Reducing Disparities Through Cultural Competence:
By David Mckay Wilson
In our increasingly globalized society, cultural competence is crucial in the delivery of health care to patients from around the world. The way patients perceive illness, communicate their symptoms to professionals, and take to treatment modalities can depend, in part, on their cultural background. Culturally competent care requires a dedication by healthcare professionals to consider the attitudes, values and behaviors that are influenced by the worlds in which their patients live.
Digest Magazine caught up with eight alumni to learn about how cultural competence informs their work in diverse communities—from Philadelphia to a Navajo reservation in New Mexico to the back streets of Quito, Ecuador. These stories detail the issues that arise, and how the healthcare professionals—cognizant of cultural attitudes—respond in ways that promote healing while respecting their patients.
John N. Boll, DO ’98
When Dr. Boll grew up in Pennsylvania’s Lancaster County, his family physician, Joel Samitt, DO ’64, had a large practice among the region’s Amish families, many of whom depend on lay healers for primary care but seek out mainstream medicine for acute care.
Today, Dr. Samitt is Dr. Boll’s role model as he serves as assistant director of the Williamsport Family Medicine Residency Program, in central Pennsylvania, where he’s building on the Williamsport Regional Medical Center’s long-standing service to the Amish community.
He says the Amish, who can be leery of mainstream medicine, gravitate to practitioners who respect their culture. “Word gets around in the community,” says Dr. Boll, who did a three-year residency in Williamsport and returned to the area in 2012.
The Amish come for care in Williamsport, either with a major medical problem, or a nagging illness that has yet to heal after being diagnosed and treated by their community’s non-licensed healthcare provider.
Afterwards start the negotiations as the cost of medical services can be a major issue. Most Amish lack health insurance, so their medical care is covered by their community’s own aid program. The Amish are engaged healthcare consumers. So they take their time to consider whether to undergo certain diagnostic tests.
“They may want to think on it or seek out another opinion,” Dr. Boll says. “There are many levels of deciding. They may decide they don’t want the test. They are willing to live with the uncertainty.”
Most important, he says, is to establish a relationship of trust early on, and then work with the patient to come up with a treatment plan. That means understanding patients’ financial constraints, their cost-consious nature, and the non-traditional treatments they had received from the community’s lay healers.
At times, that can be difficult for a physician, especially when a patient opts to live with an ailment instead of pursuing the full panoply of diagnostic tests and aggressive treatment.
He recalls one Amish patient who arrived at his clinic complaining of fatigue and blurred vision. She’d been diagnosed with Lyme disease. Dr. Boll’s testing determined she didn’t have Lyme, and he referred her to a neurologist who wanted to conduct a battery of tests. She met with the neurologist, but decided against the testing regimen.
“As a provider, you want to answer all the questions, get them the diagnosis and get them improved,” says Dr. Boll. “We still don’t know why her vision is blurred. But she’s OK with that, whereas other patients might not be.”
Charmaine San Yee Chan, DO ’05
Dr. Chan, an instructor in family medicine, works two days a week at PCOM’s Family Medicine Clinic in Rowland Hall, where she sees patients from all walks of life.
Dr. Chan, who emigrated with her family from Hong Kong to the United States when she was age 12, says it’s important to understand the cultural and ethnic background of her patients as she begins an exam. Having worked in Indonesia for two years after graduating from Vassar College, she’s aware of gender sensitivities of those from the Muslim world. She has learned that men prefer male providers, and women want female practitioners to examine them.
“I’m trying to make our staff cognizant of it, so we don’t make a mistake,” says Dr. Chan, who returned to PCOM in 2012 after serving three years with the National Health Service on a Navajo Indian reservation in New Mexico, and a one-year stint as a physician for the U.S. Armed Forces in Virginia.
On the reservation, Dr. Chan provided care to a population that drives up to four hours through the high desert to visit the clinic and hospital. There, she worked to overcome language barriers and a mistrust of the health service among a community with a high rate of teen suicide, depression, diabetes and injuries from motor vehicle crashes.
She found the Navajo were quite receptive to osteopathic manipulative medicine, as the traditional Navajo healers also use hands-on therapies. “We started an OMM clinic and they loved it,” says Dr. Chan.
