The promise and paradox of cultural competence

"When in Rome…": structural determinants impacting healthcare access, health outcomes, and well-being of South Asian older adults in Ontario using a multilingual qualitative approach

With the increase in international migration, the need for an equitable healthcare system in Canada is increasing. The current biomedical model of healthcare is constructed largely in the Eurocentric tradition of medicine, which often disregards the diverse health perspectives of Canada's racialized immigrant older adults. As a result, current healthcare approaches (adopted in the US and Canada) fall short in addressing the health needs of a considerable segment of the population, impeding their ability to access healthcare services. This study aimed to identify and understand the structural and systemic factors that influence healthcare experiences and well-being among South Asian older adults in Ontario, addressing a significant gap in empirical and theoretical knowledge in the Canadian context. We conducted in-depth individual and dyadic interviews (n = 28) utilizing a descriptive multilingual cross-cultural qualitative approach. Through this research, participants expressed that their understanding of well-being does not align with that of their healthcare providers, resulting in unmet health needs. Our study uses an intersectional lens to demonstrate participants' perceptions of virtual access to care and systemic factors, such as mandatory assimilation and whiteness as a taken-for-granted norm impacting the health and well-being of South Asian older adults. The findings of this research can offer valuable insights to healthcare providers and policymakers in developing culturally competent practices, guidelines, and training policies that effectively address the healthcare needs of the South Asian population in Canada.

The CARE (Curiosity, Attentiveness, Respect and Responsiveness, and Embodiment) Model: Operationalizing Cultural Humility in the Conduct of Clinical Research

Cultural competence training has been criticized for reinforcing existing stereotypes, ignoring intersectionality and inadvertently marginalizing some individuals and groups. In contrast, cultural humility offers the possibility of transformational learning, requiring individuals to pursue a lifelong course of self-examination. This approach makes authentic engagement with others possible. We review the premises underlying cultural competence and cultural humility, as well as proposed models for the integration of cultural humility into the clinical context. We propose a new model for the integration of cultural humility into clinical research: CARE, signifying Curiosity, Attentiveness, Respect and Responsiveness, and Embodiment. We conclude that the concept of cultural humility can be integrated into the conduct of clinical research.

A Comparative Case Study Analysis of Cultural Competence Training at 15 U.S. Medical Schools

PURPOSE

Twenty years have passed since the Liaison Committee on Medical Education (LCME) mandated cultural competence training at U.S. medical schools. There remain multiple challenges to implementation of this training, including curricular constraints, varying interpretations of cultural competence, and evidence supporting the efficacy of such training. This study explored how medical schools have worked to implement cultural competence training.

METHOD

Fifteen regionally diverse public and private U.S. medical schools participated in the study. In 2012-2014, the authors conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 third- and fourth-year medical students, along with 29 focus groups with an additional 196 medical students. Interviews were recorded, transcribed, and imported into NVivo 10 software for qualitative data analysis. Queries captured topics related to students' preparedness to work with diverse patients, engagement with sociocultural issues, and general perception of preclinical and clinical curricula.

RESULTS

Three thematic areas emerged regarding cultural competence training: formal curriculum, conditions of teaching, and institutional commitment. At the formal curricular level, schools offered a range of courses collectively emphasizing communication skills, patient-centered care, and community-based projects. Conditions of teaching emphasized integration of cultural competence into the preclinical years and reflection on the delivery of content. At the institutional level, commitment to institutional diversity, development of programs, and degree of prioritization of cultural competence varied.

CONCLUSIONS

There is variation in how medical schools approach cultural competence. Among the 15 participating schools, longitudinal and experiential learning emerged as important, highlighting the needs beyond mere integration of cultural competence content into the formal curriculum. To determine efficacy of cultural competence programming, it is critical to conduct systematic assessment to identify and address gaps. While LCME standards have transformed aspects of medical education, further research is needed to clarify evidence-based, effective approaches to this training.

Intersectionality in Clinical Medicine: The Need for a Conceptual Framework

Intersectionality has become a significant intellectual approach for those thinking about the ways that race, gender, and other social identities converge in order to create unique forms of oppression. Although the initial work on intersectionality addressed the unique position of black women relative to both black men and white women, the concept has since been expanded to address a range of social identities. Here we consider how to apply some of the theoretical tools provided by intersectionality to the clinical context. We begin with a brief discussion of intersectionality and how it might be useful in a clinical context. We then discuss two clinical scenarios that highlight how we think considering intersectionality could lead to more successful patient-clinician interactions. Finally, we extrapolate general strategies for applying intersectionality to the clinical context before considering objections and replies.

Reimagining Cultural Competence: Bringing Buried Dynamics Into the Light

Many organizations attempt to increase cultural competence as one way to foster organizational change to enhance equity and inclusion. But the literature on cultural competence is largely silent on the role of emotion, despite the strong feelings that inevitably accompany work in cross-racial dyads, groups, and institutions. We offer group relations theory as an approach rooted in the importance of emotions, especially anxiety, and offering a rich awareness of how unconscious processes, including defense mechanisms like splitting and projection, drive that anxiety. We show how this approach helps us both diagnose and address difficult dynamics, including by recognizing entrenched power inequities. We draw on examples from others’ research as well as our own research, teaching, and consulting to illustrate key concepts. Ultimately, we argue that buried emotions can create distance and inhibit change. Surfacing and addressing them can foster connection and provide a way for organizations to move forward.

Guidelines for Teaching Cross-Cultural Clinical Ethics: Critiquing Ideology and Confronting Power in the Service of a Principles-Based Pedagogy

This paper presents a pedagogical framework for teaching cross-cultural clinical ethics. The approach, offered at the intersection of anthropology and bioethics, is innovative in that it takes on the "social sciences versus bioethics" debate that has been ongoing in North America for three decades. The argument is made that this debate is flawed on both sides and, moreover, that the application of cross-cultural thinking to clinical ethics requires using the tools of the social sciences (such as the critique of the universality of the Euro-American construct of "autonomy") within (rather than in opposition to) a principles-based framework for clinical ethics. This paper introduces the curriculum and provides guidelines for how to teach cross-cultural clinical ethics. The learning points that are introduced emphasize culture in its relation to power and underscore the importance of viewing both biomedicine and bioethics as culturally constructed.