Mandating cultural competency: Should physicians be required to take courses?

Study after study has shown that racial and ethnic disparities exist in health care delivery. How do health care professionals and others eliminate them?

One approach appears to be gaining momentum: Mandate cultural competency training for physicians.

In 2005, New Jersey began requiring physicians to take continuing medical education courses that provide a grounding in culturally competent patient care, in addition to CME courses needed to maintain their licenses.

California also mandates cultural competency training for physicians, while Maryland "strongly recommends" it. And debates about requiring such training are taking place in Arizona, Colorado, Florida, Georgia, Kentucky, New Mexico, New York, Ohio and Washington, according to the Dept. of Health and Human Services' Office of Minority Health.

"My sense is that [cultural competency training] is increasing dramatically," said Robert Like, MD, professor of family medicine and director of the Center for Healthy Families and Cultural Diversity at the University of Medicine & Dentistry of New Jersey-Robert Wood Johnson Medical School. "It has reached the tipping point and has even begun to spread globally."

Some physicians bristle at the training mandates.

Debate over the measures frequently extend over several state legislative sessions, and physician organizations often are on the front lines urging their defeat. Opposition is to be expected, say those who support the initiatives.

"Ultimately, there is going to be resistance to change," said Joseph Betancourt, MD, assistant professor of medicine at Harvard Medical School in Boston and a proponent of cultural competency training. "The goal of this set of teachings is not about making anybody feel they are incompetent or racist in any way. It is about professional development. It is about learning the latest science in communications and communicating across cultures."

Supporters of mandated training point to an increasing number of studies showing that patients from minority groups fare less well in the nation's health care system than do white patients. For example, a study in the August Journal of Health Care for the Poor and Underserved found that physicians do not differ from the general population or other highly educated people in subconscious racial bias. The study's author said this could help explain disparities in care.

"Physicians aren't trying to be disparate, but how can we have all these studies showing a black and a white patient going in with the same conditions but receiving different treatments?" asked Mildred Olivier, MD, vice chair of the Commission to End Health Care Disparities' Physicians Awareness Education and Training Committee. The commission was formed five years ago by the American Medical Association, the National Medical Assn. and the National Hispanic Medical Assn.

Implementing state laws

In New Jersey, the competency law requires physicians to earn six CME credits in cultural competency training over two years, in addition to the 100 CME credits already required for licensure.

The state medical board specifies topics that must be covered in training. Among them: common definitions of cultural competence, race, ethnicity and culture; an appreciation for the traditions and beliefs of diverse patient populations; an understanding of the impact that stereotyping can have on medical decision-making; strategies for recognizing and eliminating health care disparities; and ways to enhance skills and techniques to overcome language barriers, including working with interpreters.

The Medical Society of New Jersey opposed the mandate specifying the number of credit hours when the bill was introduced in 2002. The society's Council on Legislation and Board of Trustees ultimately voted "no position" on the measure.

The state's first cycle of license renewals recently was completed under the law. An audit to determine compliance with the cultural competency training requirement will be conducted later this year, a spokesman said.

California took a different approach with its 2006 law. All courses, including CME courses, taught to physicians must contain clinically relevant cultural and linguistic information, such as how symptoms of various diseases may present themselves differently in specific groups.

A course on a disease or condition, for example, could include the impact on a specific minority population, perhaps a group that lives in the community in which the course is taught.

"The onus of the responsibility is left with the CME administrators," said Sheryl Horowitz, PhD, administrator of the cultural and linguistic competency program at the Institute for Medical Quality, a subsidiary of the California Medical Assn. that implements the legislation. The state requires 25 CME credits each year. "For a course to be accredited for CME, the administrators have to provide evidence that they are incorporating cultural competency into their activities."

Meanwhile, Ohio is considering a cultural competency bill introduced this year, said Tim Maglione, senior director for government relations at the Ohio State Medical Assn. The association opposes measures that mandate cultural competency training. Similar bills have been introduced in the past few years but generated little activity, he said.

"We recognize that there are public health problems with racial and ethnic disparities," Maglione said. "Our concern is with the content-specific nature of the bill. Where does it end? Next thing you know, there will be 50 specific hours of CME that legislators have deemed important, but that might not fit in with the clinical needs of physicians."

Those concerns are echoed by Barbara Ellman, associate director for policy at the Medical Society for the State of New York. "We feel it's important training, but we wouldn't want to add another course on top of everything," she said. The state already mandates a course in infection control, and New York physicians don't want to see any additional mandates.

The medical society is working with sponsors of a bill that would add cultural competency training to a course on risk management that many physicians already take. Completion of the risk-management course, which is given by the state's largest medical liability insurer, is voluntary, and completion earns physicians a 5% discount on their medical liability premiums.

In Maryland, which takes a voluntary approach to cultural competency training, a bill was introduced this year designed to help physicians and other health care professionals identify cultural competency courses. The measure would require the state's Office of Minority Health and Health Disparities to assist professional societies by providing information about existing training programs and offering technical assistance to societies wishing to develop their own courses.

Despite skepticism and opposition to mandated cultural competency training, some physicians have been surprised by the knowledge they've gained.

Peter Hasler, MD, medical director of the Santa Barbara (Calif.) County Public Health Dept., attended a CMA conference on cardiovascular disease. He said he learned that Hispanics have lower rates of heart disease than whites, despite high rates of obesity and diabetes among Hispanics. "That's important for me to know as a physician," he said.

Gregory Costello, MD, a member of the board of directors of the Medical Society of New Jersey, thought he was culturally aware from working with a diverse group of patients at St. Joseph's Hospital in Paterson, N.J. But he said an online course he took "posed a lot of questions I had not thought about and pointed out things I did that might be perceived as being incorrect."

Dr. Olivier, of the Commission to End Health Care Disparities, is among those who approve of requiring cultural competency courses.

"We have to make it mandatory, because people would just not do it," she said.