From Unequal Treatment to Quality Care

We congratulate the American College of Physicians (ACP) on its position on racial and ethnic disparities (1). The position is comprehensive and consistent with the ACP's mission and can be a model for other specialties and disciplines. The emphasis on enhancing cultural competency is worthy of note because of the role such competency can play in improving outcomes. As noted in the position statement, competency among all health care professionals and support personnel is critical to achieving better outcomes. Not only must practicing physicians be diligent in acquiring cultural competency skills through continuing education, they must ensure that those supporting them in their practices do the same. Translation services are essential to providing culturally competent care because they are key to communication when the clinician and the patient do not speak the same language. Evidence shows that professional translation services are associated with improved patient satisfaction and adherence, as well as improved provider satisfaction (2). For these reasons, clinicians should use professional translators and should consider them to be essential participants in clinical encounters with patients who do not speak the same language. We should not rely on volunteers, who are often family members, friends, or untrained support staff, because this is not consistent with best practices for culturally competent care. Unfortunately, payers do not reimburse for interpretive services, but this shortsightedness does not absolve clinicians of the professional responsibility to provide them. The ACP has taken a strong and commendable position on reimbursement of translation services, especially for Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP). To make progress on its agenda for racial and ethnic disparities, the College must place this issue at the top of its policy agenda. Effective communication is a prerequisite for high-quality care. Cultural competency training and interpretive services are good foundations for eliminating racial disparities in health care, but they are just a good beginning. We must also focus our efforts on addressing the subtle forms of bias, such as stereotyping. Many aspects of bias are based on an unconscious cognitive adaptive strategystereotypingthat enables people to make sense of a complex environment. But stereotyping can also negatively affect communication between the patient and physician. As noted in the Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (3), research on stereotyping and practical approaches to eliminating it is an essential part of the comprehensive, long-term set of solutions required to eradicate racial and ethnic disparities. Closing the gap by eliminating the disparities in care between racial and ethnic groups and white populations in the United States is not enough. Unfortunately, even when we close the gap, we will not achieve an acceptable level of care for many conditions. For example, Cooper and Hickson (4) demonstrated disparities between minority and white children enrolled in Medicaid in getting corticosteroid therapy after an emergency department visit. Sadly, the rates of follow-up therapy for all groups fell far short of the ideal. The ACP's leadership and strong commitment to closing the gap and raising the bar are commendable. If the ACP can translate its excellent position statement into a sustained program to change practice, it can make a difference for all patients in this country.