Recognizing the Hidden Curriculum in Cultural Competency

Margot Savoy, MD, MPH, FAAFP, FABC, CPE (Originally published in the October, 2014 issue of DelFamDoc)

Recently I was asked if I first consider myself Black or female. My response was “neither.” It’s not that I don’t consider myself a Black woman, but I tend to think of myself first as a physician and then everything else. The question itself struck me as strange. Why would anyone be confined to being only one “thing?” I began to wonder how often we are trying to squeeze our patients (or colleagues) into convenient classification boxes? If the answer is more that we care to admit, how can we ever truly have a patient-centered, culturally competent interaction with one another?

The Hidden Curriculum

The hidden curriculum refers to the “set of influences that function at the level of the organizational structure and culture including, for example, implicit rules to survive the institution such as customs, rituals ad taken for granted aspects.“ The danger of the hidden curriculum is that it is not subject to review because everyone involved from the learners to the faculty take for granted the values and lessons it imparts. Often this subtle unspoken set of expectations and behaviors is a powerful unrecognized driver of the culture. While often discussed in medical education in relation to professionalism, the hidden curriculum can have a profound impact on other areas of medicine like cultural competency.

Cultural Competency: From Crosse to CLAS

A culturally competent system of care acknowledges and incorporates- at all levels–the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally-unique needs.”¹ The monograph describes a system (and an individual within a system) as striving to attain proficiency through an on-going developmental process that encourages the system to “ 1) value diversity; 2) have the capacity for cultural self-assessment; 3) be conscious of the dynamics inherent when cultures interact; 4) have institutionalized cultural knowledge; and 5) have developed adaptations to diversity.¹ Figure 1 shows an adaptation of the continuum described in the monograph of how a system responds to cultural differences.¹

In 2001, the United States Department of Health and Human Services Office of Minority Health released the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS standards). This collective set of mandates, guidelines, and recommendations was intended to inform, guide, and facilitate required and recommended practices related to culturally and linguistically appropriate health services. While initially slow to be adopted, the CLAS standards are now integral to routinely used quality metrics such as Patient-Centered Medical Home certification and Meaningful Use attestation.

Sipping Water From a Fire Hose

Cultural competency is a vast topic to cover in a short period of time. Asking a learner to “sip water from a fire hose” requires him to reorganize and simplify the information so that it can be effectively applied in real situations. Heuristics are problem solving strategies using readily accessible, though often loosely applicable, information to simplify the problem. Also known as “rules of thumb” or stereotyping, it allows a person to take a seemingly impossible set of options and whittle it down to a manageable few.

When my scout leader prepared us to camp overnight in the woods, she could not teach us every type of leaf we might encounter, but there were some she clearly needed us to avoid. Instead of trying to teach them all, she simply warned “leaves of 3, let it be” meaning poison ivy and oak tended to have leaves in threes so don’t touch them. While I’m sure there are other leaves best left untouched and some leaves in threes which were safe, overall it was a reasonable strategy (to this day I have never had poison ivy/oak dermatitis). However, when we apply these same types of heuristics to something more complicated like cultural competency problems are bound to ensue.

Challenging our Assumptions about Cultural Competency

The medical community recognizes the importance of being culturally sensitive and competent; however, simply drafting standards and check-lists is unlikely to change behavior if the hidden curriculum remains unexamined. Often the hidden curriculum becomes evident in the heuristics and language we use on a daily basis.

• Do you automatically schedule every patient named Gonzalez a Spanish-speaking interpreter?
• Do you check off the African-American box for every Black patient without asking?
• Does your medical record have a way to record a gender other than male or female?

Having interpreters available is fantastic, and if your staff assumes every Gonzalez speaks Spanish you may be right some of the time—but when you are wrong, how will that patient feel? Similarly if you automatically check off the African-American box for every dark-skinned patient without asking first about her heritage, you will mislabel many patients including the many fair-skinned patients who are African-American but don’t fit your “rule of thumb.” And it isn’t just about race/ethnicity/language— a transgender patient doesn’t want to feel awkward every time she presents to your office because your EMR says she is male but she appears female and there is no place to choose transgender on your registration form. Assuming race/ethnicity, excluding gender options and guessing language preferences are all subtle but real manifestations demonstrating that you still have a long journey on the path to cultural competency.

