- Email: [email protected]
Cultural competency in diagnostic imaging1
Perspective
Cultural Competency in Diagnostic Imaging1 Frank H. Lee, John A. Worrell
This observational essay on cultural competency attempts to define cultural competency, its significance and relevance to radiology, and concludes with some reflections on the ethics of cross-cultural competency. The common perception that radiologists do not experience physician–patient interaction reflects a dated and incomplete understanding of the many roles that radiologists fulfill in a modern imaging department. For this observational essay on cultural competency, we studied a range of radiological subspecialties at a tertiary care medical center (Vanderbilt University Medical Center, in Nashville, Tennessee). Significant radiologist–patient interactions, especially in the areas of interventional radiology and women’s imaging, were readily apparent. Furthermore, a significant cross-cultural interaction was also present within the department as a whole in its dealings with a culturally diverse patient population. The staff of the radiology department in general was aware of the term “cultural competency,” but members of the staff had difficulty in articulating its full meaning, significance, and relevance to radiology. Practitioners of most radiological subspecialties were practicing a form of cultural competence without fully realizing it.
WHAT IS CULTURAL COMPETENCY? The definition of “cultural competency” is still evolving. Health care administrators, physicians, staff members of health-care facilities, and the public each emphasize different values of cultural competency. Perhaps it is not surprising to find that the very definition of cultural competency can depend on the culture of its origin. The funAcad Radiol 2005; 12:232–236 1 From the School of Medicine (F.H.L.) and the Department of Radiology and Radiological Sciences (J.A.W.), Vanderbilt University, Nashville, TN 37232-2675. Received September 23, 2004; revision requested November 8; revision received November 15; revision accepted November 16, 2004. Address correspondence to: J.A.W. e-mail: [email protected]
© AUR, 2005 doi:10.1016/j.acra.2004.11.018
232
damental idea of cultural competency may be expressed as follows: Cultural competency is “A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations” (1). In expanding on this general definition, the words “culture” and “competency” should be closely examined. Defining the term “culture” is not an easy task. Most people understand culture in its broadest sense, and interpret it as something that characterizes distinct groups. In considering a population, typical groupings are by sex, age, and race. Further division may involve nationality, ethnicity, and religion. The United States Census categorizes citizens according to such characteristics. However, there also exist a variety of subcultural categories, such as level of education, occupation, homelessness, and survivors of violence. Indeed, the subdivision of cultures is limitless. In general, culture can be defined as “integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” (2). The importance of identifying culture exists at two levels. At one level, an institution identifies a large group of persons who share a culture. This effort often produces groups categorized by language and for which medical translation services can be provided. An example is the identification of persons of Hispanic culture who require interpreters of medical Spanish. The functional identification of such broad cultural groups works well in providing broad support for patient care, as opposed to identifying all of the many different forms of Latin ethnicities. However, a problem arises when other cultures are ignored. A Hispanic patient from Puerto Rico may describe her symptoms as “fatiga,” which a Spanish interpreter from Spain translates as “tired.” However, in Puerto Rican Spanish, “fatiga” is used to describe wheezing from asthma (3). The next level of culture is the individual or personal level. A culturally competent physician can distinguish a patient’s personal culture. This personal culture is the
Academic Radiology, Vol 12, No 2, February 2005
convergence of multiple memberships in various cultural and subcultural groups that contribute to an individual’s personal identity (4). For example, a physician may mistakenly overgeneralize the strong tolerance of Vietnamese women to pain and automatically consider this characteristic as existing in a second-generation Vietnamese– American teenager. However, the Vietnamese–American teenager probably has a culture that differs markedly from that of her mother. The individual patient resides within a milieu of multiple cultures. “Competency” is also a word fraught with diverse implications. In the general context of multicultural practice, however, competency “implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities” (5). Cultural competency, like the importance of identifying culture, also works at two levels. At the institutional level, a competent health-care system requires: ●
●
●
A staff that respects [the] health-related beliefs, interpersonal styles, and attitudes and behaviors of the individuals, families, and communities it serves. Administrative, management, and clinical and organizational assessment and processes that strive to ensure a uniform and consistent response by all staff members in every policy, procedure, and interaction. Recruitment, retention, and training of staff members that reflect and respond to the values and demographics of the communities served (4).
