Recognizing cultural differences and personal biases can help clinicians provide more equitable care
As US populations become increasingly diverse, clinicians have a heightened responsibility to provide care that is informed by a patient’s cultural background.
Health care delivery and patient outcomes can be enhanced when practitioners learn to identify their own biases about people, recognize systems that oppress patient populations, and acknowledge the limitations to fully understanding another person’s culture. Practicing cultural humility means actively engaging in self-evaluation and self-critique, recognizing and leveling power imbalances, and fostering meaningful partnerships with communities.1 This process of ongoing personal and professional development is a lifelong commitment. Adopting this approach can facilitate practitioners’ ability to thoughtfully advocate for their patients and provide the best possible care for all.
Culture—beliefs, behaviors, attitudes, and practices that are learned, shared, and passed on by members of a group—is multifaceted and dynamic.
Implicit Bias and Disparities in Health Care
Having positive or negative attitudes toward another person, group, or thing, also known as bias, is a natural phenomenon. Some biases are positive and helpful, acting as mental shortcuts that allow for quick problem-solving and decision-making; other biases are based on stereotypes, rather than actual knowledge of an individual or circumstance, and can lead to distorted clinical decision-making and discrimination. Implicit bias refers to unconscious attitudes and beliefs towards a person, group, or idea that are learned over time.2,3 Even well-meaning people may hold unconscious biases that can be just as harmful as overt expressions of prejudice.4
There is significant evidence that many clinicians hold stereotypes related to race, gender, socioeconomic status, and other characteristics that influence their interpretation of patients’ behaviors and symptoms, as well as their clinical decisions.2-13 For example, several studies have found that clinicians hold implicit stereotypes of Black patients as being less compliant and less cooperative than white patients.5 These stereotypes and biases frequently operate outside of conscious awareness and likely contribute to health disparities that are not otherwise attributable to patients’ socioeconomic status, access to health care, and other known social determinants of health.
In 2003, a groundbreaking report by the Institute of Medicine demonstrated that racial and ethnic minorities consistently receive a lower quality of health care across a wide range of procedures and diseases, and identified implicit bias and stereotyping among health care providers as factors that may contribute to health disparities.8 Subsequent research has found evidence of bias in the diagnosis and treatment of people of color, as well as other stigmatized patient populations:
- Black and Hispanic patients, across treatment settings, are significantly less likely than white patients to be prescribed opioids for similar types of pain.9 Similar racial/ethnic disparities in prescribing have been observed among pediatric patients treated for abdominal pain in emergency departments.10
- American Indian/Alaska Native and Black women are two and three times more likely, respectively, to die from pregnancy-related causes than white women nationally.11 Among Black women with a college degree or higher, the pregnancy-related mortality rate is five times higher than that of white women with a college degree and 1.6 times that of white women with less than a high school diploma.
- Health care providers spend less time in appointments, provide less education about health, and are more reluctant to perform certain screenings with patients who have obesity, compared to thinner patients.12
- Women in same-sex relationships are 25% less likely to receive Pap tests and mammograms than women in different-sex relationships, even after controlling for sociodemographic characteristics, health insurance coverage, smoking status, and self-rated health.13
These findings and others suggest that clinicians’ beliefs about certain groups of people can influence the quality of care their patients receive, regardless of clinician intent.
Awareness of one’s own biases is important, especially when working with patients from different backgrounds and/or identities, and clinicians can take steps to reduce the impact of bias on their clinical practices.
What is Cultural Humility?
To address the issues of health disparities and provider bias, many medical institutions have adopted “cultural competence” training, which aims to increase practitioners’ ability to understand, communicate with, and effectively interact with people across cultures.14 A more patient-centered and holistic approach, however, is that of cultural humility. Instead of assuming a false sense of mastery of a finite body of material with a discrete end point (as is implied by the use of the word “competence”), the culturally humble clinician pursues a lifelong process of self-evaluation, learning, and accountability.1,14
This framework urges clinicians to adopt a curious, open, and self-reflective stance in partnership with patients and communities. It acknowledges the complexity and fluidity of culture, and the need to relinquish the role of “expert” to the patient who can offer unique insight into their own culture and its relevance to the clinical encounter. Clinicians’ shared experience in one dimension of culture or identity—such as language, sexual orientation, socioeconomic status, geography, religion, social habits, gender, or race/ethnicity—should not lead them to believe they understand the other intersecting and often nuanced dimensions of patients’ identities.
Cultural humility is a lifelong journey and commitment to acknowledging one’s own discomfort, assumptions, and misinformation about other people, and to redressing the inherent power imbalances in the patient-clinician dynamic.
This approach challenges clinicians to also acknowledge the social and structural factors, such as racism and limited economic opportunity, that may disadvantage patients who come from marginalized groups. It encourages clinicians to continually work to reduce disparate treatment of patients and advocate for equitable treatment for all patients.
Putting Patients’ Health Into Context
Patients may have different experiences, values, and preferences than their clinicians, and these details should be respectfully sought out and taken into account when making recommendations and clinical decisions.
