Integrating between cultural competence and humility: a qualitative study of Israeli pediatric cardiologists

Abstract

Background

Working with culturally diverse populations in pediatric cardiology settings requires cultural competence and cultural humility. However, little is known about how physicians integrate these approaches. In this study we examined how pediatric cardiology providers describe the incorporation of cultural competence and humility into healthcare services provided to families of children with congenital heart disease (CHD) in pediatric settings in Israel, a country characterized by significant cultural, ethnic, and religious diversity.

Methods

Semi-structured interviews were conducted with 17 pediatric cardiologists (12 men, five women; age 45–71 years) from various regions in Israel. Participants had between eight and 33 years of experience in the field. Interviews explored physicians’ perspectives on cultural competence and humility in their daily work with children and families affected by CHD. Data were analyzed using thematic content analysis with an interpretive phenomenological approach.

Results

Three main themes were identified: (1) Cultural awareness, or physicians’ examination of their own cultural and professional values, particularly evident among those from minority backgrounds; (2) Cultural knowledge, or the understanding of families’ health-related beliefs and cultural values, acquired primarily through direct clinical experience rather than formal training; and (3) Cultural skills, including the use of culture-specific expressions, integration of spiritual leaders, and navigation of language barriers. The findings revealed an interplay between cultural competence and cultural humility, with physicians demonstrating varying levels of self-awareness and adaptation to diverse cultural needs.

Conclusions

Whereas participants demonstrated substantial cultural knowledge and skills, they faced challenges related to self-awareness and a lack of systematic approaches to cultural practices. The study highlights the need for structured support and training in cultural competence and humility within pediatric cardiology settings, particularly in culturally diverse contexts. Future interventions should focus on developing and implementing effective healthcare delivery models specifically designed to address the needs of vulnerable populations in pediatric settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-026-02825-y.

Congenital heart disease and family adjustment

Congenital heart disease (CHD) is one of the most common types of birth defects, affecting eight per 1,000 babies born globally [5], with prevalence increasing over time [76]. The impact of chronic illnesses such as CHD extends beyond the ill child, creating an entire family’s psychological and social vulnerability [2, 79], as the family must make complex healthcare decisions under conditions of pressure and uncertainty [20, 56]. High-quality communication with healthcare providers is essential for effective shared medical decision-making between families and medical teams [73]. For healthcare providers, particularly in CHD counseling, comprehensive information must be delivered clearly, a hopeful stance must be maintained, and it must be ensured that families understand potential challenges [77].

Although families expect to be included in all parts of the care provided for their child, with regular opportunities for transparent, empathic communication about their child’s CHD condition [33], current interactions between families and cardiologists often fall short of meeting these needs [50]. These interactions may also vary significantly based on cultural differences [11, 80]. In the current study, we focused specifically on the role of culture in physicians’ communication with families and qualitatively examined how, and in what ways, cultural competence, as well as cultural humility, are incorporated into healthcare services provided to children with CHD in pediatric settings.

The term culture refers to knowledge, values, beliefs, assumptions, perspectives, attitudes, norms, and the customs that people inherit when they participate in a society [31]. Although race and ethnicity are often analyzed through the broader concept of culture [51], healthcare research suggests that studies should include not only ethnicity and race but also take into consideration the intersections between ethnicity, race, gender, age, class, education, religion, sexual orientation, and physical ability, as well as the unequal distribution of power and the presence of social inequities [10, 12].

There has been a consensus in the last decades that culture mediates the ways in which people understand and manage their health treatment and their relationships with health institutions, their expectations from the treatment, and health literacy [48]. To provide effective and culturally responsive healthcare services [7, 61], cultural competence was introduced as a framework that promotes respect for cultural diversity and differences, emerging as an increasingly important skill [1, 46].

Cultural competence

Cultural competence can be defined as healthcare professionals’ understanding of how culture affects an individual’s beliefs and behaviors and the need to adapt their (i.e., healthcare professionals’) strategies to meet clients’ individual needs [63]. Additionally, cultural competence promotes a patient-centered approach to care that carefully considers the patient and provider’s socio-cultural background in the care provided [74], thus increasing the possibility of effective healthcare for people from various cultural backgrounds [4, 63].

Providers who value cultural competence aim to collaborate effectively with individuals from different cultures, improve healthcare experiences and outcomes, and reduce health inequities and disparities [72]. Cultural competence comprises three main elements: (a) cultural awareness of practitioners’ own cultural values, beliefs, and attitudes; (b) cultural knowledge, which involves building an educational foundation on the health-related beliefs, practices, and values of culturally and ethnically diverse populations, understanding disease incidence and prevalence within these groups, and assessing treatment efficacy across different cultural and ethnic populations; and (c) cultural skills, which includes the abilities used to combine awareness and knowledge about others [52, 53] and to provide culturally appropriate services that are reflected in effective communication and intercultural interactions [18, 59]. Culturally competent communication in healthcare incorporates ongoing self-assessment of cross-cultural relations, social structures, and power differentials; expansion of cultural knowledge; and adaptation of communication to meet culturally unique needs [6].

Cultural humility

Despite gaining widespread acceptance over the years, the cultural competence framework has faced criticism, such as the assumption that the practitioner is from a dominant culture and that the framework lacks a power analysis [18, 27]. Scholars in recent years have proposed moving beyond cultural competence (which emphasizes a “way of doing”) to embracing cultural humility (which focuses on the healthcare provider’s “way of being” with the patient) [35, 55]. Cultural humility is guided by values that promote diversity and equity, and it involves being mindful of power dynamics and hierarchy in cross-cultural interactions. This approach requires maintaining a culturally humble and respectful stance, being open to others, and developing mutually beneficial, non-paternalistic partnerships with communities for the benefit of individuals and defined populations [34]. Cultural humility emphasizes perpetual curiosity and the recognition that healthcare providers are learners, as patients remain the only true experts of their own experience [47].

In any medical setting, cultural competence, cultural humility, and positive provider-patient interactions, along with good care experiences, are crucial. However, when viewed through the prism of family-centered care, it seems clear that in pediatrics, these aspects take on added significance: Pediatric healthcare providers are tasked with the dual responsibility of navigating cultural differences not only in their direct interactions with young patients, but also in understanding and respecting the cultural values, beliefs, and practices that shape how families make decisions about their child’s care [45].