A culturally competent institution recognizes the cultural values and needs of diverse groups and is able to interact with those values and needs in a respectful manner. Examples of institutional competency are translation services and multilingual signage. Competency at the individual level in encounters between a physician or staff member and a patient involves more specific interactive capabilities. A critical aspect of this interaction is a culturally sensitive approach to asking about a health problem. Some questions that a culturally competent physician may ask are as follows: ● ● ● ●
What do you call your problem? What do you think caused your problem? What do you fear most about your illness? What treatment do you think you should receive? (6)
CULTURAL COMPETENCY IN DIAGNOSTIC IMAGING
Some additional signs of competency include knowing when and how to use a language-interpretation service. For example, a physician should look and speak directly to the patient and not the interpreter. But above all, an open mind is the key to cultural competency.
WHY IS CULTURAL COMPETENCY IMPORTANT? In accord with long-standing predictions, the minority and foreign-born populations of the United States have increased significantly over the past several decades. In California, the “minority” populations became the majority in 1999 (5). Nashville, Tennessee, has experienced a three-fold increase in its foreign-born population in the past decade (7). It is clear that all parts of the United States are experiencing a significant influx of newcomers from around the globe. With their new cultures, these newcomers bring a host of opportunities and challenges to all medical facilities, from small rural clinics to large urban medical centers. Underscoring the importance of meeting these challenges is the observation that “racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income,” are taken into account (8). A major part of this disparity is in the interpersonal aspects of care, such as patient– physician communication (9). The practice of cultural competency by physicians and medical institutions is an effort to eliminate such disparities in health care. By providing the patient with a familiar means of communication and a comfortable and openminded environment, one can increase the quality of care while also increasing patient satisfaction.
RELEVANCE OF CULTURAL COMPETENCY IN RADIOLOGY Cultural competency is always relevant as long as there are multiple cultures being serviced by and within the radiology department. Multiple cultures and subcultures are served by radiology, in subspecialties such as emergency, general, interventional, and cardiothoracic radiology, nuclear imaging, and women’s imaging. There is also a subgrouping of services by profession, such as administrator, radiologist, technologist, nurse, transporter, and receptionist. Unique values and characteristics exist
233
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within each category. For example, although technologists and nurses work in overlapping areas of radiology, each serves different functions and receives particular training. Interventional radiologists work in the special-procedures suite as well as the recovery room, outpatient clinic, and at the patient’s bedside. On the other hand, radiologists at women’s imaging centers more closely resemble primarycare physicians because of the continuous care their population requires. Recognizing pluralism in oneself and one’s own department is a significant step toward recognizing pluralism in the patient population. Nevertheless, most radiologists have infrequent interactions with patients. Instead, staff personnel, including technologists and nursing staff members, largely handle the procedures for gathering patient data and interact with patients. Indeed, technologists often become the de facto representatives of radiologists in the procedure room. They come into immediate contact with the patient during pre- and post-procedural routines. It is the technologist who describes a radiologic procedure in layman’s terms to the patient. The technologist also frequently performs the procedure after explaining it. A technologist may be alone with a patient in a private setting, and will interact physically and verbally with the patient. Yet the technologist may be one of the least trained members of a diagnostic imaging team in the areas of patient interaction and cultural competency. In general, the burden of cultural competency falls on the radiology department as an institution, including technologists and nursing staff, with the radiologist assigned an enabling and supporting role. Perhaps the two biggest challenges a Radiology department faces in providing culturally competent care are the diversity of its patient population and the demands of time. Unlike other specialties, the radiology department does not separate its patient population. It does not differentiate by sex like OB/Gyn. It does not differentiate by age like geriatrics and pediatrics. Radiology receives patients of every culture, race, ethnicity, sex, age, and personal experience. It receives expecting mothers, hyperthyroid patients, and victims of domestic violence. The list is as diverse as there are illnesses that can be diagnosed. Also, the current state of radiology offers little opportunity for continuous care. Patient care is essentially a cross-sectional undertaking in radiology, although there may be multiple studies or procedures in a series. Except for portable examinations, patients either arrive for their appointments or transporters bring the patients from their rooms, technologists serve the patient’s radiological need, and the patient interaction is complete. The patient spends
