CCPP Module 19, Section 4: Cultural Competence and Inclusive Care Delivery
MODULE 19: COMMUNICATION, COUNSELING, AND PATIENT ENGAGEMENT

Section 19.4: Cultural Competence and Inclusive Care Delivery

Develop the skills of cultural humility to provide care that is respectful of and responsive to the diverse beliefs, practices, and linguistic needs of your patients, thereby building trust and improving equity.

SECTION 19.4

Cultural Competence and Inclusive Care Delivery

From Clinical Expert to Curious Learner: Building Bridges of Trust Across Diverse Patient Populations.

19.4.1 The “Why”: Beyond the Science to the Story

In your training as a pharmacist, you have mastered a universal language: the language of science. You understand pharmacokinetics, pharmacodynamics, and biochemistry—principles that are true for the human body regardless of where a person was born, what language they speak, or what they believe. This scientific foundation is the bedrock of safe and effective medication use. However, a prescription is not fulfilled in a laboratory; it is fulfilled in the complex, nuanced, and deeply personal context of a patient’s life. And in that life, culture plays a profound role in shaping beliefs about health, illness, and medicine.

Providing care that is clinically excellent but culturally blind is like trying to navigate a city with a perfect map but no understanding of the local traffic laws, customs, or language. You know the destination, but you are likely to get into accidents, cause offense, and ultimately fail to arrive. Cultural competence is not about abandoning your scientific principles; it is about learning to apply them in a way that is respectful of, and responsive to, the individual patient in front of you. It is the recognition that a patient’s cultural background—their values, beliefs, family structure, communication style, and lived experiences—is as important a piece of clinical data as their creatinine clearance or their list of allergies.

This work is no longer considered a “soft skill” or an elective in patient care. It is a core competency for providing safe, equitable, and effective healthcare. Disparities in health outcomes between different racial and ethnic groups are well-documented and persistent. While rooted in complex systemic issues, many of these disparities are exacerbated at the point of care by communication breakdowns, mistrust, and a failure to provide care that aligns with a patient’s cultural framework. As a pharmacist, you are uniquely positioned to bridge this gap. By developing the skills of cultural humility, you can move from being a dispenser of medications to a builder of trust, ensuring that every patient, regardless of their background, feels seen, heard, and respected. This is the foundation upon which true therapeutic alliances are built, and it is essential for achieving the ultimate goal of medicine: improving the health and well-being of all people.

Pharmacist Analogy: The Master Compounding Pharmacist

Imagine you are an expert compounding pharmacist. You have a standard, FDA-approved base cream that you use for many formulations. It is stable, effective, and works perfectly for 90% of preparations. You know its properties inside and out. This is your standard, evidence-based approach to care.

One day, a dermatologist sends you a prescription for a new, highly specialized active pharmaceutical ingredient (API) for a patient with a rare condition. You cannot simply mix this new API into your standard base cream and expect it to work. You must first become a student of this new ingredient. You must ask: What is its pH? Is it hydrophilic or lipophilic? Is it sensitive to light or oxidation? Does it require a specific preservative system? Ignoring these unique properties and forcing it into your standard base will likely result in a product that is unstable, ineffective, or even harmful. The new API will crystallize, separate, or degrade. The failure is not with the API, but with your failure to adapt your process to its unique needs.

Cultural humility is the art of pharmaceutical compounding applied to human interaction. Your evidence-based clinical knowledge is your standard base. The patient is the unique and complex API. You cannot simply mix your standard recommendations into their life and expect a good outcome. You must first become a curious student of that patient. You must ask, with genuine respect: What are your “pH and solubility” (your core beliefs and values)? What is your “stability profile” (your sources of strength and support)? What are your “excipient incompatibilities” (your fears, past negative experiences, and health beliefs)? Only by understanding these unique properties can you skillfully compound a therapeutic plan that is “stable” and effective within the specific formulation of that patient’s life. A one-size-fits-all approach leads to therapeutic failure; a customized, culturally responsive approach leads to a stable, trusting, and effective therapeutic alliance.