Cultural factors in family adjustment and communication in CHD

Studies that have examined cultural variation factors related to the adjustment and communication (with healthcare teams) of families of children with CHD have mainly focused on families’ experiences [15, 22, 49, 57, 65, 66]. Some studies have shown that the likelihood of families from diverse racial and ethnic backgrounds to encounter negative experiences when accessing pediatric care may contribute to poor health outcomes for children with CHD [3, 16, 21, 22, 44].

In the specific field of pediatric cardiology, communication is a critical determinant of clinical outcomes. CHD frequently necessitates high-stakes medical decisions—such as pregnancy termination or complex neonatal surgeries—often under conditions of extreme pressure and uncertainty [20, 56]. Research indicates that cultural and linguistic factors significantly influence these moments; specifically, a lack of alignment between a family’s primary language and the medical team is highly correlated with negative outcomes, including delayed prenatal diagnosis of CHD [28] and decreased counselling success overall [22, 41, 43].

Beyond clinical metrics, cultural factors shape the psychological adjustment of the family. Linguistic discordance often leads to reduced parental trust in medical staff, a diminished sense of transparency regarding treatment [41], and feelings of social isolation during a child’s hospitalization [22]. Furthermore, deep-seated cultural beliefs, such as fatalism, are not just background variables but can actively guide families as they navigate the struggles of illness, suffering, and end-of-life decisions [61]. Conversely, a cultural match or concordance in sociocultural identities—such as shared levels of religiosity—serves as a primary facilitator of care, allowing for smoother communication [29]. Consequently, the ability of providers to practice cultural competence and humility and navigate these diverse ‘worlds of meaning’ is essential for ensuring equitable, family-centered care.

The Israeli demographic mosaic

Israel, facing cultural and language differences, as well as continuous waves of immigration, is a mosaic of diverse ethno-national-religious identities [62]. The population consists mainly of Jews (77%), Arabs (21%), and foreigners (2%) [36]. The Jewish community itself is ethnically diverse, with Jews from Ashkenazi, Sephardi, and Mizrahi backgrounds; it spans various religious observance levels and exhibits language and socioeconomic differences across communities. The Arab population includes Muslims, as well as smaller groups of Bedouins, Druze, and Christians, spread across both urban and rural areas. This diversity means healthcare providers frequently encounter patients from a variety of cultural and ethnic backgrounds [29] where ‘worlds of meaning’ may not align. Although the subject of health disparities and cultural competence in Israel has gained increased attention [23, 29, 67, 68], the specific influence of these identities on communication within Israeli pediatric cardiology remains under-examined [29, 54] specifically in pediatric settings.

Clinical stakes and the research gap

In the specific field of pediatric cardiology, demographic complexities translate into significant clinical challenges. Broadly, the importance of cultural competence is underscored by international evidence indicating that cross-cultural communication is a matter of clinical safety rather than just professional courtesy [17]. This is because linguistic and cultural discordance are not merely social hurdles; they are directly correlated with critical negative outcomes [28] and reduced parental trust in medical staff [41, 43].

Current standards for best practice in the field of CHD emphasize the critical importance of physicians being aware of families’ educational, religious, and ethnic backgrounds while recognizing their own implicit and explicit biases [42]. To our knowledge, although no study has examined pediatric cardiologists’ characteristics or experiences working with families from diverse backgrounds in Israel, international research highlights significant variations in care. For instance, Walsh et al. [77] found that pediatric cardiologists in the Northeastern United States were more likely to provide detailed counselling on long-term survival rates than colleagues elsewhere—a difference the authors attributed to patient demographics rather than clinician-specific variables. Crucially, Walsh et al. [77] recommended that future studies explore how cardiologists’ personal biases (religious, political) might influence their counselling practices.

This need is further underscored by a recent systematic review [78], which revealed a major imbalance in CHD research: while families’ experiences were examined in 22 studies, healthcare providers’ perspectives were examined in only one study. This gap limits our understanding of how providers and healthcare systems respond to family needs. Despite the established standards of care, there remains a significant lack of research exploring how physicians themselves perceive and describe the incorporation of cultural competence and humility into their clinical work. The present study addresses this global and local gap by examining these clinician-reported strategies within the unique Israeli context.

Within the Israeli healthcare system, persistent disparities in health literacy and accessibility exists, particularly among marginalized subgroups such as the Arab Bedouin population [69]. These high-stakes clinical moments—often involving decisions regarding pregnancy termination or complex surgeries—are frequently deeply rooted in a family’s religious laws and beliefs. In the unique landscape of Israel, where Jewish and Arab communities navigate diverse ‘worlds of meaning,’ the ability to employ both cultural competence and cultural humility is essential to mitigate these risks and achieve health equity [23, 29, 67, 68]. However, while broader Israeli research identifies concordance as a facilitator of care [29], there remains a significant gap in understanding how clinicians locally describe their navigation of these complex identities during life-altering consultations. This study addresses this gap by examining how Israeli providers perceive and report their incorporation of cultural competence and humility within this specific demographic mosaic.

Purpose of the current study

The present study aims to address a significant research gap, as to our knowledge, no prior studies have addressed the intersection of culture and clinical consultations for families of children with CHD in Israel or elsewhere. Utilizing a qualitative approach, we examine how pediatric cardiology providers in Israel describe and perceive the incorporation of cultural competence and cultural humility into their clinical practice. Specifically, the study explores clinicians’ self-reports regarding their navigation of diverse ‘worlds of meaning’ within the unique Israeli demographic mosaic, seeking to understand how they balance structured cultural knowledge with the perpetual curiosity and self-reflection central to cultural humility. Furthermore, we aimed to investigate the interaction between these two concepts to determine the roles that cultural competency and cultural humility play in either facilitating or hindering one another within the clinical encounter. By focusing on physicians’ descriptions of their communication strategies and cultural adaptations, this research provides insights into how the high-stakes challenges of CHD are managed from the perspective of the cardiology workforce, interrogating the gaps that influence care which have previously remained under-examined in the Israeli pediatric context.

Methods

Study’s design

A qualitative approach was used to examine physicians’ perceptions of cultural competence and humility in their daily work with children with CHD and their families. This study is part of a larger research project aiming to explore how physicians communicate and pursue decision-making among patients with CHD and their families. A study that focused on pediatric cardiologists’ views of the roles of children, parents, and physicians in the triadic medical encounter was recently published [37]. The study team developed the interview guide used in the current study, which was designed to explore emerging themes (Please see Appendix 1).

