A warning (I feel like I give warnings a lot about my posts, what is that about?) – for one of my MPH classes, the challenge for our final paper was to pick a current topic in medicine/healthcare/health policy and write about the effects on health care access, quality, and cost. This post is therefore rather LONG. Brace yourselves, breathe deeply… it’ll be okay. But if you have any question as to what I eventually want to do with my life – this is just a taste.
The paper starts with a reference to Dr Pauline Chen’s Well Blog on the NYTimes – I’ve mentioned her many times before but this article is where my love for her blog came to be. I’ve linked her article in the blog post; the rest of the references are provided at the end. If you cant access them and are interested, let me know.
Oh and an explanation/revelation – throughout medical school and residency, I never really placed a great emphasis on LGBT health. Which, as an provider within the LGBT community, is rather unfortunate. A friend once asked me if I was involved in any research or advocacy for the LGBT community – and I said no. Sure, I started a gay-straight alliance at my medical school; but LGBT health issues were never at the forefront of my mind. There was already so much to learn about “garden variety” medicine. I have to say that LGBT health issues are slowly becoming a passion of mine. Perhaps this paper is just the tip of iceberg. Enjoy!
In recent years, cultural competency has become a buzzword in medical schools across the United States as an opportunity to diminish health disparities between various racial, ethnic, and cultural groups. A recent article by Dr. Pauline Chen in the New York Times details a scenario highlighting the inadequacy of training with regard to lesbian, gay, bisexual, and transgender (LGBT) medical issues. The article notes the lasting implications of the lack of culturally competent care by describing the story of a transgender patient undergoing a routine operation. Chen writes,
“the operation had gone well; but years later the doctor’s glaring oversight continued to haunt the rest of us. The patient had obviously not felt comfortable disclosing her transgender identity, and the doctor had clearly not asked the right questions.”1
Chen argues that many healthcare providers are well versed in treating cancer and curing infections but are “lost” when caring not only for transgender patients, but all LGBT patients.1 The article points to a growing body of literature detailing the failures of cultural competency in medical education, particularly in the area of LGBT health.2–5 As more data regarding health disparities unfolds, cultural competence clearly plays an important role in reducing these disparities in the healthcare system. The questions remain, however, over existing policy regarding culturally sensitive education and the effects of culturally competent care on access, quality, and cost.
Federal legislation regarding cultural competency remains minimal at best.4 Article VI of the Civil Rights Act was the first step toward eliminating culturally based health disparities by specifically prohibiting discrimination by agencies receiving federal funding, including hospitals receiving Medicare dollars. The Department of Health and Human Services (HHS) addressed health disparities in the Healthy People initiatives; sadly HHS noted a surprising increase in disparities among 13% of the Healthy People 2010 objectives. The dramatic increase in health disparities seen during the last decade heavily influence the Healthy People 2020 objectives, with specific mention of LGBT related health issues as a new objective.6 In association with the Institute for Healthcare Improvement, HHS also developed the Health Disparity Collaborative to address racial and ethnic disparities at federally funded community health clinics.4 Research to address culturally related healthcare disparities is sponsored at the federal level by the National Institutes of Health and the Agency for Healthcare Research and Quality; however, many of these initiatives are largely focused on improving language barriers between providers and patients.4 Furthermore, the Healthy People guidelines and federally funded research do not constitute federal legislation or regulations, and therefore carry little weight with regard to legal ramifications for failing to promote culturally competent care.