19.4.2 The Foundational Shift: From Cultural Competence to Cultural Humility

For many years, the goal in healthcare was “cultural competence.” This term, while well-intentioned, has limitations. “Competence” suggests a state of completion—that one can learn a finite set of facts about a cultural group and then be “competent” to treat them. This can unintentionally lead to a “checklist” approach and a new form of stereotyping (e.g., “All patients from culture X believe Y”).

The modern, preferred, and more effective concept is cultural humility. Coined by physicians Melanie Tervalon and Jann Murray-Garcia, cultural humility is a profound and necessary shift in mindset. It is not about becoming an expert in every culture. That is an impossible task. Instead, it is a lifelong commitment to three core principles:

  • 1. Lifelong Learning and Critical Self-Reflection: A commitment to continuously examining your own beliefs, biases, and assumptions. It is the humble recognition that you are not the expert on anyone else’s experience.
  • 2. Recognizing and Challenging Power Imbalances: Acknowledging the inherent power dynamic in the clinician-patient relationship and working to level it by empowering the patient as the expert on their own life.
  • 3. Institutional Accountability: A commitment to advocating for and developing policies and practices within your organization that promote diversity, equity, and inclusion.
Masterclass Table: Competence vs. Humility – A Mindset and Behavior Shift
Concept “Cultural Competence” Mindset (The Old Way) “Cultural Humility” Mindset (The Better Way)
Goal To become an expert in the beliefs and practices of other cultures. To become aware of one’s own limitations in understanding another’s experience.
Process Mastering a finite list of cultural “facts.” It is a destination. Engaging in a lifelong process of learning, self-reflection, and partnership. It is a journey.
Patient Role The patient is an object of study, an example of their cultural group. The patient is the expert, the teacher of their own unique cultural identity and experience.
Clinician’s Stance “I know about your culture, so I know what’s best for you.” (Paternalistic) “I don’t know your experience, so please teach me what I need to know to provide the best care for you.” (Collaborative)
Behavioral Example A pharmacist assumes a quiet Asian patient doesn’t have questions because they read in a book that people from that culture are non-confrontational. A pharmacist notices a patient is quiet and asks with curiosity, “I’ve shared a lot of information. I’m wondering what’s going through your mind right now?”

19.4.3 The LEARN Model: A Practical Framework for Cross-Cultural Encounters

Cultural humility is the mindset; the LEARN model is the practical, step-by-step tool for putting that mindset into action during a patient encounter. Developed by Berlin and Fowkes, it provides a simple, memorable framework for navigating conversations where cultural differences may be a significant factor. It moves the focus away from assumptions and toward a respectful, negotiated care plan.

The LEARN Model: A Pharmacist’s Playbook

This model is your guide to turning a potentially difficult cross-cultural conversation into a productive and trust-building partnership.

  1. L – Listen:

    Goal: To understand the patient’s perspective of their health problem without judgment or interruption.
    Action: Use active listening and open-ended questions. Elicit their “explanatory model” of illness. What do they call their problem? What do they think caused it? What do they fear about it? What kind of treatment do they think they need?

  2. E – Explain:

    Goal: To explain your own perception of the clinical problem, respectfully and in simple, jargon-free terms.
    Action: Share the biomedical perspective clearly and concisely. Avoid technical language. Use analogies or drawings. For example, “From a medical standpoint, we see high blood pressure as a problem where there is too much pressure inside your blood pipes, which can damage them over time.”

  3. A – Acknowledge:

    Goal: To show respect for the patient’s perspective by explicitly acknowledging and discussing the similarities and, more importantly, the differences between your two points of view.
    Action: This is the most crucial and often-skipped step. It validates the patient’s beliefs. “So, I hear you saying that you believe this illness is related to an imbalance of hot and cold in your body. I also hear the doctor’s concern about the high pressure in your blood vessels. It sounds like we’re looking at this from two different, but equally important, angles.”

  4. R – Recommend:

    Goal: To offer a treatment plan, but as a recommendation, not a command.
    Action: Propose your therapeutic plan, linking it back to the patient’s own goals. “Based on what we’ve discussed, I would recommend a treatment that includes this ‘water pill’ to help lower the pressure in your blood pipes.”