Participants

We utilized purposive sampling to contact 18 physicians who specialized in pediatric cardiology, in order to ensure that the study population had a broad range of experience managing children with CHD, conducting CHD evaluations, and having subspecialty training and exposure to CHD [24]. Author UK (a senior pediatric cardiologist) made the initial contact with the physicians to present the study objectives; Those who agreed to participate were interviewed by two experienced social workers (author YKV and RD). Of those approached, 17 agreed to participate (94% response rate). This sample represents approximately 20–25% of the total Israeli pediatric cardiologist community, providing a significant cross-section of the local workforce. Study participants included 17 pediatric cardiology providers (12 men, five women), consisting of 16 Jewish and one Arab physician (age 45–71 years, M = 54.2, SD = 8.05) all of whom were Hebrew-speaking. The Jewish participants represented a spectrum of religious observance (secular to ultra-Orthodox). The sample included 15 cardiologists and two cardiac surgeons working in various areas of Israel. Experience in the field ranged from eight to 33 years; all participants had experience with babies and children, and 13 participants specialized in fetal medicine as fetal cardiac consultants. Five participants had experience working with adult patients. All participants worked in public hospitals and outpatient clinics. To ensure the anonymity of those involved, and given the sensitivity of the subject and the small community of pediatric cardiologists in Israel, we will provide no further breakdown of the sample. Our study included videotaped in-depth, semi-structured interviews [61]. Interviews lasted for an hour and a half on average.

Data collection

Through open-ended questions with prompts, physicians were interviewed about the clinical encounters and communication processes they had with families of children with CHD, based on multiple clinical examples. Authors YKV and RDconducted in-depth, semi-structured interviews to facilitate a thorough understanding of the interviewees’ subjective experiences and perceptions [24]. To facilitate a thorough understanding of the participants’ subjective experiences and perceptions, the interview guide was developed to explore the intersection of culture and clinical practice in pediatric cardiology (Please see Appendix 1). Reflecting the study’s focus on clinician self-reports, the guide was structured into four primary parts to allow themes to emerge naturally from the physicians’ narratives: 1) Professional Background and Career Paths: Physicians were first invited to describe their career trajectories and formative professional years. To elicit reflection on their professional identity, they were asked: ‘To what extent during your training were you exposed to such conversations? Were there figures that influenced you to do something similar or change?‘. Furthermore, the guide explored the impact of international experiences, specifically asking those who had worked abroad as cardiology fellows how they reintegrated diverse professional values into the Israeli medical landscape. 2) Mapping the Clinical Encounter: This section established the practical context of the physicians’ work. Sample questions included: ‘How are these encounters conducted (location, duration, attire, and how you introduce yourself)?’ and ‘Who participates in the conversation (father, mother, both parents, child, or other relatives)?’. 3) Communication Content and Style: To understand how physicians perceive their delivery of high-stakes information, the guide explored their preferred modes of presentation and emotional framing. Participants were asked: ‘How do you present the topic—focusing on technical information about the defect or its implications?’ and ‘What message are you trying to convey—optimism, pessimism, or realism?‘. 4) Cultural Adaptation and Professional Reflection: The final part utilized targeted prompts to explore how physicians report adapting their care for diverse families. Questions included: ‘Do you gather information from the family about their family or personal background?’ and ‘Do you try to create a cultural adaptation—language, vocabulary (using terms from the parents’ world)?’. The guide concluded by asking clinicians to evaluate their satisfaction with these encounters and how their personal values might guide their clinical interactions. This structure ensured that the interviews remained open to the clinicians’ unique descriptions while providing a comprehensive account of the strategies they perceive as essential for navigating the complex Israeli demographic mosaic. For additional details on the interview guide please see Karni-Visel et al. [37] as well as Appendix 1. All interviews were conducted between August 2021 and February 2022, recorded, and transcribed. They took place in Hebrew via Zoom, and lasted about 90 minutes each. Each interview occurred in a private location chosen by the interviewees, with no repeat interviews. Field notes were taken and discussed by the interviewers. In this study we specifically explored physicians’ cultural awareness, knowledge, and skills (i.e., their cultural competence) as well as their cultural humility in their daily work with families of children with CHD.

Data analysis

A thematic content analysis [14] was conducted to analyze the data, adhering to an interpretive phenomenological perspective [70, 71]. All transcripts were read thoroughly by authors YS, YKV and RD , who performed open coding, marked the separate content units of meaning from the interviews, and shared these materials with the group. A deductive-inductive hybrid approach to thematic content analysis was employed [61]. To remain fully open to the physicians’ unique narratives and the specific nuances of the Israeli context, the researchers did not initially approach the data with a predefined theoretical codebook. Instead, the analysis began with an open coding phase, during which authors YS, YKV, and RD read the transcripts thoroughly to identify and mark separate content units of meaning based directly on the participants’ descriptions.

As the analysis progressed, the research team recognized that the emerging patterns and units of meaning strongly aligned with the three pillars of the Cultural Competence framework. Consequently, a secondary coding phase was conducted to organize these findings into three top-level categories: Cultural Awareness (physicians’ personal backgrounds/values), Cultural Knowledge (understanding families’ beliefs), and Cultural Skills (behavioral adaptations). Within these theoretical categories, specific sub-themes—such as the role of fatalism, the use of culture-specific expressions, and the integration of spiritual leaders—emerged inductively to reflect the nuanced experiences of the cardiology workforce. All five authors collaboratively reviewed the mapping of these inductive findings back to the deductive framework until consensus was reached.

In order to achieve code and meaning saturation, the authors conducted as many interviews as necessary [32]. Researchers reached saturation when they agreed that the theoretical categories repeated themselves and were sufficiently grounded. Throughout the research process, the researchers presented the findings and theoretical conceptualizations to the other authors, who added their own input and approved the final findings [75], ensuring that the findings accurately reflected the pediatric cardiologists’ experiences.

Ethical considerations

The institutional review board (IRB) at Sheba Medical Center approved all study procedures (SMC-8070-21). Interviewers did not interview physicians with whom they were already acquainted prior to the study in order to ensure participants’ confidentiality. In addition, once a physician confirmed participation in the study, no identifiable details of their interview were shared with other members of the research team. In order to protect participants’ confidentiality, the content of the interviews was only made available to the research team after names and details were changed. All names appearing in this paper are pseudonyms, to further protect participant identity.

