S5E9: The Flaws of Cultural Competency in Health Care

Lina: Can we briefly mention how Timmy's been loving his little sauna?

Hạ: He usually bothers me when we're recording, but he's just happy up there right now.

Lina: Timmy is a cat, by the way.

Mariam: It's kind of shameful that we haven't talked about Timmy the cat on this podcast. I think our listeners need to know who Timmy the cat is.

Lina: But to start us off, hello, everyone. This is Lina from the virtual studio. I am here with Ha and Mariam today, and we wanted to talk to you guys about the concept of cultural competency in healthcare and how that translates into care and what we think about it and what it should look like, I guess.

Mariam: This is a topic I feel like we've been wanting to talk about for a long time.

Hạ: I feel like it's a super important topic too because there's a lot of talk, especially considering all the recent events and all the move of medicine towards equity, diversity, and inclusion about cultural competency.

Lina: Yeah. So to start us off, I just kind of really wanted to put out the definition that exists in all the trainings provided to healthcare workers right now. Cultural competency or cultural competence training are the behaviors, the attitudes, the policies that come together that will ensure a system that an individual can function effectively and appropriately in a diverse cultural interaction and settings.

So usually, when these trainings are done, people are kind of given a background of information about different cultures and things to avoid, things to be aware of, things to be respectful of. And that's kind of the trainings that are put in right now by a majority of programs.

And this was started a while back. It was developed by social workers in the 1980s, and a lot of other kind of healthcare organizations, and social organizations picked it up and started training its individuals on it saying that, "We need to be culturally competent and this is the way to increase the diversity and make sure that our healthcare population gets the care they need."

Mariam: First and foremost, when I think of even just the term "competence," it's like mastering a skill, right? So, at the end of the day, the way that we're presented with cultural competence in our training is to master the skill of understanding other people's cultures.

And I just think that that is so interesting, right? How can we be masters of every single culture? And what does that truly mean when we say masters of understanding a certain culture?

The first thing that comes to mind when I think of how we're trained in cultural competency, at least for me, I think of refugee populations that we serve. And a lot of the time when we get trainings with these communities, it's a lot of, "Here's a set of rules to abide by. Master this set of rules." And these rules could look anywhere like, "Don't look at them in the eye when you're talking to them because that's disrespectful in their culture," or, "You need to be aware of this type of body language when you're speaking to a person from this culture." Just this set of rules to follow while we're delivering care. And there's something about that that feels very off to me personally.

Lina: I've seen it done personally to my care or my family's care. And it's always been to the point that sometimes certain questions are not asked because they're like, "We know that we shouldn't disrespect these women by asking them about a Pap smear." And then at that point, you're going into a territory where you're ignoring certain parts of that care because of something that you've been taught not to do because you think you're respecting someone's culture in a sense.

Hạ: Completely agree with all of that. And another thing that I really think about too . . . it's interesting that one of the full definitions according to Merriam-Webster . . . one of their options is "proper or rightly pertinent," which then also makes me consider, "What is considered proper? What is the standard that we're using to measure these skills on, and how can our ability to navigate cultural landscapes and experiences even be measurable?" And that's what cultural competency seems to give the sense of.

As you all expressed, it does end up being these very, "Oh, let's get them in a very concrete, tangible way." Except the problem is culture isn't very concrete or tangible.

And I think about it a lot in that I remember one time when I was getting care at a clinic, and it was a clinic that serves a lot of immigrants and refugees because that's where my family has been going all of the time. And we had a third-year medical student come in to give me care. It was in my mind because the moment that he walked in, he looked at me and then spoke very slowly, "Do you speak English?" And immediately, I felt as if the door and the trust with this provider was closed.

And when I think about it, I think, "Well, maybe he thought that this was something that was valid to do, that was culturally competent, per se, to consider about all of these different languages that are spoken," especially since he was working in a clinic with a lot of people from different backgrounds. But in translation, it can be very off-putting.

And so that's one of my issues, is that I think a lot of times people take culture, which can be so rich and full and so able to really be transient and changing, and they boil it down into these very rigid notions.

