Studying Cultural Competence, Race and Quality of Care

    • July 14, 2009

The Problem: Racial differences between physicians and their patients may impact the quality of care patients receive. Cultural competence—the ability of a health care provider to bridge cultural differences to build an effective relationship with a patient—has been promoted as a way of reducing racial disparities in health care, but there is little evidence about what cultural competence means and how much it will help.

Grantee Perspective: Somnath Saha, MD, MPH, was an assistant professor of medicine at Oregon Health & Science University and a staff physician at Portland VA Medical Center. He wanted to learn more about the impact of physicians’ cultural competence and race and the quality of care that patients received.

As a participant in the Robert Wood Johnson Foundation (RWJF) Generalist Physician Faculty Scholars Program from 2003 to 2007, Saha was able to explore both of these issues. “The program provided an opportunity to do innovative research that it would not have been easy to get other support for,” he said.

Saha and colleagues developed a framework for cultural competence based on 26 focus groups with 142 Black, Mexican-American and White men and women, and a review of published models of cultural competence. The framework summarizes the knowledge, awareness, attitudes, skills and behaviors that collectively characterize what has come to be known as “cultural competence.”

Using this framework, and with additional funding from the Agency for Healthcare Research and Quality, (2005–08, $1.4 million), Saha and his colleagues designed the Culture and Medicine Survey. They tested the survey with 45 primary care providers (69% White, 24% Asian and 7% Black; 44% were women) at four HIV clinics. They also surveyed 437 patients about taking their medications and reviewed their medical records. The patients were predominantly Black (58%), with 25 percent White, 14 percent Latino and 3 percent other; 34 percent were women.

To study the impact of the physician’s race on patients’ perceptions and trust, Saha and his colleagues videotaped 32 vignettes of simulated patient–physician encounters. The encounters featured eight physician–actors (two Black men, two Black women, two White men and two White women) who discussed heart disease with a patient–actor and recommended bypass surgery. Saha and his team then randomly assigned 238 patients (45% Black and 55% White) to view one of the vignettes and then surveyed them.


  • In the study of cultural competence, Saha et al. found:

    • Minority patients of providers with higher self-rated cultural competence were more likely to be taking HIV medications, had greater self-efficacy (belief in their ability to succeed) in managing their medication regimens and took more of their prescribed medications than patients of providers with lower self-rated cultural competence.
    • Racial disparities in HIV care and outcomes were present among the patients of providers with low self-rated cultural competence, but not among those whose providers had higher levels of cultural competence.
  • In the study of the impact of the physician’s race, Saha et al. found:

    • Black patients indicated a higher likelihood of undergoing surgery, if they were the patient in the simulated interaction, when the physician was also Black.
    • For Black patients, but not for White patients, viewing physicians of the same race was associated with higher ratings of physician behavior and competence. Black patients also reported more trust in and comfort with physicians of the same race and rated them more highly overall.

Together, these studies indicate that a physician’s race can affect patients’ perceptions, trust and decision-making, independent of the physician’s behavior, but also that there are specific attitudes and skills that may allow physicians to overcome barriers that racial differences impose on their interactions with patients.

Saha, who was promoted to associate professor at Oregon Health & Science University in 2005, continued his cultural competence research after he completed the Generalist Physician Faculty Scholars Program. Under a National Institutes of Health grant, he developed and tested tools to measure cultural competence and racial bias among physicians, including refining the Culture and Medicine Survey (2007–09, $346,500).

“This program was pivotal in my career. It gave me unconditional support to do the work I wanted to do and made me really feel my work was valued and important,” said Saha. “It was an opportunity to be a part of a network of amazing thinkers and future leaders and people who could stimulate my own thinking and progress.”

RWJF Perspective: The Robert Wood Johnson Foundation established the Generalist Physician Faculty Scholars Program to create a cadre of respected generalist leaders in medical schools who would be in a position to influence curriculum, admissions and scholarship. Junior faculty in family medicine, internal medicine and pediatrics conducted research and built their careers under the guidance of mentors.

“Given the shortage of primary care physicians, we need innovative approaches to encourage medical students to choose careers in generalist fields. The Generalist Physician Faculty Scholars Program was designed to emphasize a scholarly foundation for generalism and improve the quality of the education provided to students who choose this important career path,” said Pamela S. Dickson, MBA, assistant vice president of RWJF’s Health Care Group.

When the program ended in 2008, RWJF created the Robert Wood Johnson Physician Faculty Scholars Program to strengthen the leadership and academic productivity of junior medical school faculty who are dedicated to improving health and health care. It is open not only to generalists, but all physicians.

Somnath Saha, MD, MPH

Somnath Saha, MD, MPH
Generalist Physician Faculty Scholar