Author Positionality Statement: The research team represents an interdisciplinary collaboration between the fields of Social Work (Authors YS , YKV , RD) and Pediatric Cardiology (Authors UK, LS). This dual lens allowed the study to integrate clinical cardiac expertise with psychosocial perspectives on power dynamics and cultural safety. To ensure confidentiality and mitigate professional power imbalances or bias, interviews were conducted by two experienced social workers (Authors YKV and RD) who did not interview physicians with whom they were already acquainted. The final thematic analysis involved all five authors, fostering a balanced interpretation that critiques inherent power hierarchies while respecting clinical realities.

Findings

The analysis utilized a deductive-inductive hybrid approach. While the process began with an inductive open-coding phase to remain fully open to the physicians’ unique narratives, the research team found that the emerging patterns and units of meaning aligned strongly with the three pillars of the Cultural Competence framework. Consequently, the findings were organized into three primary themes: (1) Cultural awareness, which includes the physicians’ examination of their own cultural or professional values; (2) Cultural knowledge, namely the physicians’ knowledge about the family’s health-related beliefs and cultural values; and (3) Cultural skills, or the physicians’ communication and behavioral ability to interact effectively with culturally different people. Within some of these themes, we also identified cultural humility in the physicians’ commitment to self-evaluation and critique, along with their efforts to develop mutually beneficial and non-paternalistic partnerships with families from diverse cultural backgrounds. Within these theory-guided themes, specific sub-themes emerged inductively from the participants’ descriptions, such as the use of culture-specific expressions and the role of spiritual leaders. We will now continue with a description of the three main cultural competence themes. In each theme we describe a sub-theme consisting of findings related to cultural humility as they manifest in the delivery of healthcare services for CHD in the pediatric setting.

Cultural awareness

Six participants discussed how their overlapping identities—including their personal backgrounds, religion, gender, and the cultural influences experienced while studying abroad—shaped their professional values and healthcare delivery. Of these participants, two were specifically asked about these influences, while four spontaneously reflected on them, representing a diverse subgroup of women, Orthodox individuals, and immigrants. These clinicians perceived their cultural affiliations not as siloed traits, but as an integrated “way of being” that either facilitated or hindered communication. For example, communication was often reported as smoother when the physician and family shared a concordance in sociocultural identities, such as similar levels of religiosity. Conversely, three cardiologists described a dynamic process of reintegrating their identities after international fellowships, where they had to balance foreign professional styles with their “deeply Israeli” roots.

The pediatric cardiologists’ awareness of and use of their own religious background

Three participants described how their own background informed their clinical stance and helped navigate power imbalances. Roni a 63-year-old religious pediatric cardiologist, explicitly utilizes his shared religious identity to build partnership:

I usually say I am a religious person too [i.e., when the affected family is religious as well]. And… that there is only one physician, and that it isn’t me [but God]. I am just a messenger who tries to “keep the faith” as much as possible…. It goes well, it goes smoothly… this dialogue goes really well. Particularly among ultra-Orthodox and Orthodox people.

By framing himself as a “messenger” rather than the sole medical authority, Roni aligns his professional role with the ultra-Orthodox value of trusting a higher power. It is common among Orthodox and ultra-Orthodox individuals to put their trust in a force greater than themselves, during both challenging and good times (“with the help of God,” “it is all from (God) above”). This demonstrates how his religious and professional identities overlap to facilitate a non-paternalistic dialogue that “goes smoothly” in order to convey his message to the families he encounters.

Cultural awareness and humility

Three participants reflected on how their “way of being” evolved through the challenge of practicing in different professional cultures. This was described as a need to reconcile an “adjusted style” upon returning to Israel. Gil (52) noted the tension between his “deeply Israeli” identity and the softer, more ambiguous communication style he observed in the United States Gil, a 52-year-old pediatric cardiologist, said:

When you are in Israel, you are very Israeli, I mean deep down. I mean: “The child needs surgery; sit down.” Then you go abroad to the United States and you see a whole new way of doing things:“How, how, how are you? Please sit down; we have to talk a little bit about the child and how he is. We might have some concerns about his condition and we might think that maybe an operation could be good.” When you return to Israel, you wouldn’t say things like this… it’s like, it doesn’t fit. It takes a while for you to take on your own adjusted style.

Gil acknowledged that being exposed to a different culture enriched his communication with families during consultations. However, upon returning to Israel, he reverted to his previous methods, finding the new approaches less appropriate and less beneficial in the local context. Consequently, he did not fully assimilate the new things he had learned. In another interview, Oded, a 71-year-old pediatric cardiologist, said:

In the United States, in a pediatric hospital, a physician would never say to a pregnant woman carrying a fetus with a heart defect, “Don’t worry; I will see you again at his Bar Mitzvah or wedding.” It wouldn’t happen; physicians there don’t relate to the emotional part or the more extra personal parts.

Oded (71) noted that the interpersonal and emotional parts of Israeli care—such as mentioning a future Bar Mitzvah or wedding to a pregnant woman—would not happen in a U.S. hospital. These narratives show that for these physicians, cultural humility involves an active cultural awareness where they intentionally choose a direct, “eye-level” style that reflects their authentic Israeli identity, believing that families in the local context have little patience for ambiguity.

Cultural knowledge

Over half of the participants (n = 9) described their cultural knowledge. Most described this knowledge as being based on what they had learned from working and interacting with families from different cultures. Specifically, they referred to the main role that religion could play in families’ coping with the child’s diagnosis, as well as religious concerns such as preferences regarding pre-natal exams and abortions in the event of a poor prognosis; the implications of the disease for the child’s and families’ future; and the preference to conceal the child’s illness from their community. Cultural knowledge also referred to the kind of information that families from various backgrounds were interested in obtaining (i.e., understanding the medical procedures in depth, practical information on different procedures, genetic concerns).

