AMA Journal of Ethics^®

Can evidence-based medicine (EBM) and cultural competence in medicine (CCM) be practiced simultaneously? To answer this question we must understand what each is. Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence, primarily from clinical trials, in making decisions about the care of individual patients. In general the goal of EBM has been to improve quality through the standardization of medical care. Cultural competency in medicine, by contrast, is the delivery of health services by workers who understand cultural diversity and factor it into the clinical setting and who respect individuals' health beliefs, values, and behaviors. Given these definitions, it would appear that the two practices conflict [1].

EBM and CCM share a common goal; both fundamentally work to improve the quality of health care, but they work at different levels—EBM focusing primarily on the standardization of care for all populations; CCM focusing on the individuals who make up those populations. Recently, however, EBM has begun to integrate aspects of CCM by incorporating individual circumstances and preferences into decision protocols. CCM has likewise developed methods to elicit patients' explanatory models—how they understand their illness—to avoid stereotyping and oversimplification of culture [2]. And there is increasing recognition that CCM could use a dose of EBM.

The two approaches share another trait—both are experiencing some backlash. Like many new ideas, EBM and CCM were initially applied in overly simplistic ways. This problem was exacerbated by the fact that both base their recommendations on modal information derived from populations and subgroups. EBM guidelines derive from population-based studies, while early teaching modules on CCM were based on general, or average, health beliefs among subpopulations—learning about Asian health care meant listening to a lecture about alternative treatments such as coining. EBM experienced a backlash over fears of "cookbook medicine" or clinical stereotyping, while CCM experienced a backlash over fears of cultural stereotyping.

As a result, as EBM and CCM evolve, they seem, in fact, to be merging. Today, both fields often claim to offer evidence-based and culturally competent care that is also patient centered [3-4]. But on face value, EBM's emphasis on standardization and CCM's emphasis on uniqueness remain at odds. Ultimately, for the two approaches to work together, we will need to see that EBM can be patient-centered and culturally competent and that CCM can demonstrably improve health outcomes. Can implementation of EBM guidelines make patients feel more listened to, empowered, and respected? Can CCM lead to fewer medical errors and better health outcomes? These important questions remain to be answered.

More to the point, physicians may ask whether it is possible to practice culturally competent and evidence based medicine. Patient preferences may be considered where multiple legitimate options for care exist, but this might not always be the case. Are there always multiple acceptable options from which to choose, and who gets to decide what is "acceptable?" And given today's more complex understanding of CCM, before clinicians can apply principles of cultural competence, they need to know how to identify patient preferences and values effectively. This raises another question: Is there evidence that such a nuanced understanding can even be measured, let alone affect health outcomes? Skeptics of cultural competence note the relative lack of empirical evidence linking training in CCM with improvements in health outcomes [5].

To evolve in complementary ways, EBM and CCM need to move toward clearer definitions of what they are and how they can be measured. Even more fundamentally, both need more clarity on the core ways in which they aim to improve health care quality. Our health care system and the individuals who provide care struggle to treat patients from a multitude of backgrounds with respect and dignity, while at the same time providing the best evidence-based medicine possible. For a truly open dialogue to exist, EBM should admit that it tends toward standardized clinical decisions, which can reduce individual discretion for both clinicians and patients. On the other hand, the CCM movement should admit that it promotes individual discretion, and therefore might lead to greater variability in clinical decision making. All of which is to say that we need a comprehensive research agenda to examine the intersection between EBM and CCM and to show that respect for cultural preferences is worthwhile and that the tools of EBM may be adapted to foster patient participation in their own health care decisions.