Welcoming All Patients With Cultural Competency

Minorities have varying perceptions of eye care.

By C. Cordell Adams, M.D.

A Rrecent survey, Americans’ Attitudes and Perceptions About Vision Care,¹ which highlights differences among various ethnic groups in attitudes and perceptions about eye care has me thinking about how race and ethnicity factor into an ophthalmic practice. Ultimately, I think the well-rounded ophthalmologist must be skilled in eye care, above all, and welcoming to all patients in the community. This requires a certain degree of "individualization" when treating our patients.

My pediatric patients are more comfortable with me if I don’t wear a white coat. Some of the African-American women in my practice like to chat about their church activities before getting down to the business of an eye exam. Other patients do not speak English well and are thrilled if I have someone on hand to explain what I am doing in their native language. To me, being able to speak to a patient in a way that puts him/her at ease just makes sense.

The Changing Face of Patients

Changing U.S. demographics mean that practitioners who once treated a majority white-American patient base will soon find themselves practicing in a different world. The nation’s cultural diversity, while certainly concentrated in some areas, permeates even areas that were once homogeneous.

According to 2005 census data, one-seventh of the U.S. population is Hispanic, making them the largest and fastest growing ethnic or racial minority in the country. By 2050, Hispanics are expected to make up nearly one-quarter of our population. By contrast, African-Americans, once the largest minority group, have remained at a fairly steady 12% of the population. Census data also show that about 12% of the U.S. population is foreign-born. Nearly 20% of people in this country speak a language other than English at home — although the majority of these individuals (55%) speak English well. Given the demographic trends, it certainly behooves all of us to make sure that our offices are welcoming to all ethnicities.

The survey, conducted by Harris Interactive on behalf of The Vision Care Institute of Johnson & Johnson Vision Care, Inc. (TVCI), reveals some interesting statistics that every eyecare practice ought to review. The survey polled more than 3,700 adults of various ethnic backgrounds (Hispanics, African-Americans, Asian-Americans and Caucasians). Participants were polled about their attitudes toward, perceptions of, and experiences with, vision care.

Survey Findings

Across the board, survey respondents agree that maintaining their vision is an important priority. Nevertheless, there are cultural differences we need to consider. Asian-Americans, for example, are least likely of all the groups surveyed to strongly agree that taking care of their eyes is as important as other health issues and are also least optimistic that vision correction can improve activities such as driving, work performance and reading.

Caucasians demonstrate greater knowledge and awareness of vision conditions and treatments than other groups surveyed. For example, whites are much more likely to know exactly what vision conditions such as myopia/nearsightedness, hyperopia/farsightedness, astigmatism and presbyopia are and to understand that treatments for these vision conditions are available (Figure). They are also significantly more likely to know there are treatments available for conditions such as glaucoma, cataracts, and age-related macular degeneration (AMD).

Among all the groups surveyed, there is limited awareness of presbyopia and the options for treating it. Only 38% of those 40 and older know exactly what presbyopia is, and just over half (53%) of people in that age group know there are treatments available for it. With the availability of bifocal and multifocal contact lenses, multifocal and accommodating intraocular lenses and other surgical options for presbyopia, this is clearly an area where increased patient education is warranted.

Figure. Caucasians have a greater knowledge of vision conditions than non-caucasians.

Nearly nine in 10 respondents (86%) agree that serious health problems can be detected through a thorough eye exam. African-Americans (45%) are most likely to strongly agree with that statement, while Asian-Americans are least likely to strongly agree (28%). Nevertheless, African-Americans are most likely to report that they do not have a regular eyecare provider. So we have the conundrum that even though African-Americans are disproportionately affected by glaucoma, hypertension and diabetes, and although they know eye exams are important in diagnosing these problems, they are not getting the ophthalmic care they need.

Far too often, I see an African-American patient for an initial glaucoma consultation whose optic nerve already shows significant damage. Typically, the patient has been referred by another provider because of a suspicious cup:disk ratio. I often find myself wishing I could have started that patient on IOP-lowering medications 5 or 6 years ago, before there was glaucomatous damage.

Educating Minority Patients

I find that people of all races and ethnic groups are unaware that their medical insurance plan will cover eye exams for certain conditions. People assume that anything related to their eyes or their vision is only covered by a vision plan. Since many people do not have a vision plan or have one that covers an eye exam once every 12 or 24 months, they put off taking care of their eyes. An annual or biannual visit is simply not standard of care for patients with a medical condition like glaucoma or cataract that need to be followed at least twice a year.

One way that ophthalmologists can reach out to and educate minority patients is through primary care physicians and optometrists of the same race or ethnic group as patients. These professionals are a powerful source of referrals in their own communities.

While a majority of my patients are Caucasian, I know that I receive many referrals from African-American physicians and optometrists simply because I am also African-American. Hispanic doctors also refer patients to me because they know I speak some Spanish and have a multicultural staff. Sometimes you have to make an extra effort to reach patients outside your own ethnic group — advertise in targeted local circulation newspapers, participate in local festivals, markets or other venues where health and vision screenings might be offered.

Relationships with Eyecare Providers

Most survey respondents say they regularly see an optometrist (42%) or an ophthalmologist (32%). The remaining 26% either do not have a regular eyecare professional or don’t know whether they see an optometrist or an ophthalmologist.

People overwhelmingly turn to their eyecare providers, rather than to friends, books, or the Internet, for information about vision and vision care products. However, as in medicine in general, we do see a little bit of a trust gap in eye care.