Three participants, however, expressed a different viewpoint. They believed that differences between families were based not on cultural characteristics, but rather on other personal or social characteristics. As a result, they did not claim to have unique knowledge about specific cultures, and perceived themselves as having “no knowledge” of particular cultural traits as a result of these interactions. This latter perspective illustrates the integration of cultural humility into cultural knowledge, fostering meaningful and intentional interactions with the patient as a unique individual, rather than as a stereotype of their cultural group. By adopting this stance, physicians shift from being ‘all-knowing’ experts on a culture to being perpetually curious and inquisitive about the specific family’s needs and perspectives.

Pediatric cardiologists’ learned knowledge on health-related beliefs, practices, and cultural values of culturally and ethnically diverse populations

This subtheme highlights pediatric cardiologists’ perceptions of how religion and perceptions of fatalism facilitate disease management. Fatalism refers to the belief that all events are part of God’s will, which influences families’ faith, religious beliefs, and sense of fate. This belief can guide families as they navigate struggles and challenges, including making crucial decisions and managing the family member’s disease. In both Arab and ultra-Orthodox Jewish cultures, it is commonly believed that everything in the universe, including health and illness, is controlled by God’s will and is a result of divine fate.

Roni described a gap he witnessed in the initial processes that families go through in terms of their faith in God on the one hand, and their understanding and acceptance of the child’s situation, on the other hand.

Parents’ reactions differ according to their culture as well…Secular Israelis who come for surgery, most of the time they have already internalized the diagnosis, they have come to terms both with the child’s diagnosis and the heart defect. And they more or less have made their peace with it. The ultra-Orthodox have faith; I’m not sure whether they can make their peace with the child’s defect but they have faith in God. But with the child’s defect I’m not sure [that they can make their peace with it].

Yael, a 65-year-old pediatric cardiologist, described her preferred practices she learned about from working with pregnant women from both the Arab and ultra-Orthodox Jewish communities who had fetuses with severe heart defects and a medical indication for abortion, against the backdrop of a society or religion that forbade it:

Among the Bedouins, among the Arab population, it is extremely rare to have an abortion. Only if they have experienced such a deformity before. If they have experienced one before, then they know what they’re facing and they decide to end [the pregnancy]. If they haven’t experienced it and don’t have it in the nuclear family or in the immediate environment around them, then they continue [the pregnancy] until the end…almost zero abortions. If it’s an ultra-Orthodox population, the same thing. They ah… they continue [the pregnancy] to the end.

Cultural knowledge and humility: Pediatric cardiologists’ “not knowing”

Participants reflected upon the stance of informed “not knowing,” a stance that may provide a buffer to reduce racial bias and stereotyping as well as promote racial justice. On the basis of their narratives, it seemed as though this strategy allowed them to develop a deeper understanding of the unique personal, social, and cultural identities of the families with whom they worked. Fares, a 46-year-old pediatric cardiologist, described his view regarding cultural knowledge:

Some people accept it [the disease or problem]. They’ll say, “It was from Allah, this is what God has given us.” And whatever happens, they say, “Alhamdulillah” [praise be to God]. So, they welcome whatever happens, and this is their way of coping with everything that is happening…But what I have come to understand is that this has nothing to do with their level of religiousness. It has to do with the way each person reacts personally. Some people are very religious and believe in God, but they still don’t accept [the situation], and they ask, “Why is this happening to us? What have we done?” And some say, “Okay, it is what it is, we accept it.” And when I tell them about the risks of catheterization or surgery, which may be dangerous and life-threatening, they say, “Yes, do what you can and whatever happens, it is written [from God], and so it will be.”

This perspective was also shared by Ehud, a 62-year-old pediatric cardiologist, who believed that cultural knowledge was not something that could be fully achieved or approached with a “tick-box” mentality, which might give healthcare teams a false sense of confidence. Instead, he advocated for a broader view based on humanistic values, avoiding oversimplified understandings of other cultures based on stereotypes, and cautioning against homogenizing cultural groups into a collective “they.”

Cultural differences do not manifest themselves in [families’] intelligence, or in reactions, or in, ah… I can’t catalogue the differences culturally, aa… I can’t do the aa… do the heh, this separation culturally. There’s a whole spectrum, there’s a whole range of people, and it does not correlate with culture. The communication is sometimes ah… different, but you know, the reactions are sometimes ah… different, but ultimately, they [people] express the same thing… I performed surgery in Nigeria, and I operated in Morocco, and I operated in Russia and Kazakhstan and here. I operated on Palestinians as well as on children from Ramat Hasharon [a Jewish city in Israel]. Everyone reacts differently. Everybody bows in a different way, expresses gratitude in their own way, but they all say the same thing.

Cultural skills

Fifteen participants described their interactions with families from culturally diverse backgrounds and the communication skills they developed over the course of their careers.

These skills represented their more “practical” abilities, resulting from both their awareness and their knowledge about others, with the aim of providing appropriate and effective, intercultural interactions.

Unlike the two previous themes in which we identified at least one sub-theme as cultural humility, in this theme we identified both cultural competence and cultural humility in each of the sub-themes. As a result, and unlike the first two themes, cultural humility will be described as an integral part of each sub-theme.

The use of culture-specific expressions and examples related to the child’s future

Almost half of the participants (n = 6) talked to the families about the child’s medical status by using culture-specific examples related to the child’s future. Dov, a pediatric cardiologist said, “These conversations require an understanding of the person standing in front of you. In what language do I speak to him? What images do I use?” Additionally, Dov said:

The first thing I do when I come in is I make small talk with the family for a few minutes before I talk to them [about the problem]. I try to learn the “language” and expressions that would make it easier for them to understand [what I’m telling them]. The way we speak to families from ultra-Orthodox communities is different [from the way we speak to other families], and there are certain specific things I won’t say to them… the same thing with Arabs from East Jerusalem… You learn over time what’s important to them [the families], and how to give them the information you wish to convey.

In this passage, Dov indicated how he approached families, aiming to get to know them better and thus communicate with them more effectively. This approach reflects his cultural humility and “way of being” with the patient. His goal was to develop mutually beneficial and non-paternalistic partnerships with families from diverse cultural backgrounds.

In another interview Mira, a 49-year-old pediatric cardiologist, said:

For Jews, the question of whether their child will be able to serve in the army and whether the child can become a combat soldier is crucial. This is the context in which you explain the situation to them. You say to them, “You won’t even be able to lower his military health profile and he will even have to serve in combat duty.” In terms of the mother, I have closed the case; this is good news for her. Now she understands. If you say to the Bedouins, “The child will get married and have children, everything will be fine,” then they understand the situation. Otherwise, they wouldn’t collaborate with us.

