Respect and empathy in teaching and learning cultural medicine.

We were introducing the topic of health disparities to a group of medical students when it happened. The film we used showed the difficulties of an elderly Asian American with cancer negotiating the health care system. Some of the students had expressed their beliefs that cultural competence was an important part of studying about disparities and the class was going smoothly. But I had noticed him, sitting in the corner, quiet and looking down, seemingly disinterested at first, then growing restless and increasingly agitated. Suddenly he burst out, “Why are we talking about CULTURAL competence? We should just talk about COMPETENCE! All we need to do is treat each patient as an individual!” He stopped and looked embarrassed. The room became silent and slowly all eyes turned from him to me. Time stood still and I felt fully present—a classroom crisis, and as the Japanese character for crisis reveals, there was the possibility of a dangerous collapse of my carefully planned lesson and also the opportunity for a transformative learning moment. This was not the first time, and I had learned to anticipate such reactions. In my experience, students comprehend health disparities when shown statistics that reveal the prevalence of certain diseases in particular populations. They follow along when the reason for disparities is explained as biological. However, difficulties emerge when social explanations are given for disparities, such as unequal medical care. This raises the ugly head of prejudice and discrimination, creating difficulties for trainees, depending on where they are in their own development. Some who are in denial, naive, or ignorant may be unable to connect to the topic. Others are in conflict, guilt-ridden, feel attacked or left out. These individuals tell me later about their fear and confusion as they feel themselves reduced to a stereotype of the privileged, entitled oppressor or the culturally insensitive clinician. They want to be seen and heard, in other words, respected. As a counseling psychologist I know that not being seen, humans find it hard to move and resist the determined efforts of others to change us. A battle for power and control ensues. Defenses go up, resistances arise, options disappear, and creative efforts to prevent annihilation burst forth in a fight for one’s existence. I tried to empathize more with these trainees and consider deeply how we could best enable them to learn. Acknowledging that one is prejudiced, and that this impedes one’s ability to care for certain people is tough to swallow. Opening and accepting that one is at a lower level of cultural consciousness and racial identity development and acting to change that is not easy. In my experience, most people don’t learn well by being told they are deficient and then offered the chance to discuss it, and certainly not medical students who are highly invested in their intelligence and capabilities. I now begin by telling trainees that disparities is a topic for everyone, because we all have experiences and knowledge of difference and exclusion. My goal is to engage trainees from the beginning in “their” topic, one that concerns them as much as anyone else. I confront them with my assumption that some are already checking out because they see topics like culture, race, and diversity as about “others” and for “others.” They think they already know how to relate with different kinds of people or feel they do not need to learn anything because they will just treat all patients the same, in a colorblind, equitable manner. I tell them that I suspect some are even angry that their time is being wasted on such an unnecessary subject when so many more important things need to be learned. I ask them to stay with me and discover what disparities means to them in their quest to be the best doctor they can. We reflect on what they know about being different, isolated, invisible. We consider diverse forms of human experience, including, but not limiting ourselves to race, ethnicity, and gender. I ask them what they know about poor patient satisfaction, poor access to services, or poor physician communication. We explore their personal experiences with illness and healing and encounters with the medical system. Then I tell them that while we all have experiences that help us understand these issues, for some people these issues are acute and extreme—and the greater the differences between doctor and patient the worse it gets. Health disparities are about inequalities, and poor care due to human shortcomings in understanding others, known by volatile words such as prejudice, bias, and discrimination. I challenge trainees to realize how their own limitations in understanding others impede their capabilities of providing optimal medical care to diverse people. My hope is that with this approach trainees can be moved in some small way to greater empathy and respect for their patients. I find that they are open to self reflection and transformation once they feel empathized with and respected. As a trainer, I try to model how to respectfully and effectively communicate about healthcare with diverse populations. I include myself among those who need to continually challenge ourselves to develop, teaching cultural competence as cultural humility and from a position of cultural humility, placing myself with them, a senior fellow traveler with my own challenges of remaining open and learning from my patients every day. Health disparities education is inherently difficult because it focuses on differences, which is volatile, emotional and divisive for all of us. A teacher must be prepared to deal with resistance in the form of withdrawal or defiance, seeing these as precious teaching opportunities and learning moments. I try to be mindful, listening with my heart. I know there are no pat answers and nothing less than a sincere engagement is required. I attempt to model respect and empathy in my encounters with trainees hoping they will learn and extend these gifts to their diverse patients.