that may sound touchy-feely but there are excellent methods to standardize these encounters and follow them. as far as what is referred to as the cultural competency, i think that the physician is an important figure. when it comes to chronic illness, patients have this lifelong diet and exercise, if you are poor and your life is chaotic that is not always a priority. have a relationship with the halo personnel, the nurses and secretaries in the clinic, the ones that patients have the best relationships with. the nurses are the folks who are drawn from the community to -- they are the ones who follow them up and engage them. with chronic care which is a big burden, an engagement is really huge. that is a local kind of thing.

>> those categories -- >> i agree. >> i wanted to continue the cultural confidence area here. obviously it seems to me the cultural competence has to be something important. on the other hand there is a bit of a tension between that and that studies of dr. chandra and dr. bach. it would seem as cultural competence is the root of the problem, the studies would have come out differently. when minorities are going to the same medical facilities, that whites going to, you would expect those would specialize in non minority patients, they would be the least culturally competent, and yet, if i am understanding correctly, the problem is not in that area. in the area where we suspect

greater cultural competence because minorities the going to those doctors more often. regardless of who those doctors are, if they're getting repeat patients. is there some way that this can be pursued in your studies to find out how important cultural competence issue is? it really does strike me as a significant tension the tween what is being discussed here and what we are actually getting in outcomes, it would be a travesty if we put our efforts in developing cultural competency if that is not the problem. >> my response to that, i don't think of the world as being either mexican war -- mechanism b. when it comes to heart attacks and strokes it is the quality of the provider and possible, the hospital is very will -- able to

do angioplasty within 45 minutes of the patient being brought in. that will determine survival lot more. if you look at quality of ambulatory diabetes care we see disparities within physician provider networks. that might speak to number of stories of education and to literacy and the potential benefit that a patient receives, could also speak to cultural competency. my only point was the focus on cultural competency is not going to yield the same benefit as the focus on raising the quality of ambulatory care, all of the networks that serve minority patients. it is swamped by the fact that at least when you look at diabetes care, it looks like again and again, minority patients, because of the way they live, providers are having real trouble delivering high quality care. >> the right way to clarify this in terms of full spectrum, there are a variety of issues, we have

to not find the unilateral or silver bullet solution. if we look at the data, cultural confidence is very important. if you look at the full spectrum of data, we find much of what dr. chandra and peter have published, to understand there are quality of care issues in terms of delivery care, but if it was just a linear situation where it was just that, as dr. chandra pointed out, it would be 60/forty, 100% correlation. to understand the importance of workforce diversity and all of that is truly what we're trying to get at in terms of understanding the disparity. that is some of the work that dr. chandra and peter have published have been instrumental in understanding the rules of geography and the full spectrum of datapoint to other factors

which are important and cultural competency is one. >> one of the major problems in health care is compliance of patients with constructions from the health provider. we have a tremendous problem of compliance within a few weeks. many patients made it -- may not be following their physician's orders, that is based on not understanding what the provider has said or not trusting the provider. that is where cultural competence in terms of better communication, better ability to understand the patient and the patient's values. >> a couple things, the first, i want to be clear, i speak to dr. chandra, jump in if i disagree. it is difficult to us as researchers who focus on nuanced distinctions like the one you just talked about, emphasize

sufficiently that you see the large problem even as we drove down and eliminate possible explanations. no one is suggesting that there aren't important, large differences that are intolerable and unconscionable. what we are focused on is very much to your question, what is the right approach, what are the most strategically affective approaches for eliminating things that are within our concerns. on the topic of cultural competence, you are right, the correct interpretation of our data, given that there is no -- we detect no difference between blacks and white pass by individual doctors, doctors are well matched those patient groups or that's cultural overlay is on correlated. on the topic of cultural confidence -- competence, i have questions and concerns that i find the concept intriguing. the first is that there is a general conflation between the

notion of cultural competency and health literacy and linguistic competency if you will. i use those as different issues. the issue of health literacy, well-documented. the gaps that many suffer in different settings. secretary sullivan mentioned a profound one. those issues are often conflated with the issue of cultural competency with linguistics groups. that lacks a robust definition for people like dr. chandra and i to study it. i also think it is uncertain given the lack of definition, how we address a cultural competency shortfall if one exists. i am not sure necessarily that and richie the physician work force with minorities and members of other ethnic groups, which is something i fully support, is something that would necessarily address this gap. i do think it is important, i am

a physician and educator, i teach at cornell medical school, i think it is important to appreciate that medical schools are moving towards cultural competence, focused within their curriculum and we should appreciate the medical and education is a zero some game. the work of dr. chandra and my work have demonstrated profound gaps in clinical knowledge amongst doctors and with workforce regulations and other features taking away from an education environment, we have to appreciate that every player of demand we put on them academically to enrich their ability in one area necessarily takes away from some other area. we have to be very careful that we don't take away the doctor's ability to reintegrate in an instant to teach him to talk to a patient about what is going on. that is my caution. >> i have one more question