234
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so little time in Radiology that there may not be sufficient time for any staff member to gain their trust and show significant form of cultural competency. Due to this problem, several radiologists questioned, “Do we even need cultural competency?” To explore this question, two subspecialties, Interventional Radiology and Women’s Imaging were closely examined for areas of radiologist-patient cross-cultural interactions. As it turns out, these two subspecialties involve significant radiologist-patient interaction and afford a possible paradigm for improving patient care by additional training in cultural competency. Interventional Radiology Interventional Radiology (IR) is different from most other subspecialties of radiology because of direct patientradiologist contact. An IR suite resembles a surgical operating theater more than it resembles most other radiological facilities. In IR, the radiologist obtains informed consent and also gives the pre- and post-procedural instructions. Significantly, the procedure is done by the radiologist, and the patients are awake during most procedures. In IR, therefore, the burden of cultural competency rests more on the radiologist than any other radiological subspecialty. The interventional radiologist must perform the pre- and post-procedural routines that include explanation of procedure, risks, benefits, informed consent, and post procedural interactions. These are obvious areas of patient care where cultural competency plays an important role. But unlike most surgeons, the interventional radiologist interacts with the patient during the procedure as well. Most often, the patient is under conscious sedation. The patient can hear all that is going on. These patients potentially experience pain and discomfort during invasive procedures and can see and sense tubes being placed into their body. The IR suite is probably the most overlooked area in which cultural competency could be practiced. Words of comfort and encouragement, and explanations of what’s happening during a procedure can go a long way in helping the patient feel safer and involved. Ignoring a conscious patient during a procedure can appear insensitive and objectifying to the patient. Also in the operating room or interventional suite, it is important to recognize “ethnic styles” without over generalization. For example, certain Asian cultures encourage tolerance to pain. Southeastern Asian women are believed to endure much pain
Academic Radiology, Vol 12, No 2, February 2005
without expressing it. In contrast, Latino women are believed to express pain more readily (10). Women’s Imaging Unlike interventional radiology, women’s imaging deals exclusively with females. The majority of the procedures in women’s imaging specifically involve images of the female reproductive organs. Women’s imaging is also different from other radiological specialties in that there is long-term patient care. Women usually have screening mammograms once a year, and any additional studies as needed. The most apparent forms of cultural competency in women’s imaging are displayed throughout the building. These take the form of bouquets, elegant wallpapers, and soothing music. This stands in dramatic contrast to other radiological subspecialties that present a mostly sterile appearance. Such spa-like experience in women’s imaging is an attempt at appealing to an area of women’s culture. By combining radiology with a spa-like environment as opposed to a sterile hospital-like environment, women’s imaging centers attempt to reduce the anxiety of their patients. Women’s imaging centers also have the unusual burden of additional federal regulations via the Mammography Quality Standards Act (MQSA). Included in this act is a requirement of notification to the patient in the form of a letter. When a patient has been screened for breast cancer, a formal letter must be sent to the patient indicating that the tests were negative or that the patient must return for further studies or procedures. The unfortunate part of this requirement is that the letter does not have to be culturally and linguistically competent. Although a patient at the center may request an interpreter, the post-procedural letter is not required to conform to the culture and language of the patient. Once the patient has left the building, the need to provide continuous linguistic services seems to leave with the patient. The notification letter is written only in English, perhaps at a sixth grade reading level. However, it is possible that many recent immigrants and first generation immigrants will not be able to decipher this letter. This leads to the possibility that a third party, perhaps an English-speaking child, relative, or neighbor, will be entrusted with the power of translation. At the root of this problem is that there is no connection between interpreter services and post-procedural services. If a patient requests a translator for the duration of her stay, it may be a good
CULTURAL COMPETENCY IN DIAGNOSTIC IMAGING
idea to send a translated letter as a part of post-procedural cultural competency.
