Robinson Papp Laboratory
On cultural competence and hospitality

On cultural competence and hospitality

by | Jul 24, 2023 | Diversity and disparities

By Jessica Robinson-Papp

This past week I’ve been reading about Diversity, Equity and Inclusion (DEI) initiatives in academic medicine and I keep running across the term “cultural competence.” It’s one of those terms that I think I know the meaning of but if I stop to think about it I really don’t. It certainly rolls off the tongue… “cultural competence” is an alliteration and a double dactyl, the latter being a rhythm employed in playful poems like the one which begins “Higgledy Piggledy.” (Jessica Robinson is also a double dactyl, but the Papp ruins it, oh well.)

So what is cultural competence? The origin of the term is attributed to a 1989 paper by Terry Cross and colleagues titled: “Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children who are Severely Emotionally Disturbed.” The definition of cultural competence in the monograph is:

“Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.”

Cultural competence is also described as “continuous expansion of cultural knowledge and resources” and “holding culture in high esteem.”

Does it make sense that having extensive cultural knowledge and holding culture in high esteem will help doctors work effectively with diverse patients and colleagues? In the most basic sense, I think the answer is clearly yes. If I am aware that other cultures exist and accept that as a good thing I will likely be more effective in the healthcare workplace. Or said in reverse, if I cannot accept that people are different from me, I will probably not be a very good doctor.

But it’s more questionable whether in-depth knowledge of and esteem for culture is better than basic acceptance. Since cultures are diverse, deepening knowledge would require understanding the nuances of multiple specific cultures, and there are resources (for example, the book Multicultural Health by Lois A. Ritter and Donald H. Graham) designed to help healthcare providers do just that. However, this approach presents two problems. The first is one of scope. Many, many cultures exist and it is not reasonable that a healthcare professional should have significant knowledge of all of them. However, even if this were possible, you still run into the second problem of what to do with this knowledge. Should we somehow behave differently toward people based on ideas about their culture? Even with the best intentions this feels too close to stereotyping and bias. Cultural competency seems to be most practical for healthcare providers who serve one or a few specific cultural groups or communities, but as diversity increases, the utility of cultural competence as it was originally conceived becomes unclear.

The idea of requiring “esteem” for culture as contained in the original definition of cultural competence is also problematic. There are certain aspects of certain cultures that I cannot and should not esteem, as exemplified by the status of and practices toward women and girls in many cultures. Definitions of cultural competence have evolved and the National Center for Cultural Competence, based at Georgetown University, asserts that there is no one definition. But many definitions still contain some notion of “esteem,” such as “respect” or “value.” This too is problematic because as a doctor I have to connect with and provide care for every person who enters my clinic. This cannot depend upon my judgment of their personal character, let alone upon an even less specific judgment of their culture. For example, my clinic participates in a program serving the recently incarcerated. Given the imperfection of the criminal justice system, many of these people are likely innocent of significant wrongdoing. But some, I imagine (I never ask), have done terrible things. If I have to respect someone and/or their culture to take good care of them, I am in trouble. Fortunately, professionalism demands I set myself aside and connect with patients however I can.

And so we arrive at the vaguer definitions of cultural competence. For example, the American Psychological Association which has defined cultural competence as “the ability to understand, appreciate and interact with people from cultures or belief systems different from one’s own.” This seems very reasonable. Indeed we should try to understand our patients, we need to be able to interact with different types of people, and as for appreciate… maybe not totally necessary but not a dealbreaker either. Problem here is that the definition could just as easily read: “the ability to understand, appreciate and interact with people.” People, period, regardless of their culture or beliefs. This idea already has another name: hospitality. In his popular book, Setting the Table: The Transforming Power of Hospitality in Business, restauranteur Danny Meyer describes hospitality: “In the end, what’s most meaningful is creating positive, uplifting outcomes for human experiences and human relationships. Business, like life, is all about how you make people feel.” Ultimately, our goal as healthcare providers should be to connect effectively with individual patients so we can understand their illnesses and they can trust in our ability to help them. It is time for a new framework to understand and teach this process.

When leaving home is hard

When leaving home is hard

by | Jul 7, 2023 | Clinical trials

By Bridget Mueller, MD PhD.

The PAIRED Project team is always excited to meet new research participants. Usually, our research coordinators have spent a lot of time talking to them in advance and planning out the details of the visit over multiple phone calls. But surprisingly often, after all this lead up, the participant doesn’t show up and then stops answering our calls. Some of our Gen Z team members started using the term “ghosting” to describe these events, referencing the broader cultural phenomenon of abruptly cutting off all contact without explanation.

As someone relatively new to clinical research, I found the phenomenon confusing. And after spending several days talking to our team members and my own clinical patients, I’ve concluded that there is neither a simple nor single answer. People are complex and the reason an individual decides, seemingly at the last minute, not to participate in a study is likely multi-faceted, involving social, cultural, and logistical barriers. But I have a hunch that personality may play an important and perhaps underappreciated role in ghosting (at least in the research context).  In a classic experiment called “the open field test,” a mouse is placed in a 3-foot by 3-foot white plexiglass box for five minutes. Normally, mice spend the first minute walking cautiously along the edges, remaining in the shadows, before exploring the open, bright center. Out in nature, this evolutionarily adaptive behavior reduces the risk of being spotted by a flying predator. But mice who are more vulnerable to stress spend the majority of the five-minute test hugging the perimeter of the box. Even when baited with a few tasty peanut butter morsels, most don’t venture to the center of the box for long.

As an introvert, I felt a connection to these cautious and sensible mice. Is a peanut butter chip really worth being eaten by a hawk? Maybe our ghosters are like me and my perimeter-hugging mice. Despite a genuine desire to participate in a clinical trial, perhaps when the time comes to actually leave home to meet new people, answer personal questions, give blood, and engage in all the other research procedures, the fearful brain takes over and our prospective participant turns off the phone and remains on the couch.

So, how, as scientists, do we increase the likelihood that an introvert in pain will show up for the studies that are needed to find new treatments? Community engagement? Fewer in-person study visit requirements? I’m not sure, but the Paired Project is going to start asking. We’re acknowledging that participating in science can be hard, particularly when in pain, and we will ask every potential participant, “What can we do to make this visit easier for you?” We’ll let you know what we learn.