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( continued from page 11 ) compliant with my recommended medications . I had their trust .
But it all changed when I returned to Louisville and joined my first practice in a blue-collar neighborhood . There were no ethnic communities for me to make house calls . The Black and Vietnamese patients I saw all had to drive or take a bus to see me . Instead of my being a Kentuckian in the neighborhoods of their comfort zone , my patients had to come to me . One of my patients from Laos was in the house of Sisavang Vatthana , the last King of Laos . Escaping from the Communist takeover , she fled to the U . S ., eventually arriving in Louisville . She had no marketable skills , so she fell into becoming a housekeeper . I found it very difficult trying to understand the culture she was used to in Laos , and her shame at being relegated to her current role . I tried to treat her as though she were still in the Laotian Palace — but not sure she perceived my intentions . My Black patients coming to me in my office setting seemed more laconic and introverted in my office than others who saw me in my Philadelphia office , located in their neighborhood . My first clinical office was placed in my comfort zone , but not theirs . I found that medication compliance was much lower among non-white patients I saw in Louisville than I had found in South Philadelphia .
This lower compliance rate among patients treated by physicians whose cultural and linguistic heritage is significantly different is a well-recognized phenomenon . Numerous studies have shown Medication Possession Ratio ( MPR ) to be lower among Black American patients than for white patients . The MPR is the ratio of medication held over time i . e ., a 30-day prescription refilled at 30 days is a higher ratio than one filled at 60 days , suggesting that the medication is not being taken as prescribed . The poorer compliance rates among Black people have been described in studies of conditions such as hypertension , diabetes , epilepsy , glaucoma , HIV , depression and others . Most studies have focused on gender , race , education , primary language and having a primary care physician . The race and ethnicity of the prescriber are rarely captured in the studies on compliance .
However , studies on trust in health care providers and adherence have shown significantly higher adherence rates with higher rates of trust . This has been documented in separate studies focused on Black men and Black women focused on such conditions as hypertension and inflammatory bowel syndrome . Studies in the social services journals more so than medical literature describe the trust factor based upon the concordance of the race or ethnicity of the prescriber and the patient . This would suggest a return to medical segregation in order to achieve greater compliance . Clearly there are ethical concerns with such matching of patients and prescribers . The Association of American Medical Colleges ( AAMC ) pointed out that in 2018 , 56.2 % of active physicians in the U . S . were white , with 17.1 % Asian , and similar rates of Black and Hispanic ( 5.0 % and 5.8 %, respectively ). Unknown and other represented the rest . The demographic distributions of physicians are not aligned with the population distribution in this country . The U . S . Census Bureau indicated for 2021 that 76.3 % of the U . S . population is white — much higher than for physician percentage . This same applies to Asian Americans who represent 5.9 % of the population . But Black Americans represent 13.4 % of the population — a much higher percentage than that of Black physicians . This same maldistribution applies to the 18.5 % of the population that is Hispanic . This is compounded by the geographic variations . It is clear from structural and ethical positions , that we cannot achieve higher medication compliance by using concordance of race / ethnicity of prescriber and patient as a surrogate of trust .
It comes down to the ability of the practicing physicians to establish that trust so that their patients believe in what their doctor recommends — a very old-fashioned concept but one that is even more essential with the increasing diversity in America . As physicians we recognize that trust comes from active listening , consistency and honesty with our patients , and communicating effectively . With patients from backgrounds similar to ours , these are difficult but generally achievable . It is with people of different cultural or linguistic backgrounds that we frequently need help . Programs have been developed for physicians by both the American Medical Association ( https :// www . ama-assn . org / delivering-care / health-equity / 7-keys-overcome-linguistic-cultural-barriers-equitable-care ) and the Department of Health and Human Services ( DHHS ) https :// thinkculturalhealth . hhs . gov / education / physicians ). This DHHS program offers nine hours of CME through registration on this website .
The physician must approach the patient recognizing that language is just one of the barriers , but cultural differences can be just as significant . It is tempting to use family members as interpreters when the patient does not speak the physician ’ s language . However , policies prohibit using family members to interpret except in emergency situations . Alternatives include telephonic interpreter services or local immigration services . The patient or patient ’ s family may have feelings about the best mode to use for interpretation . Post-visit summaries that are provided in the patient ’ s native language both show the physician ’ s commitment to care for the patient and bring home the key points of discussion . If the EHR does not offer a variety of languages for the post-visit summary , then translation programs such as Google Translate can be helpful in framing the medical information / patient instructions into a language understood by the patient .
Cultural competence carries the doctor-patient interaction beyond that of simple translation of concepts , to a greater level of communication . That involves understanding the patient expectations , body language , how empathy is delivered and received , and mutually acceptable engagement . The approach to the patient who emigrated from Asia is different than one from Sub-Saharan Africa or from Eastern Europe . Knowing the customs that may seem little
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