Dr. Chan says it’s important to consider a patient’s socioeconomic background when crafting a treatment plan—especially for patients without health insurance, or with plans that carry hefty co-pays for medication or office visits. “You need to be aware of the cost of medication you are prescribing,” she says. “And if your patient is coming to the clinic by bus, you want to be sure to send them to a specialist who is local.”
Dr. Chan also takes special care with the developmentally disabled adults who are treated at the PCOM clinic and the Roxborough Health Care Clinic in Philadelphia’s Roxborough neighborhood. She has found that addressing the developmentally disabled patients—and not just their caregivers—pays off. She teaches the PCOM medical students this approach in the clinic.
“Some of the students can be a little afraid, because they’ve never been exposed to this invisible population,” Dr. Chan says. “Too often the developmentally disabled are ignored. But even if they can’t talk to you, the fact that you say ‘hi’ to them makes them react so differently. If you address them, they’ll often cooperate in the exam.”
Robert Evans, DO ’98
To overcome disparities in health care in New York City’s South Jamaica, Queens, neighborhood, in 2009 Dr. Evans founded a healthcare management company that today serves 7,000 patients in three primary care clinics. His company, Community Wellness Centers of America, has helped integrate care for thousands of residents in Queens, a New York City borough with about 2 million residents, which has seen the closure of several community hospitals in recent years. “We’ve built an infrastructure where people can come for multiple-specialty care,” says Dr. Evans. “It’s working.”
He’s also building what he calls a “diabetes center of excellence” for early detection and treatment of a disease that affects one in eight adult New York City residents, according to a city health department report. And many of those New Yorkers with diabetes don’t yet know they have the disease.
Risk factors for Type 2 diabetes include obesity, physical inactivity, high blood pressure and race, with African Americans and Latinos more likely than Caucasians to contract the disease. The center aims to provide the setting for a holistic approach to combatting the disease that addresses the multi-faceted pathology through education, treatment and case management with electronic medical records.
The center will include lectures on diet and exercise—two key ways to fight diabetes. “The majority of African Americans with diabetes end up getting it because of their lifestyle,” says Dr. Evans, who keeps fit riding his bike. “We need education about obesity, the food people eat and its relationship to diabetes. When you go into some African American communities, you’ll see people eating food that is high in fat and cholesterol.”
For Dr. Evans, building the diabetes center is a way to improve health outcomes in the neighborhood where he was raised. He came to PCOM at age 36, after a three-year stint playing professional basketball in Germany, 10 years as a New York City police officer, and studies in biomedical research at Delaware State University.
Dr. Evans has found that combatting disparities in health care for underserved racial minorities takes more than top-class care in the clinic or hospital. It can also involve creating institutions within these communities to provide the care, and making linkages with elected officials to finance those dreams. The diabetes center will be built with the assistance of a $5 million state grant.
He’s also working with Stephen Benjamin, the mayor of the city of Columbia, South Carolina, on establishing a diabetes center there. “South Carolina has one of the nation’s highest rates of diabetes,” says Dr. Evans. “The mayor saw what we were doing in Queens, and thinks it would work in Columbia.”
Amanda Fischer, DO ’11 (GA–PCOM)
Dr. Fischer’s medical education—and Christian faith—has brought her face-to-face with underserved populations all over the world.
Dr. Fischer, in 2008, went by boat up the Amazon River on a medical mission trip to provide health care to villagers in remote Brazilian communities. The next year, she traveled with the Christian Medical and Dental Association to a town on Honduras’ northern Caribbean coast to assist in surgeries for women in a rudimentary operating room.
In Georgia county clinics, she treated indigent patients during her residency rotations. “The patients in the county clinics appreciate what we strive to do for them,” she says. “Many of them have had to fight to get care.”
Once she completes her board exams, and begins working in a family medicine practice in Rome, Georgia, Dr. Fischer plans on volunteering at The Free Clinic of Rome, a faith-based nonprofit agency that provides health care to the uninsured of Floyd, Polk and Chattooga counties in northwest Georgia.
“I want to give back to my community,” says Dr. Fischer, in the third year of the Floyd Family Medicine Residency in Rome. “I want to do my part to provide care to those who can’t go to the other clinics.”
With a population of 36,000, Rome is the region’s largest municipality and the healthcare destination for residents from across the rural countryside. A burgeoning Latino community has grown up as immigrants arrive to work on local farms. Learning Spanish to better communicate with these patients without the need of a translator is among Dr. Fischer’s long-term goals.
