with health professionals from particular groups. Make an effort to learn that and become comfortable with that." Dr. Sullivan says healthcare personnel will increase their chances of working where they want if they learn about the cultures located in a certain area. Both Dr. Sullivan and Dr. Rios believe a greater number of healthcare organizations and institutions will be looking for culturally competent employees. "People with knowledge of other cultures will definitely be in demand," Dr. Sullivan predicts.

According to the AMA, physicians are required to be proficient in four areas: cognitive knowledge, technical skill, behavior and management. Cultural competence has been offered as a fifth skill point. If America wishes to remain at the forefront of quality healthcare, its medical professionals must find a way to eliminate the disparities between its citizens. - KARA KITTS, Staff Writer