Lina: Exactly. That's the problem. And I've seen it kind of on the healthcare side where I'm a third-year medical student right now, and I've definitely been in clinics that do have a bigger population of refugees, immigrants, or just a more diverse population in general. And I've seen it happen where they kind of reduce someone's whole identity into a set of rules, a set of notions to follow.

And the trainings increase in those clinics because they expect a more diverse population for who they're helping. But it does translate into that notion of kind of reducing someone's identity, and it can affect their care.

Mariam: I also want to note that it's almost like cultural competency just reinforces white supremacy, right? Kind of just what you were saying, Lina. It's reducing down a population that's "different from the norm," right? And that "norm" is white supremacy. We're given this metric of how to understand a certain culture, and we reduce it down to a set of stereotypes. Let's be real. At the end of the day, it is a set of stereotypes of how we envision these cultures from a Western perspective.

But at the end of the day, when you reduce down somebody's identity to these stereotypes to deliver care, that reinforces racism in the system, right? It upholds white supremacy. And I think that's something that needs to be said when we're having this conversation.

I think the intention behind cultural competency can start off with people really wanting to deliver great, amazing, trauma-informed care to diverse communities. But I think the issue is that metric that, "I'm going to master this. I'm going to learn all the sets of rules to understand different cultures." And that's just not . . . Ha, you said it so beautifully. That's not what culture is. Culture is not something to be measured like that.

Lina: Yeah. And a question that was brought up to me is someone agreed with me for all those points. And I was like, "Yeah, we can't a master culture, we can't know everything, but I don't want to be disrespectful." That was kind of their objection to that. They were like, "I don't want to be disrespectful. I don't want to say something wrong."

Hạ: And one of the things that I think about with that is it's still very othering because you're suddenly afraid of being disrespectful just by looking at maybe that person's name, the color of their skin, what they're wearing, and just making that decision.

But why is it for someone who doesn't have a "foreign-sounding name" and all of that, you walk in without thinking, "Oh, I don't want to be disrespectful," and you just ask them the same questions that you're taught about and you don't worry about, "Oh, I should avoid these questions, or I should definitely ask these questions because of the identities I assume they hold"? Whereas if it's someone who has maybe a white-sounding name, doesn't have a darker skin tone, you can walk in and have an open book.

And for social history, it's all an open book to ask instead of really reducing them to what you think they're going to answer.

And so I find just making that assumption is disrespectful, because your not being afraid of being disrespectful to a certain subset of people just based on these very specific indicators that make you think they should be a certain way is more disrespectful than being open-minded to all they can be.

Lina: It definitely kind of exacerbates the idea of putting people into the "other" box, which feeds into the elitism of medicine itself because then we're just always approaching our patients with this kind of, "They are someone else. They are someone else that I need to help. They have 'other' identities to them and I need to try to be careful about the otherness of them."

Mariam: There's a lot of anxiety around it, right? As y'all were talking, I was thinking about this session that I was sitting in on, some diversity-related content in our training, and they were talking about trauma-informed care, but specifically acknowledging the history of oppression within the medical system against people of color and how that translates today to underrepresented, underserved communities.

And somebody in the group said something along the lines of like, "I have all this information in my head about all of this historical oppression. When I meet with somebody from this community, am I supposed to be just thinking about all that historical oppression while I'm doing the patient history? Am I supposed to be thinking about how to incorporate that thinking about everything that this person potentially might have been through knowing all this history? How do I translate that information into delivering care to these patients?"

I recognize that was a very big question. Sorry.

Lina: I was like, "Oh, my gosh."

Mariam: I know. That was a lot. But for me, I can tell you all what came up for me. I think it's less so about all of the oppression in its totality against a certain community. But again, it goes back to this notion of we're taught to just reduce a person based on these stereotypes, these things that we're taught. We're taught that that's trauma-informed, anti-racist care, but at the end of the day, you are erasing a whole person. You're making assumptions about a person that you wouldn't otherwise make assumptions about.

That's not to say you wouldn't necessarily acknowledge that this person may be impacted by that historical oppression. That's not what we're trying to say. But it's giving that person the respect that they deserve and having the humility in that space to talk to them about what's important for them in that patient-provider relationship.