“We have translators for many of those we treat in indigent care,” she says. “You worry if they are conveying all that you are trying to convey. You wonder how much is lost in translation.”
Dr. Fischer, who grew up in the southeast Georgia town of Claxton, was a music major at Georgia Southern, and then transferred to biology as she considered following her father into a career in physical therapy. But at a meeting of the university’s pre-medical professionals group, she learned about PCOM’s Georgia Campus in Suwanee, which opened in 2005. She liked what she heard—especially about osteopathic medicine’s holistic approach to healing. She arrived in 2007, as part of the campus’ third entering class.
“It really hit home for me,” she recalls. “It was related to PT as well, with the hands-on techniques. I liked the philosophy behind it.”
Evelyn Partridge, DO ’79
Dr. Partridge was among two African Americans in PCOM’s class of 1979, and the only black woman among those 211 fledgling physicians.
Thirty-four years later, Dr. Partridge, who has a solo family practice in Philadelphia’s Frankford neighborhood, serves patients from the broad spectrum of racial and ethnic groups: African American, Latino, Caucasian, Asian and Haitian. “You have to understand where a patient is coming from, and break things down in ways that help them understand it better,” says Dr. Partridge, who grew up in north central Philadelphia.
Those sensitivities extend to gender. Studies show that minorities and women have been underrepresented in some clinical trials used by pharmaceutical companies to test the viability of new drugs. That means that the drugs may not necessarily work as well on those underrepresented groups.
To combat that bias, Dr. Partridge has worked with the Eastern Cooperative Oncology Group to include women from her practice in the clinical trials of a drug that researchers hope will prevent breast cancer. The group allowed Dr. Partridge to help conduct trial in her primary care setting.
“We know that women with chest complaints are treated differently [from men],” says Dr. Partridge, who serves on the vestry of the George W. South Church of the Advocate in Philadelphia. “It really helped that we could accrue that trial in a family medicine setting where they felt comfortable.”
Dr. Partridge’s solo practice takes her around the city most Fridays on house calls she does in part with a local visiting nurses association. The service allows her to assess the health of her bedridden patients, and see how their environment might be changed to help in their recovery. She’ll also consider the home environment to determine if changing the surroundings, or bringing in more staff assistance, could very well improve a patient’s health or prevent a life-threatening injury.
“You look at their support systems, and see if there are any safety issues,” says Dr. Partridge. “It’s good to judge them in their own environment.”
Ramona Patillo, PsyD ’13
Prior to the summer of 2013, school psychologist Dr. Patillo often felt frustrated when assessing Latino students because of her inability to communicate with their Spanish-speaking parents, who might provide insight into their offspring’s behavioral issues or learning problems.
Then she traveled to Ecuador in June 2013 to become immersed in the language— living with a host family, studying the language, and working with South American children through the Ecuador Professional Preparation Program.
In Quito, she’d stay up each night until the wee hours, memorizing vocabulary and learning how to conjugate Spanish verbs. Her investment paid off handsomely. By the end of the four-week program, she’d become conversant with both children and adults, and had gained a deeper understanding of Hispanic culture.
“You can’t help people if you can’t communicate with them,” says Dr. Patillo, a school psychologist at the Redding Middle School in the Appoquinimink schools in Delaware’s New Castle County. “You need the language skills that go beyond the greeting. You need to understand what the parents are telling you, and they need to understand what you are saying to them.”
She caught a glimpse of different Ecuadorian populations during her stay. One week, her group worked with the impoverished preschool-age children of incarcerated fathers, who played aggressively but rarely cried with the rough-and-tumble interactions. At another setting, they dealt with the children of over-protective middle-class parents who appeared to coddle the children.
“We put together a program to communicate to the parents about typical development, for children from ages one to four,” she says. “We talked to parents about what they should expect from their typically developing children and provided them with strategies that they could use to help their children with academic and behavioral deficits.”
Dr. Patillo, the daughter of African American and Native American parents, grew up in North Philadelphia’s predominantly black Strawberry Mansion neighborhood. Her awareness of race and cultural differences was sharpened during her undergraduate years at Howard University, where she befriended Caucasian students, who were in the distinct minority at one of the nation’s leading historically black colleges.
“That’s where my perspective changed,” says Dr. Patillo, who previously worked as a school psychologist at schools in Wilmington and Camden, Delaware. “I got to thinking about how they felt to be minorities in an all-black university. I think I knew how they felt. I understood how it felt to be a fly in a bucket of milk.”
