Applying Cultural Dexterity to Patients in Radiology

The demographics of the United States is evolving, though the radiology workforce remains relatively racially homogenous. In 2020–2021, only 4% of radiology residents were Black or African American, 6% were Hispanic or Latino, and 1% were American Indian or Alaska Native. These numbers have minimally increased over the past decade, given that in 2010, 3% were Black or African American and 5% were Hispanic or Latino.¹ Given that racial and ethnic concordance has been shown to improve patient care, it is important to have a workforce that is more representative of and trained to work with a diverse population.² Less than 20% of radiology residency websites include a diversity statement, and many radiology programs do not offer formal training on cultural sensitivity.³ There have been growing calls from within the field to provide proactive measures to teach and incentivize more culturally adept care and equitable research.^3,4

In radiology, most imaging interpretations occur without prior knowledge of patients’ demographics, which contributes to a lack of awareness of racial disparities among radiologists.⁴ Disparities in radiology, however, exist and are perpetuated in the imaging cycle through technology diffusion, imaging quality, access, and differential screening rates.⁴ Addressing these disparities is critical because minorities are at increased risk for developing highly morbid conditions that may be amenable to early detection radiographically, and therefore receive subsequent prevention and treatment.⁴ Patients with limited English proficiency (LEP) experience fewer preventive services and reduced cancer screening, representing another opportunity through which radiologists can advance patient care.⁵

Radiologists communicate with and provide their expertise to nearly every medical and surgical specialty, and imaging reports are often made visible to and read directly by patients after the CURES Act enactment. A forward-thinking radiologist may write their reports with language that considers multiple readers who may engage with their words, including other radiologists, physicians, and patients. Many radiologists interact directly with patients, including breast, musculoskeletal, and interventional radiologists who build rapport with patients in a short visit while also performing an intervention. These subspecialists must establish trust and communicate effectively with patients of all backgrounds to develop relationships, obtain informed consent, guide patients through procedures, and address post-procedural care and pain management. Given these ubiquitous requirements for articulate report generation and patient interaction with rapport building, it is critical that a radiologist can communicate with a diverse patient population in a variety of circumstances.

Cultural competency and cultural humility are terms that have been widely circulated and incorporated into undergraduate and graduate medical education. Cultural sensitivity is a key component of two of the six Accreditation Council for Graduate Medical Education core competencies.^6,7 Most residency programs, however, have yet to provide residents with specific training on how to actively employ cultural sensitivity. Cultural dexterity, as described in the context of providing surgical care, builds beyond the static idea of cultural competency and the passive tendency of cultural humility, and describes the ability to recognize, navigate, and value cross-cultural interactions through the application of the key tenets of curiosity, respect, and empathy.⁸ With gradual improvements in the representation of historically marginalized racial and ethnic groups within the radiologic workforce and the adoption of cultural dexterity as a framework to teach and practice, the field of radiology has an opportunity to improve health equity and advance patient-centered care.

Curiosity

Curiosity is a key element of cultural dexterity that encompasses the willingness to explore another’s perspective with the intention of gaining a better understanding of one another. This is an active process that requires self-awareness about internal assumptions, biases, culturally driven attitudes, and behavioral tendencies that may affect perception and responses in different settings with patients. For example, a patient may be hesitant or refuse to receive a biopsy for a suspicious breast lesion found on mammography. Rather than making assumptions, a radiologist must approach the situation with curiosity and openness to learn the patient’s current understanding of the situation. What is her health literacy or beliefs about what a cancer diagnosis ultimately means? Is she paying out-of-pocket for each mammography and struggling with the lack of cost transparency? Ultimately, exploring the patient’s experiences and values will be the first step to providing equitable care.

Respect

Fundamentally, respect is the effort of honoring the intrinsic virtue of a patient’s paradigm or cultural belief system. Respect, however, can be threatened when a provider may not agree with the decision of a patient. Disagreement is common throughout the practice of medicine; physicians may disagree with each other, and patients or their families may disagree with providers. A patient with a suspicious incidental finding that requires follow-up may not choose to do so due to prior instances of injustice within their community or family by the medical system. Cultural distance between provider and patient can make these experiences difficult to navigate. A radiologist in a charged situation should apply cultural dexterity in the sense of separating judgement from a belief or practice that disagrees with their own philosophies.

Empathy

Empathy may be a more familiar and practiced skill to many given the emphasis it receives throughout medical training; however, to truly relate emotionally in cross-cultural encounters, one must seek to understand the attitudes and experiences that influence patients’ decision-making. Asking questions that demonstrate this desire to truly care is a respectful and authentic form of empathy. For example, a patient with metastatic cancer being seen by interventional radiology for a palliative g-tube may have an unexpected response when the procedure is explained to him and his family. The culturally dexterous interventional radiologist will seek to understand what constructs form the basis of the patient’s feelings around end-of-life and palliative care and help advocate for the patient and his goals with the primary team.

Just like many of the other core skills of clinical care in radiology, cultural dexterity is a skill that must continuously be practiced and adapted to the individual needs of every patient. Radiologists are often at the center of multi-directional communication and need training and support to approach all situations, but especially cross-cultural encounters, with cultural dexterity in mind. Radiologists who understand the framework and application of cultural dexterity will help provide more equitable care to all patients, particularly those from historically marginalized groups and those with LEP. Formal training in cultural dexterity is needed across specialties, but especially within radiology, so that we can provide high-quality patient care to those who need it most.