I once received a sign-out on a patient from the emergency department for a well-appearing young child who was admitted for a urinary tract infection. Normally, a simple urinary tract infection does not warrant a hospital admission, so I asked further questions. The emergency room attending added that the patient received a prescription for oral antibiotics at an earlier emergency room visit, but the parents did not pick up the medication. Passively, the attending mentioned that the parent's "noncompliance" necessitated the admission.
This statement bothered me. The label of noncompliance presupposed an intentional choice on the part of the family to ignore medical advice. After speaking at length with the family, they revealed that transportation issues and the father's work schedule prevented them from picking up the medication. The interaction reminded me about the need to practice with cultural competence, and, further, how implicit bias can surreptitiously insert itself in our daily interactions.
Cultural Competency: A First Step
Cultural competency is defined as acquiring the knowledge and skills necessary to address the needs and vulnerabilities of different populations in order to provide access and care. Born out of the social psychology movement of the 1980s, it was quickly adapted to healthcare with two books by the Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare and Who Will Keep the Public Healthy?.
Later development of cultural competency courses worked to sensitize healthcare providers to the conditions faced by the underserved and most affected by health inequalities, namely ethnic and racial minorities.
Culture is not solely defined through a racial or ethnic context. Health advocacy consultant Karen Fletcher defines culture as "people acting from a similar set of ideas and beliefs about how the world works." She contends that viewing cultural competency through the narrow lens of race or ethnicity focuses too much on differences, thus potentially widening the divide between the "traditional beliefs" of the minority and the more "conventional or mainstream beliefs" of the majority.
Furthermore, as these beliefs are tallied and attributed to groups, the danger of stereotyping presents itself. As effective as cultural competency has been in increasing awareness of the needs of others, more is needed to avoid widening the cultural gap.
Cultural Humility: A Necessary Second Step
Coined more than 20 years ago by Melanie Tervalon, MD, MPH, and Jann Murray-Garcia MD, MPH, cultural humility is defined as "a lifelong process of self-reflection and self-critique." Rather than starting with a goal of understanding others, the individual is tasked with first understanding themselves, their beliefs, and their biases. Culture in this sense is not limited to ethnic or racial scopes. For example, a practice of cultural humility encourages me to explore how I relate to others as a medical doctor, a father, or as an Asian cisgender male. Each of these identities affects how I relate to others as well as how others relate to me.
Drs Tervalon and Murray-Garcia describe the three principles of cultural humility as:
A lifelong learning process because our experiences, our patients' experiences, and the world are always changing
An awareness of our lack of knowledge about others' beliefs and values, coupled with a recognition of our assumptions, prejudices, and the power imbalances that may be present (such as the physician-patient relationship)
The recognition of the importance of institutional accountability
The relationships fostered by cultural humility mean that cultural competency is no longer a binary goal of mastering knowledge about particular groups. Instead, it is about striving to understand the dynamic process of culture and how it can influence both ourselves and others.
Anthropologist Dr Margie Akin offers the following exercises to start your journey in cultural humility:
Identify your own cultural and family beliefs and values.
Define your own personal identity: ethnicity, age, experiences, education, socioeconomic status, sexual orientation, religion.
Identify or recognize your personal biases and assumptions about people whose values differ from your own.
Describe a time when you became aware that you are different from other people.
Patient-centered care is one of the six domains of quality healthcare defined by the Institute of Medicine. Adopting a more culturally humble and competent approach enriches not only our professional lives but also our personal lives.
Not a Simple Story
The remainder of my patient's hospital stay was uneventful but yielded additional details of her home life. I learned that her father worked a construction job that made it difficult for him to leave work. I learned about other young family members in the household that prevented her mother from leaving to fetch the medicine. The family also struggled with language and transportation barriers daily. In addition, I learned how I took for granted the ease with which I can obtain whatever my family needs. This was not a simple story of being "noncompliant" by choice; this was a story of being unable to comply for lack of one. It is a stark reminder that with regard to cultural competence and humility, my journey has only just begun.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Giancarlo Toledanes. Cultural Humility in Medicine: Moving Beyond Race and Ethnicity - Medscape - Dec 03, 2021.
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