When I renewed my physician assistant license on the Oregon Medical Board (OMB) website last year, its questionnaire asked if I had participated in any “cultural-competence” training. Given that I had completed continuing medical education only for my specialty, cardiology, I selected “no.” A small message at the bottom of the screen warned that while I was exempt for this license renewal, such training would be mandated in the years to come.
Cultural competence literature and trainings have become increasingly prevalent in the medical field. A PubMed search shows a rapid rise in use of the term, beginning in the 1990s and peaking in 2019, and the U.S. Office of Minority Health lists “strengthening cultural competence” as one of its key objectives for health care. The OMB’s Cultural Competency: A Practical Guide for Medical Professionals defines it as “a life-long process of examining values and beliefs, of developing and applying an inclusive approach to health care practice in a manner that recognizes the context and complexities of provider-patient interactions and preserves the dignity of individuals, families and communities.”
Fair enough. What’s troubling comes a bit earlier: “the goal of a ‘culturally competent’ health system is to eliminate disparities between different cultural groups,” the OMB guide says. What constitutes a cultural group is not defined, and the process by which such disparities will be eliminated is also left to the reader’s imagination. The OMB’s guide continues, “The goal of a culturally competent provider is to commit to doing their part, both as a clinician, but also as a system change agent.” And here I thought we were just practicing medicine.
The OMB’s guidance makes one wonder if the writers have ever worked in a busy clinic, much less interacted with flesh-and-blood human beings. Consider the following recommendations. “Continue to Explore and Educate yourself about the different Latino stories in your community.” “When your identity or background—race, age, gender, etc.— doesn’t match the patient’s, look for extra support within your staff, institution, or beyond.” “Although White patients do not experience racial marginalization, they may experience other forms of discrimination—examine assumptions of native language and home country.” “Ask people for their pronouns always, even people you think ‘don’t look’ trans or genderqueer; when in doubt, default to they/their/theirs and inform your staff to do so as well.”
Finally, in the rural health-care section, the OMB advises medical workers to “be wary of the polarizing effects of electoral politics at the local level—community building can make changes that benefit people regardless of ideology.” It’s curious that only rural patients—who may vote in the opposite political direction of the cultural-competence brigade—come with a warning.
In any event, a pamphlet or (more typically) a short training workshop can’t bestow true cultural competence upon its recipients. When treating patients, certain skills, such as proficiency in a second language, are clearly desirable. But these necessities are being solved through technical innovation with virtual interpreters, not social engineering. We are asked to believe that something as complex and loosely defined as a culture can be distilled into a PowerPoint presentation, the viewers of which can then print a certificate asserting their mastery of it.
Such trainings have questionable empirical benefits. A review of cultural-competence training in BMC Medical Education writes that the hours spent in cultural-competence training are too limited to make a difference, and then notes that “much of the remaining time is exhausted on trading in cultural stereotypes and surface-level information.” In a thankfully brief week of cultural-competence training in physician-assistant school, my class watched narrated footage that juxtaposed nonwhite people living in poor, decrepit sections of the country and white citizens on a country club golf course. What we gained from this is anyone’s guess. Colleagues in other fields, such as counseling, have offered similar stories.
Finding clear, longitudinal data demonstrating the effectiveness of these trainings is quite a challenge. Studies that may reveal the constraints of the cultural-competence approach often insist that we “need more research” and “require a greater understanding” rather than concede a flaw in this approach. One systematic analysis of methods for measuring cultural competence found that they “varied largely,” with “suboptimal” metrics that “lack methodological rigour”—raising the question of how cultural competence can be taught if it can’t be measured in any reliable way.
But publications on the negative consequences abound. An article in Harvard Business Review is representative. “Trainers [say] that people often respond to compulsory courses with anger and resistance—and many participants actually report more animosity toward other groups afterward,” the article notes. By contrast, voluntary trainings—and ordinary, interpersonal contact with people of different gender, race, and background—reduces bias and makes people more willing to work alongside different groups. In short, ordinary behavior leads to more harmonious results than do protocols mandated by self-anointed experts in the fields of “diversity” or “culture.”
Despite these shortcomings, such trainings are likely here to stay. Medical facilities face pressure to signal their commitment to social justice. Enough decision-making has already been ceded to third parties—insurance companies dictating the cost-benefit calculus of a given treatment, the federal government handing down penalties or awarding reimbursements to hospitals—that one more group telling us what counts as competence won’t be surprising. One hopes that medical workers will continue to engage with their patients on an individual level to understand their personal health-care needs—the kind of competence that truly matters.
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