When a doctor doesn't look an Asian-American patient in the eye, that might be seen as a sign of respect. But making eye contact is encouraged with black patients, according to the American Academy of Orthopaedic Surgeons, which has published a guidebook for culturally competent care.
As the country's ethnic profile diversifies, some states are trying to assure that health care providers are trained in "cultural competency."
New Mexico passed a law last year requiring that higher education institutions with health education programs provide such training, though the state still is grappling with how it will be implemented. New Jersey and California are among a handful of states with similar measures already in place.
"We don't expect that a provider is going to know everything about every nationality," said William Flores, chairman of New Mexico's task force charged with developing the curriculum. "The critical thing here is developing sensitivity and the understanding that not every culture responds to medical providers in the same way, sees medicine in the same way."
Dr. Elizabeth Szalay, an associate professor of pediatric orthopedics and pediatrics at the University of New Mexico's Carrie Tingley Hospital, said that it's important for doctors to understand how patients may be different, but patients also need to be open about themselves, by asking questions and revealing their beliefs, concerns or fears.
Navajos often are reluctant to do so, without the coaxing of a social worker, said Linda Henderson, who interprets for Navajo patients. They view Western health care as foreign and won't question a doctor even if they don't understand what is being recommended, she said. It's a matter of respect.
"From our people's point of view, we're offending the doctors, because they're the experts as far as modern contemporary medicine," said Henderson, from Sanostee in the Navajo Nation.
Cynthia Lin, 55, of Taiwan, says she never has experienced a cultural barrier between herself and doctors, which she attributed to her open attitude.
She felt the need to tell a pediatrician once about something that's common among Asian babies — that they are born with a sort of bruised look near the buttocks.
"Some doctors may think, 'Oh my goodness, what happened to the baby's butt?"' said Lin, who lives in Albuquerque. "(But) the doctor understood that's just how Asians are. If the physician already knows about it, if they are aware that certain races have certain characteristics, then they don't have any doubts."
The New Mexico task force is holding meetings around the state to gather input on what should be included in the training and hopes to have the curriculum in place by 2010, Flores said.
New Jersey's law is similar to New Mexico's, requiring that the state's medical schools provide instruction to their students as a condition of receiving a degree. But the schools also must provide cultural competency training to licensed physicians who did not receive the training while they were in school — something Flores said the New Mexico Legislature might tackle down the road.
Although New Jersey's law was passed in 2005, the regulations weren't finalized until April.
California had a voluntary program in place since 2003 but later made it mandatory for the state's 400 continuing medical education providers.
Under the law, every CME course has to have an element of cultural and linguistic competency, which are accredited by the Institute for Medical Quality.
Alecia Robinson, project administrator for the Cultural and Linguistic Competency Program under IMQ, said how the requirements would be met has largely been left up to the providers.
"Each program is unique," she said.
Medical providers agree there's no one resource that can make a person culturally competent, but they say it's important to be familiar with a culture, drop any stereotypes or bias and treat patients in the appropriate way.
"It's a mind-set," Robinson said. "I've heard people speak of it as a level of humility about understanding different cultures. That's quite appropriate."