Special Theme: Cultural Competence: OTHER: Teaching and Learning Moments
HIXON, ALLEN L. MD
Dr. Hixon is assistant professor, Department of Family Medicine, University of Connecticut School of Medicine, Farmington.
With appreciation to Robert Cushman, MD, for discussions exploring the educational implications of the concept.
To educators, the concept of “competence” is enticing. The ACGME Outcome Project has brought into focus the need to develop reliable methods for the evaluation of our trainees' “competence” in several domains. Embedded in the competence movement and the desire for culturally appropriate care for diverse groups is the now accepted and politically-correct buzz word, “cultural competence.” But the concept of competence, which denotes an endpoint—a mastery of a body of knowledge and skills—may insidiously lead us down the wrong path when applied to cross-cultural interactions. Culture is not a finite data set to be mastered, but instead a concept that is complex, dynamic, and individual.
In 1998, I happened upon an article published in the Journal of Health Care for the Poor and Underserved. The authors of this article, Melanie Tervalon and Jann Murray-Garcia, put forward a useful construct termed “cultural humility.”1 This important contribution, cited in only three articles in the intervening years, has not yet become part of the extensive and important discussion of cross-cultural practice and education in the medical literature. As opposed to the “mastery” of sets of information about other groups, cultural humility is built on the concept of self-reflection and self-critique, skills critical to lifelong learning. It acknowledges the power imbalances in the physician–patient relationship that are often exaggerated when common language, culture, or health beliefs are not shared. Finally, it strives to partner with individuals and specific community groups around clinical care and health advocacy.
The cultural humility concept reminded me how powerful labels can be in creating and defining our reality. Although our shared “medical culture” is based largely on achieving competence, we should take care when applying this term broadly to mastering other cultures. We may find that competency-based education can be applied more easily to the domains of knowledge and skills than to attitudes. Communication skills built upon the attitudes of openness, flexibility, self-reflection and, yes, humility are ultimately what will make individuals responsive and sensitive in the delivery of care to diverse populations. This is the framework medical educators should be striving to introduce, model, reinforce, and evaluate. This is the path of lifelong learning about oneself in relation to others that is most fruitful.
1. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor and Underserved. 1998; 9:117–25.