which should be for you, dr. bach. you mentioned geographical disparities. do you have any research that tells us what the disparities are between not races, but rural versus suburban verses there and residents? >> let me ask that certain to amitabh. >> that speaks to the enormous body of work that comes out of don of medical school. you see a strong association from new england states with states like utah and montana which are able to deliver with the dartmouth people call highly effective care and not particularly high prices and the gradient in the southern states including california. california looks like a southern state. there is a world difference driven largely by a handful of

extraordinarily good academic medical centers that are in urban areas. that is not automatically the case that urban hospitals outperform rural hospitals. in general, you also see gradients aligned in ways we don't understand. there appears to be some linkage of quality. we can have a separate conversation about what quality i have in mind. we have highly effective care that is very cheap including flu shots, medicare beneficiaries, mammograms. if you look at those measures of quality, it also appears to be the case that areas of the united states that have greater specialists relative to generalists, in an absolute sense, the composition of the physician work force is biased towards specialists. those are the areas that do poorly in terms of delivering

high-quality care. how does it line up? there's something about the physician work force, even given specialists may be better treating a particular condition, it is possible that you have some fragmentation of care that arises when you have more specialists involved in the care process but that is a hypothesis that has never formally been tested. >> abigail thernstrom. >> thank you for coming and i apologize for being late. i have become tired so i am swimming underwater a little bit. but i do have one remark and one question. they're both questions. fall notion of cultural competency bothers me. let me make move to another area

where there are analogous arguments made in the area of education, k-12 education, there is a lot of chatter in the world of educational literature on the question of whether the racial gap in academic achievement is to to inadequate cultural competence on the part of a lot of teachers. and the record here is very clear. what the term ended the occasional outcomes is the quality of teachers by all of the standard measures. what ritter as a team scores? where did they go to college? what do they know? teachers can't teach what they don't know, too many teachers

don't know very much. it has nothing to to do with anything one would call cultural competency or skin color. this squares with a message that one of you delivered, i can't remember which, parents don't care. there has been a lot of survey data on this, they don't care what the color of their teacher is, they care about the quality of their teacher in terms of the lessons that are being delivered and the outcomes. the teachers, does a fourth grade teacher know any math? usually the answer is no. and are the children learning

any math? the places i look at are primarily run by whites, started by whites, charter schools, none of the parent's care. what they know about that school is it is teaching kids. the whole question of cultural competency and how you define it really troubles me. in terms of -- i will go back to my broncs example. in terms of differences the tween care delivered in different areas, the question was brought up, rolled verses urban, you go back to rise favorite school in the south bronx, there is a sign in the

hallway, never take a child to whatever the local hospital is in the south bronx. under no circumstances. no teacher is to go to that hospital. this has been the same in one city. this is not rural verses urban, this is a huge difference in quality between hospitals a mile apart. i am not sure what the reason is that you get such a dysfunctional hospital in south bronx in new york, but i don't have any doubt that the message with in that school has been well thought out. 2 questions. what do we mean by cultural

competency? are we really zeroing in on something that is ultimately very important? the second question, you look at that bronx hospital and what is going on. >> there has been a lot of information and literature coming out, looking at cultural confidence and its impact on health care, i call your attention to harvard's program in georgetown. >> the definition of cultural competence is what? >> you can narrow it down to 2 things, respect for the person's

culture? >> how do you measure that? >> measure it in how you treat a patient, how you interact with patients, how your staff interacts with patients, there are a number of sarah goods. one of the things we have to do is educate people in the role of culture. we have a large and growing student population in my part of the state, as well as the mexican population, there is no question that language, understanding the impact of the culture, making sure that simply writing a prescription or telling them what to do is going to have them follow through, that is not even upon the physician and health-care provider. to communicate in family structure in order to adhere -- >> isn't that true of low income whites as well? i know a physician who was running a clinic in a low income

area, finding exactly the same problem. >> that is why i go back to understanding and respecting those differences. >> that is a class difference. >> it might be a social class difference, but it is much more broad if you look at it. my point was it is an education that needs to be given to the whole issue of one's culture and cultural confidence and good care. recent reports show less than half of all health-care institutions have mandatory courses on cultural competence. there has been a push in a couple states, new jersey being one of them, a couple states have similar statutes to require as part of your license to have some continuing education on cultural competence so you can understand that a little bit

better in terms of providing the best possible care with your patient. >> let me interrupt. if i could switch back to education, i think education courses and cultural competence, they are rife with great big -- racial and ethnic stereotypesing, they are a disaster by and large. those courses worry me as a consequence. maybe it is not true in medicine. >> let me answer that question. we are getting good feedback from peter bach and the research they're doing. take a look at the institute of medicine, those of you who are familiar with the institute of medicine, what it is and what it does, it pulls together a group of national experts on any printed the topic area to investigate and publish an unbiased, non partisan view on any particular topic. something the institute of medicine and highlighted was the

