Ensuring Service Quality

The Importance of Cultural Humility

Over the past few decades, practitioners across the health care spectrum have become more and more conscious of the importance of culture. This is partly a result of a broader sensitivity to different cultures and an appreciation of the richness of experience inherent in embracing diversity. Even beyond this, however, health care professionals and academics have come to understand the ways in which culture plays a crucial role in improving both the patient experience and patient outcomes. Culture affects everything from lifestyle choices to the patient-doctor relationship to the decisions patients and families make at critical moments.

Cultural humility is the phrase that many researchers and practitioners now prefer as a guideline for approaching our interactions with people of other cultures. Although the term was coined in 1998, it has only recently gained more widespread acceptance. This represents both greater awareness of culture and a recognition that previous ways of thinking about culture in health care have fallen short.

For much of the past three decades, cultural competency has been the watchword for incorporating awareness of culture in the health care field. The goal of cultural competency is to familiarize health care practitioners with various cultures, especially as it concerns their attitudes towards health care. By educating practitioners about the people with whom they will interact, they will be prepared to be sensitive and respectful, to anticipate questions and concerns that patients will have, and to avoid saying things that will cause unnecessary tension.

In recent years, researchers and practitioners have begun to recognize that cultural competency, while helpful, can be inadequate or even counterproductive. If our goal is to remove cultural barriers between practitioner and patient, cultural competency falls short in several important ways.

First, educating practitioners has its limits. As much as we can learn, we can never really become experts in someone else’s culture without intensive study and extended exposure, something that is impractical for most of us. A survey found that even after decades of emphasis on cultural competence, one in five physicians still felt unprepared to address important socio-cultural issues that affect patients’ medical decisions.

Second, and perhaps most crucially, cultural competency training can give us a false sense of confidence. We assume we know all there is to know about a culture and, as a result, spend less time listening to our patients. We may know broad trends about a culture but not appreciate important nuances that are important to the person sitting in front of us. We might recognize some obvious elements, like race, as cultural factors, but not less obvious elements like geographic location or economic class. If the goal of cultural competency is to replace our natural assumptions, we may instead be replacing old assumptions with new ones.

Cultural humility is a framework that provides us with a new way of thinking about culture. As the term implies, cultural humility takes as its starting point the awareness that we can never claim full knowledge of someone else’s culture. Our task instead is to approach our patients with humility, to constantly seek to learn about them and to question and correct our own assumptions.

According to Tervalon and Murray-Garcia, who originally coined the term, cultural humility has three major components:

  • First, it involves a lifelong commitment to self-evaluation and self-critique. We must be humble enough to be open to learning new things. We must look at ourselves critically, retool the ways in which we relate to people of different cultures, and expand our understanding of the many aspects of culture.
  • Second, we must address power imbalances where none exist. In other words, our position as it relates to our patient is as an expert; we possess knowledge that the patient does not. This, however, can distract us from appreciating that the patient has knowledge that we do not; knowledge about their culture, faith, history, and priorities. Cultural humility means that we learn to see the patient as the expert as well.
  • Third, we must aspire to develop partnerships with groups which advocate for others. Recognizing that cultural awareness is a societal issue, we must seek to broaden our impact and advocate for cultural humility wherever possible.

Approaching health care with cultural humility can open new doors of possibility. Instead of approaching our patients with the assumption that we know what is important to them or what they would say in a particular situation, we need to approach our interactions with them as the chance to learn something new. We can view them as our teachers, our guide to a culture about which we know something but stand to learn much more.

In my experience, there is no health care setting in which cultural humility is more important than in palliative care and hospice. It is here that the discussions are the most sensitive. It is here that culture plays an outsized role in the decisions patients make. And it is here that an insensitive remark from a nurse or social worker will create the most tension and mistrust.

As just one example, picture yourself as the loved one of someone facing a terminal illness. Suppose the patient, despite her diagnosis, has a good quality of life, can enjoy time with family, and is content and accepting of her situation. Suppose then, a doctor proclaims that because the patient has a terminal condition, no more treatment will be provided at all, the patient may eat nothing but pleasure feeds and insurance will not pay for any more medication. Naturally, we would be outraged, we would suspect the doctor of trying to kill our loved one, and we would certainly not trust any suggestion that doctor made ever again.

This is an outlandish example, to be sure. But in many ways, it can describe the feelings of a family who has a different cultural view of the end of life than we do. If we are culturally arrogant – that is, if we do not take the time to understand our patients’ priorities – then despite our best efforts at being reasonable, we can come across as being just as insensitive as that doctor who doesn’t have a clue.

Let us examine some specific issues in hospice and palliative care where culture plays an outsized role.

