Maybe ‘cultural humility’ is a better term to use
By Jennifer Hasch, RDH, BS
Merriam-Webster defines the word competent as “having requisite or adequate ability or qualities.”1 Competent, done, finished. It connotes finality to learning. I finished a skill in clinic; I now have competency in this. One definition is “acceptable and satisfactory, though not outstanding.”2 Is this a health-care provider’s goal when it comes to cultural interactions with our patients? Mediocrity?
Therein lies the issue. An outsider, no matter how interested or compassionate, can never fully understand a culture, language, or tradition of a group to which they do not belong. The learning does not magically end. We do not reach competence in someone else’s story. The better terms are cultural responsiveness or cultural humility. As Meredith Minkler stated so well in the Journal of Urban Health in 2005, “We can never become truly competent in another’s culture. We can demonstrate a lifelong commitment to self-evaluation and self-critique, to redress power imbalances and develop and maintain mutually respectful and dynamic partnerships with communities.”3 Taking a course in sociology or diversity for our prerequisites does not make us the master of tolerance. Cultural responsiveness is action, not ideology. Cultural humility is being cognizant of differences, willing to admit that you may know little to nothing about the culture of the person, but that you are ready to do what it takes to make the patient feel safe and comfortable in your care.
How we teach and think about this concept matters. In an increasingly diverse population, clinicians encounter people with cultures and backgrounds outside of their own every day. As early as 1995, this topic appeared in the Journal of Health Care for the Poor and Underserved:
“The necessity for multicultural medical education provides researchers and program developers with the challenge of defining and measuring training outcomes and proving that chosen instructional strategies do indeed produce these outcomes. However, in the laudable urgency to implement and evaluate programs that aim to produce cultural competence, one dimension to be avoided is the pitfall of narrowly defining competence in medical training and practice in its traditional sense: an easily demonstrable mastery of a finite body of knowledge, an endpoint evidenced largely by comparative quantitative assessments.”4
These authors so eloquently state that cultural humility does not have an end goal that is easily tested or quantified. It is a way of approaching care, an openness to learning new things, and a constant awareness of the absence of knowledge. It is treating each patient as an individual, with the consideration that his or her life, diet, and relationships may be sharply different than anything we have experienced. Cultural humility is finding a way to collaborate with the patient on better health outcomes, within the confines of his or her own life and habits.
My clinic, a federally qualified health center in Louisville, Kentucky, has a large patient population from the country Nepal. When I first began working in this setting, I asked women with nose piercings, via translator phone, to please remove their jewelry for x-rays, as is standard for diagnostic imaging. I was quickly informed that this was not possible, and learned more about the piercing traditions as time went on. My patients told me that many young girls have had their noses pierced before the age of five. The golden ornaments are not removable but are made as full and whole circular loops after placement.
We do not reach competence in someone else’s story. The better terms are cultural responsiveness or cultural humility.
I was told about the relational and spiritual significance of the piercings and realized that asking them to remove them was culturally insensitive, and frankly, pointless. My patients told me that some would not remove this jewelry until after their husbands died, and that the golden nose ornaments protected their husbands from evil spirits. Learning these details about the Nepali culture helped me to avoid an offensive moment, but did not make me an expert on the culture by any means. What that knowledge taught me, more than anything, was that I knew very little about Nepal, and that I had a desire to make my patients feel comfortable regardless of where they were from.
Cultural humility also encompasses being language sensitive. Effective communication is nonnegotiable when building trust and explaining treatment to a patient. Our standard of care includes educating the patient, and part of that is ensuring understanding. It is not necessary to raise your volume or slow the speed of your cadence. If a patient does not speak the language, it is just that simple. I have seen this approach take place so often in clinical settings. The person does not need a robot; they need a translator. Get the proper translation services. Save yourself from frustration and the patient from belittlement, and ensure proper communication. Hoping the patient “gets it” is simply not enough. The US Department of Health and Human Services has a website with great resources called thinkculturalhealth.hhs.gov. They use the acronym CLAS, which stands for culturally and linguistically appropriate services. They describe CLAS this way:
“For us, culturally and linguistically appropriate services (CLAS) is a way to improve the quality of services provided to all individuals, which will ultimately help reduce health disparities and achieve health equity. CLAS is about respect and responsiveness: Respect the whole individual and respond to the individual’s health needs and preferences.
“Health inequities in our nation are well documented. Providing CLAS is one strategy to help eliminate health inequities. By tailoring services to an individual’s culture and language preferences, health professionals can help bring about positive health outcomes for diverse populations.
“The provision of health services that are respectful of and responsive to the health beliefs, practices, and needs of diverse patients can help close the gap in health outcomes. The pursuit of health equity must remain at the forefront of our efforts; we must always remember that dignity and quality of care are rights of all and not the privileges of a few.”5
“Dignity and quality of care are the rights of all and not the privileges of a few”: This is a powerful statement. Speaking English or being born in the United States should not increase our chances for healthy outcomes and access to care, but they do. It is our duty as clinicians to help remove those barriers by offering safe and supportive settings for patients from vulnerable populations. Our cultural responsiveness comes through when we admit that we are not the Anthony Bourdains of dentistry. We cannot possibly master the intricacies of every corner of the world as suggested with a term like “competent.” On the contrary, it is our responsibility to accept every person for who they are and remain open to what makes them most comfortable and at ease. Ask care appropriate questions, commit to being a lifelong learner, and advocate for the patient’s fair treatment and access to resources. To learn more about the recommended national standards of CLAS, go to https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf.
Jennifer Hasch, BS, RDH, of Louisville, Kentucky, is the founder of the PHRDH blog RDHonamission.com. She is the 2017 recipient of the Colgate ADHA community outreach award for cofounding a mobile charity clinic in December 2015 for Louisville’s most vulnerable populations. That program has provided more than $300,000 in free dental services for the community. She is a full-time administrator and clinician in a federally qualified health center. Hasch believes in collaboration versus competition, and that a person’s legacy is only as large as their love.
1. Competent. Merriam-Webster website. https://www.merriam-webster.com/dictionary/competent.
2. Competent. English Oxford Living Dictionaries. https://en.oxforddictionaries.com/about.
3. Minkler M. Community-based research partnerships: Challenges and opportunities. J Urban Health. 2005;82(2 Suppl 2):ii3-12:ii4. doi:10.1093/jurban/jti034.
4. Tervalon M, Murray-García J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998 May;9(2):117-125:118. doi:10.1353/hpu.2010.0233.
5. US Department of Health and Human Services. Culturally and linguistically appropriate services (CLAS): What is CLAS? Think Cultural Health website. https://thinkculturalhealth.hhs.gov/clas/what-is-clas.