  5. N – Negotiate:

    Goal: To collaboratively develop a treatment plan that the patient understands, accepts, and can incorporate into their life and belief system.
    Action: This is where the partnership solidifies. “Let’s work together to find a plan that makes sense to both of us. How would taking this ‘water pill’ fit with your approach to balancing hot and cold? Are there other things you are doing for your health that we should include as part of this plan?”

Masterclass in Action: Using the LEARN Model for a Patient with Diabetes

Scenario: A 62-year-old Latina patient, Mrs. Sanchez, is newly diagnosed with type 2 diabetes. Her A1c is 9.8%. She is prescribed metformin. During counseling, she seems hesitant and mentions that she believes her “sugar sickness” is a punishment from God for past sins and that only prayer can truly heal her.

LEARN Step Pharmacist’s Action & Script
Listen Pharmacist: (Uses an open-ended question) “Mrs. Sanchez, I can see you have some concerns about this new diagnosis. To help me understand, could you tell me a little more about what you think is causing this ‘sugar sickness’?”
Patient: “I have not been a good person. God is punishing me. My grandmother had this, and she died. I just need to pray more.”
Explain Pharmacist: “Thank you for sharing that with me. Your faith sounds very important to you. I’d like to share the medical perspective on this, if that’s okay? From a medical viewpoint, we see this condition as a problem where the body has trouble using sugar for energy, so the sugar builds up in the blood. This medication, metformin, works like a helper to allow your body to use that sugar better.”
Acknowledge Pharmacist: “It sounds like we have two different, but very important, ways of looking at this. You see this as a spiritual illness that requires a spiritual solution like prayer, and I see it as a medical problem that requires a medical solution. I want to be clear: I believe your faith and prayers are a powerful and important part of your healing. We don’t have to choose between them.”
Recommend Pharmacist: “I would recommend that we add the metformin to your healing plan. Think of it as a tool that can work alongside your prayers to help your body get stronger.”
Negotiate Pharmacist: “What if we thought of it this way? You can continue your prayers, which are essential for your spiritual health. And at the same time, we can use this medication, which is a gift of science, to help your body physically heal. They can work together as a team. How does that sound to you as a path forward?”

19.4.4 Key Domains of Cultural Inquiry

While we must avoid stereotyping, it is helpful to be aware of common areas where cultural values can diverge from the standard biomedical model. Your role is not to know the answer for any given culture, but to know what questions to ask with sensitivity and curiosity. The following are key domains to explore.

1. Explanatory Models of Health and Illness

The “biomedical model” that dominates Western medicine sees disease as a result of pathophysiology—germs, genes, and cellular dysfunction. This is just one of many ways of understanding illness. Many cultures have deeply held beliefs that attribute illness to other causes. Understanding a patient’s explanatory model is the first step in bridging a cultural divide.

Table: Contrasting Explanatory Models for Type 2 Diabetes
Model Perceived Cause Beliefs & Implications for Care
Biomedical Insulin resistance, genetic predisposition, lifestyle factors. Treatment focuses on medication, diet, exercise, and blood glucose monitoring. The patient has a high degree of control and responsibility.
Spiritual/Metaphysical A punishment from God, a test of faith, the result of a curse or “evil eye.” Patient may believe the primary cure lies in prayer, repentance, or traditional healing rituals. They may see medical treatment as secondary or even irrelevant. This can lead to a sense of fatalism and non-adherence.
Hot-Cold/Balance Model (e.g., Traditional Latin American, Chinese) The body is out of balance. Diabetes is often considered a “hot” disease. Patient may seek to restore balance by consuming “cold” foods and herbs. They may perceive medications as “hot” or “cold” and may be reluctant to take a “hot” medicine (like metformin) for a “hot” disease, fearing it will worsen the imbalance.
Social/Emotional The result of a strong emotional shock, intense grief, or social stress (“susto” in some Latin American cultures). Patient may believe that resolving the emotional or social issue is the key to a cure. They may prioritize emotional support and traditional remedies over medication.

