Moving Beyond the Culture of Competence in Medical Education
by Sula Ndousse-Fetter
Physicians interact with people in some of the most vulnerable moments of their lives. In these moments they get a snapshot of a life, and must piece together information to inform a course of treatment, or make a diagnosis. As one might imagine, communication is central to the physician’s ability to most effectively serve a patient’s needs. The way in which physicians interact with patients shapes their healthcare experience—a positive interaction is, quite literally, life changing. A bad interaction can leave a patient with inadequate care, along with feelings such as mistrust and fear. The importance of the patient-physician relationship is particularly salient for individuals who belong to communities of color that have been historically neglected or mistreated by medical and other institutions. This is the case not only because this mistreatment has shaped health outcomes for such populations, but also because it has also shaped attitudes towards seeking care and trust in the medical establishment. Therefore, a physician’s ability to communicate and interact with patients is critical to their ability to effectively provide care and to counteract the health care narratives of the past still impacting the present. Part of this imperative means grappling with personal biases and judgments that shape communication.
Cultural competence is one educational model that has emerged in response to the acknowledgement of the physician’s role in overcoming healthcare inequities. Cultural competence seeks to build an understanding of the ways that patient beliefs and behavior (i.e. culture) may influence the patient-physician interaction. Generally, the model is explored at both the institutional and clinical level. The educational methods used to integrate it into medical curricula and workplace trainings are diverse, but often involve an exploration of the generalized “beliefs” held about certain identified demographics and an examination of how those beliefs may manifest into personal bias.
As such methods have been gaining traction, they have also been met with critique. Some question whether attempting to define and assign beliefs and behaviors might exacerbate already pervasive stereotyping and othering. Others argue that an emphasis on cultural difference runs the risk of obscuring structural forces at play in a patient’s life—socioeconomic or educational forces which potentially shape care and care-seeking far more than their cultural beliefs. And there are also those who question whether the idea of “competency” frames cross-cultural interactions as something that can be mastered, rather than as a constant process of learning from the patient and of overcoming engrained social conditioning.
Clearly the cultural competence model can be interrogated and refined from many different angles. What do we mean by “culture”? Is “culture” something one can become competent in? And is “competency” what we should be aiming for? If culture is defined only as “ethnicity, nationality, and language,” does it serve as a sufficient lens through which to examine the forces acting on a patient’s life? Or do we need a more dynamic and permeable view of culture that allows for intersectionality? This dynamic view of culture would allow for change and heterogeneity—a permeable understanding of culture permits it to be cut through by “economic, political, religious, psychological and biological conditions.” Still, this approach to culture would need to be embedded within an understanding of the structures that shape such conditions.
Physicians need more than a conventional understanding of “cultural difference.” They intimately care for individuals and families that face both personalized and structural social, economic, and political inequities and injustices. Having been inducted into a caretaking profession, physicians must provide care for the physical, mental and emotional effects of individual and structural violence; in doing so they must also engage in critical self-reflection on their own complicity in those structures and forces that marginalize, discriminate and silence.
A recent article published by Wear et al. describes a curriculum that integrates structural analysis and antiracist pedagogy. This curriculum aims to promote analysis of those structures and forces that shape health outcomes across many social and economic divides. In engaging with antiracist pedagogy, the teaching emphasizes humility, self-reflection, and the necessity to ask hard questions that can reveal difficult truths. Wear et al. emphasize the need for “students and faculty to look deeper into themselves, the culture of medicine, and the larger structural contexts” that they, and their patients, exist within.
As we work towards grappling with the modern day effects of historical legacies to improve the health of diverse communities, it is clear that how we frame questions and identify problems is key to creating effective interventions in medical education.
Sula Ndousse-Fetter is a senior at Harvard University studying Chemical and Physical Biology and Global Health. She is invested in exploring the intersection of medicine, science and the social to address inequalities and build a better sense of health.
To learn more about a more holistic, intersectional medicine and continue this conversation:
Arther Kleinman and Peter Benson: “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It”
Melanie Tervalon and Jann Murray-Garcia: “Cultural Humility versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education”
Jonathan Metzel and Dorothy Roberts: “Structural Competency Meets Structural Racism: Race, Politics and the Structure of Medical Knowledge”
Example Cultural Competence Guide for Health Care Professionals in Nova Scotia