Advancing health equity conversations through cultural humility

In 1998, Drs. Tervalon and Murray-Garcia created the concept of “cultural humility” as a way to transcend the prevailing but limiting concept of cultural competence in teaching medical students and trainees how to respectfully deliver health care to the increasingly diverse populations of the U.S. The cultural competence paradigm leads health care professionals to assign patient group traits or labels. On the other hand, cultural humility incorporates a lifelong commitment to reflection, self-evaluation, and self-critique, seeking to amend power imbalances and develop mutually beneficial partnerships with communities while also considering institutional roles in accountability.

In our experience teaching about cultural humility, faculty, learners, and trainees have said that cultural humility has been important for them in providing “guidance through an understanding of humanity.” As professionals and educators embracing cultural humility, we realize that many aspects of culture are specific to individuals and uniquely influence individuals’ perspectives on health. Twenty-four years after the concept’s introduction, it is as relevant as ever. We affirm that embracing cultural humility ensures curiosity and eliminates acts of condescension. To be humbled is to be vulnerable, disconnected from pride, and willing to listen, leading to growth.

The reflection and evaluation of our positions, the power that we may have over others by virtue of our professional hierarchies or practice, and the parts of our living experiences that demonstrate some form of privilege. Given the state of health disparities and inequities, we should also acknowledge our complicity in marginalization by simply participating in this health care system. We should be raising our critical consciousness, recognizing our ability to identify oppressive actions and structures that shape our society and invite us to act. We must also acknowledge the layers of cultural identity and recognize that the answer is not entirely understanding others but understanding ourselves.

The following steps are a way to begin being culturally humble and willing to learn and grow from your patients.

1. Reflect on your own identity, values, and motivations. Remember, cultural humility begins with ourselves. It means a lifelong process of self-reflection and self-critique whereby the individual starts with an examination of their own beliefs and cultural identities. What tools can you use to reflect? Journaling, sharing about your life with others? Think about the pivotal moments of your life that shaped who you are today. What are those moments that send you through this path?

2. Don’t assume an individual represents a group. Remember that a patient is an individual. This means that they neither represent nor ascribe to all. Latinx patient is nested in a complex web of identity involving the country of origin or heritage, neighborhood, generation, religion, etc. To ascribe the same Latinx assumptions, ascribed health beliefs, and needs to a fourth-generation Tejano teen and a grandparent who is a recent immigrant from the Dominican Republic living in the Bronx would be nonsensical. Treat the patient and not the culture.

3. Ask questions and compassionately listen to concerns. Active listening is a key skill in medicine. It means listening for the messages conveyed with and underneath words as well as those communicated through body language. It means being sensitive to the suffering of self and others, with a deep commitment to try to prevent and relieve it.

4. As health care providers and researchers, we must keep in mind medical and research ethics and the impact of structural racism on health. Do you remember to research and medical ethics? How about structural racism today?

Some examples of atrocious acts in the name of medicine include the Tuskegee Syphilis Study in the U.S. and Guatemala by the U.S.; obstetrics and gynecology experiments on enslaved women; and birth control testing causing a generation of Puerto Rican women to become sterile. This is not erased from history but carried through generational trauma. In addition, daily reminders of structural racism, including its contribution to health and health care inequities such as disparate treatment and outcomes in COVID-19, drive home the understanding that mistrust is not just a product of the past. Mistrust in science and medicine is also fueled by what happens to a family member, neighbor, or friend as they navigate the health system. Mistrust is the outcome of the way our grandmother was treated at her appointment. Mistrust comes with the way we treat our own health care workforce.

We have a moral obligation to acknowledge that the advancement of medicine has and continues to come at a great cost to marginalized/minoritized communities. Next time we are holding this conversation, we should remember these lessons and humbly accept that there is a reason for mistrust.

5. Embrace not knowing and earn trust. Medical training teaches us to project steadfast confidence to patients, even if it may instead lead to mistrust if our predictions are not borne out. The most appropriate response sometimes may be, “I do not know the answer to that, but I will find out for you.” or “I do not know how you will get through that, but I know you will, and I know we will do it together.”

6. Partner with the communities that you serve. Medicine’s responsibility is to take care of the community, listen to the community, and advocate and build coalitions with communities. Remember that it is a humbling act to engage in learning with communities, not just about the communities that we are part of. There are great examples of these efforts. Cultural humility includes engagement in response to community-led concerns.

7. Reflect some more. Find a way to set aside time to reflect on one’s encounters is crucial. Ask yourself: Did you demonstrate empathy? Did any bias you may hold play a role in a conversation? What do you need to learn more about? What did you have in common with your patients? Were you an example of what it is to embrace cultural humility?