CONCLUSION Cultural competency is in many respects an ethical balancing act. It involves learning about culture, the embrace of pluralism, and accommodation. Instead of viewing cultural competency as a means to achieving a utilitarian form of happiness, cultural competency should be viewed as being an integral part of the duty of a physician. In other words, cultural competency should be practiced not because it makes the most people happy but because it is the right thing to do (11). However, after a physician learns of culture and cultures and embraces pluralism, how are the limits of accommodation identified? How will patient autonomy and social justice be weighed? Take for example the case of a white male undergoing heart surgery who demands that a black pump technician not be present. The patient clearly prefers a “whites only” operating room. Should the surgeon comply and ask the black technician to leave the operating room? Is this a form of cultural competency? Included in the gray areas of cultural competency are the pitfalls of stereotype, prejudice, and racism. Over-generalizations and over-emphasis on defining the patient by his culture can result in negative repercussions. Over accommodation can also lead to a bottomless pit of relativity in which physicians are asked to accommodate unjust requests for the sake of multiculturalism. Clearly there are many ethical considerations contained in the concept of cultural competence. But the primary importance of cultural competence is to improve the quality of health care for everyone, including the care of persons of different cultures in the United States. The idea of cultural competency implies that the largest portion of the changes and accommodations to achieve better care for a multicultural society should be made on the side of the health care system. It asks that the health care system be more flexible in understanding and accepting patients of different cultures. Physicians are asked to carry much of this burden. In a specialty like radiology where most patient contact seems dismissed as insignificant or appears to be pushed to the technicians and nurses, radiologists should step forward and take more interest in their patients. IR and Women’s imaging are two areas of radiology where significant and sensitive cross-cultural interaction can lead to better care. If
235
LEE AND WORRELL
seeing through the body is the business of radiologists, then perhaps it will be an easier transition for radiologists to recognize the cultures that reside in every individual. ACKNOWLEDGMENTS
We thank Peter R. Bream Jr, M.D. and Cheryl R. Herman, M.D., and Elizabeth Heitman, Ph.D. for their help and encouragement in this project. REFERENCES 1. U.S. Department of Health and Human Services, OPHS, Office of Minority Health, Assuring cultural competence in Health Care: Recommendations for National Standards and Outcomes Focused Research Agenda, 1999. 2. Anderson LM, Scrimshaw SC, et al. Culturally Competent Healthcare Systems: A Systematic Review. Am J Prev Med 2003; 24(3S). 3. U.S. Department of Health and Human Services, Health Resources and Services Administration, Mitigating Health Disparities Through Cultural Competence, Aug 2002. copy available at http://hab.hrsa.gov.
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4. Health Resources and Services Administration, U.S. Department of Health and Human Services, Cultural Competency Works 2001. 5. U.S. Department of Health and Human Services, OPHS, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care: Executive Summary, Contract #28299-0039 March 2001. 6. Kleinman A. Patients and Healers in the Context of Culture. Berkeley, CA: University of California Press; 1980. 7. Cornfield DB, Arzubiaga A, BeLue R, et al. Final Report of the Immigrant Community Assessment, Prepared under contract #14830 for Metropolitan Government of Nashville and Davidson County, TN, Aug 15, 2003. 8. Smedley BD, Stith AY, Nelson AR. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Healthcare, et al. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, D.C.: National Academy of Sciences, Institutes of Medicine, 2002. 9. Cooper LA, Roter DL, Johnson RL, et al. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med 2003; 139:907–915. 10. Chesanow N. The versatile doctor’s guide to ethnic diversity. Medical Economics Sep 7, 1998; 135–146. 11. Paasche-Orlow M. The ethics of cultural competence. Acad Med 2004; 79:347–350.
