Cultural competency training in medicine


When I renewed my physician assistant license on the Oregon Medical Board (OMB) website last year, its questionnaire asked if I had participated in “cultural competency” training. Since I had completed continuing medical education only for my specialty, cardiology, I selected “no”. A small message at the bottom of the screen warned that if I was exempted for this license renewal, such training would be mandatory in the years to come.

Cultural competency literature and trainings have become increasingly prevalent in the medical field. A PubMed Search shows a rapid increase in the use of the term, beginning in the 1990s and peaking in 2019, and the US Office of Minority Health lists “enhancing cultural competence” as one of its primary health care goals. OMB Cultural Competence: A Practical Guide for Health Professionals defines it as “an ongoing process of examining values ​​and beliefs, developing and applying an inclusive approach to health care practice in a way that recognizes the context and complexities of caregiver-patient interactions and preserves the dignity of individuals, families and communities.”

Fair enough. What’s troubling comes a little earlier: “The goal of a ‘culturally competent’ healthcare system is to eliminate disparities between different cultural groups,” the OMB guide states. What constitutes a cultural group is not defined, and the process by which such disparities will be eliminated is also left to the reader’s imagination. The CAMO guide continues, “The goal of a culturally competent provider is to be committed to doing their part, both as a clinician, but also as an agent of system change. And here, I thought we were just practicing medicine.

The OMB’s advice makes one wonder if the writers have ever worked in a busy clinic, let alone interacted with real, flesh-and-blood humans. Consider the following recommendations. “Keep exploring and learning about the different Latino stories in your community.” “When your identity or background – race, age, gender, etc. – does not match that of the patient, seek additional support within your staff, your institution or beyond.” “While white patients do not experience racial marginalization, they may experience other forms of discrimination – examine assumptions about mother tongue and country of origin.” “Always ask people their pronouns, even people who you think ‘don’t look’ trans or genderqueer; if in doubt, default to them/theirs and instruct your staff to do the same.

Finally, in the section on rural health care, the OMB advises medical workers to “beware of the polarizing effects of electoral politics at the local level – community building can bring about change that benefits people, no matter whatever their ideology. It is curious that only rural patients – who can vote in the political direction opposed to the cultural skills brigade – receive a warning.

In any case, a brochure or (more generally) a short training workshop cannot confer real cultural competence on its recipients. When treating patients, certain skills, such as fluency in a second language, are clearly desirable. But these necessities are solved by technical innovation with virtual interpreters, not by social engineering. We are asked to believe that something as complex and loosely defined as a culture can be distilled into a PowerPoint presentation, from which viewers can then print off a certificate affirming their mastery of it.

Such formations have questionable empirical advantages. A review cultural competency training in BMC medical training writes that the hours spent on cultural competency training are too limited to make a difference, then notes that “much of the remaining time is spent exchanging cultural stereotypes and surface information”. During a thankfully brief week of cultural competency training at a medical assistant school, my class watched narrated footage that juxtaposed non-white people living in poor, run-down neighborhoods around the country and white citizens on a field. country club golf course. What we gained from this is anyone’s guess. Colleagues in other fields, such as consulting, told similar stories.

Finding clear longitudinal data demonstrating the effectiveness of these trainings is quite a challenge. Studies that can reveal the limitations of the cultural competence approach often insist that we “need more research” and “need better understanding” rather than admit a flaw in this approach. . One systematic analysis methods of measuring cultural competence have been found to “varie considerably”, with “suboptimal” measures that “lack methodological rigour”, raising the question of how cultural competence can be taught if it is cannot be reliably measured.

But publications on the negative consequences abound. An article in harvard business review is representative. “Trainers [say] that people often respond to run with anger and resistance-and a lot participants actually report more animosity toward other groups thereafter,” the article notes. In contrast, voluntary trainings – and ordinary interpersonal contact with people of different genders, races and backgrounds – reduce bias and make people more willing to work alongside different groups. In short, ordinary behavior leads to more harmonious results than do protocols mandated by self-proclaimed experts in the fields of “diversity” or “culture”.

Despite these shortcomings, these formations are likely to remain. Medical institutions are under pressure to signal their commitment to social justice. Enough decision-making has already been handed over to third parties – insurance companies dictating the cost-benefit calculation of a given treatment, the federal government imposing penalties or issuing reimbursements to hospitals – that one more group of us saying what counts as a skill won’t make it surprising. It is hoped that medical workers will continue to engage with their patients on an individual level to understand their personal health care needs – the kind of skill that really matters.

Photo by Christopher Furlong/Getty Images

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