“We may have different religions, different languages, different colored skin, but we all belong to one human race.”
– Kofi Annan
Cultural competence is a long-neglected subject area in the field of medicine. In fact, one might say with examples like the Tuskegee Syphilis Study, that the medical profession has been notably deficient in this regard. Given the increased emphasis on promoting health outcomes – which must implicitly include long-standing health care disparities for minority populations (on the metrics of race, ethnicity, language, and sexual orientation among others) – this discipline will be essential to the success of all 21st century physicians. White Coat Checklist has framed a consistent approach to topical issues to help medical school applicants frame an issue with both perspective and coherent respect:
- Historical Perspective & Implications
- Arguments In Favor
- Arguments Against
- Inclusive Response
The maturity and presence of self-control for a moment of thoughtful introspection will only grow in importance as health care systems and hospitals assume much more direct responsibility and financial risk for actual patient outcomes.
Historical Perspective & Implications
Appropriate factors for consideration include the following:
What is my own cultural identity?
Are there specific components (race, ethnicity, etc.) can I identify as particularly meaningful upon self-reflection?
How does my own cultural identity, and those of my patient, impact my ability to be an effective health care provider?
What knowledge is available to me regarding the makeup of the local patient population I may be called upon to serve?
Have I identified new sources for such information in the future as I relocate geographically for new work opportunities?
Have I located strategic partners for my care practices such as case managers, hospital chaplains, family members?
Do my colleagues share the mission of providing culturally competent care? Can I identify any potential barriers?
Can I effectively quantify how this knowledge base makes me a better physician?
Have I partnered with non-clinical stakeholders (IT, patient access, etc.) to ensure our organization invests in this capability?
The first question regarding life illustrates the multi-layered and highly subjective nature of this discussion. One of the most complex aspects of this area of study is that many aspects of diversity are ‘invisible’ – take, for example, the case of someone who may identify as ‘gay’ but not publicly self-identify as such even to close friends and family, let alone in the workplace. This is a component of medical history which would conceivably impact health care delivery – including HIV screening, and other specific sub-types of preventative care – which are often highly sensitive topics for patient-provider discussion. Similarly, a patient’s self-identify could conceivably include components such as pansexuality which can exist quite independently from social expectations which many individuals accept as normative. It is these murky complication issues that often lead to provider objections – for instance, how to know the full degree that an individual may self-identify (and the corollary of being obligated to appropriately act on such information) when standards of practice are not readily available, regularly stressed, and/or effectively integrated into the existing daily process of clinical care. Tellingly, the Fox medical drama house devotes the episode Humpty Dumpty to addressing these types of questions and grappling with the boundaries of patient/provider relationships. Clearly cultural competence is a nuanced issue that does not lend itself to any ‘slam-dunk’ answer.
Arguments In Favor (‘Pro Competence’)
- Narrative evidence abounds that the adoption of Culturally and Linguistically Appropriate Standards (CLAS) can meaningfully improve health care outcomes in case study settings
- Unconscious or subconscious perceptions can sharply differ from conscious attitudes and beliefs – shaped in part by messages from the media and popular culture
- Without appropriate awareness of the potential for bias, providers have been known to treat patients of differing backgrounds with lesser standards of care including perception of patient-reported pain
- The New Jersey State Board of Medical Examiners requires a one-time six hour formal CME in the field of Cultural Competency
- Patients have specific rights in terms of access to effective patient-centered care under the Civil Rights Act of 1964, Title VI and the Americans With Disabilities (ADA) Act, among others
- The Institute for Healthcare Improvement (IHI), a leading healthcare quality improvement organization, has dedicated considerable resources toward the creation of a cultural competence glossary in order to standardize definitions for the purposes of clinical discussion
Arguments Against (‘Anti Competence’)
- Physicians have neither the time (in a fee-based payment structure) nor training in cultural competency best practices in order to be able to incorporate these approaches day to day – especially since such services are not reimbursed by nearly all health insurance/payer entities
- While some enterprises, namely vertically integrated organizations like Kaiser Permanente and Geisinger Health System have reported successes in this regard, it can be argued that most standalone provider organizations have neither the resources nor capabilities to not only undertake such work but invest in the resources needed to monitor and perfect this discipline as part of the ongoing continuum of care
- A lack of consensus on this issue is fairly evident given the few state medical boards which currently require cultural competency training; even those which have opted to do so have not incorporated ongoing training or assessment requirements
- Cultural competence can be highly dangerous in the clinical setting, especially when time is limited and training may be extremely basic, if providers use such a perspective as a short cut – taking broader generalizations as specifically applicable to a given patient without seeking to verify such information directly with the patient
Inclusive Response Examples
It’s entirely possible to use the evidence above to support several responses in an interview setting. The examples below attempts to illustrate the effective combination of both halves of the available arguments in combination with the historical perspective to offer a thoughtful response which demonstrates both personal reflection and active external engagement regarding the issue at hand.
Appropriate Response: In Favor, With Balanced Discussion of Topic
“Cultural competence is certainly a hot-button topic in the 21st century United States and a topic worthy of study by medical school candidates. An impressive number of policy organizations and health care provider thought leaders have invested considerable resources in understanding patient populations in the most specific sense in order to support effective clinical outcomes. At the same time, most hospital/health system organizations are neither structured nor incentivized to address these categories of health disparities and only a handful of state medical boards currently require even one-time training on this highly sensitive topic. Given the radical changes currently underway in the medical field including technology investments, new models of care, and revolutionary new approaches for both clinical treatment and prevention, I personally look forward to incorporating cultural competence into my personal model of patient care and will certainly welcome opportunities to collaborate on this emerging discipline in the years to come.”
Appropriate Response: Personally Opposed, But Sensitive to Patients and Legally Compliant
“Cultural competence is certainly a hot-button topic in the 21st century United States and a topic worthy of study by medical school candidates. An impressive number of policy organizations and health care provider thought leaders have invested considerable resources in understanding patient populations in the most specific sense in order to support effective clinical outcomes. At the same time, most hospital/health system organizations are neither structured nor incentivized to address these categories of health disparities and only a handful of state medical boards currently require even one-time training on this highly sensitive topic. Given the radical changes currently underway in the medical field including technology investments, new models of care, and revolutionary new approaches for both clinical treatment and prevention, I personally welcome any additions to clinical care with the potential to improve patient outcomes although I imagine that most of the responsibility for innovating new cultural competencies will rest with front line providers – health coaches, case managers, and social workers – specifically dedicated to preventing patients from ending up in circumstances that require medical treatment by a licensed physician.”
White Coat Checklist’s Member Resources section includes the free AppTrackR medical school dashboard to allow applicants to track their target schools in real-time, question prompts for composing a compelling personal statement, and real-life secondaries essays to learn from the mistakes of prior applicants who have successfully matriculated. Members are also eligible to Contact WCC to ask questions or request 1:1 Advising or Remote Editing Sessions for individual targeted support.