Nearly everyone takes for granted that people wish to avoid pain. With so many recent advances in pain management, there is often no medical reason why patients should have to suffer, and much of our efforts in palliative care are focused on avoiding just that. But, while this is a nearly universal goal, cultural humility will show us that not all cultures view pain in the same way. In some cultures, stoic tolerance of pain is seen as noble, while admitting pain is taken as a sign of weakness. Some cultures may have a more fluid definition of pain, in which physical, emotional and spiritual pain are seen as intertwined. For some religious patients, suggesting that increasing morphine will decrease their suffering may be taken as offensive. Religious patients will sometimes want to retain cognition at almost any cost so that can they can continue to pray and perform other religious activities.

As is the case for many issues in palliative care, cultural humility helps us understand both the pain that patients are experiencing and their priorities in addressing it. We need to be humble in order to pick up on the signs of suffering, which may be expressed very subtly. And we need to be humble in suggesting solutions, expressing our awareness that every patient has a different hierarchy of priorities.

Another time when cultural humility is most imperative is when we conduct conversations about deciding on a plan of care.The assumptions we make, the questions we ask, and our tone and attitude can have a huge effect on a patient’s decisions and ultimate outcome.

I recall a meeting I once had with a woman who was preparing to enroll her elderly father in hospice. She was expressing her appreciation at the way she had been treated by our team. Six months earlier, she said, her mother had been ill. To her mind, the staff at the hospital had put inordinate pressure on her to change her mother’s modality of care. Her exact words, in fact, were, “If another social worker had mentioned palliative care to me, I would have thrown something at them.”

What was fascinating to me was that this woman was not opposed to hospice in principle; we were, after all, meeting so that she could enroll her father into hospice. What she was so offended by was the feeling that palliative care was being forced upon her inappropriately. I am sure that the social workers with whom she interacted meant no harm and were perfectly reasonable. But they failed to appreciate the cultural and religious needs of this patient and family. It was unthinkable to this woman that they would give up trying to cure her mother before she felt satisfied that all reasonable options had been exhausted. In her case, it was unthinkable to her that they would consult hospice without consulting their religious leader. Had those social workers practiced cultural humility – had they taken the time to understand what was important to the family and how the issue should best be framed – I am quite sure there would have been a different, and better, outcome.

What is true of deciding about hospice care is true about many other decisions along the way. Some families will want to consult with their religious leader before making an important decision. Some patients will be enthusiastic about a DNR order and some will find the mere suggestion offensive. In some religions, continuing to provide a patient with hydration, however minimal, can be of supreme importance, and the suggestion of extubation, however reasonable, can be fraught with emotion. Trust is our most important currency; if we open a conversation in the wrong way, we create a communication barrier that is very hard to overcome.

Cultural humility provides the framework for avoiding these problems. Culturally humble practitioners set assumptions aside. They encounter the patient and family as a unique case and try to understand what is important to them. They present facts and medical realities but not opinions or priorities. They demonstrate respect for the patient’s decisions and acceptance of the patient’s priorities. By letting the patient and family take the lead, we earn their trust and can move forward together.

It is important here to reflect on another aspect of cultural humility as it relates specifically to the health care professional. Each health care profession has a language and culture all its own. Part of practicing humility requires us to be aware of our own assumptions and the way in which those assumptions inform our attitudes. For example, a nurse might have a natural inclination to treat any and all discomfort, while some cultures might distinguish between pain and discomfort. A speech therapist might recommend no food by mouth as a precaution, while a family might place great emphasis on being able to eat even a little bit. Humility requires us to set aside our professional inclinations and see the bigger picture. Questions – genuinely curious and respectful questions – are the most important tool in our cultural humility toolbox.

Finally, to be culturally humble, we must remind ourselves that we are not treating a disease – we are treating a person. The person we encounter in a hospital bed will have many issues weighing on his or her mind, and their physical illness might not be the first one on the list. There will be social considerations, religious questions and concerns, and past experiences with loved ones vying for their attention. We need to be humble so we can tease out these issues and understand who – not what – we are treating.

There is an important ritual in Jewish tradition called a mezuzah. A mezuzah is a scroll that is placed on the doorpost of every room. Inside the decorative case, there is a little scroll that contains passages of the Bible. These passages implore us to remember our duties, to be aware of God’s presence and be faithful to God everywhere we go.

Why do Jews place these on the doorpost? It is to remind us that every time we enter a new situation, we must pause to remember the potential for goodness that exists. As we open a door to meet someone new, we leave our assumptions outside and approach them with humility. To use a modern term, it reminds us to practice wakefulness, to be aware of the impact our words and actions can have on the people we encounter.

At the end of life, priorities change. The drive for a cure often takes a backseat to having quality time with family. Expressing the fullness of our religions and cultures becomes more paramount. Cultural humility points the way towards achieving the goal of every palliative care and hospice provider: providing our patients with the best experience possible.


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