Unpacking Bias, Shoring Up Cultural Sensitivity

Photo by Steve Gilbert Augustus White

It’s not too much of an exaggeration, said orthopedic surgeon Augustus White, the Ellen and Melvin Gordon professor of medical education, to say that your best guarantee of good medical care is to be white, male, young, heterosexual, skinny, and well-off.

“In our society today, there are 12 different groups who receive inferior care” because of conscious and unconscious bias among health care workers, said White. The deprived dozen are Asian Americans; African Americans; Latinos; Native Americans; gay, lesbian, bisexual, and transgendered (GLBT) people; the poor; women; the elderly; the disabled; the obese; immigrants; and certain religious groups.

White heads the committee working to make sure that culturally competent care—“the skills, knowledge, and attitudes to allow you to take good care of a patient who is of a culture other than your own”—is being woven into an HMS education. The accrediting Liaison Committee on Medical Education calls for students to be taught to recognize personal prejudices and how they might compromise care, he noted. And that means rethinking even a cornerstone of HMS education—the tutorial.

White’s committee has been planning with course directors to “work into the tutorials culturally competent care case activities,” with Helen Shields’s course on gastrointestinal diseases as the pilot. Her students will study three cases involving cultural issues: an obese man unable to pay for medication; a woman taking herbal pills sent by her family in Hong Kong, a preparation that can actually do harm to her health; and an alcoholic with hepatitis C and cirrhosis who drinks with fellow military veterans, but conceals the habit from his doctor (as a Polish man, he also eats Polish food high in salt). “Obesity, poverty, use of ethnic alternative medications, alcoholism, and eating ethnic foods that are detrimental are all factors that may lead to less than optimal care,” Shields said, “unless each factor is recognized and discussed by the physicians and team treating the patient.”

Beyond tutorials, “Every course the student takes, every clerkship the student rotates on, should include some element of culturally competent care education,” said White. It will be part of the new required courses, Introduction to Social Medicine and Medical Ethics and Professionalism. The Patient–Doctor series will be a key transmitter of cultural-awareness education, especially with regard to the appropriate and effective use of a translator for patients speaking a foreign language.

And the directors of the new Principal Clinical Experience at the major teaching hospitals are also developing cultural competence initiatives. White said there’s a unique challenge to implementing this aspect of curriculum reform: “Culturally competent care is probably the only thing that we’re asking our faculty to teach which they themselves have never been taught. We need to understand ourselves before we understand cultural competence.” Two of our faculty, Daniel Goodenough and Roxana Llerena-Quinn, have developed an excellent course to enhance self-awareness. In a protected, confidential, supportive setting using carefully selected readings and videos, the course guides the participants through exercises that cause self-reflection on one’s own biases.

How easy is this to teach? “It’s extremely difficult and extremely important,” said White. “None of us wants to think our grandmothers and friends are receiving inferior care because they’re in some particular group.”

—Rich Barlow

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