You are one of the health care practitioners in a community health center that provides primary care to a multi-ethnic, multi-lingual urban community. Many, but not all, of the patients live below the poverty line. Physicians and nurses see a large volume of patients with challenging medical and psychosocial issues.

Lately you have realized that the scheduling of patient visits has become something of a nightmare. Because of the high volume of patients, the wait for an appointment for routine care can be anywhere from six to eight months or more. Even acutely ill patients often wait for two to three days to see a health care provider. Out of frustration, many patients are walking in without appointments, often during lunch hour or late in the afternoon when everyone is getting ready to leave.
What makes the problem so challenging is that 20 to 40 percent of patients fail to show up for appointments on a given day. Because of this high no-show rate, every other appointment on physicians' schedules is double-booked with the expectation that, out of the 30 to 35 scheduled patients, only 20 to 25 will actually show up. Occasionally, however, most of the patients do show up - and when a significant number of acutely ill patients also arrive, the work environment becomes unbearably chaotic for everyone. Providers become harried and more likely to make mistakes, patients wait for long periods of time in crowded waiting rooms, and the atmosphere becomes increasingly hostile as the stress level mounts.

It is clear that the quality and experience of health care for many of these patients is suffering partly because of a simple lack of access to care. And it is becoming increasingly clear also that the better-insured and English-speaking patients may be getting better access: they are more likely to get a timely appointment because they are more demanding of the system, and they are more likely to keep and show up for their appointments because of better communication. You are interested in finding a way to promote more equitable access to health care.

1. One aspect of patient-centered care is fostering a culturally sensitive and diverse clinic environment that makes patients feel more welcome. What are some ways in which this may be accomplished?

2. In order to provide good care for a culturally diverse patient population, it is important to gain some understanding of their ways of being (their belief systems, their traditions, their feelings towards western medicine, etc.). Can you think of a particular patient population in your area that may have unique beliefs about health and illness that would be important to understand?

3. How well do you know your patients? Can you think of a patient population (a culture, ethnicity, religious group, sexual orientation) with which you do not have much familiarity? How might this lack of knowledge impact your care?

4. What are some ways in which you could be better educated in regards to the beliefs and traditions of the patient population in your area? How might that intervention benefit the patients?