I once received a discharge on a patient from the emergency department of a small, good-looking child who was admitted for a urinary tract infection. A simple UTI usually doesn’t warrant hospitalization, so I asked more questions. The emergency room who attended added that the patient had received a prescription for oral antibiotics on a previous visit to the emergency room, but that the parents had not picked up the medication. Negatively, attendees stated that a parent’s “non-compliance” necessitated acceptance.
This statement bothered me. The designation of non-compliance presupposes a deliberate choice on the part of the family to disregard medical advice. After speaking at length with the family, they revealed that transportation problems and the father’s work schedule prevented them from obtaining medication. The interaction reminded me of the need to practice cultural competence and, moreover, how implicit bias can surreptitiously insert itself into our daily interactions.
Cultural competence: the first step
Cultural competence is defined as the acquisition of knowledge and skills necessary to meet the needs and vulnerabilities of different populations in order to provide access and care. It originated from the social psychology movement in the 1980s, and was soon adapted to healthcare through two books by the Institute of Medicine, Unequal treatment: Confronting racial and ethnic disparities in health care And Who will keep the public healthy?.
After developing cultural competency courses, she worked to sensitize health care providers to the conditions faced by the underserved and most affected by health inequalities, ie racial and ethnic minorities.
Culture is not only defined by a racial or ethnic context. Health advocacy consultant Karen Fletcher defines culture as “people who act out of a similar set of ideas and beliefs about how the world works”. She maintains that looking at cultural competence through the narrow lens of race or ethnicity places great emphasis on differences and thus potentially widens the gap between the “traditional beliefs” of the minority and the more “traditional or dominant” beliefs of the majority.
Moreover, as these beliefs are accounted for and attributed to groups, the danger of stereotyping presents itself. To the extent that cultural competence has been effective in raising awareness of the needs of others, more is needed to avoid widening the cultural divide.
Cultural Humility: A Necessary Second Step
Coined over 20 years ago by Melanie Travalon, MD, MPH, and Jean Murray Garcia, MD, MPH, cultural humility is defined as “a lifelong process of self-reflection and self-criticism.” Rather than starting with the goal of understanding others, the individual is first tasked with understanding himself, his beliefs, and his biases. Culture in this sense is not limited to ethnic or racial domains. For example, practicing cultural humility encourages me to explore how I relate to others as a doctor, father, or as an Asian male. Each of these identities affects how I relate to others as well as how others relate to me.
Dr. Trevallon and Murray Garcia describe the three principles of cultural modesty as:
A lifelong learning process because our experiences, the experiences of our patients, and the world is always changing
Awareness of our lack of knowledge of others’ beliefs and values, along with acknowledgment of our own assumptions, biases, and power imbalances that may exist (such as the doctor-patient relationship)
Recognizing the importance of institutional accountability
Relationships fostered by cultural humility mean that cultural competence is no longer a binary objective of mastering knowledge about particular groups. Rather, it is about seeking to understand the dynamic process of culture and how it can affect ourselves and others.
Anthropologist Dr. Margie Akin offers the following exercises to begin your journey into cultural humility:
Outline your cultural and family beliefs and values.
State your personal identity: race, age, experiences, education, socioeconomic status, sexual orientation, and religion.
Identify or learn about your own biases and personal assumptions about people whose values differ from yours.
Describe a time when you realized that you were different from others.
Patient-centered care is one of the six areas of quality health care identified by the Institute of Medicine. Adopting a more modest and culturally 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 about her home life. She learned that her father worked in a construction job, which made it difficult for him to quit. She got to know other young family members who had prevented her mother from leaving to get her medicine. The family also struggled with language and transportation barriers daily. Plus, I learned how to take for granted the ease with which I can get what my family needs. This was not a simple story about being “non-compliant” with one’s choice; This was a story of not being able to comply with not having one. It’s a stark reminder that in terms of cultural competence and humility, my journey is just beginning.
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About Dr. Giancarlo Toledanes
Giancarlo Toledanes is an assistant professor of pediatrics and a physician at Children’s Hospital of Texas Children’s Hospital and Baylor College of Medicine in Houston. His professional interests include quality improvement, health equity, faculty development, and social psychology. When he’s not in the hospital, he’s a cook and groomer for his wife, an amateur LEGO builder for his son, an ambitious unicorn for his daughter, and a burp rag for his baby daughter. Connect with him on Twitter: