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By Jessica Robinson-Papp, MD MS<\/strong><\/p>\n This past week I\u2019ve been reading about Diversity, Equity and Inclusion (DEI) initiatives in academic medicine, and I keep running across the term \u201ccultural competence.\u201d It\u2019s one of those terms that I think I know the meaning of but if I stop to think about it I really don\u2019t. It certainly rolls off the tongue\u2026 \u201ccultural competence\u201d is an alliteration and a double dactyl, the latter being a rhythm employed in playful poems like the one which begins \u201cHiggledy Piggledy<\/a><\/strong>.\u201d (Jessica Robinson is also a double dactyl, but the Papp ruins it, oh well.)<\/p>\n So, what is cultural competence? The origin of the term is attributed to a 1989 paper<\/a><\/strong>\u00a0by Terry Cross and colleagues titled:\u00a0\u201cTowards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children who are Severely Emotionally Disturbed.\u201d<\/em>\u00a0The definition of cultural competence in the monograph is:<\/p>\n \u201cCultural 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.\u201d<\/em><\/p>\n Cultural competence is also described as \u201ccontinuous expansion of cultural knowledge and resources<\/em>\u201d and \u201cholding culture in high esteem<\/em>.\u201d<\/p>\n 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.<\/p>\n But it\u2019s 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\u00a0Multicultural Health<\/a><\/strong>\u00a0by 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.<\/p>\n The idea of requiring \u201cesteem\u201d 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\u00a0National Center for Cultural Competence<\/a><\/strong>, based at Georgetown University, asserts that there is\u00a0no one definition<\/a><\/strong>. But many definitions still contain some notion of \u201cesteem,\u201d such as \u201crespect\u201d or \u201cvalue.\u201d 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.<\/p>\n