Cultural Competency in Diagnostic Imaging1 Frank H. Lee, John A. Worrell
This observational essay on cultural competency attempts to define cultural competency, its significance and relevance to radiology, and concludes with some reflections on the ethics of cross-cultural competency. The common perception that radiologists do not experience physician–patient interaction reflects a dated and incomplete understanding of the many roles that radiologists fulfill in a modern imaging department. For this observational essay on cultural competency, we studied a range of radiological subspecialties at a tertiary care medical center (Vanderbilt University Medical Center, in Nashville, Tennessee). Significant radiologist–patient interactions, especially in the areas of interventional radiology and women’s imaging, were readily apparent. Furthermore, a significant cross-cultural interaction was also present within the department as a whole in its dealings with a culturally diverse patient population. The staff of the radiology department in general was aware of the term “cultural competency,” but members of the staff had difficulty in articulating its full meaning, significance, and relevance to radiology. Practitioners of most radiological subspecialties were practicing a form of cultural competence without fully realizing it.
WHAT IS CULTURAL COMPETENCY? The definition of “cultural competency” is still evolving. Health care administrators, physicians, staff members of health-care facilities, and the public each emphasize different values of cultural competency. Perhaps it is not surprising to find that the very definition of cultural competency can depend on the culture of its origin. The funAcad Radiol 2005; 12:232–236 1 From the School of Medicine (F.H.L.) and the Department of Radiology and Radiological Sciences (J.A.W.), Vanderbilt University, Nashville, TN 37232-2675. Received September 23, 2004; revision requested November 8; revision received November 15; revision accepted November 16, 2004. Address correspondence to: J.A.W. e-mail: [email protected]
© AUR, 2005 doi:10.1016/j.acra.2004.11.018
232
damental idea of cultural competency may be expressed as follows: Cultural competency is “A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations” (1). In expanding on this general definition, the words “culture” and “competency” should be closely examined. Defining the term “culture” is not an easy task. Most people understand culture in its broadest sense, and interpret it as something that characterizes distinct groups. In considering a population, typical groupings are by sex, age, and race. Further division may involve nationality, ethnicity, and religion. The United States Census categorizes citizens according to such characteristics. However, there also exist a variety of subcultural categories, such as level of education, occupation, homelessness, and survivors of violence. Indeed, the subdivision of cultures is limitless. In general, culture can be defined as “integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” (2). The importance of identifying culture exists at two levels. At one level, an institution identifies a large group of persons who share a culture. This effort often produces groups categorized by language and for which medical translation services can be provided. An example is the identification of persons of Hispanic culture who require interpreters of medical Spanish. The functional identification of such broad cultural groups works well in providing broad support for patient care, as opposed to identifying all of the many different forms of Latin ethnicities. However, a problem arises when other cultures are ignored. A Hispanic patient from Puerto Rico may describe her symptoms as “fatiga,” which a Spanish interpreter from Spain translates as “tired.” However, in Puerto Rican Spanish, “fatiga” is used to describe wheezing from asthma (3). The next level of culture is the individual or personal level. A culturally competent physician can distinguish a patient’s personal culture. This personal culture is the
Academic Radiology, Vol 12, No 2, February 2005
convergence of multiple memberships in various cultural and subcultural groups that contribute to an individual’s personal identity (4). For example, a physician may mistakenly overgeneralize the strong tolerance of Vietnamese women to pain and automatically consider this characteristic as existing in a second-generation Vietnamese– American teenager. However, the Vietnamese–American teenager probably has a culture that differs markedly from that of her mother. The individual patient resides within a milieu of multiple cultures. “Competency” is also a word fraught with diverse implications. In the general context of multicultural practice, however, competency “implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities” (5). Cultural competency, like the importance of identifying culture, also works at two levels. At the institutional level, a competent health-care system requires: ●
●
●
A staff that respects [the] health-related beliefs, interpersonal styles, and attitudes and behaviors of the individuals, families, and communities it serves. Administrative, management, and clinical and organizational assessment and processes that strive to ensure a uniform and consistent response by all staff members in every policy, procedure, and interaction. Recruitment, retention, and training of staff members that reflect and respond to the values and demographics of the communities served (4).