Caucasians (82%) are more likely than non-Caucasians (74%) to trust their eyecare professional to provide reliable information. This may mean we have to work harder to gain the trust of those who have either not been treated fairly by the healthcare system in the past or perhaps are relatively detached from or new to the healthcare system.

Some patients actively seek out providers who are "like them." Half of Asian-Americans say that they see an Asian/Pacific Islander eye doctor. Much smaller percentages of African Americans (14%) and Hispanics (19%) say they see an eyecare professional from their own ethnic group.

It is human nature that people want to feel welcome. It helps if there is someone who looks like them or speaks their language — the individual does not have to be the doctor. While I would never advocate hiring solely on the basis of race, it makes good business sense to have a staff that reflects the makeup of your local community. You can also make a conscious effort to show more diversity in the pamphlets you make available, and in paintings, décor and advertising.

Language is a major component of cultural understanding. A large percentage of my patients are Spanish-speaking and I will always ask a Spanish-speaking staffer or interpreter to join us if my diagnosis or findings may not be good news for the patient. In such cases, I am not comfortable relying on my non-native Spanish because I want to be absolutely certain that the patient fully understands his or her medical problem and my recommendations.

Patterns of Eye Care

About three-quarter of Americans believe people should have their eyes examined at least once a year, and they acknowledge that an eye exam is still needed, even if they aren’t having trouble seeing. They also responded honestly about whether they actually follow through on this knowledge — the reality is that only 50% have seen an eyecare professional in the past year and one-quarter have not been to the eye doctor in more than 2 years.

Again, we see some interesting ethnic breakdowns in the survey. Hispanics are least likely to have seen an eye doctor in the past year, even though they are more concerned than other groups about their vision. African-Americans are most likely (59%) to say it is important to get an eye exam even when their vision is fine. Asian Americans are least likely to agree with that statement (31%).

This makes sense to me. African-Americans in my practice are more motivated than other groups to seek ophthalmic care because they have a strong and not entirely unfounded fear of going blind. Glaucoma is rampant in the black community, so many African-Americans know someone personally who has lost their vision to it or to some other condition.

Overall, 14% of respondents report they do not have a regular eyecare professional. African-Americans (21%) are most likely to report they do not have a regular eye doctor, despite being the group most at risk for glaucoma and hypertension or diabetes-related ocular complications. Across all groups, one-third of parents say their children have never seen an eye care provider.

Why are so many people noncompliant with regular checkups for their eyes? In some cases, there is a lack of awareness of recommended regular care, but as the survey shows, most people know they ought to go. More often, it is a lack of attention to their personal health, lack of money or perception that going to a doctor when you are not sick is a waste of money and time.

What Encourages Patient Compliance?

It may be more important to look at the flip side and understand what motivates people who do go to the ophthalmologist. Advancing presbyopia is the motivating factor for many patients, but I find this to be less true for Hispanics, who make up a large share of my patient base. New consults with Hispanic patients typically arise from one of two reasons. The first is that their general practitioner has referred them to me for evaluation because of their diabetes or hypertension. The second reason is that they have a cosmetically unappealing pterygium or pinguecula, both of which are common in the Hispanic community.

Overall, 29% of those polled said they always get their eyes checked on a set schedule. Asian-Americans are most likely to do this, while Hispanics are least likely. One in five patients (17%) say they scheduled their last eye exam because their doctor’s office reminded them it was time for a checkup.

Here is an area where simple measures can make a big difference in improving compliance. In our practice, we not only send out reminders but have patients address their own reminder postcards before they leave the office. Seeing their own handwriting when they get that card in the mail seems to have a powerful impact.

Another area where we can reach out to patients who might not know that help is available is in the area of computer vision syndrome. In the Harris/TVCI poll, people report spending 5.1 hours per day looking at a computer screen. A majority of respondents experience headaches, dry or tired eyes, or other symptoms associated with prolonged computer use. Asian-American (58%) and Hispanic (52%) computer users are significantly more likely to experience computer-related discomfort than Caucasians (43%) or African Americans (41%). Offering solutions for computer-related strain gives us an opportunity to bring these patients into the practice, solve a real problem for them and perform a medical eye exam at the same time.

Building Cultural Competency

Of foremost importance to me and to my patients, I believe, is that I be good at what I do. There is no denying the secondary importance is providing a welcoming environment. Patients want to go to doctors they like and want to have a pleasant experience while they are in your office. To my mind, figuring out how to boost a patients’ comfort level with me and my practice is an important chairside skill. One might call this skill set "cultural competency" or cultural sensitivity. However you wish to term it, building a practice that welcomes all your patients is a subtle, but important, element in patient compliance with visits and treatment regimens.

The findings of the Harris/TVCI poll discussed here largely reflect my own experience treating a diverse patient population. Additionally, they offer valuable insights into the steps all of us can take to make our practices more sensitive to a diversity of patient needs. OM

Reference

1. Harris Interactive. Americans’ Attitudes and Perceptions About Vision Care. Available at: www.harrisinteractive.com/news/newsletters/clientnews/2006_JohnsonJohnsonVisionCare.pdf. Accessed May 16, 2007.

C. Cordell Adams, M.D., is in private practice in general ophthalmology in Dallas, Texas, with 40% of the practice geared toward his fellowship training in glaucoma at Baylor University Medical Center. Contact him at (214) 826-7231 or cordella@flash.net.