importance of cultural healthcare, i am not a teacher so i can't speak for education but i have respect for teachers and the importance of workforce diversity. one of the other pieces of data we can certainly understand from that very important report is the importance of concordance between groups in terms of understanding particular patients. here is where we get to the heart of cultural competency. understanding the patient and being able to understand the cause. that could be a poor white patient, a rich white patient, a static patient, russian patient, understand the cultural background of the patient and being able to interpret that in terms of the health care setting. when talking about cultural common-sense, we are focused on ethnicity, but the broader concept of cultural competency

means understanding that patient and being able to raise that patient. reading e k gs are important, patients care more when you care about them and understand their stories and read their coming from. one of the things dr. sullivan alluded to, talking about work force data, this idea that we train the work force that is reflective of our nation and what our country represents is important not just in terms of altruistic goals, but in terms of the health outcomes that we can point to. [talking over each other] >> i want to respond to the e cagy issue. >> hold on, folks. [talking over each other] >> i should be on. i am not on? in response to the cagey example, that wasn't an arbitrarily just example. data suggests the time to reach

profusion in myocardium proportion -- myocardial infarct and, processes in emergency rooms, where people are profuse, shows the steps have to do with in decision that the point where data arrives. the reading is extremely important to. just as making sure when blacks or other minority groups have our tax they get repro fused at the same point as white patients at high performing infusion. institutions. i have lots of health care things that i could rattle off. >> commissioner abigail thernstrom is right, i thought i had one in here, sorry i don't, of cultural competence, mind-numbing leave they. the distinctions you made between linguistic competence and anthropological competence, especially when you work with either a population, you want to know what home remedies they use, this is extremely

important. at its worst, cultural competency training has devolved into a version of racial sensitivity training with stereotypes, i wonder how i am supposed to treat my black patients differently than white ones, you mentioned joseph betancourt, a have a quotation from him which is revealing. what he really shows is what you said, which is that this is about universal factors in dealing with other human beings, in this case within the medical setting. he says an informal cultural competence that has, quote, the fall from implementing the principles of patient center care including exploration, empathy, responsiveness to patients needs, that is on an individual basis. as you say, to respect that in all individuals, this group

based at those is hard to translate into a clinical setting. >> i want to emphasize, we speak of cultural competence, this is not simply racial or ethnic. good example of cultural and and is today, medical students are -- half of medical students are women. when i went to medical school, less than 5%. the presence of women in medicine has helped to improve women's health-care because there are many efforts of communication that women--many women feel much better having a woman physician. doesn't mean the male physician is incompetent, but if the patient is reticent in communicating, and we heard earlier about translators where the family doesn't translate anything, is a 2 way street. in my view, cultural competence includes that sort of thing. we are much better off because

today we have women health professionals as well as men. in many cases when some women are reticent to share with men intimate details of their medical care, they can do that with women and get better care. that is one example of cultural competence, has nothing to do with race or ethnicity. >> at this point i would like to thank you. this has been an informative exchange. >> mr. taylor? i will be brief. we are on a short schedule, the second cattle. i want to thank everyone for coming. i want to encourage, since c-span3 is here, the press to read the transcript and shy away from taking the blunt instrument approach to this issue that i see taken so often to label disparity as a result of bias or

discrimination. i am concerned that what i hear, that minorities are clustered around a certain number of physicians, that is what i hear. i am not a physician. i have come to this as a consumer. i want to know why there's not more of a discussion about this clustering and why black folks are not told that the outcome in large part depends on where you're going. we are going to go to the same place with a bad outcome. why isn't anybody telling us that? i have great concern about that. is not hard to document. let's put it on the chart. i could tell my folks to go other places, where the outcomes are better. i am going to leave on that point and if nothing else comes

out, i will fill that out for to day. >> there's nothing left for me to say other than thank you very much. let's take a 5 minute break and start the second panel. [applause] [inaudible conversations] ♪ >> just ahead on c-span2, more on health care as analysts proposed changes for the industry. then washington correspondent george stephanopoulos gives his

insight on the political challenges that president obama faces on passing comprehensive health care legislation. later, the senate returns at 1:45 eastern for morning business, gaf will to gavel coverage on c-span2. later today from the national press coverage, remarks on the organization's effort that eliminating polio around the world and the lessons that can be applied to other vaccines. the global health cancel is the host of this event. you can see it live at 1:30 p.m. eastern on c-span 3. how is c-span funded? >> i have no clue. >> a government grant? >> the nation's, advertising for products. >> public money.

>> taxes. >> how is c-span funded? 30 years ago america's cable companies created c-span as a public service, private business initiative, no government mandate, no government money. >> now political and health policy analysts discuss proposed legislation to restructure the industry and the changes needed in the mental-health field. this event was part of a conference hosted by the group mental-health america. [applause] >> on behalf of the panel i want to thank mental-health of america for inviting us. this is a massively timely subject, particularly in view of the last panel. this fits with where all of us want to focus our time a