A culturally competent institution recognizes the cultural values and needs of diverse groups and is able to interact with those values and needs in a respectful manner. Examples of institutional competency are translation services and multilingual signage. Competency at the individual level in encounters between a physician or staff member and a patient involves more specific interactive capabilities. A critical aspect of this interaction is a culturally sensitive approach to asking about a health problem. Some questions that a culturally competent physician may ask are as follows: ● ● ● ●
What do you call your problem? What do you think caused your problem? What do you fear most about your illness? What treatment do you think you should receive? (6)
CULTURAL COMPETENCY IN DIAGNOSTIC IMAGING
Some additional signs of competency include knowing when and how to use a language-interpretation service. For example, a physician should look and speak directly to the patient and not the interpreter. But above all, an open mind is the key to cultural competency.
WHY IS CULTURAL COMPETENCY IMPORTANT? In accord with long-standing predictions, the minority and foreign-born populations of the United States have increased significantly over the past several decades. In California, the “minority” populations became the majority in 1999 (5). Nashville, Tennessee, has experienced a three-fold increase in its foreign-born population in the past decade (7). It is clear that all parts of the United States are experiencing a significant influx of newcomers from around the globe. With their new cultures, these newcomers bring a host of opportunities and challenges to all medical facilities, from small rural clinics to large urban medical centers. Underscoring the importance of meeting these challenges is the observation that “racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income,” are taken into account (8). A major part of this disparity is in the interpersonal aspects of care, such as patient– physician communication (9). The practice of cultural competency by physicians and medical institutions is an effort to eliminate such disparities in health care. By providing the patient with a familiar means of communication and a comfortable and openminded environment, one can increase the quality of care while also increasing patient satisfaction.
RELEVANCE OF CULTURAL COMPETENCY IN RADIOLOGY Cultural competency is always relevant as long as there are multiple cultures being serviced by and within the radiology department. Multiple cultures and subcultures are served by radiology, in subspecialties such as emergency, general, interventional, and cardiothoracic radiology, nuclear imaging, and women’s imaging. There is also a subgrouping of services by profession, such as administrator, radiologist, technologist, nurse, transporter, and receptionist. Unique values and characteristics exist
233
LEE AND WORRELL
within each category. For example, although technologists and nurses work in overlapping areas of radiology, each serves different functions and receives particular training. Interventional radiologists work in the special-procedures suite as well as the recovery room, outpatient clinic, and at the patient’s bedside. On the other hand, radiologists at women’s imaging centers more closely resemble primarycare physicians because of the continuous care their population requires. Recognizing pluralism in oneself and one’s own department is a significant step toward recognizing pluralism in the patient population. Nevertheless, most radiologists have infrequent interactions with patients. Instead, staff personnel, including technologists and nursing staff members, largely handle the procedures for gathering patient data and interact with patients. Indeed, technologists often become the de facto representatives of radiologists in the procedure room. They come into immediate contact with the patient during pre- and post-procedural routines. It is the technologist who describes a radiologic procedure in layman’s terms to the patient. The technologist also frequently performs the procedure after explaining it. A technologist may be alone with a patient in a private setting, and will interact physically and verbally with the patient. Yet the technologist may be one of the least trained members of a diagnostic imaging team in the areas of patient interaction and cultural competency. In general, the burden of cultural competency falls on the radiology department as an institution, including technologists and nursing staff, with the radiologist assigned an enabling and supporting role. Perhaps the two biggest challenges a Radiology department faces in providing culturally competent care are the diversity of its patient population and the demands of time. Unlike other specialties, the radiology department does not separate its patient population. It does not differentiate by sex like OB/Gyn. It does not differentiate by age like geriatrics and pediatrics. Radiology receives patients of every culture, race, ethnicity, sex, age, and personal experience. It receives expecting mothers, hyperthyroid patients, and victims of domestic violence. The list is as diverse as there are illnesses that can be diagnosed. Also, the current state of radiology offers little opportunity for continuous care. Patient care is essentially a cross-sectional undertaking in radiology, although there may be multiple studies or procedures in a series. Except for portable examinations, patients either arrive for their appointments or transporters bring the patients from their rooms, technologists serve the patient’s radiological need, and the patient interaction is complete. The patient spends
