Dr. Jo Li Yung is a family physician with three years invested in her first private practice in Metropolis. Because of her national origin and language skills, she started her practice by reaching out to first-generation Chinese immigrants. She also has been successful in attracting many other patients whose families are of Asian origin. She started with a narrow but growing demographic group, and she is consciously building on this foundation to reach out to other segments of the community. Her practice is thriving.

Dr. Joseph Young has been a family doctor in Metropolis for 20 years. His solo family practice serves the neighborhood where he grew up, and many of his patients have been with him for years. His practice also serves a narrow demographic group. Eighty-five percent of his patients are white European-Americans aged 55 to 70, although to Dr. Young the patients just seem “normal.”

Unfortunately for Dr. Young, this segment of the community is shrinking. Black, Hispanic/Latino, Asian and other families are moving in, while older, white, “Anglo” families are moving out or passing on. Dr. Young doesn't know it, but in the last three years he has lost 20 percent of his patients to nursing homes, death, retirement communities and the suburbs. The neighborhood is changing. His practice is not. His patients are aging and dying, and so is his practice.

America is a changing neighborhood

Today, 12.9 percent of the U.S. population is black. Hispanic and Latino individuals make up the most rapidly growing segment of the population (11.2 percent), and by 2020 they will be the largest ethnic minority group in America. By the year 2050 these so-called “minority groups” will actually grow to represent nearly 50 percent of the U.S. population. They are indeed an emerging majority. (See “Minorities: The emerging majority in the U.S. population.”) Does your practice reflect a changing America? Does your patient mix reflect your diverse community? If not, then your practice may be aging and at risk of dying. There are five critical steps for diversifying your practice.

1. Assess your practice

Look at your patient mix. What's the age distribution of your patients? Gender mix? Ethnicity? Is it a broad base that assures practice stability in a changing marketplace? Consider your clinical patient mix as well. What are your top 10 diagnoses for ambulatory visits? How many different kinds of office procedures do you do in a month? Would you attract a broader patient mix by opening your office to minor emergencies or work-related injuries? How about travel medicine as an avenue for reaching out to neighbors who have relatives in other countries, or who enjoy travel for business or leisure?

Look also at your competition. What other physician practices serve your neighborhood? Do any of them fill a distinctive market niche? Does there appear to be a market opportunity? For example, if five of the six other practices in your neighborhood are made up of internists focused on adults, chronic disease and the elderly, perhaps there is an opportunity for you to reach out to younger segments of the market. Could sports medicine attract teens and young adults? Maybe you want to get back on the referral list for newborn care at the local hospital, or maybe you could do community screenings, preschool immunizations or back-to-school check-ups. If you connect with young mothers, there is a good chance that other members of the family will follow.

2. Assess your community

What is a reasonable, geographically defined area from which you can expect to draw patients? Defining the demographic profile of this local market or “catchment area” is your first priority if you are to define your practice's potential for attracting new patients.

Age, gender, ethnicity, income, source of employment and level of education — all this information is available at the county, ZIP-code, or even census-tract level. The old approach for obtaining this information was to head off to a large public library that had rows of books on shelves in their “census repository” section. Now you can generate customized reports from this information at the U.S. Census Bureau's Internet Web site (www.census.gov). Using the “Maps” link (http://tiger.census.gov), you can generate a custom map of your neighborhood with color coding of block groups based on a single variable such as family income, the percentage of the population that is Hispanic or the percentage over age 65. (See the sample map below.)

If you want multiple variables, click on “Access Tools” at the Census Bureau home page. For example, by selecting “1990 Decennial Census Look-up” and then choosing the STF3-B file for ZIP-code-level data, you could find the number of black households with family head age 45–54 and with family income over $35,000 per year (Table P87-b, “Race of Householder by Age by Household Income”). Other useful data tables include “Language Spoken at Home” (Table P-31) and “Aggregate Family Income by Family Type and Presence and Age of Children” (Table P-109).

Because 1990 census data is becoming increasingly out-of-date, many sources provide population updates based on the Census Bureau's annual Current Population Survey (CPS) or other market research data. You can order a customized demographic or market analysis report from a market research company. For example, CACI Marketing Systems (www.demographics.CACI.com) will produce a report with detailed population estimates and three- to-10-year population projections on a defined geographic area (e.g., combine several ZIP codes or draw a 3-mile radius around your practice site). For $75 to $350, CACI will mail you a customized report with all the demographic, housing, employment and educational parameters you need within 48 hours. You can even obtain detailed projections on your local consumer purchasing behaviors, ranging from eyeglasses to toothpaste. Similar information can be generated from online services, such as CompuServe's neighborhood reports (keyword: DEMOGRAPHICS), which give you immediate results for as little as $10.

3. Create a culturally competent practice

First, look at your facility. From the outside and into the public reception area, your practice might appear attractive and professional. For many of us, that would be a positive image. We may not see that this image also carries a hidden message of a practice targeting the mainstream, English-speaking, majority-race, Judeo-Christian community.

Practices that are conscientious in building a diverse patient base find ways to signal their openness to a broader mix of patients. Se habla Español is a good start, but only if it's true. Having a second language on your signs or as an option on your voice-mail system is another medium for sending the message that your practice is open to all. Maybe your reception area could become known for its Asian decor or its Caribbean sculpture.

Look honestly at your team, as well. Will they all look and sound the same through the eyes and ears of a person from another country, another ethnic group or a different generation? You may need some help with this. Ask as many people as you can. Is there a person on your team who relates well to a segment of the community that you have difficulty with? Does someone speak another language?

