When I say … cultural competence

Short abstract

In this month's "When I say…", Stanyon et al. frankly discuss 'cultural competence' in terms of power and privilege in the clinic and in the classroom.

Everyone identifies with a culture; however, ‘cultural competence’ remains an elusive yet all‐encompassing term. Emerging in the 1980s, ‘cultural competence’ evolved from addressing the needs of populations deemed different from the ‘mainstream’ culture, to a byword for striving for social justice by the late 2000s. However, the shift from outdated terms such as ‘mainstream culture’ to ‘multiculturalism’ accompanies a move towards cultural complacency, with culture treated as a static, oversimplified concept disconnected from the contributions to health inequalities made by race, power and social disadvantage (Kumagai and Lypson). ¹ Misunderstanding and misuse of the term ‘culture’ have been highlighted as part of the problem. The assumption that culture is synonymous with ethnicity and guides behaviours and beliefs in fixed, linear ways permeates teaching and contributes to the reinforcement of cultural stereotypes and ‘othering’ (Gregg and Saha), ² limiting the very goals ‘cultural competence’ pertains to uphold. Additionally, misuse has seen the conflation of ‘cultural competence’ with political agendas to bridge cultural divides, where it is used as a solution to the disparities and systemic injustices experienced by minority populations (Gregg and Saha). ²

Linguistically, ‘cultural competence’ poses additional challenges. The use of ‘competence’ implies the existence of attainment levels that have been externally validated. Accepting that culture is an evolving blend of traditions, beliefs, socio‐economic factors and lived experience, who defines what competence in any culture means in real terms, or where one culture ends and another begins? In the drive towards competency‐based medical education, cultural education and training has been taken for a ride: reduced to fit knowledge, skills and attitude frameworks, without due consideration of the consequences of assigning ‘competence’ to a concept internally identified and individually experienced through a socio‐political lens. Retrospective reflection over the last decade has embraced the need for change; ‘competence’ has been dropped from the couplet, leading to the emergence of alternative terms such as cultural ‘sensitivity’ and cultural ‘awareness’ (George et al). ³ This has progressed to terms replacing ‘culture’ altogether—such as ‘diversity’, which encompasses both the heterogeneity within cultures and addresses the unique experiences of the individual (George et al). ³ Finally, ‘critical consciousness’ emerged in 2009 (Kumagai and Lypson), ¹ marking the acknowledgment that introspection to address personal bias and an active connection with social justice are prerequisites for effective cross‐cultural education. However, the term ‘cultural competence’ persists in many medical curricula.

Despite progress with nomenclature, we are still far from addressing the power, oppression and privilege underlying ‘cultural competence’. The dominance of the doctor's narrative and the selection by the doctor of specific patient voices—often well‐resourced and educated—has been raised as a source of oppression and critically unpacked through a postcolonial lens (Sharma et al). ⁴ To progress in delivering meaningful ‘cultural’ education, where the authentic, lived experience of marginalised groups is critical to the learning experience, such lessons apply more strongly. Patients must be allowed to share their views as experts and co‐educators or there is a risk of undermining the inherent principles of cultural competency education.

The examination of power and privilege in ‘cultural competence’ is incomplete without discussion of international applicability, where the western origins and perspectives of the concept should not be ignored. In their discussion about Taiwanese medical education, Lu and colleagues rightly question whether ‘cultural competence’, with its underlying assumptions and meanings developed in a western context, is valid and applicable in their own circumstances (Lu et al). ⁵ This is a global issue, with the lack of guidance or frameworks to ensure meaning and relevance in the local context an example of the privilege afforded to western educational concepts, which are frequently adopted before an evidence base is established. English language privilege—the academic equivalent of white privilege—goes unchecked, demonstrated by publications in which systematic reviews and meta‐analyses exclude non‐English language studies with no attempt to scrutinise other language publications, or when article rejections to papers submitted by non‐native English speakers are accompanied by offers of paid in‐house English editing services. Such practice creates a power dynamic favouring those with greater English proficiency or whose institutions can fund editing services, affecting the evidence base on which today's medical education is built and tomorrow's research conducted.

So far our review has explored the normative uses and aspirations for ‘cultural competence’ in medical education. This is (a) in the provision of programmes that foster skills to identify discrimination and promote social justice when confronted by health inequalities, and (b) in promoting a decolonised curriculum which provides students with source material that reflects the heterogeneity in and experience of the societies in which they are training. However, we propose a third domain: the extrapolation of ‘cultural competence’ to academia and the classroom.

How students and authors communicate—such as how they construct arguments, present ideas and interact—is deeply rooted in culture. Such differences permeate all forms of communication, with multiple frameworks in existence to conceptualise them. In Japanese culture, communication is implicit, where importance is given to what is not said as well as what is said. Reactions are introverted, silence is commonly used, and a high degree of effort is put towards maintaining long‐term relationships. In contrast, native English speakers communicate in more direct ways; language is more transparent, reactions are visible and extroverted, silence is uncommon, and individual tasks are prioritised over the longer‐term relationship. Such traits, although generalised, affect performance—for example in medical interviewing, team‐based learning and in the giving and receiving of feedback. Our vision of the ‘culturally competent’ teacher is someone with a critical awareness of these cultural differences and their impact, and who can recognise where support may be required and to what degree. In all situations, English privilege must be consciously checked, alongside power dynamics, internal bias and discrimination.

In the last 30 years, ‘cultural competence’ has expanded far beyond its original scope, influenced by changing practice and limited by its own terminology. Cultural competence evolved from a desire to deliver high‐quality care to diverse populations. Now, as we re‐examine its meaning in medical education today, it is time to extend the values demanded by ‘cultural competence’ across all spheres of practice. As educators and academics, it is our responsibility to use this as a tool to promote critical consciousness and check privilege—not just in the clinic, but also in the classroom and in the literature.