Cultural skills were frequently enacted through the physician’s overlapping role as a parent and a member of the ‘Israeli mosaic’. Mira (49) demonstrated how her professional medical expertise intersected with her cultural identity by framing a child’s cardiac recovery through the milestone of combat military service. By drawing on her understanding of what an ‘Israeli mother’ values, she moved beyond technical data to ‘close the case’ for families, showing that her communication was informed by her positionality within the culture as much as her clinical training.

Integrating spiritual leaders into family support systems

Eight participants described involving a spiritual leader (mainly a rabbi) when families from religious backgrounds were faced with a medical decision that needed to be made. Seven participants perceived the rabbis as helping the families make a decision that was good for them, whereas one physician had a difficult time with the process of consulting rabbis, given that rabbis lack the required medical knowledge to make such decisions. Rafael, a 58-year-old pediatric cardiologist, said:

We use the system here, we have a system of rabbis we talk to and are in contact with, for one thing in order to help couples whose fetus has a heart defect that, let’s say for the sake of argument, makes the pregnancy not viable. Ok? So [the family will turn to them] if they wish to terminate the pregnancy. There are also families in which even if the fetus is not viable, they say, “We understand what you’re saying, we understand everything, but we’re not going to do anything about it. This is our worldview.” Fine. I do not stand in judgment. A phrase we always use is that there is no wrong decision; there is a decision that is right for every family.

Yoni, a 49-year-old pediatric cardiologist, also talked about the rabbi’s role within the family’s care system:

I always try to make it clear from the beginning that we are all one team… For example, we are in Jerusalem and a lot of people want to include their rabbis on the team, and there are some people [physicians] who find this notion very disturbing. It doesn’t bother me personally… we are all in the same boat here and it is very important to make it clear at the beginning. There is no “us against them.”

Yoni seemed to acknowledge the complexity that might arise from adding other people to the team, highlighting the overall aim to which they all aspire and to the cultural humility aspects of his work – namely, developing mutually beneficial, non-paternalistic partnerships with families for their and their children’s benefit. Although it appears that he did not necessarily share the same religious beliefs as the families he described, his primary goal of ensuring the child’s health transcended any cultural differences between them. From these examples it seems that this approach requires maintaining a culturally humble and respectful stance and being open to others’ cultural preferences while at the same time maintaining self-awareness. On the other hand, Roi, a 54-year-old pediatric cardiologist, described his personal conflict regarding the healthcare decision being made solely by the rabbi:

What is difficult for me many times in conversations with people from the ultra-Orthodox sector is that after you explain everything and go into detail and they ask questions and they understand, [they say]: “OK, we heard everything, now the rabbi will decide.” So, it’s like, after all that, having someone else make the decision. For me personally, it is a little difficult and also, I feel a little frustrated: If the rabbi is the one who’s going to make the decision, then why did we bother sitting and talking?… I admit that, after having come across this, the next time I give information it will be much more to the point and I will also ask if they want me to talk to the rabbi directly or if the rabbi has questions and so on.

Roi’s words reflect his recognition of the crucial role that rabbis can play in families’ decision-making. However, his own values conflict with the idea that the rabbi is the one who will make the healthcare decision, not the family, and his frustration with this notion results in his feeling he shouldn’t even bother talking to the family; he should just talk directly with the rabbi. Roi’s words exemplify the ways in which cultural skills and encounters with families build upon the two previous components we described (cultural awareness and knowledge), and therefore lead to a more conscious, sensitive, and integrated approach by the physician.

“In the end it’s not your words that reach the parents’ ears”: communicating with families whose Hebrew proficiency is limited through translation

Eight participants described the challenging use of translation in the medical setting when communicating with non-Hebrew-speaking families. Participants highlighted both the practical and technical challenges of finding a suitable translator, along with difficulties related to the quality of the translation. These challenges impact the quality of their work, professionalism, and relationships with families. Through their discussions about this frustration, it was clear that they engaged in continuous self-reflection and self-critique while also recognizing the power imbalances that this situation created. Many participants described using medical team members (e.g., a nurse, other medical staff) to translate the conversation with the physician, or using one family member to translate for another family member. Some described using telephone translation services provided by the Ministry of Health. Noa, a 49-year-old pediatric cardiologist, said:

I think one of the hardest things is to explain [the situation] to parents who don’t speak your language, because you always feel that you’re not clear enough. I mean, no matter what you do and no matter how much you use a translator, in the end it’s not your words that reach the parents’ ears.

Haim, a 61-year-old pediatric cardiologist, further described the challenges in translating:

Sometimes the translator tries to comfort the family or tell them the child’s medical status in a less, less harsh, and less acute way. He doesn’t want to talk about death…translation is an area that limits things to a certain extent, and there is room for improvement.

Ehud, a 62-year-old pediatric cardiologist, further described his experience with non-Hebrew-speaking families:

I’m not sure that the parents get the, like, it’s really sad to say it like this, but like they don’t get the best “product” they can get. Because of the lack of time, the lack of resources, because of the multitasking, certainly the ones who don’t speak Hebrew [don’t get the best “product”]… I do a bad job with them. I’m telling you this unequivocally. In terms of talking to them. The conversations are not good. And the closer the families are culturally to you, then the easier it is for you to turn the conversation into something that flows and takes them exactly to the points you want them to reach.

These words highlight the physicians’ frustration and feelings of impaired professionalism, and the inadequate treatment that such families receive due to the lack of communication and insufficient adjustment to their needs. These ongoing challenges appear to affect families’ experiences and the level of trust they may have in the medical process and the healthcare team. The participants’ reflections and frustrations seem to be rooted in cultural humility and values that promote diversity and equity. They are keenly aware of how inadequate translation underscores power dynamics and hierarchies in cross-cultural interactions, and how this aspect impacts their professionalism.

Discussion

In the current study we examined how cultural competence and cultural humility are incorporated into pediatric CHD care. According to the findings, most participants demonstrated and incorporated these concepts in various ways when providing care to children with CHD and their families.

