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Transcending Cultural Competency with Awareness and Compassion
posted 11.09.2015

By Joseph Sacco

The patient, an African American man in his late 50s, was critically ill and tethered to a ventilator. Bacteria grew from his blood, his kidneys had shut down and his liver had been rendered wooden and cirrhotic by decades of silent hepatitis C infection. His death, in hours or days, was inevitable.

His brother, sister and pastor, also African American, sat at the ICU conference room table, shocked and angry. A week ago, he was fine! I had gathered them to discuss his care, and knew the conversation would be difficult. I am a white, middle-age male. I wear a button-down shirt and tie, a stethoscope draped around my neck. My appearance and my race had the potential to make an already difficult discussion much harder. Race-based disparity is common in healthcare, an unfortunate truth now staring back at me as I thought about how to begin the conversation. The patient’s family and friends may have already judged me. “What scam,” they could well be thinking, “does the white man have for us today?”

What Is Cultural Competence?

Racist attitudes are ever present. My white colleagues may claim to be prejudice-free—they “like black people” or “have black friends”—but these platitudes miss a deeper truth. Racism is ubiquitous, even if it’s often unconscious, and thus all the more insidious and difficult to root out. It is a white person’s unthinking assessment that a black man in a hoodie and saggy pants is a drug dealer, or a white woman instinctively locking the car door when driving in a black neighborhood.

In contrast, “cultural diversity,” the idea that culture and, by extension, race, brings characteristics that distinguish one group from another, is a politically correct and generally accepted construct. “African Americans have a tradition of shared family decision-making and commitment to Christian values.” “Latinos may hide a terminal diagnosis from a sick loved one.” “Men are the decision makers in Muslim families.” Such generalizations are not regarded as racist, and people who are consciously aware of and take into account such distinctions without judgment are considered “culturally competent.”

The conversation was as difficult as I had predicted. The patient’s brother sat in scowling silence, arms crossed over his chest. His sister peppered me with questions about cirrhosis, sepsis and kidney failure. I explained that my job was to assure that the patient’s loved ones understood his condition and choices for his care. I was not surprised when they elected to continue the most aggressive medical interventions possible. The patient had spent years living on the street, drowning in drugs and alcohol. Medical care had amounted to hours of sitting in a dingy clinic waiting area, then 15 minutes with a harried doctor who would admonish him not to smoke and drink and refer him to a specialist months in the future. Why would they now forgo the most intensive possible medical care?

Confronting Our Unconscious Bias

For me, the only way to prevent racism from influencing my medical practice is to confront it head on. That black woman at the take-out counter in the hospital coffee shop? My white upbringing tells me she works in housekeeping. My conscious mind looks again and recognizes her as a member of the surgical attending staff.

And, just as I am prone to judge others, I know others judge me. That white guy with a stethoscope and tie? He doesn’t care about us—we’re black. And while “cultural competency” tells me about the tradition of shared family decision-making among black people, it says nothing about that black guy—the one sitting across the conference room table. He may not have spoken to his family in years. The task is to be conscious—of one’s own assumptions and of the subtle truths that apply to groups, but not individuals. The task is to be open-minded about the person at hand.

I concluded the meeting by telling the patient’s family that I understood their distress. I, too, had experienced the fear and sadness of having a critically ill loved one. My thoughts, I said, were with them. I asked if we could meet at the patient’s bedside the following day, and they agreed. Only the pastor thanked me for my time.

I followed up in 24 hours. Keeping promises, even the most minor, is critical to building trust. The sister, Yvette, spoke in an entirely different tone. Even her body language was less guarded. The family now understood how sick the patient was. They were trying to decide what to do. It was hard, Yvette said, and I agreed. It was terribly hard. We agreed to meet again the next day.

When we did, the transformation was complete. I now had a face and a name. I was the doctor who had been truthful and compassionate. I had allowed the family the time they needed to observe the patient’s progress and to make a decision about his care. They had seen with their own eyes that I had been truthful, that the white doctor did not have a racist agenda. Now, the whole family thanked me, and even the scowling brother accepted my handshake.

What the family decided to do next is not relevant. What is relevant is that trust was established, that relationship transcended race, racism, cultural diversity. A face, a name and a little bit of caring and compassion had transcended it all. 

Joseph Sacco, M. D., is founder and director of the Palliative Medicine Consultation Service and Hospice Inpatient Unit at Bronx Lebanon Hospital Center in New York City

Editor’s Note: This article appears in the November/December 2015 issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store or Join ASA.

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