Culturally Competent Care Tackles Bias and Racism in the US Medical System—Here's What to Know About It
As a kid growing up in a low-income community of color in Toronto, Rosie Mensah never saw a doctor or other health care provider who looked like her. "A lot of people in my neighborhood were struggling to take care of themselves and their families," she tells Health. "But going to the doctor didn't always help. It often felt like we were being blamed for what we were experiencing."
Although the Canadian health care system is quite different from that of the United States, issues like poverty and racism transcend national borders. Mensah's own family struggled with food insecurity, which inspired Mensah to become a dietitian and food justice activist.
Yet becoming a health care provider herself didn't solve the problem. "You don't learn about systemic racism during dietetics training," she says. One of Mensah's first jobs out of college was in the diabetes education program for a community health center, where her mission was to teach clients how to eat healthy on a budget. "But when I sat down with my clients, what I heard over and over again was, 'I know what to eat, but I'm working three jobs to pay my rent' or 'I'm dealing with immigration issues, or trauma,'" Mensah explains. "They didn't need me to teach them how to eat healthy. Everyone already knew that. They needed to talk to me about what was going on in their lives."
What Mensah's clients really needed is an approach known as "culturally competent care," where providers are trained to understand the structural barriers that many patients face in pursuing health—such as poverty and food insecurity, as well as systemic racism and other forms of oppression. The term was first introduced in the 1980s, and in recent years it's become a buzz word for researchers studying how to reduce racial and ethnic health disparities.
"We have to acknowledge that health care exists within our dominant culture, so when folks with more marginalized identities seek health care, they often don't feel safe," Hilary Kinavey, MS, LPC, a therapist who specializes in the treatment of disordered eating, tells Health. Kinavey is also a co-founder of Be Nourished, a nonprofit organization in Portland, Oregon, which offers workshops, retreats, and online courses for health care providers covering how to offer trauma-informed and weight-inclusive care. "At a minimum, culturally competent health care means acknowledging that there is a power imbalance in the room," she says.
Kinavey says that the power held by health care providers, just by dint of their job but especially if they are white, straight, cisgendered, thin, and/or male, influences how much patients of other races, gender identities, and body sizes feel able talk about their concerns and challenges. And although diversity is increasing among health care professionals, the Association of American Medical Colleges reports that more than half of active physicians are white, while 17.1% are Asian, 5.8% are Hispanic, and 5% are Black.
The field is also still male-dominated, with women making up just 35.8% of active physicians (although that may change, as women now apply to medical school at similar rates to men). "It can also determine whether a patient expects to be understood and even just how long it's taken them to get to the appointment," Kinavey explains. "The onus has to be on health care providers to recognize how our privilege limits our ability to help the person in front of us."
The consequences of culturally incompetent care
Culturally competent care isn't just nice to have; it's a crucial starting point to addressing long-standing inequities in health, Rashawn Ray, PhD, executive director of the Lab for Applied Social Science Research at the University of Maryland and a fellow at the Brookings Institution, tells Health. "We know that Black people, in particular, are more likely to be misdiagnosed and that their pain is likely to be under-treated because providers are less empathetic and more biased towards their Black patients."
Indeed, when researchers analyzed emergency room data from 2003 to 2010, they found that even among children, Black patients received pain medication less often than white patients and were much less likely to receive opioids for severe pain, according to a 2015 study published in JAMA Pediatrics. This bias within health care can have devastating consequences: Between March and September 2020, Black women died from COVID-19 at 3.8 times the rate of white men in Michigan and 1.6 times the rate of white men in Georgia, according to a new study from Harvard researchers. Other research has documented that Black people are less likely to be tested and sicker when they do receive treatment than white patients. Studies have linked similar biases with worse health outcomes for other communities of color as well.
Queer patients also face systemic bias and stigma in health care settings. One 2015 study found implicit bias in favor of straight patients was pervasive among heterosexual health care providers, who tended to prefer straight male patients over everyone else. As a result, many lesbian, gay and transgender patients feel unsafe even sharing their identities with health care providers, which limits their ability to access necessary treatment. In a 2017 survey, 8% of LGBQ participants and 29% of transgender patients said a health care provider had refused to even see them; the survey subjects also reported verbal abuse and unwanted physical contact from providers.