234
Academic Radiology, Vol 12, No 2, February 2005
so little time in Radiology that there may not be sufficient time for any staff member to gain their trust and show significant form of cultural competency. Due to this problem, several radiologists questioned, “Do we even need cultural competency?” To explore this question, two subspecialties, Interventional Radiology and Women’s Imaging were closely examined for areas of radiologist-patient cross-cultural interactions. As it turns out, these two subspecialties involve significant radiologist-patient interaction and afford a possible paradigm for improving patient care by additional training in cultural competency. Interventional Radiology Interventional Radiology (IR) is different from most other subspecialties of radiology because of direct patientradiologist contact. An IR suite resembles a surgical operating theater more than it resembles most other radiological facilities. In IR, the radiologist obtains informed consent and also gives the pre- and post-procedural instructions. Significantly, the procedure is done by the radiologist, and the patients are awake during most procedures. In IR, therefore, the burden of cultural competency rests more on the radiologist than any other radiological subspecialty. The interventional radiologist must perform the pre- and post-procedural routines that include explanation of procedure, risks, benefits, informed consent, and post procedural interactions. These are obvious areas of patient care where cultural competency plays an important role. But unlike most surgeons, the interventional radiologist interacts with the patient during the procedure as well. Most often, the patient is under conscious sedation. The patient can hear all that is going on. These patients potentially experience pain and discomfort during invasive procedures and can see and sense tubes being placed into their body. The IR suite is probably the most overlooked area in which cultural competency could be practiced. Words of comfort and encouragement, and explanations of what’s happening during a procedure can go a long way in helping the patient feel safer and involved. Ignoring a conscious patient during a procedure can appear insensitive and objectifying to the patient. Also in the operating room or interventional suite, it is important to recognize “ethnic styles” without over generalization. For example, certain Asian cultures encourage tolerance to pain. Southeastern Asian women are believed to endure much pain
Academic Radiology, Vol 12, No 2, February 2005
without expressing it. In contrast, Latino women are believed to express pain more readily (10). Women’s Imaging Unlike interventional radiology, women’s imaging deals exclusively with females. The majority of the procedures in women’s imaging specifically involve images of the female reproductive organs. Women’s imaging is also different from other radiological specialties in that there is long-term patient care. Women usually have screening mammograms once a year, and any additional studies as needed. The most apparent forms of cultural competency in women’s imaging are displayed throughout the building. These take the form of bouquets, elegant wallpapers, and soothing music. This stands in dramatic contrast to other radiological subspecialties that present a mostly sterile appearance. Such spa-like experience in women’s imaging is an attempt at appealing to an area of women’s culture. By combining radiology with a spa-like environment as opposed to a sterile hospital-like environment, women’s imaging centers attempt to reduce the anxiety of their patients. Women’s imaging centers also have the unusual burden of additional federal regulations via the Mammography Quality Standards Act (MQSA). Included in this act is a requirement of notification to the patient in the form of a letter. When a patient has been screened for breast cancer, a formal letter must be sent to the patient indicating that the tests were negative or that the patient must return for further studies or procedures. The unfortunate part of this requirement is that the letter does not have to be culturally and linguistically competent. Although a patient at the center may request an interpreter, the post-procedural letter is not required to conform to the culture and language of the patient. Once the patient has left the building, the need to provide continuous linguistic services seems to leave with the patient. The notification letter is written only in English, perhaps at a sixth grade reading level. However, it is possible that many recent immigrants and first generation immigrants will not be able to decipher this letter. This leads to the possibility that a third party, perhaps an English-speaking child, relative, or neighbor, will be entrusted with the power of translation. At the root of this problem is that there is no connection between interpreter services and post-procedural services. If a patient requests a translator for the duration of her stay, it may be a good
CULTURAL COMPETENCY IN DIAGNOSTIC IMAGING
idea to send a translated letter as a part of post-procedural cultural competency.
