Mrs. Smith, a 60-year-old black woman, presented to my office visibly upset about a recent appointment with a subspecialist. She had been treated poorly, she said, from the moment she arrived at that physician's office. Most telling, the patient said, was that the subspecialist assumed that her heart disease was related to a diet that included a lot of fried chicken and other Southern dishes. In reality, Mrs. Smith has been a vegetarian for more than a decade, and her condition is more likely related to her family history.
As I apologized for my subspecialty colleague's actions, I was reminded of the importance of cultural proficiency in health care. I also was reminded that not only must we be culturally competent, we also should possess what has been termed "cultural humility."
I asked the medical student rotating with me if she was familiar with this term. She responded that she was familiar with cultural competency but not cultural humility. Unfortunately, she is not alone. It is imperative that we understand these terms as we strive to care for our increasingly diverse population and address health disparities in our communities.
Culturally competent care respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes and behaviors. Cultural competency is the foundation to reducing disparities by being culturally sensitive and providing unbiased, high-quality care.
Cultural proficiency takes things a step further. According to the AAFP's position paper on the issue, cultural proficiency is not just the acceptance of cultural differences, but rather is "a transformational process that allows individuals to acknowledge interdependence and align with a group other than their own. Culturally proficient health care, in particular, makes use of a patient's language and culture as tools to improve outcomes for that individual."
But we must not overlook the critical component of cultural humility -- having a humble and respectful attitude toward people of other cultures. It involves ongoing self-exploration combined with a willingness to learn from others. It helps us recognize our cultural biases and realize that we can't know everything about a culture.
The concept of cultural humility was developed by Melanie Tervalon, M.D., M.P.H., and Jann Murray-García, M.D., M.P.H., more than 20 years ago to address health disparities and institutional inequities in medicine. It is now used in public health, social work, education and nonprofit management, but is underutilized in health care.
Tervalon and Murray-García described three principles of cultural humility. We must continue learning throughout our lives because we are ever-changing based on what is going on with us and with our patients. We must be humble about our level of knowledge regarding our patients' beliefs and values, aware of our own assumptions and prejudices, and active in redressing the imbalance of power inherent in the physician-patient relationship. Finally, we must recognize the importance of institutional accountability.
Cultural humility gives us a greater understanding of cultures that are different from our own and helps us recognize each patient's unique cultural experiences. As family physicians, we treat the whole person. We are involved in the communities we serve, and we maintain ongoing patient-physician relationships. In addition, we are trained to ask many questions. We learn from our patients and their families and acknowledge their cultures and how these cultures affect health, without making assumptions (as my colleague did with Mrs. Smith). Through these efforts, we are able to promote accessible, affordable, culturally proficient and high-quality care.
Patient-centered care is respectful and responsive to the individual patient's preferences, needs and values, and it ensures that these values guide all clinical decisions. To achieve this, physicians and staff must be not only culturally competent as we care for our diverse populations and strive for health equity, but also culturally humble. Only then might we truly be culturally proficient.
Ada Stewart, M.D., is a member of the AAFP Board of Directors.