Patients in larger bodies face chronic weight stigma in medical settings, which many researchers agree plays a significant role in their increased risk for weight-linked health conditions like heart disease, diabetes, and asthma. After analyzing audio recordings of 208 patient encounters by 39 primary-care physicians, scientists found that doctors established less emotional rapport with their higher-weight patients, according to a study published in a 2013 issue of the journal Obesity.
In another paper published in 2014, the same lead researcher found that 21% of patients with BMIs in the overweight and obesity ranges felt that their doctor "judged them about their weight"—and as a result, they were significantly less likely to trust their doctor and even to return for follow-up care. Providers spend less time with patients with high BMIs and are sometimes even less willing to perform standard care, such as pelvic exams, at the gynecologist's office.
In May 2018, a Canadian woman named Ellen Maud Bennett died only a few days after receiving a terminal cancer diagnosis; in her obituary, her family wrote that Bennett had sought medical care for her symptoms for years, but only received weight loss advice. "Advocating against oppression in health care is the work I have to do to literally stay alive," Shilo George, a consultant and fat activist in Portland, Oregon who conducts workshops for fat people on navigating the health care system, tells Health.
The importance of cultural humility
"Cultural competency" is not a perfect solution to systemic health care inequities. Many advocates worry that it reinforces the idea that doctors and other health care providers can become experts on the culture or struggles of the patients they work with, even if they don't share the same cultural identities. "The term suggests some sort of mastery over the issues, which you're never going to have," says Mensah. She uses the term "cultural humility" in the trainings she offers to fellow dietitians, because it emphasizes the need for providers to check their own biases and assumptions. "You can be knowledgeable about a group and yet still hold so many biases towards them," she explains.
Often those biases manifest when doctors perceive a patient to be lying, withholding information, or otherwise noncompliant. "It is a rational response for a Black person to be pessimistic or distrustful of health care because of its structural inequity," says Ray. "Low-income people, and particularly people of color, are accustomed to providers talking at them, not to them. Immigrant patients are used to providers assuming they don't speak English, but not bothering to get a translator. The patient is the health care customer, but these folks are more often viewed as a hinderance to what's going on."
By the same token, patients in larger bodies often encounter doctors who assume they are lying about their lifestyle habits, assuming that they can't possibly be eating healthy or exercising and still have a high body weight. These assumptions can cause a breakdown in trust that makes it far more likely that a patient will lie or avoid mentioning issues that they expect the doctor to judge or misunderstand. "What we really need to train providers to do is practice continued learning about the communities they serve," notes Mensah.
Margaret Black, MD, a white family medicine doctor in Portland, Oregon, strives to adopt this approach with the various communities she serves. "I'm fat, so I know some patients seek me out because they have an expectation of sameness there—and they're right," she tells Health, noting that she's felt a similar comfort level providing care for gender non-conforming folks—although there was a learning curve to navigate in terms of their hormone protocols. "On the other hand, I have many Vietnamese patients, and I feel really underprepared to care for them sometimes," she admits. "I can recognize that I don't have the cultural competency there and have more work to do in order to communicate and partner more effectively with them."
That might sound simple, but Kinavey says it's difficult for many health care providers to stop thinking of themselves as the expert in the room. "Providers have been taught, 'I'm having good relationships with patients if they think I'm the best,'" she explains. "But that's not a relationship. We need to be able to listen and value the patient's lived experience and knowledge about their body." She helps providers consider how subtle shifts in where they sit in the room and whether they look at the patient while they're talking might help build rapport. And she encourages them to say, "if I'm not the best person for this conversation, I'm happy to help connect you to someone who is." This opens up the possibility of "identity matching" with a provider, so patients can see someone of the same race or gender identity.
"This can be really important, especially for patients in need of mental health care," says Ray. "If you're seeking out a therapist because of racial trauma, for example, you don't want to have to relive that trauma by educating a white provider who hasn't done this work."
You may be wondering why identity matching is so important for a person of color, a woman, or a queer or fat person, when it would be considered bigotry for a white man to ask for only white male providers. But it comes down to health risk. "A white man doesn't experience the kind of stigma or discrimination that negatively affects his health the way someone with a marginalized identity does," Louise Metz, MD, an internist and owner of the Mosaic Care Clinic in Chapel Hill, North Carolina, tells Health.
