There is an abundance of evidence indicating that many providers treat their patients differently depending on the patient's race and ethnicity.^[1] In addition to other social factors, race, ethnicity, and language have significant influence on the quality of the doctor-patient relationship. As a health care provider, it is important to begin with the realization that bias is inherent in all of us because we all view and experience life through our uniquely developed cultural lenses. Beyond the aforementioned factors, our cultural lenses are even influenced by the medical training process. Our history and experience can lead us to make assumptions about others based on their race and ethnicity. The first step in surpassing these tendencies is to acknowledge their existence,

A 2005 study identified cultural factors that influence racially/ ethnically diverse patient perspectives about the quality of their care. The following table illustrates some of these factors ^[2]:

Factors Affecting Patients’ Perceived Quality of Care

Patients reported more positive experiences when they perceived that the providers . . .

• Showed sensitivity to Complimentary and Alternative Medicine (CAM)
   
• We willing to incorporate CAM into treatment plans
   
• Had ethnic concordance with the patient
   
• Included family in healthcare discussions and planning
   
• Accepted the role of spirituality

• Were receptive to including ministry in treatment
   
• Respected spiritual preferences

• Took a humanistic approach

• Showed sensitivity to patients’ needs for privacy
   
• Made eye contact
   
• Offered thorough, non-technical explanations
   
• Showed sensitivity to patients’ privacy needs
   
• Sat down with patients despite time constraints
   
• Treated patients as equals in their care

• Elicited information from patient

• Did not make assumptions about health beliefs, education, etc.
   
• Encouraged questions and voicing concerns

Recommendations from patients to physicians on ways to enhance clinical encounters . . .

• Do not make assumptions about insurance due to patient race or ethnicity.
   
• Accept and equally prioritize patients receiving a broad spectrum of insurance plans.
   
• Take time to understand the patient’s understanding of the health concern.
   
• Assume the patient is an equal partner who is interested in his/her health.
   
• Use resources to address language barriers (obtain interpreters, bilingual staff, or translated materials).
   
• Take time to explain the illness from a medical perspective but consider it part of a larger understanding that also includes the patient’s perspective .

•   Pay attention to the patients’ subjective experiences.
   
•   Pay attention to the patients’ understandings of disease etiology.

With so many issues to consider, it may seem impossible to identify a consistent strategy to use in order to elicit patient beliefs/understandings about their condition, assess your own beliefs, identify potential strategies to address the illness, and determine the best treatment course given the diversity on awareness, beliefs and understanding.

The L-E-A-R-N Model provides a strategy for providing culturally competent healthcare^[3-7]:

Listen with sympathy and understanding to the patient’s perception of the condition.

Explain your perceptions of the problem and what would be your strategy for treatment.

Acknowledge and discuss the differences and similarities between your perspectives.

Recommend treatment while remembering what you have learned about the patient’s cultural parameters.

Negotiate agreement. Make sure you understand the patient’s perspective so that you can ensure the treatment plan fits his/her cultural framework.

When following the L-E-A-R-N Model, the following questions may help to elicit the patient’s perceptions^[2]:
1. What do you think caused your problem?
2. Why do you think it started when it did?
3. What does your sickness do to you? How does it work?
4. How severe is your sickness? (Perhaps asking the patient to rate it on a scale of 0 to 10)
5. How long have you been sick? After how many days of being sick did you become concerned?
6. What problems has it caused you?
7. What do you fear about it?
8. What other treatments have your friends/family/others told you about for this condition?
9. What are the most important results you hope to receive from treatment?
10. Whom do you wish to include from your family and community in your treatment?
11. With whom should we share results of your treatment?

NOTE: The LEARN model and above questions can also be applied to any clinical encounter – even when cultural differences are not as critical.

There are several other models that may also be used in the cross-cultural clinical encounter. For more information, please view the following links:

BATHE Model (Background/Affect/Trouble/Handling/Empathy)

Kleinman’s Explanatory Model

For a faith-based approach, visit the following:

Campinha-Bacote’s Culturally Competent Model of Care

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