During a lecture on ethics and cultural competency in my first year of medical school, a lecturer splashed the following statements on the screen:
Illness & Disease:
- Western Culture:
- Seen as result of biophysical or mechanical causes
- Many cultures of Africa or Asia:
- Seen as a result of divine intervention, punishment or an act of grace, or acts of spiritual powers that seek to do harm
I was flabbergasted — stunned that one can claim any semblance of expertise on the sickness and grief of millions of people, thousands of years, uncountable stretches of sinew, land, faith and life using just fragments of sentences and sense. Albeit an extreme example, this lecture slide demonstrates the highly erroneous and problematic aspects of the “cultural competency” framework that is currently being used in physician training as a component to combatting racialized health care disparities.
The issues with the slide are many. It seems to suppose that “divine intervention” does not influence the beliefs of people outside Africa and Asia. As if religion composed of spirits is a primitive cultural relic, but a bearded man on a cross does not participate in “divine intervention” or “acts of grace.” As if “Western culture” is comprehensively in tune with biomedical literature while “other” civilizations do not yet grasp the germ theory. As if one can distill the beliefs towards illness and disease of entire continents in one bullet point.
The cultural competency framework that has become the mainstay of medical education is often times employed in incredibly reductionist ways. It seems to propose that exposing physicians to homogenized, static and packaged ideas of culture will aid them in estimating patient behavior, preference or response in the clinic, thereby diminishing health care inequality. Training like this paves the way for even well-intentioned student-doctors to be explicitly ignorant under the auspices of clinical benefit. It spoils the good intent to create better patient outcomes by legitimizing the validity of stereotypes and the development of physician bias.
“Simple as 1-2-3”
CultureVision boasts that it is the “first comprehensive, user-friendly database that gives health care professionals access to culturally competent care.” The subscription-based service is “simple as 1-2-3.”
“Let’s say a Chinese patient comes into labor and delivery … simply logs onto the CultureVision website. Next, click on the Chinese section and finally click “Labor, Birth and Aftercare.” Just that quickly you have the information you are looking for, and within minutes you are contributing to a better healthcare experience for the patient.”
The website’s automatic slideshow is entitled “Did you Know?” and shifts between graphics that include messages such as: “some Latina new mothers consider themselves to be in a ‘cold’ state for six weeks after a birth, and may wish to consume only warm foods while recuperating,” and “some Asian immigrants may wish to avoid floors and room numbers with a ‘4’ in them.”
The notions presented by this company sound eerily close to “X group of patients think, talk, believe, eat, and feel like Y.” In fact, if you remove “some” and “may” in their statements, that’s exactly what they’re saying. To be fair, knowledge of customs is not necessarily useless — there is no intrinsic harm in having basic knowledge of certain cultural traditions or beliefs. However, the exertion of these assumptions in the clinic, the idea that a physician can diagnose a patient’s cultural, ethnic and racial background through cursory physical examination and then quietly consult an application to infer their beliefs, is all together reductive and inadequate. In attempts to individualize medical care, physicians are trained to utilize identities as standardized representations — the “Chinese immigrant” is not an individual, but a placeholder that represents a larger population.
My parents are immigrants trained in quantitative disciplines. My grandparents grew up in Taiwan and later lived in Japan, Ireland and the Netherlands. I was born in a suburban town in Michigan. My education was primarily American, though I have studied abroad in London and Denmark. This is my sixth year in Providence, RI as a member of Brown University’s community. I am a cisgendered woman. I am a medical student, an ethnic studies graduate, a second child, a sister, a public optimist and personal pessimist.
These all contribute significantly to the ways I think, and to what I believe.
My culture is much more than “American,” much more than “Taiwanese,” and spans much more than the hyphen between “Taiwanese-American” could ever encompass.
And it’s definitely more complicated than “Asian.”
Beyond reinforcing racial profiling in the clinic, racializing “cultural competency” is reductive of human experience. In 1994, the US Department of Health and Human Services defined cultural competency as care that “incorporates cultural differences into the provision of health care,” going on to define cultural communities as populations “who may be distinguished by common values, language, world view, heritage and institutions of beliefs about health and disease.” Given that this definition encompasses a large variety of social identities, why does cultural competency so often utilize skin color phenotype as a proxy for racial identity, and subsequently, systems of belief? Using “culture” as a reference to race seeks to understand health care experiences and beliefs through a single prism, divorcing it from existing and dynamic intersections class, gender, sexuality, locality and more. The employment of racial as subheadings for expertise on “cultural competency,” really whittles down to an attempt towards “racial competency,” which sounds, and is, problematic.
The Standardized Patient
In focusing on the racial identities of people of color, cultural competency frames whiteness as a standard — a default — from which racial otherness departs and is made foreign. This enforces the idea that the values and beliefs of people of color are “different” and therefore require special training to understand and accommodate. But what are these values different from? These “cultural values” are noted as deviations from ideas of normalcy, while the dominant systems that have come to define normalcy escape the scrutiny of “culture” in their own right. So why is culture racialized in a way that often excludes white populations? Is white not a race? Does whiteness not have a cultural set of “values, language, world view, heritage and institutions”?
Is Italian food not ethnic?