Dr. Metz describes the approach her practice takes as "inclusive and affirming care." "This means we acknowledge the diversity of our patients and respect the varying cultural and social factors that may affect their health," she says. In practice, Dr. Metz and her team have worked hard to consider how comfortable patients of different backgrounds will feel in their waiting room and exam rooms: Are the spaces accessible for people of all abilities? Do chairs work for folks in larger bodies? Does the art and décor represent the diversity of their patients? And she makes sure to prioritize diversity in hiring so that patients can see themselves reflected in the clinic's team members.
"It's not just about saying 'you're included here,'" says Dr. Metz. "It's also about acknowledging the reality of stigma-fueled health disparities. I might say to a patient, 'I haven't experienced [systemic racism or discrimination], but I want to know what health care has been like for you in the past.' Because so often, it hasn't been an affirming experience and we need to name that."
Advocating for yourself
In a perfect world, every health care provider would come out of graduate school having done extensive cultural competency work, and the kind of trainings offered by Mensah and Kinavey would be required continuing education. But until that happens, most of us are limited by finances, geography, or other resources to a certain pool of providers—who may or may not be sensitive to our particular needs. It's not your job to educate your doctors about your cultural identity, but there are ways to encourage them to do the work and meet your needs.
George recommends writing up a personal "health and wellness statement" that lets providers know your cultural identities and preferred terminology. (Hers notes that she prefers to be called "fat" and finds the term "obese" offensive.) You can also highlight your health and wellness concerns or goals and note any boundaries you need to feel safe in their care. George's form states that she does not want to discuss eating or weight loss due to her eating disorder history. "My current doctor read that and two years later, when I came in with food poisoning, asked permission to give me a list of foods that would be easier on my stomach," George says. "It meant so much that she remembered and respected that. I knew I could trust her."
If you feel awkward presenting such a document to your provider, email it in advance or hand it to the receptionist when you check in. But know that every doctor interviewed for this article said they would welcome that information. "I'd be really excited to get a letter like that," says Dr. Black. "I can't speak for everyone. But I do think doctors both appreciate when patients can be concise and yet also respond so well when we know a patient's story."
Even if you don't give doctors a written statement, it can help to write down your symptoms or concerns and any questions before the visit. "Then go in and read from that script," advises Ray. "Recognize that going to the doctor can be stressful, and when we get stressed out, we can get silent or shut down. Having everything written down will make it easier for you to be heard."
Remember too, that you have the right to refuse any aspect of treatment that feels unsafe to you, whether that's not getting on the scale when it's time to take your vitals, or refusing an invasive or expensive test because it hasn't been explained well. "You are a customer with rights and agency, and you get to say yes and no," Dana Sturtevant, MS, RD, Kinavey's co-founder at Be Nourished, tells Health. "It's okay to ask a provider to slow down and answer questions."
Get second and even third opinions whenever possible. "Your first option may be the white doctor that's down the street, but maybe you travel a little further just this once to get another opinion from a doctor who matches up with you by race or gender," Ray explains. "You'll feel more confident in your treatment plan once you have all of that input."
However your experience with a provider goes, look for ways to give feedback—whether in person or later through a patient satisfaction survey, which many clinics email to patients after every visit. And share your experience with your community, too. "If you had a bad experience with a provider, report that to protect the next person," suggests Ray. "But if you have an amazing experience, tell people that too." You can post reviews on Yelp, on social media, or talk about your experiences in community groups or at your place of worship. "Research shows that Black people who attend church are more likely to use health care, because Black churches are networks and people share information on which doctors treat them well," notes Ray.
Above all, remember that while we've been conditioned to think of doctors as all powerful and all knowing, they aren't. You have the right to ask questions and advocate for what you need during any health care encounter, and you can be confident that doing so will improve not only your own experience but also have ripple effects across your community. "It is challenging to navigate health care systems," says Mensah. "But don't give up. There are providers out there that are doing the work and want to help."
Virginia Sole-Smith is the author of The Eating Instinct: Food Culture, Body Image and Guilt in America and writes the newsletter Burnt Toast.