Cultural competency training should not rely on stereotypes

Two physician readers submitted the following post about a topic that is becoming increasingly important to family physicians. In addition to the Curbside Consultation discussed below, AFP has also previously published clinical reviews of cross-cultural medicine and cultural diversity at the end of life.

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While we appreciate Dr. Gupta’s insights into culturally specific care for Indian patients in the July 1, 2010 Curbside Consultation, “Improving Sensitivity to Patients from Other Cultures,” we feel that the article's emphasis on learning culturally specific stereotypes can be potentially misleading for clinicians. Cultural competency training has traditionally involved memorizing culturally specific “rules” (e.g., Muslims don’t shake hands). Although learning about a particular group’s cultural norms can be helpful, it may also lead to stereotyping and false assumptions. Because clinicians are caring for increasingly diverse populations, including growing numbers of immigrants and refugees, there are too many cultural groups with too many norms to become familiar with.

A more practical approach to cultural competency has emphasized not the patient’s background, but instead, the “implementation of the principles of patient-centered care, including exploration, empathy, and responsiveness to patients’ needs, values, and preferences.” In the words of another useful definition, cultural competence involves an “examination of one’s own attitude and values, as well as the acquisition of the values, knowledge, skills and attributes that will allow an individual to work appropriately in cross cultural situations.” Published tools aid in learning and teaching these skill sets. Busy clinicians are better served by using these tools to practice culturally sensitive and individualized patient-oriented care, rather than memorizing lists of cultural norms and “rules."

Bernadette Kiraly, MD
Peter Weir, MD
Hartland Refugee Clinic
Department of Family & Preventive Medicine
University of Utah School of Medicine

Autism: recognition and management

The September 15th edition of AFP Journal Club reviews an analysis of evidence behind the persistent but scientifically discredited hypothesis that the measles, mumps, and rubella (MMR) vaccine causes children to develop autism. Since a 1998 case series published in The Lancet first suggested this hypothesis, 13 large ecologic and observational studies performed worldwide have shown no association between the receipt of MMR vaccine and autism. Nonetheless, many parents continue to believe that delaying or refusing MMR vaccine and other immunizations will protect their children from harm. Dr. Andrea Darby-Stewart notes that this is a critical educational opportunity:

A national survey conducted in 2003 to 2004 indicated that more than one fourth of all U.S. parents were either unsure of vaccine safety or refused or delayed vaccination of their children because of safety concerns. However, the most important take-home point from that survey was that the parents who changed their minds and immunized their children did so because of information and assurance provided by their health care professional. Indeed, we do make a difference!

An AFP article published earlier this year reviews guidance for family physicians on how to coordinate medical and behavioral care for children who have been diagnosed with an autism spectrum disorder. More controversial is a 2007 practice guideline from the American Academy of Pediatrics that recommends that primary care clinicians routinely screen children at nine, 18, 24, and 30 months of age using an autism-specific screening tool. In light of the uncertain evidence for improved outcomes in children identified by screening, the American Academy of Family Physicians recently nominated "Screening for Autism in Children" as a new topic for review by the U.S. Preventive Services Task Force.

Given the steadily rising prevalence of autism spectrum disorders (approaching 1 in 100 U.S. children) and that autism can present with subtle symptoms in its early stages, what approach do you take to identify this condition in practice, if any?

JUPITER, statins, and cardiovascular prevention

In February, the U.S. Food and Drug Administration approved the labeling of rosuvastatin (Crestor) for the primary prevention of heart disease in patients with an elevated C-reactive protein level and at least one other risk factor, based on a controversial study known as JUPITER (Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin). In a previous editorial, AFP medical editors Colin Kopes-Kerr, MD and Mark Ebell, MD, MS estimated that implementing JUPITER's approach to screening and treatment in clinical practice would cost more than $800,000 in testing, physician visits, and medications to prevent a single premature cardiovascular death over two years. They argued that this approach would be far more costly, but less beneficial, than counseling patients about healthy lifestyle changes:

The biggest problem with the JUPITER study is that it suggests that physicians continue to test and treat. First, though, we need to take time to think. One of the things to ponder is this: Couldn’t we do something better for patients than measuring everyone’s CRP levels and treating those with elevated values? Instead, we should wait for a study comparing CRP measurement to routine coronary risk factor assessment, including studies on cost-benefit analysis. We already know that lifestyle changes are effective and, therefore, we should focus on innovative ways to assist patients in making these changes.

In an exchange of Letters in the September 15th issue of AFP, one of the JUPITER's principal investigators defends the conduct of the study (which ended earlier than planned due to a "dramatic" statistical difference in cardiovascular outcomes between the rosuvastatin and placebo groups) and challenges the editorial's portrayal of this intervention as not worth pursuing in primary care. Dr. Kopes-Kerr's and Dr. Ebell's rebuttal highlights some important concepts in evidence-based medicine, including interpretation of P values and numbers needed to treat. (See this short article by AFP editor Allen Shaughnessy, PharmD for more information on evaluating and understanding articles about treatment.)

Since coronary heart disease risk assessment, prevention, and management can be complex, we have organized all of AFP's relevant articles and other resources in a convenient collection that will be updated whenever new information is published. We hope that this and other AFP By Topic collections will help you make confident clinical decisions. Please let us know if there is anything we can do to make them more useful in your practice.