Regardless of the approach used and given the absence of formal education or training on this topic within this sample, the physicians’ primary motivation to be culturally competent and humble appeared to be their experience of the significant impact and effectiveness that cultural reflections had on their daily work with families. These findings are consistent with recent literature that has identified increased knowledge sharing and translation, cultural alignment, access to resources, and clearer communication as essential to delivering or acquiring pediatric care for racially and ethnically diverse pediatric patients and their families [45].

The themes revealed an interplay between cultural competence and cultural humility. The concept of cultural competence refers to the ability to understand, communicate, and effectively interact with people from different cultures, requiring a set of skills and knowledge in order to function effectively in diverse environments [8]. For its part, cultural humility is the ongoing process of self-reflection and self-critique, recognizing and challenging power imbalances, and developing respectful partnerships with people from different cultural backgrounds [81]. Participants in the current study described both competence and humility by learning specific cultural preferences and seeking to understand families with different backgrounds from their own.

In line with cultural competence theory, three cultural competence themes were identified. The first, cultural awareness, was characterized by physicians’ examination of their own cultural or professional values. The second, cultural knowledge, was described as the physicians’ learned/known knowledge about the family’s health-related beliefs and culture, as well as a stance of “not-knowing.” The third, cultural skills indicates the physicians’ communication and behavioral ability to interact effectively with culturally different people. Within each of these themes we also identified cultural humility in the cardiologists’ commitment to self-evaluation and critique, as well as their efforts to develop mutually beneficial and non-paternalistic partnerships with families from diverse cultural backgrounds.

A small group of pediatric cardiologists (n = 6) demonstrated our first theme (“cultural awareness”), which includes self-awareness and self-examination of their own cultural or professional values, and the ways in which this self-examination impacts the care provided for all families. In this aspect of cultural competence, the cultural background of the clinician or clinical environment, rather than the culture of the patient, is the main focus, a finding that has also been identified in previous studies [40]. Cultural self-awareness may relate to cultural humility as well as to an additional concept that emerged in the 1990s, termed “cultural safety,” highlighting the power imbalance between provider and patient, and the requirement of health professionals to examine themselves and the potential impact of their own culture on clinical interactions [17].

It should be noted that the only physicians (i.e., the six referred to above) who reflected on their own cultural attitudes were themselves from diverse backgrounds (two Orthodox, one woman, one immigrant, and two with experience practicing abroad), who may engage in deeper cultural self-reflection and accountability for culturally safe care, informed by their personal experiences. Thus, these physicians do not operate from siloed identities; rather, their overlapping roles as women, Hebrew speakers, religious individuals, and medical experts simultaneously shape their ‘way of being’ with families [35, 55]. These overlapping identities, or intersections of identity, inform how physicians navigate power imbalances and develop non-paternalistic partnerships within the clinical encounter [10, 34].

Additionally, our results show that communication was notably smoother when physicians and families shared the same level of religiosity. Our findings regarding the ‘smoothness’ of communication when religiosity levels matched support broader Israeli research identifying cultural and linguistic concordance as primary facilitators of care [29]. The participants’ descriptions of effective dialogue when sharing a religious background highlight how identity alignment can streamline the ‘flow’ of a consultation. Conversely, the frustrations described by physicians when dealing with language barriers and inadequate translation align with existing literature showing that discordance is a significant driver of negative clinical and psychological outcomes. Interestingly, however, a study examining ethnic discordance revealed that minority patients in Israel sometimes preferred a physician of a different ethnicity due to issues of confidentiality and internalized racism [38].

A specific example of cultural adaptation challenges emerged in our findings. Two of the physician participants who had studied abroad attempted to apply communication methods they had learned internationally after returning to Israel. However, they found these approaches ineffective in the local cultural context and reverted to their previous communication styles. Their experience demonstrates that effective cross-cultural communication requires tailoring approaches to the specific characteristics of each cultural environment.

As for the second theme, “cultural knowledge,” the physicians described learning about families’ health beliefs and cultural values through direct experience rather than formal educational. This on-the-job learning through patient relationships differs from the literature describing structured education [8]. The findings highlights the importance of “teachableness” [9]: being willing to learn from both colleagues, patients, and other individuals, regardless of their social standing or accomplishments.

On the other hand, some of the physicians said that culture did not have an effect on the interactions they had with families, implying that they had “no knowledge” regarding the possible differences. Similar findings were also found in a qualitative study conducted in Israel [29], in which a group of healthcare providers reported that the culture or ethnic background of their patients had no effect on their ability to communicate about mental health distress or suicide [29]. The authors suggested that although the “color blind” strategy, a concept discussed by Frankenberg [26] in the context of American race relations, is often promoted as a way to reduce racial bias, it is important to note that such approaches are not recommended in contemporary literature [64]. In fact, color-blind approaches may mask existing inequities and prove harmful in multicultural interactions characterized by unequal social power dynamics, making them impractical in diverse societies such as Israel [29]. This finding highlights the importance of moving toward active cultural awareness rather than ignoring the cultural identities present in the clinical room.

A critical gap exists in how physicians identify patient culture; as the interviews provided no specific information regarding how the clinicians ascertained the cultural identities of their patients, there is a risk that they operate based on assumptions rather than explicit inquiry. Such a reliance on assumptions may lead to the reinforcement of inaccurate stereotypes [34, 45].

In our study, physicians’ knowledge centered on understanding families’ ethical dilemmas, such as choosing not to terminate a pregnancy despite a severe fetal heart defect. We would like to suggest that when physicians deeply understand and appreciate how cultural beliefs influence such family decisions, even when these differ from their own views, they often develop greater clarity and compassion regarding the family’s choice. This understanding enables physicians to maintain effective, long-term therapeutic relationships with families, aligning with cultural competence and humility principles of non-judgmental listening and respect for families’ decisions [10].

The third theme focused on “cultural skills” where most of the participants (n = 15) described three key communication approaches developed through their careers working with diverse groups. Participants employed these skills to help families accurately understand their child’s medical condition and make appropriate decisions. For example, some of the physicians used cultural-specific developmental milestones (e.g., Bar Mitzvah celebrations or military service) to illustrate “severity scales” that resonated with families’ cultural values and the expectations they had of healthy children. These approaches were used regardless of the physician’s own cultural background.

Physicians’ cultural skills also foster empathetic relationships with families. By incorporating spiritual leaders and using culture-specific expressions, physicians encourage collaborative care in families’ “own language” to encourage collaborative care for the child’s benefit. As the study participants recognized that cultural identity is complex and cannot be reduced to a single indicator such as religion or ethnicity [29], they stressed the importance of understanding families before applying specific approaches, showcasing cultural humility in their practice.