2. Family Dynamics and Decision-Making

In many individualistic cultures (like the U.S.), the principle of patient autonomy is absolute. The patient is the sole decision-maker. In many other collectivistic cultures (e.g., many Asian, Middle Eastern, and Hispanic cultures), medical decisions are a family affair. The “family” is the unit of care, not the individual. The eldest son, the husband, or a family elder may be the primary decision-maker, even for a competent adult patient. Imposing a strictly individualistic model in a collectivistic context can be seen as disrespectful and isolating.

HIPAA and the Family: A Delicate Balance

Navigating family involvement requires balancing cultural sensitivity with legal and ethical obligations like HIPAA. The key is to ask the patient for permission explicitly.
The Script: “I see your son and daughter are here with you today. It is your choice who is involved in your medical care. Would you like me to share this information with your family present, or would you prefer we speak privately first?” This respects the patient’s legal autonomy while creating an opening to include the family if that is their cultural preference.

3. Religion, Spirituality, and Medication Use

Faith can be a powerful source of comfort and healing, and it can also significantly impact medication adherence. It is crucial to approach this topic with deep respect and an understanding that for many patients, spiritual health is inseparable from physical health.

  • Fasting: During religious periods like Ramadan (Islam) or Lent (Christianity), patients may fast from dawn to dusk. This requires proactive dose and schedule adjustments for medications for conditions like diabetes or hypertension to prevent hypoglycemia or other adverse events. Your role is to partner with the patient to create a safe medication plan that honors their religious observance.
  • Prohibited Substances: Some medications may contain ingredients forbidden by a patient’s faith (e.g., gelatin capsules of porcine origin for Muslim or Jewish patients). Being aware of these issues and having access to resources to check excipients is a key part of culturally competent care.
  • “Divine Will” vs. Treatment: As seen in the LEARN model example, some patients may view illness as God’s will and be hesitant to “interfere” with medical treatment. The key is not to challenge their faith, but to frame medication as a tool that can work in harmony with their faith.

19.4.5 Language Access: The Foundation of Safe Communication

Providing care to a patient with whom you do not share a language is one of the highest-risk situations in medicine. Communication errors are the root cause of a huge number of adverse events. Ensuring language access is not just good customer service; it is a fundamental patient right and a cornerstone of medication safety. Federal standards (CLAS Standards) mandate that healthcare organizations provide access to qualified interpreters for patients with Limited English Proficiency (LEP).

The Dangers of Using Family Members (Especially Children) as Interpreters

It is often tempting to use a bilingual family member or friend who is with the patient to interpret. This should be avoided whenever possible, especially if the “interpreter” is a minor.
Why it’s a problem:

  • Lack of Training: Family members are not trained in medical terminology. They may make critical errors in translation (e.g., confusing “hyper” and “hypo”).
  • Editing and Filtering: Family may unintentionally edit the information to “protect” the patient from bad news or to avoid discussing sensitive topics like sexual health or substance use.
  • Role Reversal: Using a child to interpret places an inappropriate emotional burden on them and undermines the authority of the parent.
  • Confidentiality: The patient may not feel comfortable sharing sensitive information in front of a family member.

Always insist on using a professional, qualified medical interpreter, whether in-person, via video, or over the phone.

Best Practices for Working With a Medical Interpreter
  • Positioning: Arrange seating in a triangle, so that you can speak directly to the patient, not to the interpreter. Maintain eye contact with the patient.
  • Briefing: Before you begin, have a quick pre-conference with the interpreter. State the goal of the conversation (e.g., “This is a discharge counseling session for a new diagnosis of heart failure. I need to explain five new medications and confirm the patient’s understanding using Teach-Back.”).
  • First-Person Language: Speak in the first person (“What questions do you have for me?”) not the third person (“Ask her what questions she has.”).
  • Speak in Short Sentences: Pause after every 1-2 sentences to allow the interpreter to translate. This ensures accuracy and prevents information overload.
  • Use Plain Language: Avoid jargon, acronyms, and idioms that are difficult to translate.
  • Check for Understanding: Use the Teach-Back method, just as you would with an English-speaking patient. Ask the interpreter to translate your non-shaming prompt and then translate the patient’s response back to you verbatim.
  • Debriefing: After the session, thank the interpreter and ask if they have any cultural insights or observations that might be helpful in understanding the patient’s perspective.