Public health researcher Jennifer McGee-Avila, MPH, who works with the François-Xavier Bagnoud Center in Newark, New Jersey, was invited to speak to other health-care professionals about the importance of culturally competent care back in 2013. Thanks to her years of caring for patients living with HIV, McGee-Avila knew that acknowledging a provider’s culture might be different from a patient’s made a major difference in care, but she didn’t feel like that went far enough.
As she thought about how to provide better care to people based on their lived experiences rather than their labels, McGee-Avila came across a 1998 paper published in the Journal of Health Care for the Poor and Underserved. The editorial’s authors—Melanie Tervalon, MD, and Jann Murray-García, MD—called for providers to embrace cultural humility. This practice, they argued, requires accepting that a health-care provider can never fully understand another person’s background, and therefore needs to constantly self-evaluate and eliminate the power dynamic between patient and provider to work as a team towards the patient’s goals.
This novel idea resonated with McGee-Avila’s own experiences with underserved communities. “When you listen to people’s stories, sometimes you can’t help but see how the influence of social determinants [of health] or structural racism have impacted their life or their trajectory or have placed them at increased risk for certain things,” McGee-Avila says. “I think that makes you a better clinician.”
She’s not alone. The term has become a major talking point in light of widespread racial disparities in health-care outcomes—including COVID-19 to Black maternal mortality rates. Closing these vast gaps will require systemic and legislative changes, including expanding insurance coverage, reallocating medical resources to underserved areas, and addressing implicit bias in caregivers. But McGee-Avila and other experts believe that cultural humility may be an important part of the solution.
What is cultural humility and how is it practiced?
“Cultural humility consists of three essential components, which [are]: prioritizing life-long learning and self-evaluation, the minimization of power imbalance, and the importance of partnerships and advocacy,” says Leela R. Magavi, MD, a psychiatrist with California-based teletherapy service Community Psychiatry. “Patients open up to me about their fears and provide me with feedback about our discussions, and this helps me become a better individual and physician.”
The backbone of cultural humility is asking questions and actively trying to learn from patients. “We need to ask individuals and communities what they need, and listen to and act on the answer,” says Tom Cotter, MPH, director of emergency response at humanitarian organization Project Hope. “The best way to foster cultural humility as a health professional is to involve communities and individuals in their own health-care.” That starts with getting to know the patient and their background, asking questions, and not making assumptions.
Dr. Magavi also makes sure to ask patients for feedback on their sessions, showing that she values their input and is open to criticism, or ask them how they want a session to go and follow their lead. “My patients teach me things every day, and this is the beauty of cultural humility; life-long learning helps us become better physicians and human beings,” she says.
Cultural humility is a bit different from the more mainstream practice of cultural competency, which is, per Georgetown University’s Health Policy Institute, “the ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients.” Cultural competency encourages providers to learn about cultural differences that might affect how a patient experiences health and health-care, and be mindful of them in their interactions with patients. However, these “differences” when taught in textbooks are often simplistic and may inadvertently perpetuate stereotypes. Some nursing textbooks, for example, inform students that most Black households are run by single women and that Black people generally prefer foods like pork and collard greens—stereotypes exposed by nurse Ashley Coleman in a series of TikTok videos over the summer.
“In simple terms, cultural ‘competency’ emphasizes understanding differences and building on knowledge about different cultures, where cultural humility focuses on introspection and the learning process of other cultures, knowing that differences exist,” says Cathy Hung, DDS, an oral surgeon and author of Pulling Wisdom: Filling Gaps of Cross-Cultural Communication for Healthcare Providers.
“My patients teach me things every day, and this is the beauty of cultural humility; life-long learning helps us become better physicians and human beings.” —Leela R. Magavi, MD
This might seem like a subtle distinction, but the two approaches are vastly different in practice. Dr. Hung offers the story of a patient who visited her practice for a surgical extraction and repeatedly asked an administrative assistant for a discount on his copay. A culturally competent approach would be to acknowledge that this patient came from an area of Southeast Asia where haggling for medical services is entirely normal and even expected. But the approach of cultural humility involved seeking to understand more about the patient’s background and motives in order to provide him with the necessary care that he was comfortable with, rather than just labeling the patient as “from somewhere different” and working around him. With this in mind, Dr. Hung helped explain to the patient several times what a copay is and why it costs more than it would in his hometown and reassured him that the procedure was necessary rather than elective.
In the spirit of understanding, Cotter adds that providers must “know what they don’t know,” and ensure that communication with patients is as clear as possible. “Sometimes this will mean bringing in quality, trained interpreters,” he says. “Other times, it may mean triangulating communications more carefully while maintaining the dignity of the patient.”
In their original paper, Drs. Tervalon and Murray-Garcìa also suggested that physicians and other wellness professionals train in the communities they plan to care for, helping to develop “mutually beneficial and non-paternalistic partnerships” between the provider and the community. While doctors, in particular, don’t always have control over where they’re placed for residency, one option is community-based medical education (CBME) programs, such as longitudinal integrated clerkships (LIC), which were pioneered in Australia in the late 1990s and explored in a 2014 Education for Health paper. In these year-long clerkships, medical students spend a year embedded in a community, learning directly from a primary care physician.
What are the broader implications of cultural humility?
Cultural humility isn’t theoretical; the consequences of not practicing it are serious. Cotter says that providers who don’t practice cultural humility risk alienating patients or failing to communicate with them appropriately. “When it comes to health-care, cultural humility can mean the difference between life and death,” he says. He cites the case of Lia Lee, a child with epilepsy featured in Anne Fadiman’s 2012 nonfiction book The Spirit Catches You and You Fall Down (which used the case study as an opportunity to explore the importance of cultural humility). “The epileptic daughter of Hmong refugees who had resettled in California, Lia suffered severe brain damage at the age of four as a direct result of years of Western medicine colliding with Hmong beliefs that created bitterness and deep mistrust between the doctors who treated Lia and her parents,” Cotter says. (Lee passed away in 2012, 26 years after the grand mal seizure that damaged her brain.)
“Yes, we have a wealth of knowledge as practitioners, but it’s really our job to kind of take a step back and ask our patients these really important questions if we want to provide better care.” —Jennifer McGee-Avila, MPH, CHES
“Health-care professionals need to have an open mind about learning other cultures in order to repair damaging relationships due to lack of understanding,” Dr. Hung adds. That could go a long way towards addressing some of the causes of health disparities. For example, research often cites the mistrust of doctors and health care as a reason why Black people avoid seeking care—and thus a reason why they’re more prone to certain health conditions. But given the historic mistreatment of Black people at the hands of doctors, the onus is on practitioners themselves to start repairing the relationship. Cultural humility, many experts argue, is a way to begin the healing process.
If cultural humility were a widespread practice, Avila-McGee believes we might see some significant changes in health-care outcomes—”health disparities or gaps lessened to some degree,” with patients feeling that their voices are truly heard. “Yes, we have a wealth of knowledge as practitioners, but it’s really our job to kind of take a step back and ask our patients these really important questions if we want to provide better care,” she says. Because all patients deserve the best possible care.
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