Our findings indicated that although the participants showed a limited degree of cultural self-awareness, they demonstrated strong cultural knowledge and skills, implementing culturally sensitive practices based on their understanding of their effectiveness with diverse families. These findings seem to highlight a known paradox within Israeli society and a main challenge in the Israeli healthcare system [19, 39]: Although physicians engage in numerous culturally sensitive practices, they often lack self-awareness of the ways in which their own culture interacts with the family’s culture, as well as a systematic or structured approach for applying the knowledge and skills they possess [68]. Future studies should examine physicians’ self-awareness more specifically, as well as the possible implications it has for the physicians’ structured approach in applying knowledge and skills.

In addition, the study participants relied on efforts at the individual level to communicate with families who had limited Hebrew proficiency. By doing so, they aimed to overcome gaps in the healthcare system related to the cultural needs of families receiving pediatric care – gaps that limit effective patient-physician communication and the provision of equitable high-quality care [58, 69].

In recent years, there has been an ongoing debate over the merits of cultural competence and cultural humility [18, 30]. There is a growing understanding that healthcare professionals can never be fully “competent” in another’s culture; therefore, the term cultural competence should not be viewed as a binary construct (i.e., if one is not culturally competent, then one is implicitly incompetent and potentially unprepared to interact professionally with members of certain groups). On the other hand, although the concept of cultural humility addresses these gaps and may sound appealing, critics argue that it lacks conceptual clarity and a coherent framework. Additionally, it does not provide explicit guidelines for cross-cultural pedagogy, research, or practice, making it difficult for practitioners to understand and practice [18, 25].

The interplay between the two frameworks shows that as providers develop cultural skills, they become better at navigating diversity while maintaining an openness to learning [10]. Cultural humility prevents competence from becoming overconfidence and promotes continuous learning and sensitivity to cultural complexities [30, 81]. This integration emphasizes the need for both practical skills and ongoing personal development [30].

To mitigate the risks associated with an over-reliance on unstructured “personal strategies”, which may inadvertently foster biased perspectives or obscure systemic inequities, the study findings suggest that practitioners could benefit from transitioning toward systematic frameworks of self-reflection. Clinicians seeking to grow in this domain should consider adopting an informed stance of “not-knowing”, substituting cultural stereotypes with a perpetual clinical curiosity that recognizes the family as the primary expert of their own unique experience [35, 81]. This shift involves moving away from “color-blind” ideologies—which can be impractical and harmful by masking social power dynamics—toward an active cultural awareness where physicians systematically examine how their own identities and implicit biases influence the clinical encounter [6, 29, 64]. Furthermore, clinicians are encouraged to critique inherent power hierarchies to foster non-paternalistic, mutually beneficial partnerships with diverse families [34, 45]. Ultimately, given that participants reported acquiring their cultural knowledge primarily through “on-the-job” learning rather than formal preparation, the implementation of formal, structured training models is a vital step in elevating individual self-reflection into a rigorous, systematic professional standard [37, 78].

Our study focused on pediatric cardiologists’ perspective on cultural interactions. While a significant portion of the total Israeli pediatric cardiologist community (approximately 20–25%) was represented in our sample of 17 providers, the absolute number of participants remains small. A notable limitation is the underrepresentation of Arab physicians; while one Arab physician participated and provided valuable insights, the majority of the sample was Jewish. This gap suggests the need for future research that includes the perspectives of Arab healthcare providers, particularly given their unique insights into cross-cultural care in the Israeli context. Additionally, a notable limitation is that these findings are based on self-reported data, which may be influenced by the physicians’ desire to present as competent professionals. Consequently, it remains unclear if these described strategies are delivered effectively or well-received by families. Future studies should examine families’ own experiences of cultural competence in pediatric settings, specifically in Israel, to determine the clinical efficacy of these reported practices and their impact on health outcomes.

Despite these limitations, our study has several clinical and theoretical implications. Our findings emphasize that maintaining a culturally competent and humble approach is valued by pediatric cardiologists, who perceive it as enhancing their communication and relationships with families. While contemporary literature suggests that such improvements could potentially serve as a strategy to mitigate the effects of disparities [45], further research is needed to determine if the strategies described by physicians in this study result in measurable health outcomes children and families. Healthcare providers/clinicians must be culturally attuned, and services tailored, to meet the specific needs of minority groups, recognizing and accommodating the distinct requirements of various subgroups within each diverse population [13, 49].

Conclusions

This study revealed that pediatric cardiologists describe a range of cultural knowledge and skills that they believe enable effective communication with families. Although they report incorporating these domains into their daily practice and value their impact, their reflective process may remain limited by a lack of systematic self-awareness and formal training. Lacking clear protocols [37], physicians must rely on personal strategies to maintain positive relationships and cultural sensitivity. Notably, the participants reported an absence of formal training in cultural competence or humility throughout their careers, highlighting that their current strategies are almost entirely based on unstructured, direct clinical experience. This gap between practical skill and formal preparation points to the necessity for healthcare systems to move beyond ‘personal strategies’ toward structured training models that foster systematic reflection. Further work is essential to develop, assess, and bolster effective healthcare delivery models specifically designed to address the needs of vulnerable populations in pediatric settings in order to bridge the gap between practical skills and reflection, and to decrease disparities and enhance accessibility.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

YS, YKV, RD and UK led the study design. YKV and RD conducted in-depth, semi-structured interviews. LS and UK contributed to conception and design of qualitative data and to the drafting of the manuscript. YS, YKV, and RD performed the qualitative analysis and wrote the first draft of the manuscript. LS and UK a contributed to the interpretation of the results. All authors revised the article critically for its content and approved the final draft for submission.

Funding

No funding was used in the collection of information or the preparation of the manuscript.

Data availability

The qualitative data (interview transcripts) generated during this study are not publicly available due to ethical restrictions approved by the institutional ethics committee, which prohibits data sharing in order to protect participant confidentiality.

Declarations

Ethics approval and consent to participate

All study procedures were approved by the Ethical Review Board (ERB) at the Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan, Israel (SMC-8070-21) for use of interview data. Consent to use the data was given from all participants.

Competing interests

The authors declare no competing interests.