Addressing the root causes of obesity

A physician reader of AFP submitted the following post.

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Family physicians are seeing overweight and obese patients now more than ever. Therefore, the June 15, 2010 AFP article "Office-Based Strategies for the Management of Obesity" was timely, relevant, and informative. The author’s recommendations regarding counseling to improve nutrition and increase physical activity were insightful. I would like to draw attention to additional issues that have a significant impact on the fight against obesity in our patients, particularly those in minority or low income populations.

Excess weight begins with an energy imbalance: more calories consumed than calories expended over a period of time. Choosing foods such as fresh fruits and vegetables and physical activities such as jogging or vigorous outdoor play are vital to living a healthy lifestyle. But for many of our patients, these choices are not so simple. African Americans, Hispanics, and American Indians are disproportionately affected by obesity. Geographically, southern states and many rural and urban communities have higher than average rates of obesity. These communities have additional barriers that make it particularly challenging to achieve and maintain a healthy weight.

Millions of minority children live in food deserts, places where healthy, fresh food is either scarce, expensive or both. This lack of access to affordable, quality fresh fruits and vegetables has been shown to be closely associated with childhood obesity. According to Trust for America's Health and the Robert Wood Johnson Foundation, an overabundance of fast food outlets and convenience stores stocked with calorie-dense, nutrient-poor foods in areas with predominantly minority populations is strongly related to excess weight in these populations. Media and food industries advertise these foods widely, often targeting children and families of color. Similarly, many minority and low-income neighborhoods discourage physical activity due to a dearth of sidewalks, walking or bike trails, poor air quality, inadequate lighting and unkempt or inaccessible parks and playgrounds. Other factors such as long work hours for low-wage workers and limited access to commercial weight management services also pose substantial barriers to positive health behavior changes.

While it is important for family physicians to know how to assist our patients with weight control in the office, we should understand that the root causes of this problem lie in our communities. In order to "bend the curve" on the linear trajectory of obesity in this country, we must focus as intently on effecting broader social and environmental changes as we do on encouraging individual lifestyle changes in overweight and obese patients. As we educate our patients on how to live healthier, we must also educate, motivate and mobilize patients, community leaders, school administrators, employers, and policymakers about what it will take to make healthier food choices and physical activity default options rather than difficult or unrealistic choices. Family physicians must use every resource at our disposal to combat obesity, or else in time, we will all be "the biggest losers.”

Jada Moore-Ruffin, MD
Satcher Health Leadership Institute
Morehouse School of Medicine

Pacifiers for SIDS prevention?

Reducing the risk of sudden infant death syndrome (SIDS) is an outstanding example of how family physicians have partnered with professional and community organizations to successfully address an important public health problem. In 2005, AFP published an editorial that examined the progress of the then decade-long "Back to Sleep" campaign in reducing the annual U.S. incidence of SIDS from more than 5,000 to fewer than 2,500.

In recent years, however, SIDS prevention has been the subject of controversy. In 2005, the American Academy of Pediatrics released new guidelines that suggested offering infants a pacifier at nap times and bedtime, based on evidence from observational studies showing a protective effect of pacifier use against SIDS. However, many physicians expressed concern that this practice could discourage women from prolonged breastfeeding and have unintended health consequences for mothers and babies.

We revisit the controversy regarding pacifiers and SIDS prevention in the September 1st issue's Letters to the Editor, which features an exchange of views prompted by recent review articles on SIDS and risks and benefits of pacifiers. Given this information, do you think that pacifier use should be encouraged after breastfeeding is well established, as the AAP and AFP's authors recommend? Or do you feel that the evidence isn't strong enough to support this practice, and may in fact "give parents a false sense of security," as Dr. David and Katherine Abdun-Nur argue?

Screening and treatment of hyperlipidemia in children

The September 1 issue of American Family Physician inaugurates a new editorial feature that presents two opposing views on a controversial clinical topic and asks readers to post comments online. In this issue, Dr. Robert Gauer argues that because atherosclerosis begins in childhood, using cholesterol-lowering drugs in children with hyperlipidemia is essential to prevent coronary events and cardiovascular mortality in later life. On the other hand, Dr. Michael LeFevre contends that since only 40 to 55 percent of children with elevated cholesterol levels will have persistent hyperlipidemia as adults, and the potential benefits and harms of decades of drug therapy are unknown, physicians should demand a high "evidence bar" for instituting screening and treatment.

Since hyperlipidemia causes no symptoms, these views reflect in large part the dueling guidelines of the American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force (USPSTF) on lipid screening in children. While the AAP recommends that screening for hyperlipidemia begin at age 2 in children with a family history of hyperlipidemia, premature cardiovascular disease, or other risk factors, the USPSTF found insufficient evidence to recommend for or against screening in any group of children.

This leaves family physicians and other clinicians who care for children with an important clinical dilemma. Should they act now based on disease-oriented evidence and extrapolation from studies of primary prevention of cardiovascular disease in adults, or should they instead wait for patient-oriented evidence from long-term followup studies of children with elevated lipid levels? Which approach do you take in your practice, and why? You are welcome to post comments here or on AFP's Facebook page; AAFP members can also post comments on the AFP web page. We look forward to the discussion!