Gwendolyn Scott-Jones, PsyD ’08
As a clinical psychologist who conducts emergency room evaluations, Dr. Scott-Jones says that understanding a patient’s cultural background can help inform her diagnosis when she assessing the mental health of someone in crisis.
Dr. Scott-Jones, who works on-call at Nanticoke Memorial Hospital in Seaford, Delaware, says her decision could detain a patient involuntarily at a psychiatric hospital. But she needs to consider cultural factors when conducting the psychological assessment.
“Understanding culture diversity and relativity are very important in establishing rapport with a patient during an assessment. There are various cultural factors that must be taken into consideration when assessing an individual with a different cultural background. One must also take into account the individual’s schema. Not everyone needs to be involuntarily detained. Healthcare professionals need to understand the patient’s culture, and determine if he or she would best benefit from in-patient or out-patient treatment.” says Dr. Scott-Jones, associate professor and chair of the Department of Psychology at Delaware State College.
Dr. Scott-Jones, who also has a master’s degree in social work, came to PCOM for her doctorate in psychology after many years of providing forensic mental health treatment in Delaware state prisons and crisis intervention services for the state’s Division of Substance Abuse and Mental Health.
At times, Dr. Scott-Jones will be called into the hospital emergency room to evaluate a patient who doesn’t speak English. Instead of relying on family members, she’ll ask for a translator, who can serve as a non-biased interpreter. “The patient may become very guarded if a family member is serving as the translator,” says Dr. Scott-Jones. “The hospital’s translator can ensure that the clinician gets the most accurate information.”
On campus at Delaware State, she’s taking a proactive approach to overcoming the taboo of seeking mental health services by some in the African American community, who may face greater stressors in their lives as a result of racism and economic disparities. “We’re trying to alleviate the stigma of seeking out mental health treatment,” says Dr. Scott-Jones. “There are students who aren’t seeking help when they get stressed.”
Those patients may end up at their physician’s office, seeking help to heal a physical ailment. But it’s the nagging psychological problem that’s causing their inner pain. “They’ll come in complaining about a physical problem, and that comes from the taboo of wanting to get help for their personal distress,” she says. “We want them to seek mental health services instead.”
Ulrick Vieux, DO ’99
As director of mental health services within satellite clinics (which includes three New York City public schools) at the child and family institute of the Mt. Sinai Health System (St. Luke’s division), Dr. Vieux says it’s important to be aware of the issues confronting minority youth when they venture out on city streets.
For several years, the New York Police Department’s widespread stop-and-frisk policy—found unconstitutional in federal court in 2013—has targeted African American and Latino youths. These confrontations can have an impact on teens who are struggling with mental-health issues.
“Many times, students I’ve had in therapy talk about how they are harassed,” says Dr. Vieux, medical director of children’s community mental health services at St. Luke’s–Roosevelt Hospital on Manhattan’s Upper West Side. “These are things kids from other communities don’t have to suffer. And it can lead to feelings of helplessness.”
Dr. Vieux explores those issues in therapy sessions at the school-based clinics, where his mental-health team works with primary care providers who operate within the educational institutions. Dr. Vieux says these clinics embrace what’s called a “bio-psychosocial model” of medical care.
Understanding the culture in which a child has been raised can be crucial in determining the course of treatment. On occasions, changes in a child’s home environment can augment psycho- therapeutic intervention.
Dr. Vieux’s outreach extends into some of his patients’ homes, where, once a week, he’ll visit to get a better understanding of the challenges they face within their communities. His team includes intensive case coordinators—social workers who conduct up to six home visits a month for teens in need of support.
Dr. Vieux also visits the homes of students, many who come from impoverished families who live in public housing complexes. He recently visited the apartment of a child who was diagnosed with attention deficit hyperactivity disorder. The child’s teacher had suggested increasing the dosage of the amphetamine Adderall, in hopes the student would do better in homework assignments. During his visit, Dr. Vieux discovered that the home had neither a table on which the child could do his homework nor adequate lighting for reading; there was no need to increase medication.
“Visiting the child in their home builds empathy and can help with the treatment plan,” says Dr. Vieux, a psychoanalytic degree candidate at New York University’s Institute for Psychoanalytic Education. “You actually see where the patient is coming from, and it makes it easier to relate to them. Making those simple investments in a table and better lighting can really help that child.”