Manhattan Cross Cultural Group
The Quality Interactions® E-Newsletter
An Update on Issues in Cross-Cultural Healthcare

Introduction to the Quality Interactions® Newsletter

Welcome to the 11th issue of the Quality Interactions e-newsletter. This is a quarterly supplement to the Quality Interactions e-learning program that aims to provide updates on the field of cultural competence. Each issue includes a feature article, a literature update, and policy briefs on topics related to cultural competence and health disparities, including practical tips, case vignettes, and new research findings.

Feature Article

Negotiating Across Cultures: Creating Common Ground

Clinicians and patients rarely see things in exactly the same way. Cross-cultural interactions add additional layers of complexity to this situation. For example, in many cultures, questioning an authority figure (such as a health care professional) is considered inappropriate or impolite. Culture also affects patients' perspectives on illness and treatment, and their trust in clinicians' recommendations. Much of the emphasis of cross-cultural communication (a key element of cultural competence) has to do with exploring patients' perspectives. But when their views differ significantly from our views and recommendations—what are we to do? While there is no simple answer to this question, we can often turn to the process of cross-cultural negotiation for some guidelines.

Cross-Cultural Negotiation

Negotiation is the process in which two sides with differing perspectives come to a mutually acceptable agreement on a specific issue. This occurs in many aspects of life, including the clinical encounter. In this setting, the goal is to settle conflicting views on tests, treatments, and other recommendations by explicitly discussing what is important from both the patient's and clinician's perspectives and coming to a mutually acceptable plan. This can be done in an efficient, effective way by considering the following steps:

Step 1: Explore the Patient's Perspective
This may involve asking open-ended questions about the patient's understanding and concerns about the illness and its treatment.

Step 2: Explain Your Perspective
This requires providing the patient with an explanation in terms that are understandable and familiar, including explaining why you think it is in their best interest.

Step 3: Acknowledge the Difference in Opinion
Do this in a way that is non-judgmental and accepting of difference.

Step 4: Create Common Ground
This may mean offering a compromise or asking the patient what they are willing to do, and often requires some back and forth discussion in an environment where the patient feels they can be open with you.

Step 5: Settle on a Mutually Acceptable Plan
Once a plan is developed, check in with the patient again to make sure that it is acceptable. Look for any sign of hesitation on the part of the patient and discuss this openly.

You can see how these steps might work in practice in the following clinical vignette.

Literature Update

Study Finds Discussion About CAM Leads to Better Ratings of Care

A recent study in the American Journal of Public Health found that patients who used some type of complementary/alternative medicine (CAM) rated their care better if they discussed this use with their health care provider. The study surveyed 3,258 Chinese and Vietnamese Americans with limited-English proficiency who visited 11 community health centers in 8 major cities throughout the United States. Two thirds of respondents reported they had "ever used" some form of CAM therapy; however, only 7.6% of these patients had discussed their use of CAM therapies with clinicians. Among patients who had used CAM therapies during the week before their most recent visits, clinician-patient discussions about CAM therapy use were associated with better overall patient ratings of quality of care. This highlights the importance of routinely exploring whether patients are using CAM, as this may improve ratings of care, and care itself.

Insurance Coverage of Patient Self-management Devices Improves Diabetes Care, Reduces Disparities

A new study highlights that insurance coverage of patient self-management devices like self-monitoring blood glucose (SMBG) equipment may help to reduce race-related barriers to effective care. Researchers examined whether providing free home glucose monitors to 2,275 continuously enrolled adult patients with diabetes in a large, staff model HMO had greater impacts on self-monitoring among black versus white patients with diabetes. Using electronic medical record data and longitudinal survival analysis, they examined racial differences in rates of initiation of SMBG after coverage and rates of discontinuation of SMBG 18 months after initiation. Controlling for time-dependent and fixed effects, black patients were as likely to initiate SMBG as white patients before the policy, but more likely after the policy. The policy is effective in triggering additional diabetes patients to self-manage, particularly black patients, thus addressing disparities in this area.

Policy Update

The Deficit Reduction Act of 2005 Enacted, Impacts Access to Medicaid

The federal Deficit Reduction Act (DRA), signed in February 2006, enacted provisions designed to reduce federal Medicaid spending by nearly $5 billion over the next five years. One of the mandatory provisions affects Medicaid eligibility status. Now, to be eligible for Medicaid, a person must be a US citizen or a qualified alien. Non-citizens must submit documentation of their immigration status to determine whether they are qualified aliens. Before the DRA, applicants or recipients who claimed they were US citizens could verify citizenship by sworn declaration, without submitting documentation. Beginning July 1, 2006, the DRA requires the submission of acceptable documentation to prove an applicant's or recipient's US citizenship. Many are concerned about the impact this will have on access to care for illegal immigrants in the US, and its potential public health implications. There is concern this might lead to worsening racial/ethnic disparities in health and health care.


  1. Katon W, Kleinman A. Doctor-patient negotiation and other social science strategies in patient care. In Eisenberg L, Kleinman A (eds). The Relevance of Social Science for Medicine. D. Reidel Publishing Company; 1980.
  2. Ahn AC, Ngo-Metzger Q, Legedza AT, Massagli MP, Clarridge BR, Phillips RS. Complementary and alternative medical therapy use among Chinese and Vietnamese Americans: prevalence, associated factors, and effects of patient-clinician communication Am J Public Health, 2006; 96:647-53.
  3. Mah CA, Soumerai SB, Adams AS, Ross-Degnan D. Racial differences in impact of coverage on diabetes self-monitoring in a health maintenance organization. Med Care, 2006; 44:392-7.
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