It seemed clear that Pedro S had finally come to terms
with the fact that he was dying — the cancer in his
lungs had spread rapidly. But, as he sat by his bed, Pedro's
doctor sensed that something else was weighing heavily
on his patient's mind. As they discussed palliative care
strategies, Pedro finally brought up what was really bothering
him — he'd never been baptized. The revelation left
the usually unfazed physician scrambling for an appropriate
response.
Cultural competency courses were
developed with situations like this in mind and to teach
physicians the soft skills needed to cope with these
kinds of patient concerns. The big question is: do they
work? And what about how physicians' religious beliefs
impact the clinical experience for patients? After all,
physicians are dynamic partners of the doctor-patient
relationship. Two US studies attempt to give us a more
complete picture of how doctor and patient beliefs shape
the clinical encounter.
CULTIVATING
CULTURE
In the US, a disparity in health outcomes between white
and non-white populations led to federally-mandated
cultural competency training in all medical schools.
But here in Canada, medical schools are grappling with
how to train the next generation of family physicians
to be more culturally sensitive. "Culture goes
beyond language and it certainly goes way beyond ethnic
or demographic groups," said Dr Ellen Tsai, medical
director of pediatric critical care at Queen's University.
Does cultural competency training
result in better communication and care for racial minorities?
An article published in the June issue of Academic
Medicine asked whether pre-existing literature
can give us the answer. "Now that medical schools
have to provide cultural competency training, we decided
to critique the evidence that training makes a real
difference to physicians, nurses and patients and see
how well the research stands up to tough criticism,"
said study author Eboni Price, PhD, a postdoctoral fellow
at Johns Hopkins University School of Medicine, in a
Newswise press release.
The study scanned some 4,000 articles
on this topic, but only 64 tested for cultural competence.
The 64 papers were reviewed for quality of evidence
and study design, and most were found to be less than
edifying. "Of the small percentage of these studies
that actually provided detailed evaluations of the interventions,
most did not adhere to basic principles of study design,
reporting and data analysis," noted the authors.
Although most studies reported that training healthcare
providers resulted in more patient satisfaction and
better communication, none of the 64 papers tested whether
increased cultural sensitivity resulted in better patient
care.
"The difficult piece to measure
is improved patient outcomes," Dr Tsai explained.
"The impact of any particular piece of curriculum
is hard to measure outside of medical school."
Another consistent weakness was poor study design. Of
the 64 papers reviewed, only eight used control groups
and a mere three blinded the research evaluators. More
investigation is clearly needed.
More research would also come in
handy for Canadian medical schools that are just beginning
to take on cultural competency training. Getting students
to buy in to the need for this kind of training is another
challenge and some hard evidence to back up its value
would go a long way in convincing them, according to
Dr Tsai. "Students will be receptive to training
if it will improve their patients' outcomes and improve
the quality of their interactions," she said.
RELIGION
IN PRACTICE
A study by researchers at the University of Chicago,
published in the July issue of the Journal of General
Internal Medicine, looked at the flip side of this
relationship — how doctors' religious beliefs affect
the physician-patient relationship. "Doctors are
not as irreligious as we might have expected,"
said Dr Farr Curlin, internist and lead author of the
study. Among the doctors surveyed, 46% said they attend
religious services twice a month or more compared with
40% of the general population. Only 10% of doctors said
they never attend religious services compared to 19%
of the general population. Interestingly, family physicians
and pediatricians were found to be the most religious
(73% and 64% respectively) while psychiatrists and radiologists
were the least (49% and 48% respectively). Previous
studies have suggested that family physicians were as
religious as the general population but more religious
than specialists.
"It might be a very touchy
topic for specialists if you tell them that they are
less religious than family physicians and the general
population," commented Dr Umesh Jain, a urologist
at Saint Joseph Health Centre in Toronto. Dr Jain also
questions how sound the data from these previous studies
were. "The studies should be well designed,"
he said, "and they should also represent a good
sample of both the family physicians and specialists."
The researchers legitimize these
concerns in their study. "The limited sampling
frames of these prior studies make it difficult to generalize
such findings to the broader physician population,"
wrote the authors. The Chicago team attempted to provide
a more accurate baseline for physicians' religious characteristics.
To this end, they surveyed 1,144 MDs about their religious
beliefs. Surprisingly, more than half admit that their
religious beliefs influence how they practise medicine.
It's unclear if doctors become
more religious because of their work, or if people with
religious backgrounds are more likely to enter medicine.
Dr Curlin believes that doctors are able to better care
for their patients when they draw on their religious
beliefs. But this view is pretty controversial. Some
physicians argue that doctors should take care not to
mix religious beliefs with their practice as doctors
hold considerably more power in the doctor-patient relationship
and there may be more potential for abuse.
Acad Med June 2005;80(6):578-84
J Gen Intern Med Jul 2005;20(7):629-34
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