Cultural Humility, Understanding Differences

Many years ago, I heard a version of the following joke that plays on the reputations of European cultures: Heaven in Europe is where the English are the policemen, the French are the cooks, the Germans are the mechanics, the Italians are the lovers, and the Swiss organize everything. Hell in Europe is where the Germans are the policemen, the English are the cooks, the French are the mechanics, the Swiss are the lovers, and the Italians organize everything. Commonly held perceptions of the strengths and foibles of different groups of people often conform to the self-perceptions of individuals who are part of that group and can be relatively harmless in a comedic context, especially if individuals make fun of their own groups. However, cultural stereotypes can have negative consequences since they can cause us to miss or dismiss important details about individuals. This is particularly true in healthcare, where assumptions about individuals based on group stereotypes can result in misdiagnosis and ineffective treatment. For example, while training in London several decades ago, neurosurgeon Frank Vertosick, MD, observed that individuals from India were routinely diagnosed with tuberculosis regardless of their symptoms and once heard a senior surgeon state during a discussion of a case that the most important thing to know about a particular patient was that he was Irish, because it could be assumed that his health problems were related to abuse of alcohol. 1 These examples are extreme and explicit, but our ability to understand the individual needs and goals of patients can be complicated by more subtle assumptions and stereotypes. Part of affirming diversity is recognizing that “all societies generate a catalogue of distinctive differences that separate groups from one another,” but generalizations about differences can also contribute to “social stratification.” 2 Stereotypes can perpetuate differences in status and power that reinforce the dominance of the majority culture and marginalization of individuals from minority groups. Someone who does not fit with the dominant society’s ideas of “normal” can feel even more alienated from others when they are defined (often incorrectly) by their affiliation with a non-dominant group. One reason that the joke above is less likely to cause offense is that it is an example of punching up, or making fun of people with relatively more power and status. Just as punching down is considered bad form in comedy because it can increase the burden on already-marginalized people, negative stereotypes in healthcare are likely to have a more detrimental impact on individuals from a minority population than those from the dominant culture. The power differential between healthcare providers and patients can become more pronounced and result in more negative consequences when the patients are part of a minority culture or experience disadvantage from social factors such as race, ethnicity, or socioeconomic status. Why Culture Matters Individuals within a social group often share a common understanding of themselves and the world that is expressed in values, beliefs, and customs, which distinguish them from other groups. In an increasingly diverse world, we frequently encounter people whose cultural background does not match our own. Many clinicians regularly provide care to patients from cultures not as committed as theirs to the tenets of Western medicine, the belief system that dominates healthcare in America. Because our value system is so embedded, we rarely give it much thought. A familiarity with and confidence in our own value system can lead to assumptions of inferiority about individuals with whom we do not share a similar culture. We may base our interaction with others on these assumptions without even realizing that we are doing so, and a “lack of awareness of our cultural perceptions introduces the risk of subconscious imposition of our beliefs during patient interactions.” 3 Delivering effective clinical care requires that clinicians and patients understand each other on many levels, and “communication and understanding occur more easily among people who have shared cultural ideas and beliefs about how the world works; it is more difficult to acquire among people who do not have shared core beliefs.” 2 A value system includes how health and sickness are defined and “influences diagnosis by contouring the way that we legitimate symptoms and separate objective disease from subjective distress.” 2 Understanding how patients view their conditions and report goals and problems related to O&P care influences clinical decision-making in beneficial ways. On the other hand, “When a difference in perspective is misunderstood or not adequately considered, the resulting conflict interferes with accomplishment of goals and relationships.” 4 Becoming skilled in providing care across cultures will improve relationships and facilitate the achievement of patient and practitioner goals, and in that way reduce, rather than increase, the burdens patients may already be experiencing as members of a minority group. Cultural Competence The civil rights movement during the last century “demanded respect for cultural diversity and attention to racial and ethnic inequalities in society.” 5 The subsequent emphasis in healthcare on making each patient the central focus of care highlights the need for clinicians to be competent in providing care even when the patient’s values, beliefs, and behaviors differ from their own. Cultural competence has been defined as “the process by which individuals and systems respond respectfully and eﬀectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, spiritual traditions, immigration status, and other diversity.” 6 This competence requires cultural awareness, knowledge, attitudes, and skills. 2 According to Josepha Campinha-Bacote, PhD, founder and president of the private consultation service Transcultural C.A.R.E. Associates, “the underlying assumption of this approach is that the greater the knowledge about another culture, the greater the competence in practice.” 5 This perspective has been criticized as implying that there is a finite body of knowledge to be learned about another culture, and that it is possible for someone from outside of that culture to master it. 2,6 The emphasis on knowledge and skills can lead to the assumption that with sufficient training, a practitioner can successfully navigate cross-cultural encounters. Additionally, cultural competence has been criticized for failing “to acknowledge the socio-structural factors and institutional processes that contribute to social injustices as a consequence of cultural differences when compared to the dominant society.” 7 Cultural Humility In recognition of the reality that treating patients with dignity requires something more than understanding facts about a culture, cultural humility has been suggested as a way to address the perceived limitations of cultural competence. “Cultural humility refers to the recognition of diversity and power imbalances among individuals, groups, or communities, with the actions of being open, self-aware, egoless, flexible, exuding respect and supportive interactions, focusing on both self and other to formulate a tailored response. Cultural humility is a process of critical self-reflection and lifelong learning....” 