By Tu-Quynh Hoang
I chose to complete my third-year obstetrics and gynecology clerkship at Brackenridge Hospital in Austin because I wanted the challenge of training in a high-volume labor and delivery unit. And high-volume it was. Initially, the vast numbers of patients who spoke only Spanish intimidated me. But I had taken Spanish in college and felt comfortable with my level of comprehension. I quickly learned how to ask all of the essential labor and delivery questions and to counsel patients in Spanish about breast-feeding and contraception. The women left the hospital with healthy little babies in their arms, and I thought I was doing a good job.
Then one day I was working in the gestational diabetes clinic when the nurse slid a chart into my hands and said, “I’ve got one for you.” As I rifled through the pages I saw reflections of myself. The patient was a full-term Vietnamese woman, just two years older than me, experiencing her first pregnancy. On the examining table, despite her gravid belly, she looked frail and small. Her timid smile could not hide the mixture of anticipation and fear on her face as she clung to her husband’s hand. I bowed politely, introduced myself, and gently asked if she would prefer speaking in English or in Vietnamese. She gratefully chose Vietnamese, and we proceeded to have a rich clinical encounter. We discussed her treatment regimen, and I offered as much reassurance as I could. I wished her well for her imminent delivery, and we both walked away fulfilled.
Two days passed. I reported to labor and delivery for overnight call, and discovered the same young patient, now in active labor. When I walked into her room, she reached out her arm and called me by name. And at that moment, I realized how much our common culture provided her comfort in her time of ultimate need.
Although she was surrounded by highly trained nurses and doctors, all she wanted was to be treated by me, the Vietnamese medical student. Hours later, she gave birth to a beautiful baby boy. When, in the midst of her elation and exhaustion, she asked about the shape of his eyelids, I could only smile at this cultural nuance that I alone understood.
Being able to assist in this young woman’s first delivery was the highlight of my clerkship and one of the most significant experiences of my medical school training. However, it also made me recognize how much I had shortchanged all of the Hispanic patients I had encountered. Although I could stumble through a history and physical in my broken Spanish, I couldn’t offer those patients the quality of care they deserved. I had no understanding of the social and cultural influences they carried with them. I did not make the most effective use of translator services available. I did not ensure that the concerns of those patients were fully and appropriately addressed by someone who had the linguistic and cultural skills I lacked. I concluded that I did not do such a good job, after all.
Like most care providers in the United States today, I can either silently pat myself on the back for coming away from that experience with a lesson learned or join in the formidable struggle to change the health care system into one that more accurately reflects the face of the nation and that sees “culture” as a tool for more effective health care delivery rather than a deterrent to it. In this age of “political correctness,” it is all too easy to throw around terms such as cultural competence and salve our consciences. But what does it mean to be culturally competent? And why is it important? The answers are right before our eyes. Racial and ethnic disparities in healthcare in the United States persist despite our best efforts. Minority populations suffer disproportionately from some of the most deadly conditions, such as diabetes and cardiovascular disease. And yet these disparities are often left unaddressed by a health care system that lacks the time and motivation to understand the factors that contribute to a patient’s health behaviors. It is well-established that effective communication between a care provider and a patient leads to higher patient satisfaction, improved rates of adherence to proposed interventions, and ultimately to better health outcomes. It is only logical then, that we should strive for more effective communication. But to do so requires that we have a better understanding of how cultural influences affect a patient’s health beliefs, practices, and attitudes toward health care. Achieving that understanding, particularly in a population as culturally rich and diverse as that of the United States, can only come with much time and effort.
And while broadening our knowledge of external cultural influences would undoubtedly improve the quality of care we provide to many patients, we also must recognize that many face many barriers intrinsic to the current health care system. For instance, medical researchers have not adequately studied health conditions in minority populations. As a result, most of our public health measures do not adequately address the needs of these people. Public health information and educational materials are not readily accessible to many ethnic groups, and even when available, they usually are not culturally sensitive. Furthermore, many minority populations lack access to care by health professionals of similar ethnic or cultural heritage. This is because the demographics of our health care faculty and leadership do not reflect the demographics of the population we serve. It is only natural that in such a system, the concerns of a cultural minority go unheard and underrepresented.
Hence, it is apparent that many sociocultural and institutional factors play into the disparities seen in our health care system today. And though it may appear to be a mere esoteric bit of social and political theory, cultural competence does in fact make a difference in the lives of many individuals. It was particularly striking to me in the life of the Vietnamese woman who left satisfied with the care I gave her, and in the lives of all the Hispanic women who most certainly had hoped for better.
My experiences at Brackenridge Hospital’s labor and delivery unit taught me that there is so much more to cultural competence than linguistic proficiency. Competence encompasses an appreciation for the ways in which culture shapes a patient’s values, beliefs, and health behaviors; an understanding of how these values, beliefs, and behaviors intersect with our health care system; and most important, it involves action to devise interventions that meet the culturally unique needs of patients. In order to be truly competent, we must make greater strides to institutionalize cultural knowledge. To do this, we need to provide more thorough cultural training for health care professionals. We also need to devise policies that eliminate the barriers to care faced by cultural minorities. We must formulate culturally sensitive public and preventive health campaigns to promote better health outcomes. And we must work toward creating a health care system that more accurately reflects the population it serves by achieving more culturally diverse leadership. Only then can we even begin correcting the racial and ethnic disparities we see today. Only then can we call ourselves culturally competent. Only then can we say we have
done a good job.