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Monday, October 10, 2005

"Cultural Competency" is not a competency to be checked off like a thoracentesis

Articles on cultural competency seem to be found in almost every journal lately. Certain aspects of this movement have not felt right to me. Linda M. Hunt, an Associate Prof at Michigan State , does an excellent job of explicating some of these aspects. Her article is worth reading;here are some of the highlights:
"Cultural competency (CC-my abbreviation) remains a vaguely defined goal with no explicit criteria established for its accomplishment or assessment. This lack may in part be due to the elusive nature of its central construct:culture". Nevetheless, there are increasing requirements for physicians to receive training in area for which no or few valid criteria for assessment exist.Various residency program include it as do medical schools. The influential IOM recommended training CC for medical students and in New Jersey has passed a law mandating physicians receive training.
She says further, " It is not possible to predict the beliefs and behaviors of individuals based on their race, ethnicity, or national origin."...Paradoxically..what originated in a desire to promote respect for individual differences may instead promote stereotyping and essentializaing...It may reinforce the belief that culture can be diagnosed and treated."
Much of what she said is encapsulated in a comments made by a letter writers to DB's Medical Rants. Letters no 3 and 4 seem on target . Physicians treat individuals not members of some arbitrary sociological construct. Treat patients with respect. Don't worry that a given patient might have some attitude or belief based on their alleged membership in some cultural classification subgroup.
She continues ;"..it [the cultural competency movement] has too often represented culture as a decontextualized set of traits providing a template for the perceptions and behaviors of of group members"..."specific ethnic cultures are represented as a codified body of characteristics that can be identified and then either modified or manipulated to facilitate clinical goals."
Does she offer an alternative? ( my alternative would be do drop the programs, but I don't see that happening for a while). She recommends two things. First be respectful of the unique perspective each patient brings . Respect is certaintly a core value. The second is a bit harder to put into real life clinical experience. Hunt recommends what she calls "cultural humility" by which she means to explore through conversations with the patient similarities and differences between his own and each patient's goals, capacities and priorities. That is quite an assignment even with limitless time but not likely to be achieved in a 10-15 clinical encounter let alone a 7 minute one.
Allegedly, somehow the clinical competency movement is supposed to further the goal of reducing or elliminating the gap between the medical care haves and the medical care havenots.
How programs with poorly defined goals, a flawed conceptual foundation and an intellectual regression to treating folks as members of groups will achieve that remains unclear. Even the much more restricted goal of improving doctor patient communication is not likely to be greatly improved by putting old wine (racial streotypes) into a new bottle. A recent Johns Hopkins study is said to have demonstrated that CC training improved some aspect(s) of patient satisfaction and physician understanding but - not surprisingly-no data are found demonstrating improved health care.
Hunt's closing paragraph says in part " ... being appropriately cognizant of and more responsive to cultural issues shoudl not be thought of a reaching a 'competency' " but she says an ongoing process in which there is a "respectful recognition" of the unique set of charateristics and attitudes and concerns of individual patients.


Roy M. Poses MD said...

For a very jaundiced take on the cultural competence issue, see this essay just out by Norman Levitt:

Anonymous said...

I am a board certified pediatrician who had a successful thirty year, malpractice free practice in New Jersey.Ten years into retirement I still maintain my Academy Fellowship and state license for the benefit of family and friends who need my help. Where do I take this course and finally become culturally competent?