Lina: For me, it's important to be aware. It's important to know all these things that affect healthcare, to know kind of the systemic racism that we know happens in healthcare, the inequalities that happen, but to also remember when we're meeting a patient to have that interaction, be very patient-centered, and to come to where they are at, to come to what they want their care to look like, what they want to give you, what information they want to give you.

When we're trying to put all these assumptions and information in our mind when approaching patients, you are dictating what that interaction is going to be like. And I think we need to step away from that, come in with awareness, but also make it patient-centered.

Hạ: I was going to say I wholeheartedly agree, Lina. And it makes me think of this actual recent interaction I had on the wards.

So we had a trans patient. And I remember that a lot of people came into the room just assuming, "Well, they're trans, so of course they have mental illness as a component because that's a huge component to it." So a lot of the discussion about their concerns, about the pain they were feeling outside of the room, and I felt then it perpetuated within the room, was kind of a dismissal of their sentiments and their feelings because there's a mental health component to it.

That's just me summarizing kind of the thought process that I was getting from a lot of the team.

There was a point where the patient went and said, "I feel I'm not being listened to the way that I would like to be heard." And in that situation, I think it's a moment where, yes, you can recognize the oppression that trans and queer patients have held within the medical system and see why this patient would be a bit more resistant to the treatment team and uncertain about the treatment team. And you can bring that in to recognize that, "I should be a bit more collaborative. I should really think about how I present and talk about things in that regard."

But the issue at core was just not making assumptions about this patient and to really walk in and say, "What are your goals for treatment? What is your big concern? What can we help you with?" and moving forward from there.

And I felt that that was a really interesting situation where you could see trying to be culturally competent, like being aware about pronouns and all of that, wasn't enough to really get to the patient care. What was important was meeting the patient where they were at in that patient-centered care way, as you had mentioned, Lina.

Mariam: I think it just kind of goes to show with what you both said, Lina and Ha, is there's this major theme of stripping somebody's agency away from them.

Maybe patients from underrepresented communities have experienced not super great care, and a lot of that stems from a history of oppression in certain communities. And that's a stripping of somebody's agency in a sense when they interact with the healthcare system.

But then also when you go in and you make these assumptions, kind of like what you both were saying, you're also stripping away somebody's agency when you're not having patient-centered care.

Again, it goes back to that, "Oh, I'm just going to go by this set of rules. I'm just going to make these assumptions." And in a way, even with good intentions, we can also take away agency. I think that's really important to keep in mind, especially in that patient-provider relationship.

Hạ: Mariam, when thinking about it, it angers me so much because one of the reasons why I decided to go into medicine was I worked as an HIV and HCV prevention counselor for a bit. And what I loved about it was realizing how much patient-centered care and empowering patients could be life-changing for the patient.

I loved having those conversations with patients and going, "Hey, what are your goals?" And even if they didn't match what was ideal, saying, "That's great. We'll just take it bit by bit. This is what we recommend, but I'm willing to work with you to give you that agency," and to really get to the root of their concerns and what brought them in to get STI testing. And it just makes me sad now that I'm navigating medical school to not see what made me excited.

Lina: You both put it spot on with patient-centered care. Me and you, Mariam, have talked about this before, but also trauma-informed care. This kind of came up in a conversation when it comes to refugees coming into the U.S. and getting care for the first time. They're very hesitant in communication with the physician and providing information, and it seems kind of like there's already a barrier in that physician-patient relationship.

I think we have to acknowledge how important trauma-informed care in this situation is. It doesn't have to do with their religion, their culture, their background of why they're not communicating as much or providing information. It's more this is a new place. This is a new language, new people that you're interacting with, a new system. And it's a lot to put on someone to be completely open at the beginning.

Mariam: Yeah. Lina, I remember we had this conversation specifically because you had talked about how there's an influx of Afghan refugees that are coming into Salt Lake, especially with everything that's been happening in Afghanistan recently. And I think there's a lot of anxiety among healthcare providers about how to provide the best care.

When Lina was talking to me about some of the things that she's heard just generally with how to provide the best care for these incoming Afghan refugees, it was a lot of stuff about the culture, what to expect. And it's so interesting. Hearing it, it didn't sound familiar to me as somebody who was raised by an Afghan family.

