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A Case for Cultural Competence

“Know thy patient, know thyself.” –Doctor L. Newman, Brown University

Imagine you are an American visiting a foreign country. While there, you unexpectedly develop abdominal pain and decide to see a doctor. You don’t speak the language well, but with some difficulty, you manage to set up an appointment at a nearby clinic. Interacting with the receptionist and filling out registration paperwork proves to be a challenge. Meanwhile, pain is ripping through your abdomen, and it only seems to be getting worse.

Finally, the doctor sits down to hear about your symptoms and begins to laugh quietly when you explain what is happening with your body. In broken English, the doctor tells you, “My American patients always come in complaining of stomach pain. We can look into it, but honestly, it’s probably from all those cheeseburgers and hot dogs you people like to eat.”

How would you feel in that moment? Insulted? Unfairly stereotyped? Worried about the quality of care that is about to be delivered? Unfortunately, a situation like this may be familiar to immigrants and minorities in the United States trying to access the health care system. The conversation about cultural competence in medicine is ongoing, and there is tremendous value in approaching it through the lens of the patient experience to better understand the need for improvement.

Many health care providers have the best intentions when it comes to delivering culturally competent health care, but still may not know the right way to approach patients from minority groups. Empathy and human connection are difficult to teach and too easily lost in the rigor of medical training. Even so, gaining increased sensitivity through focused education and real-life experience is an achievable objective.

Developing skills of cultural competence requires an open heart and mind–and often an uncomfortable examination of personal biases. It takes time, but along the way physicians gain greater humility and compassion, which translates to expanded access and higher-quality care for patients. There is strong evidence that cultural competence in health care leads to improved shared decision making and better health outcomes.

Case Examples

I will be upfront and admit I have been guilty of committing cultural faux pas in the past. As an intern at an Estonian hospital in 2017, I was confronted by aspects of a foreign culture that were unfamiliar and sometimes intimidating to navigate. As one shift was ending, the head nurse took me aside and explained that wheeling patients with their feet first (“ногами вперед”) was inappropriate, because that is how people are brought to burial in Slavic tradition.

I had no idea I’d been making people uneasy! Instead of dwelling in shame over the mistake, I tried to be patient with myself and promised to be more accommodating in the future. Sometimes it wasn’t convenient to execute a 180-degree turn in the narrow quarters of the hospital, but I learned that the positive emotional resonance of being transported correctly for patients outweighed any extra effort on my part.

Another example of learned cultural competence comes from a short humanitarian trip I took to the Dominican Republic as a first-year medical student. One man came into our clinic complaining of upper respiratory symptoms. On physical exam, he had large ring-like lesions on the back of his neck and midway down his trunk. Usually, an itchy, annular lesion raises suspicion for a fungal infection, but the man denied any itchiness and said the problem had been present for fifteen years. All the American doctors were stumped as well as moderately distracted from the original reason he came to be seen.

A native Dominican physician working with our team took one look and knew right away what it was: scar tissue. There is a cultural practice on the island to cut and scrape around fungal infections, which is believed to stop their spread. We learned the man’s mother had done this many years ago, leaving him with impressive, circular scars. Without access to this specific piece of cultural background knowledge, we would have probably over-treated him. Remembering this case strengthens my appreciation of collaborating with local health care workers, asking the right questions, and addressing the patient’s chief complaint.

The popular book The Spirit Catches You and You Fall Down by Anne Fadiman typifies the complexity of cross-cultural conflicts in medicine. A Hmong family living in California understood their young daughter’s epilepsy to be a spiritual condition while the medical staff operated within the framework of Western scientific reasoning. This dichotomy led to misunderstandings and ultimately obstructed patient care. You may find this case to be not only an interesting read, but also a sounding board for reflection about a better way to approach patients from different backgrounds.

While these examples relate specifically to ethnicity, it is worth remembering that identity is multidimensional. Every person represents a confluence of different backgrounds and subcultures, so it is important not to make assumptions and to meet everyone with curiosity. You can simply begin as all visits should: with a question. Ask patients about their beliefs and what is important to them.

Quick Tips and Resources

  • Ask questions instead of making statements. “I know you Jehovah’s Witnesses don’t believe in transfusions…” is a statement that makes assumptions, while an open-ended question could be much more respectful and effective. For example, “I read in your chart that you identify as a Jehovah’s Witness. Is that right? Do you have any preferences related to the use of blood products?” Let prior knowledge be a resource and not a restraint.
  • Honoring a patient’s diversity can be accomplished by finding common ground and acknowledging what you don’t know yet. Starting this conversation can establish rapport and increase your knowledge of different cultures, which will likely benefit future patients with similar preferences. Exploring a patient’s beliefs, values, and needs and hearing their story can also open your eyes to the health disparities and discrimination experienced by minority groups. This is a vital step in addressing inequality in health care.
  • Treat patients with respect, even when you can’t necessarily relate. Unconditional positive regard, a central tenet of psychotherapy developed by Carl Rogers, means interactions should be centered on patient acceptance and support. This philosophy has been shown to improve outcomes and build trust when properly applied.
  • A comprehensive understanding of your patients is an important resource not only for considerate communication, but to widen the differential diagnosis and improve clinical decision making. For example, a patient’s background may clue you into possible previous administration of the BCG vaccine, which can explain false positive tuberculosis tests. Certain diseases may be endemic to the regions of the world where they have been and should be considered, if appropriate (Chagas, hepatitis B virus, tuberculosis, schistosomiasis, Zika virus, malaria).
  • Find out what you can about faith. Nine out of ten American patients believe in God or a higher power. One study found that nearly all (94%) patients who reported that spirituality was important to them wanted their doctors to ask about their faith and be sensitive to their values, which may include facilitating visits from a chaplain or religious healers. Spirituality can bring meaning and purpose to patients, influence how they understand their disease, impact coping and recovery, and represent an integral part of holistic care.
  • Check out this free online case series, which came about as a collaboration between Stanford University and Johns Hopkins University. It discusses cultural competency in the context of ethics in global health, and the modules are short and accessible.
  • The National Center for Cultural Competence has many online resources to aid health care providers including free self-assessments and curriculum.
  • Many medical schools and hospitals have recurring cultural and LGBT+ sensitivity training, and they may even host conferences that address these topics. You can reach out to your school’s Office of Diversity and Inclusion to find out more about specific programs held at your university.

I hope these ideas and resources will be helpful in enhancing your understanding of cultural competence in the broadest sense. Patients of different ages, genders, races, ethnicities, sexual orientations, political leanings, and creeds (and various intersections of the above) are in need of compassionate physicians who will listen and respond with care. It is our great privilege to treat patients of many cultural backgrounds. May we rise to the challenge and provide the best possible health care for every individual.

Steven Duncan (5 Posts)

Medical Student Editor and Contributing Writer

UT Southwestern Medical School

Steven is a third-year medical student at UT Southwestern Medical School in Dallas, Texas (Class of 2022). In 2018, he graduated from Brigham Young University with a Bachelor of Science in microbiology and Russian. He enjoys eating curry, writing poetry, and hiking in his free time. In the future, he would like to pursue a career in primary care and global health.