Thelma Hyman is 90 years old, and she expects to be called Mrs. Hyman when she visits the doctor's office. But when the black woman recently visited the office of a white physician, he called her Thelma. "I'm not sure I'm going back to him," says the resident of Washington, D.C. "It's very important. Everyone has their own feelings about how you need to address them."

The exchange may seem inconsequential, but a growing amount of research is investigating whether these small cultural differences — most of them between white, male doctors and their diverse patients — could be a big reason for the nation's persistent health care disparities.

Thelma Hyman, 90, of Washington, D.C., who recently was disappointed when a physician referred to her by her first name. Researchers are studying cultural gaffes such as this to see if they are affecting health care disparities.

In 2005, New Jersey became the first state to require cultural-competence education for physicians to get licenses. California requires continuing medical education for doctors to include cultural and linguistic competency training.

The federal government is financing studies examining whether the training can help health care workers get diverse groups to comply better with doctors' orders.

FIND MORE STORIES IN: African-Americans | Latinos | Medicine But no study has proven cultural competency training works, either by improving doctor-patient relationships, increasing patient compliance or reducing disparities.

But examining the question is the first step to addressing the problem, says Ramon Jimenez, chairman of the diversity advisory board of the American Academy of Orthopaedic Surgeons. "Cultural competency will have to be on everybody's radar screen for generations to come. When the day comes that the melting pot is truly a melting pot, then we won't need this, but that day isn't here yet."

About six years ago, the academy gathered information for a culturally competent care guidebook and accompanying DVD for doctors with chapters on African-Americans, Asian-Americans, Native Americans, Latinos, women and religions including Islam.

The academy compiled interviews with patients of different races and cultural backgrounds with doctors familiar with diverse patients and a plethora of research. For example, the guidebook encourages doctors with Native American patients to "ask if patients may seek a healer or medicine man." It also recommends that doctors with Latino patients break the ice by asking them their country of origin.

Hyman, a retired physical education teacher and former high school athlete, had knee pain so severe that she missed family events and wouldn't leave her house without a cane.

"When I found I couldn't walk a block, that disturbed me," she says. But, like many black patients, according to the guidebook, she was reluctant to have her knees replaced or to have any other kind of surgery.

It is common for black patients to distrust doctors and hospitals for many reasons, including a general distrust of hospitals, fear that doctors may recommend surgery when it isn't necessary and concern they may suffer bad outcomes, says Tony Rankin, an orthopedist in Washington and the first black president-elect of the Orthopaedic academy.

Hyman was referred to Rankin for surgery at Providence Hospital. He replaced both her knees, and she was pleased with him. "He was very understanding," she says. "He explained what he was going to do. He allayed all my fears."

He also called her "Mrs. Hyman" and arranged meetings with her three children to answer their questions. "Just little things like that," Rankin says. "Though it seems insignificant, it makes a big difference."

Not all doctors are as keen on cultural competency training, especially if it's mandatory. Joseph Zebley III is a white male and a family doctor in Baltimore. His patients are mostly African-American and Southeast Asian, and he also sees many Haitians because he speaks French, the language of his mother.

"Just because I happen to be a white male doesn't mean I'm not comfortable with African-American culture in Baltimore city," Zebley says.

Some doctors may be uncomfortable with unfamiliar cultures, but courses in cultural sensitivity aren't the answer, he says. "You can't really teach that. You have to bond one-on-one with the patients. Otherwise, you can do all the cultural competency training in the world, and it's not going to make a difference."

The guidelines aren't meant to apply to every person in every case, Rankin says. Indeed, the guidebook carries a disclaimer: "Never assume that an individual who comes from an ethnic culture shares the traits of that ethnicity or culture."

For example, Jimenez says he might ask recent Latin immigrants if they have used a curandero, or folk healer, but he may not ask that question of a second- or third-generation Latino.

Part of knowing when and whom to ask these questions takes experience, he says: "You don't go through four years of college, four years of medical school, six more years of training and thousands of patient interviews without learning something."

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