CONCLUSION Cultural competency is in many respects an ethical balancing act. It involves learning about culture, the embrace of pluralism, and accommodation. Instead of viewing cultural competency as a means to achieving a utilitarian form of happiness, cultural competency should be viewed as being an integral part of the duty of a physician. In other words, cultural competency should be practiced not because it makes the most people happy but because it is the right thing to do (11). However, after a physician learns of culture and cultures and embraces pluralism, how are the limits of accommodation identified? How will patient autonomy and social justice be weighed? Take for example the case of a white male undergoing heart surgery who demands that a black pump technician not be present. The patient clearly prefers a “whites only” operating room. Should the surgeon comply and ask the black technician to leave the operating room? Is this a form of cultural competency? Included in the gray areas of cultural competency are the pitfalls of stereotype, prejudice, and racism. Over-generalizations and over-emphasis on defining the patient by his culture can result in negative repercussions. Over accommodation can also lead to a bottomless pit of relativity in which physicians are asked to accommodate unjust requests for the sake of multiculturalism. Clearly there are many ethical considerations contained in the concept of cultural competence. But the primary importance of cultural competence is to improve the quality of health care for everyone, including the care of persons of different cultures in the United States. The idea of cultural competency implies that the largest portion of the changes and accommodations to achieve better care for a multicultural society should be made on the side of the health care system. It asks that the health care system be more flexible in understanding and accepting patients of different cultures. Physicians are asked to carry much of this burden. In a specialty like radiology where most patient contact seems dismissed as insignificant or appears to be pushed to the technicians and nurses, radiologists should step forward and take more interest in their patients. IR and Women’s imaging are two areas of radiology where significant and sensitive cross-cultural interaction can lead to better care. If
235
LEE AND WORRELL
seeing through the body is the business of radiologists, then perhaps it will be an easier transition for radiologists to recognize the cultures that reside in every individual. ACKNOWLEDGMENTS
We thank Peter R. Bream Jr, M.D. and Cheryl R. Herman, M.D., and Elizabeth Heitman, Ph.D. for their help and encouragement in this project. REFERENCES 1. U.S. Department of Health and Human Services, OPHS, Office of Minority Health, Assuring cultural competence in Health Care: Recommendations for National Standards and Outcomes Focused Research Agenda, 1999. 2. Anderson LM, Scrimshaw SC, et al. Culturally Competent Healthcare Systems: A Systematic Review. Am J Prev Med 2003; 24(3S). 3. U.S. Department of Health and Human Services, Health Resources and Services Administration, Mitigating Health Disparities Through Cultural Competence, Aug 2002. copy available at http://hab.hrsa.gov.
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4. Health Resources and Services Administration, U.S. Department of Health and Human Services, Cultural Competency Works 2001. 5. U.S. Department of Health and Human Services, OPHS, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care: Executive Summary, Contract #28299-0039 March 2001. 6. Kleinman A. Patients and Healers in the Context of Culture. Berkeley, CA: University of California Press; 1980. 7. Cornfield DB, Arzubiaga A, BeLue R, et al. Final Report of the Immigrant Community Assessment, Prepared under contract #14830 for Metropolitan Government of Nashville and Davidson County, TN, Aug 15, 2003. 8. Smedley BD, Stith AY, Nelson AR. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Healthcare, et al. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, D.C.: National Academy of Sciences, Institutes of Medicine, 2002. 9. Cooper LA, Roter DL, Johnson RL, et al. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med 2003; 139:907–915. 10. Chesanow N. The versatile doctor’s guide to ethnic diversity. Medical Economics Sep 7, 1998; 135–146. 11. Paasche-Orlow M. The ethics of cultural competence. Acad Med 2004; 79:347–350.