The biggest step toward cultural competency in a practice is to build diversity into your team. Non-English-speaking patients are best served by same-language staff and clinicians. Translation is not enough. But cultural competence is more than speaking the patient's language. Patients look for staff and doctors who understand their use of language and behaviors and who communicate respect and dignity. They will avoid practices whose doctors and staff misunderstand their language, their culture, their values or their lifestyle.

How will you and your team learn these skills? Invest time and energy to expand your knowledge of other cultures. Read widely. For example, if you want to know something of black culture, you could start with classics, such as Invisible Man (Ralph Ellison), Native Son (Richard Wright) or Their Eyes Were Watching God (Zora Neale Hurston).

You can also get comfortable with patients who speak another language. You might start, for instance, by picking up a copy of the Spanish-language newspaper your patients read, or watching the evening news in Spanish on a cable channel. Travel widely as well, but go beyond the usual tourist experiences. For example, try living for a few weeks with a Mexican family in Cuernavaca. Search the Internet for language immersion programs, some of which are designed specifically for health professionals. Volunteer for a short-term medical mission to another country (see “Volunteer opportunities abroad”). You also may want to look for learning opportunities that you and your staff could experience as a team — and have fun doing.

Learn about medical problems specific to certain segments of the community and about folk remedies, herbal products and over-the-counter medicines that are common in families of diverse cultures and generations. You'll also be more effective in patient education if you not only speak the language, but also express yourself in a way that is respectful of the culture.

Go to all the weddings, graduations and funerals you're invited to, but especially those that go beyond your own cultural experience. Find people who can serve as cultural translators, members of one culture who have lived or worked long enough in your world to say things in a way that you can hear them, but not so long that they have lost touch with the language and culture of their family roots. As best you can, let people speak for themselves about their own culture, as captured in the title of Shanaz Moslehi's book about the experience of Iranian immigrants, Ask Me About Me.

Diversity must be nurtured, tended and consciously cultivated. It's not about getting diverse members of a team to “overcome their differences” or to work effectively in spite of their diversity, but rather to capture the value added by diversity until we can measure it in improved clinical outcomes, enhanced patient satisfaction and more cost-effective service provided to more people in our diverse communities. The Greek word dunamis means power, but it is also the source of our English word dynamite. The dynamic mix of multicultural teams is what gives them their power, but it's also what makes the whole thing a little bit explosive.

4. Reach out to your community

If you have consciously hired a diverse and culturally competent health care team, your job is half done. Your team already has ambassadors who have established relationships much wider than your own. Reward them for reaching out to these segments of the community, and honor their status in these communities. An unintended show of disrespect to them as individuals or to the patients they bring in could severely damage their credibility and their relationships in the community you are hoping to reach.

An obvious next step is advertising. Are you listed in all the neighborhood yellow pages? Buy an ad in a black community newspaper. Perhaps you could buy an ad on a Spanish-language radio station as well, or be visible as a sponsor of the public high school's year-book. To reach recent immigrants, you might support events held by an African cultural society or an Asian business association.

Outreach is a more personal form of marketing. Can you support neighborhood church activities, a local youth sports team or community fund-raising events? How about attending a neighborhood group meeting, or providing services at a community health fair? Go to high school football games, or volunteer to provide sports physicals or even to work on the sidelines. The key to this kind of outreach is integrity. Are you really reaching out to enjoy new relationships and to create a diverse practice, or is it only a gimmick to attract more paying patients? Reach out and make new friends, and the practice will take care of itself.

5. Nurture your new relationships

Relationships don't take root overnight. Perhaps the most important first step is to learn how to express respect in a way that is meaningful to individuals from various cultures. Those of us from white Anglo backgrounds, for example, may sometimes want quick reassurance from colleagues or patients that we're all OK with one another, so we make eye contact, smile all the time, use first names and touch a lot. Unfortunately, no matter how pure our intentions, this is a direct expression of disrespect for many people. For some individuals (and especially among people who have experienced racism, sexual harassment or other forms of discrimination) a pat on the back or an arm around the shoulder may be received as a potential threat or as an unconscious expression of authority, privilege or paternalism.

We must cultivate a sense of cultural self-awareness. Do you expect patients to arrive precisely on time for their appointments? Do honest people make good eye contact? How close do you let people get before they are in your space? These are all culturally derived values and perceptions. Seen through international eyes, Americans may seem impatient, placing more value on completing tasks and keeping to a schedule than on relationships and a sense of community. Compared with recent immigrants, how much time do you spend with members of your extended family (parents, in-laws, aunts, cousins, nieces, etc.) each day or week? Decades ago, the poet Langston Hughes gave us The Ways of White Folks. Can you see yourself in its pages?

Work also on recognizing diversity within minority groups. For example, the culture and life experiences and even the spoken language of a young farm worker from rural Mexico are very different from those of an older physician who fled Cuba in the 1960s and now teaches high school in Miami. We make the same mistake when we engage in tokenism, expecting that any one individual can speak for his or her community. There is great diversity within each culture and each neighborhood. If we are to serve our communities, we must seek out and amplify these diverse voices to make sure we hear all the harmonies.

The future is diversity

We all must diversify aggressively if we are to have practices that thrive in the 21st century. Diversifying our patient bases and our health care teams will enhance the business viability of our practices. We'll also become even better equipped to make a real difference in our changing communities. We'll expand our cultural awareness, and we'll make some new friends in the process. Your bottom line may show immediate returns, but over time it's your soul that will be richer. Que bueno!