The United States is becoming increasingly diverse, though the surgical workforce has been slow to follow; in 2021, only 6% of general surgeons identified as Black or African American and 7% identified as Hispanic.1 For patients of racial or ethnic minorities, most of their healthcare interactions will be cross-cultural, and provider-level factors such as poor patient-clinical communication leads to lower quality of care and inferior outcomes.2,3 While it is imperative that we actively promote diversity, equity, and inclusion in surgery, we also need to act now by training our surgical workforce to care for patients of diverse racial, ethnic, linguistic, and socioeconomic backgrounds.
There has been a growing effort to incorporate cultural competency (Appendix 1) curricula into undergraduate and graduate medical education to address disparities. Surgical residency programs have been slow to adopt compared to other specialties as a scoping review of US graduate medical education cultural competency curricula identified 61 residency programs, of which only 9 were in general surgery.4 Furthermore, for programs that do offer these curricula, they may be falling short, as students and residents report feeling unprepared to treat culturally diverse patients.5
While training surgeons on cultural competency is important for cross-cultural encounters, it may not be enough. We propose a paradigm shift from cultural competency to cultural dexterity, emphasizing the development of skills to apply knowledge to practice, with a focus on lasting institutional change. Potential barriers to the implementation of cultural dexterity include local limitations of diversity, equity and inclusion efforts which may result in resistance; time commitment to learning the skills, and lack of faculty with expertise. However, cultural dexterity overcomes this by equipping surgeons with skills that can be adapted to the unique socioeconomic, racial, ethnic, linguistic, and cultural circumstances of all patients, and by identifying institutional champions and partnering with external expert facilitators, it can assist with these potential barriers. Much like the iterative nature of learning knot tying for surgeons, cultural dexterity is a skill that is intended to be practiced and refined with each cross-cultural encounter. Cultural dexterity individualizes care by integrating curiosity, respect, and empathy (Fig. 1) and requires the adept application of socio-cultural awareness, emotional intelligence, and interpersonal skills to various culturally complex clinical encounters that frequently arise in surgery.6
Fig. 1.
Explanations of the core values to cultural dexterity: Curiosity, Empathy, and Respect.
In the context of cultural dexterity, curiosity refers to an openness to explore another individual’s perspective in the interest of achieving mutual understanding. This is contingent upon self-awareness, in which the surgeon reflects on their own culturally driven beliefs, attitudes, assumptions, and unconscious biases, as well their ability to detect and respond to subtle behavioral nuances and both verbal and non-verbal cues. Surgeons can display curiosity through compassionate querying to develop an understanding of the patient’s unique perspective. A non-judgmental line of questioning will elucidate patient concerns specific to their lived experiences, and in turn, may reduce miscommunication, non-adherence, and mistrust.
Cultural distance between the surgeon and patient can create more challenges when navigating emotionally charged situations.7 Efforts to apply cultural dexterity to difficult conversations can be thwarted if the physician neglects to separate their psychological response to patients’ beliefs and practices from the indicated medical/surgical recommendations. For example, many cultures take a collectivist approach to decision-making rather than a strictly individualistic approach. Teaching respect as a core value of cross-cultural communication encourages surgeons to accept that the belief systems of other cultures possess intrinsic virtues that should not be automatically dismissed.
While empathy is often taught as a core value to medical students, it is rarely done so in the context of cultural dexterity. Empathy in cross-cultural encounters is complex, as emotional responses and expressions are culturally driven constructs. A patient’s culture may influence their attitudes towards and understanding of palliative care, and/or their willingness to accept medical futility. The culturally dexterous surgeon can demonstrate empathy by asking appropriate questions to make themselves aware of a patient’s customs and cultural context to offer compassionate and respectful care.
With curiosity, respect, and empathy as core values, cultural dexterity must be learned, practiced, and adapted with each cross-cultural interaction. To assess cultural dexterity, surgical residents can be evaluated using self-reported surveys, objective structured clinical exams with standardized patients, and patient feedback. Previous work has demonstrated that prior to the implementation of a cultural dexterity curriculum, half of patients rated their care as culturally dexterous, but White patients were more likely to report culturally dexterous care than non-White patients.8 This welcomes the opportunity for a cultural dexterity curriculum, or the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum,9 through which curiosity, respect, and empathy are emphasized to provide high-quality and individualized care. Teaching surgical trainees to use cultural dexterity to understand individual patients’ attitudes, behaviors, nonverbal cues, and expressions is a worthy endeavor to provide equitable health care to all patients.
Source of funding
The research reported was supported by the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health under award number R01MD011685. Dr. Haider and Smink are co-Principal Investigators. Dr. Ortega is supported by the NIMHD under award number K23MD016129. This work was not supported directly by Dr. Ortega’s funding. No additional federal or nongovernmental sources of funding were used. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Appendix 1. Definitions of Cultural Dexterity and Relevant Terms
Cultural Dexterity: Application of socio-cultural awareness, emotional intelligence, and interpersonal skills that can be adapted to the individual circumstances of each cross-cultural encounter.6
Cultural Competency: Behaviors, attitudes, and policies that converge at the individual and system levels to effectively care for patients in cross-cultural situations.6
Cultural Humility: A build off from cultural competency, with the addition of introspection to address imbalances in power and strengthen sensitivity, promoting opportunities to grow from mistakes and to learn about different cultures.6
Cultural Awareness: An understanding of similarities and differences among and between cultural groups, emphasizing how one’s culture shapes their personality, beliefs, and biases.6
Footnotes
Declaration of competing interest
The authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript.
CRediT authorship contribution statement
Gezzer Ortega: Writing – review & editing, Writing – original draft, Supervision, Conceptualization. Brittany M. Dacier: Writing – review & editing, Writing – original draft. Jorge Zárate Rodriguez: Writing – review & editing. Maria B.J. Chun: Writing – review & editing. N. Rhea Udyavar: Conceptualization. Benjamin G. Allar: Writing – review & editing, Conceptualization. Alexander R. Green: Writing – review & editing. Adil H. Haider: Writing – review & editing, Supervision. Douglas S. Smink: Writing – review & editing, Supervision. The PACTS Trial Group was involved in the conceptualization, study design, and data collection of the PACTS Trial.
Contributor Information
Gezzer Ortega, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA; Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA.
Brittany M. Dacier, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
Jorge Zárate Rodriguez, Department of Surgery, Washington University in St Louis, St Louis, MO, USA.
Maria B.J. Chun, Department of Surgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
N. Rhea Udyavar, Division of General Surgery, University of Washington, University of Washington School of Medicine, Seattle, WA, USA
Benjamin G. Allar, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Alexander R. Green, Division of General Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Adil H. Haider, Aga Khan University Medical College, Karachi, Pakistan Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA.
Douglas S. Smink, Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA.
the PACTS Trial Group, Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA.
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