4 Cultural awareness must be directed inward and outward. It involves recognizing our own values and biases, as well as “being aware of how people’s culture can impact their health behaviors” and “using this awareness to cultivate sensitive approaches in treating patients.” 3 Clinicians practicing this humility must put themselves in “the potentially uncomfortable position of being learners, rather than experts, about cultures other than our own.” 2 A Synthesis of Concepts Anyone who has participated in mandatory training about social issues recognizes a difference between learning specific skills and a genuine acceptance of others. Conversely, simply having an accepting attitude is less likely to positively impact patient encounters if it is not combined with specific skills. In response to what he considers inaccurate critiques of cultural competence, one author cautions against abandoning the term and points out that “one can claim to be culturally humble and still have a limited, contorted view of diversity and difference.” 6 Rather than seeing these concepts in opposition to each other, competence can be viewed as a product and humility as a process, with humility understood as a necessary context in which competence develops. 3,5 According to sociologist Celine Yancu, PhD, “cultural humility (process) better serves patient-centered, culturally sensitive care when used in tandem with competency (product).” 2 Campinha-Bacote and others have proposed a way of thinking that acknowledges how cultural competence and humility overlap, and coined the term “competemility” to describe “the synergistic process…in which cultural humility permeates each of the ﬁve components of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural desire, and cultural encounters.” 5 We provide care to individuals, not people groups or cultures. Over-emphasizing shared values or characteristics can result in “undervaluing of unique differences of individuals.” 7 Campinha-Bacote states, “the most serious barrier to cultural competemility is not a lack of knowledge of the details of any given cultural orientation, but rather the potential to stereotype individuals. The concept of intra-cultural variation is critical to remember when gaining cultural knowledge to prevent the stereotyping of patients from different cultural groups.” 5 The priority is to learn about our patients as individuals, not just as members of a group, and “the infusion of cultural humility into cultural knowledge allows meaningful and deliberate cultural encounters to connect with the patient as a unique, individual person, and not a stereotype of the patient’s cultural group.” 5 Fostering Humility Knowledge about a culture, “such as concepts of personal space, how people like to be approached, and whether direct eye contact is desired or considered disrespectful, can facilitate positive and productive initial interactions.” 2 Developing a humble and competent approach also requires that practitioners learn from individual patients, “as opposed to maintaining power, control, and authority in the working relationship, especially over cultural experiences about which the client is far more knowledgeable.” 6 Practitioners who “make hypotheses rather than jump to premature conclusions when working with clients from diverse backgrounds” will be more effective in their initial approach and in responding to patient-specific values and goals. 7 The strategies suggested in Figure 1 can facilitate understanding in interactions with every patient, including those who share the practitioner’s culture. However, the additional challenges of a cross-cultural encounter make these skills even more impactful. Over time clinicians can develop “an intuitive grasp of needed interactions and behaviors that demonstrate cultural humility to the patient” rather than relying on a set of skills. 5 Conclusions While travelling in Europe a few years ago, I was aware of the reputations of different nationalities and acutely conscious of the reputation of American tourists as loud and ill-mannered. Some of these assumptions increased the challenges of navigating through countries with different languages and value systems, challenges which would have been even greater if, as an American of German heritage, I had been visiting non-European countries. It is not a big stretch to imagine that patients from different cultures are dealing with challenges even greater than I encountered. It is also not difficult to recognize that cultural differences relate not only to nationality or race, but also “gender, age, class, education, religion, sexual orientation, and physical ability, along with the unequal distribution of power and the existence of social inequities.” 5 The current cultural climate in America does not encourage a sober and nuanced consideration of a variety of social issues, including diversity. We are all exposed to so much punching (up, down, and all around) that it is difficult to discuss sensitive issues without offending one group or another. We can affirm the importance of cultural sensitivity in clinical practice without engaging in the culture wars that rage around us. The stakes are higher when providing O&P care than they are in comedy, and basing clinical decisions on stereotypes is no joke. As responsible providers of care to patients from a wide range of backgrounds, we do not have the option of ignoring the challenges that many of them face. Our ethical duty is to make a conscious effort to understand and affirm the dignity of every individual we interact with. What is at stake is more than our choice of vocabulary, and this caution is worth heeding: “Words matter, and words have inﬂuence, but words do not, by themselves, magically create change or make anyone humble or eﬀective when working across cultures.” 6 John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center (NUPOC). He has over 30 years of experience in patient care and education. References Vertosick Jr, F. 2008. When the air hits your brain: Tales from neurosurgery . WW Norton & Company. Yancu, C., and D. Farmer. 2017. “Product or process: Cultural competence or cultural humility.” Palliative Medicine and Hospice Care Open Journal 3(1):e1-e4. Prasad, S. J., P. Nair, and K. Gadhvi, et al. 2016. “Cultural humility: treating the patient, not the illness.” Medical Education Online 21(1):30908. Foronda, C. 2020. “A theory of cultural humility.” Journal of Transcultural Nursing 31(1):7-12. Campinha-Bacote, J. 2019. “Cultural competemility: A paradigm shift in the cultural competence versus cultural humility debate—Part I.” Online Journal of Issues in Nursing 24(1). Danso, R. 2018. “Cultural competence and cultural humility: A critical reflection on key cultural diversity concepts.” Journal of Social Work 18(4):410-30. Fitzgerald, E., and J. Campinha-Bacote. 2019. “An intersectionality approach to the process of cultural competemility–Part II.” OJIN: The Online Journal of Issues in Nursing 24(2). Image credit: stournsaeh/stock.adobe.com.

Cultural Humility, Understanding Differences

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