A handful of states have initiated legislative actions to augment federal policy. California and New Jersey currently mandate education in “culturally competent patient care” in order to obtain and maintain professional licensure.7 Largely in response to the lack of federal policy, several professional medical organizations including the Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Accreditation Council of Graduate Medical Education (ACGME) developed accreditation standards to improve undergraduate and graduate medical education. According to the AAMC,
“with the increasing diversity in the U.S. population and strong evidence of disparities in health care, it is critically important that health care professionals are specifically educated on how their own and their patients’ demographic… and cultural…factors influence health, health care delivery and health behaviors.”8
Furthermore, the AAMC has specifically recommended that medical education empower students to provide both excellent and comprehensive care to LGBT patients.5 Beginning in 2000, the AAMC and LCME mandated cultural competency education in undergraduate medical curricula; however, these standards are not tested nor are they universally implemented or standardized among medical schools.8
Among providers in the healthcare field, the importance of cultural competency and its effects on the healthcare system in relation to cost, access, and quality remains partly in question. The need for culturally competent care in the healthcare landscape is clear however, particularly with regard to LGBT health. Studies regarding LGBT related content in medical care and the abilities of medical students to care for this patient population have consistently revealed education gaps. A report by The Institute of Medicine in 2011 identified LGBT populations as facing “a profound and poorly understood set of additional health risks” as well as being “more likely to face barriers accessing appropriate medical care.”5 A 2007 survey of over 700 physicians from California indicated that almost 20% of respondents felt uncomfortable providing care to “gay patients”. Of all medical schools in the United States and Canada, one third reported dedicating no time toward LGBT content during the clinical years of medical education, while the median reported time was a mere 5 hours. While nearly all medical schools reported teaching students to ask LGBT patients about the gender of their sexual partners, more than 25% of schools did not teach students that sexual behavior and identity are disparate issues. Additionally, over 75% of deans reported the coverage of LGBT related health issues at their medical schools to be fair, poor, or very poor.5
Further research indicates that LGBT patients are aware of the lack of knowledge among medical professionals. Patients often report feeling uncomfortable with providers who are insensitive to or lack the knowledge about LGBT issues; many stated this impeded their ability to access basic as well as high quality care.9 By facilitating better communication between providers and patients, cultural competence is thought to promote quality by improving both patient satisfaction and outcomes through increasing adherence to medical regimens. Educating providers to understand the relationship between cultural beliefs and behaviors only serves to improve the quality of care for diverse populations. Culturally competent care aims to alter the “one size fits all” system to one that better responds to the needs of patients, thus simultaneously improving quality and access to care by increasing the number of knowledgeable and sensitive medical providers for culturally diverse patients.4
The effects of cultural competency on decreasing costs are less clear. Certainly providing care with the knowledge of a patient’s cultural background does not increase costs to the system. Managed care companies and the insurance industry at-large believe that culturally sensitive care may help control costs by improving patient outcomes through greater compliance. Cultural competence may ultimately help to “control costs by making care more effective and efficient.”4 Clearly the concept of “effective and efficient” care is a major component of the Patient Protection and Affordable Care Act through the introduction of Accountable Care Organizations (ACOs). While the Affordable Care Act makes provisions for improving cultural competency by promoting greater physician diversity, knowledge of cultural competency may prove critical to improving patient satisfaction and outcomes in a coordinated care system.
1. Doctor and Patient: L.G.B.T. Issues Neglected in Medical Schools – NYTimes.com. Available at: http://well.blogs.nytimes.com/2011/11/10/medical-schools-teach-little-about-gay-health-issues/?emc=eta1.
2. Pearson C. Are Medical Schools Ignoring LGBT Health? Huffington Post. 2011. Available at: http://www.huffingtonpost.com/2011/09/06/medical-schools-lgbt-health_n_950496.html.
3. Curry RH. Capturing curricula. JAMA. 2011;306(9):997-998.
4. Betancourt JR, Green AR, Carrillo JE, Park ER. Cultural Competence And Health Care Disparities: Key Perspectives And Trends. Health Affairs. 2005;24(2):499 -505.
5. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971-977.
6. Healthy People 2020 – Improving the Health of Americans. Available at: http://www.healthypeople.gov/2020/default.aspx.
7. amednews: Mandating cultural competency: Should physicians be required to take courses? :: Oct. 19, 2009. 2009. Available at: http://www.ama-assn.org/amednews/2009/10/19/prsa1019.htm.
8. Tool for Assessing Cultural Competence Training (TACCT) – Initiatives – AAMC. Available at: https://www.aamc.org/initiatives/tacct/
9. Sanchez NF, Rabatin J, Sanchez JP, Hubbard S, Kalet A. Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients. Fam Med. 2006;38(1):21-27.