If the point of cultural competency is to examine discordant beliefs or understandings between patient and physician, why do these models continue to assume a static departure point: that the health care provider is white or acultural? Thus, while cultural competency teachings attempt to recognize how culture, race and identity define health among minority groups, it fails to acknowledge how members of dominant cultural groups, institutional paradigms, doctors and training programs within hospitals are similarly influenced by a culture of their own. The framework does not ask physicians to reconsider their own notions of normalcy, or even the culture of medicine itself. In doing so, it trains physicians to seek “mastering the Other, rather than examining the internal cultures, prejudices, fears, or identifications of the Self.”
Did You Know? White Males…
As a Taiwanese-American female, I have little epistemic knowledge on what it means to be a white male, let alone the innumerous other social identities he might hold. Yet, in following the general terms of training tools today, I could seek cultural competency by reading some sort of manual on “white, maleness” as a technical skill to add to my clinical repertoire.
“Did you know that some white males enjoy watching football games on Sundays, and may be less likely to attend follow-up appointments at that time?”
Doesn’t that read strangely?
It reads as strange because whiteness is not considered a “racial category” equally alongside racial notions of “Latina new mothers” or “Chinese immigrant patients.” It reads strange because we have never received training materials on whiteness or Caucasian beliefs because it is assumed that those are standard aspects of hospital culture. It reads strange because, why don’t I just ask the patient what it is he believes. It reads strange because a manual on “what white men believe about health” sounds downright ridiculous, too broad and reductive a swatch to be clinically meaningful.
Providers do not enter the clinic with a blank slate. They arrive with their own set of beliefs and understandings that are equally different from the patient, as the patient is from the provider. The distance between both parties is the same, no matter which side you deem the starting point.
The central endeavor of cultural competency is to examine, be aware of, and consider differences in beliefs, understanding or history between patient and provider in order to mitigate unequal care. This venture is limited if we place the departure point always at the same place: one that not all health care professionals occupy.
Competency Outside the Clinic
To address health disparities comprehensively, it is important to note that the inter-cultural communication barriers that cultural competency seeks to address are not only between physician and patient, but also between patient and system. In its emphasis on individual patient interaction, cultural competency places the brunt of inequality not only within clinic walls, but within patients themselves. Locating the causes of health care disparities as largely within the context of patient behavior and lifestyle choices renders larger structural issues invisible. While addressing communication barriers and lifestyle habits is important for care, one cannot understand the scope and causes of health care inequality without looking at the entire social arena of its birth. This includes greater questions on the historical context of marginalization in multiple facets of society. The source of unequal care in America does not center only upon individual patient behavior or physician uncertainty of “foreign” cultural practices. There is more discordance to be considered than the differences between patient and provider — they are only two small players in a much bigger game.
Thus, cultural competency’s emphasis on individual physician and patient behavior as the source of health disparities does a huge disservice to larger issues of systemic inequality. It scrutinizes only perceived differences of minority populations rather than understanding the larger systems that dictate differential access to care or asking physicians to reflect on their own privileges and assumptions. Indeed health care providers who “have tolerant, nondiscriminatory attitudes will not necessarily be culturally competent if they are not trained to recognize when actions and inactions that support the status quo as usual unintentionally but systematically privilege some and marginalize others.” By collapsing larger issues of violence, poverty, and racism into more comfortable terms that allow practitioners to discuss “ethnicity” and “culture” in the context of health care inequality, the cultural competency model fails to address broader issues of power and inequity that contribute so significantly to health care disparities.
It is incredibly important that medical schools and training programs embrace the analytic frameworks of cultural humility and structural competency in lieu of cultural competency. While cultural competency sees patient preference as a series of generalized stereotypes to be mastered, cultural humility relinquishes expertise from physician to patient. It acknowledges the complex formation of individual identity and belief, and integrates a “lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations” into the profession. It guides medical students, future providers, to reflect on the “common values, language, world view, heritage, and institutions of beliefs about health and disease” they hold in their own identities.
On the other side, structural competency addresses cultural competency’s weakness in focusing primarily on the individual, clinical, patient-physician interaction to redress disparities. Structural competency instead “contends that many health-related factors previously attributed to culture or ethnicity also represent the downstream consequences of decisions about larger structural contexts, including healthcare and food delivery systems, zoning laws, local politics, urban and rural infrastructures, structural racism, or even the very definitions of illness and health.” Both cultural humility and structural competency are invaluable frames of analysis for preparing student doctors to be competent providers (instead of providers with artificially limited ‘competencies’) and together provide a much more robust scaffolding for addressing cross cultural clinical interactions and health care disparities.
Competent care is not about reading patient’s physical characteristics and indiscriminately applying what “experts” tell you about a group of people, nor is it about employing static stereotypes about social identities. Competent physician-patient interaction is about respect. It is about deferring to the expertise of the patient in ascertaining what it is that they believe and desire. Every clinical interaction is inherently cross-cultural. We cannot continue to conceptualize attention and efforts to this dilemma as a “competency,” as if a certain level of consideration is sufficient for our needs as clinicians. It is an ever-present challenge that requires deference — humility — rather than proficiency.
For further reading or inquiry:
Kleinman, Arthur, and Peter Benson. “Anthropology in the clinic: the problem of cultural competency and how to fix it.” PLoS Med 3.10 (2006): e294.
Metzl, Jonathan M., and Helena Hansen. “Structural competency: Theorizing a new medical engagement with stigma and inequality.” Social Science & Medicine 103 (2014): 126-133.