And so I think there's also this discrepancy of . . . like you said, Lina, people assume, "Oh, that's just the culture," but you also have to really factor in this component of trauma-informed care.

Hạ: Mariam, I really agree with you and Lina about the importance of trauma-informed care. And I also think that a lot of people don't realize how complex trauma-informed care is, that it can't be boiled down to a couple of strategies.

I think about it a lot too because there is also a great trend about being more trauma-informed in our care and focusing on things like adverse childhood experiences and things like that. And a lot of times when they do it, it's again boiled into things that are really tangible, which I understand why, because it seems a bit more achievable when they're tangible, but I then think it neglects a lot of the complexity of people's experiences and what brings them and what gives them fear.

I think about it a lot because, for instance, when I was young, I think my mom started getting more comfortable with healthcare partly because my pediatrician was Vietnamese. So he just understood it. He understood us. My mom didn't have to worry about trying to navigate speaking English because she could just speak Vietnamese to him. And he just kind of understood where we came from and what we needed and how we were raised and things like that. And I think that's part of trauma-informed care.

Lina: It's having people that look like you, that come from your background, that understand, and it just helps with that care. It helps with dismantling that barrier that is already there for a lot of patients.

And I can speak from this from experience. There were a lot of patients that I met that have been going to the clinic I helped in for years, but they had never really met an Arab-speaking provider, or a Muslim provider, or kind of with the intersection of all my identities. There were things that they shared with me and they told me when I kind of went back to the provider, I was told, "Oh, that's something new. We didn't know that. We really didn't know how to ask about that."

I think it's really important that we see more people from our communities in healthcare providing healthcare, because it is also important for institutions to have diverse communities from all different identities in their healthcare team.

Mariam: And at the end of the day, like you said, Lina, if the true goal is to really serve these communities that have been underserved historically and currently, part of the real solution is to have a healthcare team that reflects those communities. That should be a true initiative if we really want to have that goal of serving people from those communities.

Hạ: Mariam, to add off of that, I think another big goal is that we have to involve those communities in their care too. We can't just make decisions and also think that we can become experts on those communities. They know themselves best at the end of the day.

And I feel that this weird hierarchy of we're the medical system up top, and then there's our patients at the bottom, and this divide and not really integrating them and the community is just really frustrating and prevents us from moving forward.

Lina: Yes, Ha. And I think that translates into really what we think our care should look like, and that involves cultural humility. Cultural humility kind of covers everything that we've talked about today. It's the always self-reflection and learning and thinking about the things that you should know and the things that you should be aware of, but also knowing you're always going to be learning and you're always going to not know everything about someone, but be open to that idea.

And it also involves you being humble, like, "You know what? This is okay. This is how I will learn the most from my patient. And that's how I will provide the most care." We should step away from competency more into humility in our training.

Mariam: Yeah. I love the concept of cultural humility, because as you said, Lina, it is a life-long process and it also involves that piece of self-reflection and kind of understanding where you sit in that provider-relationship.

And it's never going to be about mastering something. It's never going to be about having this metric of accomplishing something, but that it's going to be ongoing. It's going to continuously involve you self-reflecting.

Hạ: Yes, Mariam. And I think that's what's so beautiful about cultural humility, is that it gives room for growth, it gives room for change, and it just gives room for accepting both you and the patient for all that you are as human beings.

Lina: Yes, to all of that. And we're always going to be constantly growing and learning from each other and from everyone.

Also, in addition to self-reflection and learning, it's also the other things we talked about: being patient-centered, being trauma-informed, thinking about the community always, and thinking about how we can involve the patient, the community as a whole in our care, rather than just kind of thinking about the set of rules that usually is given to us.

Thank you, Ha and Mariam, for talking about this topic with me. This was really good to discuss and I loved everything we said.

Thank you, Bundles, for listening. And we hope you come back for more. Listen to us wherever you listen to your podcasts. Be sure to like, comment, and subscribe. Tell us about how you feel. Be sure to leave us a rating.

Mariam: Just be gentle. We're fragile med students.

Hạ: Yes, please. Six out of five stars only. Thank you.

Lina: Very subtle. But yeah, thank you, guys. See you next week.

Hạ: Bye.