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Honing Cultural Humility Skills Can Improve Health Care as a Whole

humility skills

Imagine this scenario: A patient is discharged from the hospital following surgery for a complex fracture and finds herself without prescriptions to treat the pain. She comes to her primary care practice looking for relief. The resident seeing the patient notices that the inpatient record used “drug-seeking” as the reason for her not receiving medication.

But the patient had no prior history of documented substance or prescription abuse; she is a Hispanic female and the victim of a hit-and-run accident. After the discrepancy between her record and reality is brought to the attention of an attending physician, the patient is put on an effective pain management regimen. At her next follow up appointment, her primary care physician finds that the patient is thriving and successfully tapering from treatment.

The patient ultimately thrived because the resident used cultural humility. The practice of cultural humility ensured she was being charted correctly and received proper treatment for her pain, despite the potential role of implicit bias in her original inpatient record. The literature suggests that the patient would be more likely to be perceived as drug-seeking when requesting pain relief, compared to her white counterpart.

It’s a growing area of emphasis at Penn Medicine and the Center for Health Equity Advancement (CHEA) describes cultural humility as the ongoing process of developing a set of skills to approach any individual from any culture at any time. Cultural humility focuses on lifelong learning, self-reflection, removing power differentials (such as provider and patient), and demonstrating equal respect for different beliefs and points of view. In other words, an individual’s knowledge of someone else’s culture will always be limited because they cannot walk in their shoes.

“The practice of cultural humility involves viewing every encounter, be it with a patient or colleague, as a negotiation between two worldviews — yours and theirs,” said Jaya Aysola, MD, MPH, executive director of CHEA and an assistant dean of Inclusion and Diversity at the Perelman School of Medicine at the University of Pennsylvania. “It’s about approaching each person with the understanding that everyone has a culture and background, which may need to be unpacked to reach a common understanding.”

Cultural Humility and Cultural Competency

Keeping an open mind allows individuals to mitigate unconscious biases that can negatively impact our daily interactions and have shown to contribute to health care disparities.

Cultural humility is a more evolved and evidence-based way of approaching a related concept that may be more familiar, known as cultural competency. Although both terms reflect efforts to improve relationships between people, cultural competency is memorizing a set of traits connected to a certain group or a set of questions that you need to ask a specific group of people. The problem with cultural competency is that it assumes one can be “competent” in a culture other than their own, explains Aysola, and that the majority of people in the U.S. does not have a culture, or that somehow any given culture lacks diversity and does not evolve.

Cultural Humility in Action

When it comes to cultural humility in health care, the practice helps to create deeper connections and understanding between patients and providers, which may increase patient satisfaction and care outcomes.

For example, applying cultural humility to patient charting can have a direct impact on readmissions, pain management, surgical, and general health outcomes.

When a patient is documented as “non-adherent” or “non-compliant” in their chart, rather than evaluating and documenting why the patient may not be able or willing to adopt the prescribed treatment, it typically influences all future interactions. The next set of care providers are more likely to accept the statements as an absolute and are less likely to probe further and actually address the barriers preventing the patient from adopting the treatment. In the scenario where the Hispanic patient was initially labeled as “drug-seeking” in her inpatient record, despite no history of substance abuse, her primary care team used cultural humility to reflect on the implicit bias that showed up in the patient’s chart.

When it comes to training and teaching medical students, seeing cultural humility in action is more likely to move the mark on changing implicit bias than simply raising their awareness of what that bias looks like. As Aysola described in a Health Affairs blog post with two residents and a medical student, it’s more effective for medical trainees to see increasing positive role modeling, as opposed to adjusting the medical curricula.

Penn Medicine’s electronic health record (EHR) has had fields to capture demographic information across many categories, for several years. More recently Penn Medicine’s EHR was updated to offer patients the ability to indicate a non-binary administrative sex marker during registration. “Learning how our patients want to identify themselves and being able to update our operations to reflect that is a key part of the learning process and in becoming a culturally humble organization,” said Rosemary Thomas, MPH, CHES, director of operations for CHEA. “The more we know about our patients, the better we can care for them.”

Thomas stresses that while being open to that kind of continuous learning on the clinical side is vital for better patient outcomes, applying cultural humility with colleagues, managers, and staff needs to be part of the equation. Inclusive work and learning environments in health care are paramount for retention and advancement of a diverse workforce. Diversity at all levels of the organization is essential to improve care delivery.

“At Penn Medicine, we envision a health system where every diverse voice is heard, where every unique perspective is considered,” Aysola said. “Promoting an inclusive culture benefits not only those that work, train, study, and/or advance science within our health system, but also those that seek care here. When we value each other, it enhances our ability to care for our patients.”

Practicing Cultural Humility

Aysola recommends practicing cultural humility with awareness — be aware that we all often make assumptions about others based on their culture and background. It’s also important to ask open questions and practice reflective listening (others are the experts on their own lives).

Last but not least, opportunities to practice cultural humility are all around you — you have the opportunity to practice cultural humility during interactions with everyone, not just during patient interactions.


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