What Is Competency
I was becoming increasingly concerned about the gaps that “cultural competency” training left in terms of learning how to actually interact with patients of minority cultures. I also didn’t like the fact that competency implies mastery over another (in this case another’s culture). The biggest problem is that when one feels competent, he or she begins to assume the role of an expert; however, at times the characteristics or traits attributed to a particular group may actually be stereotypes or personal biases presented as “facts” about certain groups of people.
Perspectives on cultural competence vary. E-Shien Chang, a public health researcher at Rush Institute for Healthy Aging in Chicago, and colleagues, point out that “much of the literature discusses the importance of cultural awareness, knowledge, attitudes, and skills.”1 According to Jessica Gregg, MD, PhD, and Somnath Saha, MD, MPH, of the Oregon Health and Science University in Portland, Oregon, “the cultural competence movement … began … primarily by educating physicians and policymakers about culture, culture-specific beliefs, and their potential impact on health and health care.”2 More specifically, Mary Isaacson, RN, PhD, of South Dakota State University in Vermillion, South Dakota, offers this definition: “cultural competence implies that the healthcare professional has an a priori understanding of the person’s culture before engaging with the patient.”3
Humility vs Competency
Struggling with cultural competence definitions and practice attempts, I looked for another framework to help guide my work and found cultural humility. Cultural humility focuses on us. No matter which definition one chooses, the idea of cultural competency training focuses on understanding more about others. Cultural humility, first described in 1998, is a concept that has three dimensions4:
- Lifelong learning and critical self-reflection,
- Recognizing and challenging power imbalances, and
- Institutional accountability.4
Cultural humility encourages developing an attitude of not knowing and learning from the patient. Whereas cultural competence training takes place at one or several finite point(s) in time, cultural humility is an ongoing active process for the healthcare provider. Tervalon and Garcia describe it this way: “humility is a prerequisite in this process” where one “relinquishes the role of expert to the patient, becoming the student of the patient with a conviction and explicit expression of the patient’s potential to be a capable and full partner in the therapeutic alliance.”4 Chang and colleagues suggest that by following this model, we get “patient satisfaction, better medical adherence, and improved health outcomes.”1
This concept also differs from cultural competence models in that it openly addresses power imbalances between patients, providers, and institutions. It emphasizes that there must be accountability within our institutions and also within ourselves.