Intellectual Curiosity is the Key

Cultural competency is an aspirational goal. It is more than simply learning how to avoid major social blunders. It is grooming ourselves to be genuinely open and receptive to alternate points of view. We cannot reasonably expect a couple of hours of medical humanities to transform a one-dimensional sheltered person into a well-rounded culturally competent physician. The only way to open our eyes to the infinite perspectives our patients bring to each encounter is to develop our intellectual curiosity through engaging life and educational experiences. Learning to ask questions rather than make assumptions. Recognizing that that if you know one “fill in the blank” patient you only know one “fill in the blank” patient. From my point of view once you are humble enough to know you can never know what it is truly like to walk in anyone else’s shoes, your journey to cultural competency has begun. ◊

References

1. T L Cross ; B J Bazron ; K W Dennis ; M R Isaacs. “Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed.” National Institute of Mental Health. 1989.
2. Mary Catherine Beach, Eboni G. Price, Tiffany L. Gary, Karen A. Robinson, Aysegul Gozu, Ana Palacio, Carole Smarth, Mollie W. Jenckes, Carolyn Feuerstein, Eric B. Bass, Neil R. Powe, Lisa A. Cooper. Cultural Competency: A Systematic Review of Health Care Provider Educational Interventions. Med Care. 2005 April; 43(4): 356–373.
3. Murray-García JL, García JA. The institutional context of multicultural education: what is your institutional curriculum? Acad Med. 2008 Jul;83(7):646-52.
4. National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, OMH, 2001. https://www.thinkculturalhealth.hhs.gov/includes/downloadpdf.asp?pdf=EnhancedNationalCLASStandards.pdf.(Last accessed 8-11-2014)

Like I mentioned earlier today I’m at the AAFP Congress of Delegates in Washington, DC this week as the alternate delegate from Delaware. With the first official day having come to a close, I have some time to reflect on the day’s festivities.

At the AAFP COD, resolutions are referred to reference committees. These committees hear testimony from members on the various resolutions and then taking into account their expertise and the testimony shared, they draft recommendations for the Congress to consider over the next two days in session. So all day today was spent testifying about (and listening to other folks testify about) around 50 resolutions across the various reference committee hearings: Advocacy, Education, Health of the Public & Science, Practice Enhancement, and Organization & Finance.

Every COD I’ve attended there have been surprises- a combination of unexpected non-issues and presumed non-issues that actually sparked discussion, and this year was no different. Some testimony I found interesting today:

• While there was relatively little discussion about promoting emergency contraceptive options with particular attention to the differing efficacies depending on the woman’s weight, a discussion about access to abortion services quickly appeared to draw a line in the sand among members. On one side urging the Academy to take a strong stand for supporting access to abortion services and urging members to consider abortion as a procedure no different than other medical procedures. While the other side remained adamant that if life begins at conception, murder is not simply a procedure like any other medical procedure. Currently the AAFP takes a neutral stance on abortion issues which is tolerable to the “pro-life” side and until recently was acceptable to the “pro-choice” side. But it was not lost on me that some of our members may be growing weary of the neutrality calling for a strong position- in opposite directions.
• In another reference committee discussion about barriers to sterilization in Medicaid patients took on an interesting tone. Currently Medicaid patients wishing tubal ligation are required to have a 30 day waiting period before the procedure will be covered. This is not true for commercial or self-pay women requesting the procedure. Initially put in place to prevent physicians from forcing sterilization on vulnerable women of low socioeconomic status, now members are questioning why some women are considered vulnerable to being influenced post-partum while others retain unrestricted freedom of choice. A seemingly slam dunk of a resolution to me, it actually sparked some discussion. Some wondered whether all women should be required to wait 30 days. Others felt like no women should have to wait. Some expressed concerns that poor women may be subjected to undesired sterilization while others contended that creating a barrier to the woman isn’t the solution for potentially unprofessional physicians. [I found some interesting articles: perspective piece and ethics piece for anyone wishing to consider further.]
• I expected there to be significant opposition to the resolution calling for more restrictions on personal belief vaccine exemptions. I thought there would be a vocal group concerned that we were removing your right to refuse vaccinations. To my (pleasant) surprise, there was little opposition. Seeing the growing number outbreaks of vaccine preventable due to unvaccinated kids/adults as a serious threat to public health appears to be outweighing the potential restrictions to personal freedom of choice. [To read more about the risks of personal belief exemption policies visit here.]
• And the shocker of the day for me (mostly because I honestly didn’t see it coming) was a fairly loud dissenting voice to a policy to prohibit sale of unpasteurized milk and milk products. From my perspective this one was a no brainer. Why take the risk of infectious diseases when a perfectly suitable pasteurization process exists? Pasteurization was listed as one of the CDC’s top ten achievements in public health (safer healthier food supply). Yet the vocal opposition cited undue burden on farmers/families and personal preference for the benefits of raw milk as strong reasons to avoid adopting the resolution. I must admit I didn’t expect there to be 153,000 Google hits on the “benefits of unpasteurized milk” but alas they exist. Go figure.

There were plenty of other discussions and testimonies today that were interesting new perspectives I had not considered or reaffirmations of my own personal beliefs. What I think is the most impressive reflection on the whole day is that for as wide and deep as our Academy of ~116,000 members may be, all of these discussions- both formal and informal, were respectful disagreements. There was no name calling, finger wagging, slandering or personal attacks. Instead there were simply statements for or against the wide range of resolutions with varying levels of emotion and evidence supporting the provided testimony. So for now we all wait with baited breath to see the final recommendations of the various reference committees as we prepare for round 2. Tomorrow I’ll fill you in on extracting resolutions from a consent calendar and substitute amendments. But for now, go get some rest!