Education about different cultures can be used to avoid stereotypes, bias, and clinical uncertainty. Students and clinicians may greatly benefit from cross-cultural education or training. However, clinicians should be aware that achieving cultural competence is a process, and does not happen from one day to another with a textbook, or as a quick fix. Cross et al (Table 1) developed a framework in which cultural competence occurs in a continuum and in six stages: 1) Cultural Destructiveness, 2) Cultural Incapacity, 3) Cultural Blindness, 4) Cultural Pre-competence, 5) Cultural Competency and 6) Cultural Proficiency 23 . An awareness of one's own position within the different stages is the first step to achieving full cultural competence.

The Office of Minority Health published the Culturally and Linguistically Appropriate Services Standards (CLAS) in 2000 24 . One of the main themes of the standards is culturally competent care. Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations 24 . Culture refers to the patterns of behavior in humans that include language, thoughts, communication, actions, customs, beliefs, values, and institutions of race, ethnicity, religion, or social groups 25 . Culture not only refers to race, ethnicity, and religion, but also refers to gender, sexual orientation, age, disability, and socioeconomic status 24 . Educational programs should have a patient-centered focus, where the patient is the center of attention, rather than the patient's cultural group characteristics, or the disease itself.

However, many training programs use a categorical approach to teaching cultural competence by focusing on certain groups of people. Carrillo, Green, and Betancourt recommend an emphasis on the differences between individual patients, rather than groups, in cross-cultural curricula 26 . There are many different models of cultural competency/cross-cultural curricula that are currently being used in medical schools. Examples of such curricula and suggested readings in the topic are presented in Table 2 26 27 28 29 .

Many racial and ethnic minorities, especially limited English-speaking minorities, report poor communication with their clinicians and have more problems with different aspects of the clinician-patient relationship 30 31 32 . Many patients who experience poor communication are less likely to follow instructions, take medications, and follow-up with tests and appointments, all leading to poorer health 33 34 35 . Thus, effective communication is another strategy primary care clinicians can use to reduce health disparities. Effective communication can be defined as using little medical jargon, speaking clearly, and ensuring the patient understands the given information 36 . Stereotypes can be avoided if the clinician is able to gather accurate information about whether the patient understands his or her condition. Kleinman and colleagues developed a set of interviewing questions to elicit how patients understand their condition 37 . These patient-centered questions are presented in Table 3 and can help clinicians understand and address the patient's ailments.

Complex language can have a negative effect on successful communication between a clinician and patient. A report by the IOM found that the complex language that clinicians use to communicate with patients, either verbally or written, is a problem for many patients, not just recent immigrants or those with a low level of education 38 . Termed "health literacy," this important concept must be taken into account when communicating with patients.

Health literacy is defined by the National Library of Medicine and Healthy People 2010 as the "degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" 38 39 40 41 . Many factors affect health literacy, such as the patient's level of education, cultural background, and native language. The clinician's ability to effectively and appropriately communicate with the intended audience is also important 38 . Even people with strong health literacy skills have difficulty understanding written information from clinicians, such as patient information sheets and prescription drug labeling 38 . If patients have difficulty understanding instructions given by a clinician, they may not be able to understand their health condition, may have difficulty with treatment decision making, and may not take their medications correctly 38 . A patient centered approach, as shown in Table 3, where the patient's perspectives, values, beliefs, and behaviors are taken into account may reduce these communication barriers.

Clinicians and patients who do not speak the same language substantially complicate communication issues. Using trained interpreters is the best way to ensure that patients understand information that is given to them. If non-trained interpreters are used, such as family members or employees who are pulled from their regular job to interpret who are not aware of the potential problems that may arise, problems of lost information, misunderstandings, and miscommunication may occur. This may result in patients not having their needs addressed, requiring returned clinic visits, ordering unnecessary tests, or even misinterpretations regarding prescribed drugs. The Cross Cultural Health Care Program (CCHCP) developed guidelines to help clinicians work through an interpreter 42 . These guidelines state that the decision to use an interpreter is made whenever the clinician feels that language or cultural differences may cause a barrier to clear communication, or whenever a patient requests an interpreter. Choosing an interpreter may also be a challenge. The CCHCP makes several suggestions as to how to choose an interpreter. First, make sure that the interpreter is fluent in both languages; testing may be needed. Second, make sure the interpreter is trained as an interpreter. The fact that a person is bilingual does not make her or him an interpreter; there are special skills involved. Third, do not use a family member. Family members often edit the patient's message, add their own opinions, and answer for the patient. Fourth, never use a child. This creates role reversal and power reversal, and it should not be the responsibility of a child to relay bad news to parents or family members.

The CCHCP also provides suggestions on how to work through an interpreter 43 . First, request interpretation of everything, and in the first person. Second, speak directly to the patient, not to the interpreter. Third, insist that everything you say is interpreted, as well as everything that the patient says, or that family members say. Fourth, be patient. Providing care through an interpreter often takes longer. However, this will avoid wasted time, misunderstandings, or unnecessary tests.

Some organizations or clinicians' offices may be too small to hire a full time interpreter or there may be barriers to hiring bilingual staff. In such cases, another option would be using the American Telephone and Telegraph (AT&T) language line 44 . The service may be used by a subscribed client or company, or may be used by an unsubscribed individual for less frequent use. Although at first glance the price for this service may seem quite expensive (ranging from $2.20 per minute to $7.25 per minute), it becomes cost-efficient in the long run because clinicians will have a better understanding of the patients' symptoms, conditions, and life styles. Patients will also have a better understanding of their condition and their medications, and will be less likely to return due to misunderstandings.

The use of evidence-based medicine (EBM) can be another method to reduce health disparities. According to the University of Toronto Center for Evidence-Based Medicine, EBM is the integration of best research evidence that is clinically relevant with clinical expertise and patient values 45 . The need for valid information, the inadequacy of current resources, and the lack of time to spend with the patient are some reasons why interest in EBM has increased in the past years 46 . EBM can also reduce clinician bias and stereotypes by ensuring that practice is based on one's expertise and the most current applicable evidence. Adherence to evidence-based guidelines allows clinicians to make decisions that are reflective of current research findings, avoiding conscious or unconscious decisions based on bias or stereotypes. However, there are many realities that must be considered. When serving low income patients and/or individuals from underserved populations, resources may be severely limited. Utilizing the best evidence that fits the clinician's practice environment and special circumstances is recommended. For example, clinicians practicing in non-profit free clinics must make strategic and economic decisions when deciding what medication to prescribe because medications are often out-of-pocket expenses for patients. Nonetheless, studies have shown that practicing EBM has economic advantages as well. The lack of compliance with antihypertensive guidelines, by using second-line medications over first-line medications (such as hydrochlorothiazide), was associated with potential increases in health care expenditures in the range of $2.6 billion to $3.2 billion in 1996 47 . Numerous EBM resources are available on the Internet to allow primary care clinicians to keep abreast of EBM guidelines (Table 4). Use of EBM principles may potentially increase health equity among patients.

Although the recommendations provided may not be simple to implement, primary care clinicians can have a significant role in reducing health disparities through incremental changes. Education is the key to understanding patients' perspectives and providing a higher quality of care. Other steps that can be taken are conscious efforts to communicate with patients more clearly and using trained interpreters when needed. Also, communication style, such as asking questions in a more caring manner or validating a patient's concern, may have a positive impact on the health of patients. The use of EBM may be beneficial, not only for the populations that experience health disparities, but also for the patient population as a whole, reducing costs and increasing equity. The sum of our small changes, taken together, will make a significant impact.