The problem with cultural competency in medical education

“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.”

CultureVision boasts that it is the “first comprehensive, user-friendly database that gives health care professionals access to culturally competent care.” The website’s automatic slideshow, entitled “Did you Know?” shifts between 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.”

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 medical student, a second child, a sister, a public optimist and personal pessimist.

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.”

The cultural competency framework that has become the mainstay of medical education is often times employed in detrimentally 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. Knowledge of customs is not necessarily useless — there is no intrinsic harm in having basic knowledge of certain cultural traditions or beliefs. 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, however, all together reductive and inadequate. 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.

Racial competency and the standardized patient

The U.S. Department of Health and Human Services defines cultural communities as populations “who may be distinguished by common values, language, worldview, 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 categories as subheadings for expertise on “cultural competency,” really whittles down to an attempt towards “racial competency,” which sounds, and is, problematic.

In addition, cultural competency’s focus on the racial identities of people of color 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 same scrutiny of “culture.” 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, worldview, heritage, and institutions”?

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, or indeed, by 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 …

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 trends of contemporary training tools, I could seek cultural competency by reading some sort of manual on “white, maleness” as a technical skill to add to my clinical repertoire.

This reads strangely because whiteness is not considered a “racial category” equally alongside racial notions of “Latina new mothers” or “Chinese immigrant patients.” It reads strangely 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 strangely 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 locates the cause of inequality not only within clinic walls, but also largely within the context of patient behavior and lifestyle choices. While addressing communication barriers and counseling on lifestyle habits is important, the source of unequal care in America does not center solely upon 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.

In emphasizing only individual physician and patient behavior as the source of health disparities, cultural competency fails to consider larger issues of historic and contemporary 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 patient behavior, the cultural competency model fails to address broader issues of power and inequity that that remain at the heart of health care disparities.

What then?

Based on these critiques, 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.

In addition, structural competency addresses cultural competency’s failure to look beyond the 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 robust scaffolding for attending to 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 population, 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 order to ascertain 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.

Jennifer Tsai is a medical student.  This article originally appeared in in-Training.

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