Relationships with Law Enforcement
Communities of color experience disproportionately high rates of violence perpetrated by law enforcement, and are often simultaneously over-policed (e.g., hyper-surveillance, aggressive police behavior) and under-policed (e.g., slow response times, fewer crimes solved).15 Notably, young men of color are at higher risk of being killed by police than their white peers.16 In an increasingly digitized world with growing access to body-cam footage, communities of color also experience vicarious trauma from witnessing or learning about incidents of excessive use of force by police upon people of color. Understanding this broader context is critical when exploring patients’ risks for firearm injury, reasons for gun ownership, and/or receptiveness to interventions, particularly those that might involve law enforcement or conflict with patients’ self-protection goals.
Consider these hypothetical examples:
An older female patient tells her doctor that she recently bought a handgun after her house was broken into. Three people on her block were shot last year, and police in the area are known to have slow response times. Rather than focusing on the dangers of gun ownership, her doctor validates her concerns and reasons for owning a gun, discusses how to safely store the gun at home, and helps the patient enroll in an online firearms safety training course.
A young Black man expresses concern to his therapist that his brother might be suicidal. They have guns at home and live in a high-crime neighborhood. Before recommending that her client temporarily remove guns from the household or call law enforcement in an acute crisis, the therapist considers how these actions might play out for her client and his family. Not only is her client unlikely to follow this advice, but doing so could have serious unintended consequences for having initiated encounters between his brother and law enforcement officers. Instead, they work together to identify other ways to keep his brother safe.
Mistreatment in Medicine
It is also vital to acknowledge the harm inflicted upon communities of color by the institution of Western medicine, both historically and in the present day. A prime example of medical exploitation, deception, and mistreatment of Black people is the Tuskegee Syphilis Study, which, beginning in 1932, deliberately withheld information and effective treatment from 400 Black men with syphilis (who were promised free medical care) in order to study the natural course of the disease.17,18 The experiment, conducted by the US Public Health Service, continued for 40 years until it was criticized by the national press and determined by an investigatory panel to be “ethically unjustified.” At that point, 74 test subjects were still alive and at least 28, but perhaps more than 100, had died directly from advanced syphilitic lesions.
The Tuskegee Study isn’t the only example of unjust medical treatment of minoritized groups. Throughout the 20th century, tens of thousands of women, mostly women of color, were sterilized without their consent.18 Thirty-two states had eugenic sterilization laws, which authorized medical superintendents in state homes and hospitals to sterilize patients deemed “feebleminded” or “unfit” to reproduce. In California, where one-third of all compulsory sterilizations in the US occurred, the risk of sterilization was 59% greater for Latina women (mostly of Mexican origin) compared to non-Latina women.19 Likewise, in the 1970s, data suggest that the Indian Health Service sterilized at least one-quarter of Native American women of childbearing age, many without proper informed consent.20
These are a few of the many examples of the mistreatment experienced by people of color in the house of medicine, the natural result of which is suspicion and distrust of the medical institution and those associated with it. Acknowledging this harm is the first step in rebuilding trust. By integrating a historical perspective into their practice, clinicians can better understand and address why some patients might, for example, delay seeking medical care, fail to adhere to recommendations, or miss follow-up appointments—even when, from the clinician’s perspective, these actions are in the patient’s best interest.
Practicing Cultural Humility
Efforts to reduce provider bias and practice cultural humility may help reduce health disparities and improve patient-clinician interactions in general.4 Many of these strategies are not intended to directly change clinicians’ biases or suppress them (which can have negative, unintended consequences), but rather to increase awareness of one’s biases and to mitigate their adverse impacts on clinical encounters. Above all, these strategies encourage clinicians to apply a person-centered approach to care, rather than viewing patients more indiscriminately as members of social categories.
Implicit association tests, accessible online, can be used as educational tools to get people thinking about implicit bias. These tests measure the strength of associations between concepts (e.g. weight) and evaluations (e.g. good, bad), which may be related to people’s unconscious attitudes or beliefs. Journaling, receiving honest evaluation from trusted others, engaging in opportunities to learn about others (i.e. movies, books, journal clubs, dialogue sessions), and reviewing videotaped clinical encounters with an expert can also cultivate self-awareness.
To facilitate self-reflection, clinicians might ask themselves:14
- How do my cultural identities shape my worldview?
- How does my own background help or hinder my connection to patients/communities?
- What are my initial reactions to patients, specifically those who are culturally different from me?
- How do I make space in my practice for patients to name their own identities, belief systems, or relevant life experiences?
- What do I learn about myself through listening to patients, staff, or colleagues who are different from me?
Clinicians should also reflect on the ways in which cultural values and structural forces shape patient experiences and opportunities, by asking questions such as:14
- What social and economic barriers impact a patient’s ability to receive effective care?
- What specific experiences are my clients having that are related to oppression and/or larger systemic issues?
- How do I extend my responsibility beyond individual clients and advocate for changes in local, state, and national policies and practices?
Clinicians can also assess cultural humility at the institutional-level. For example, they might consider:14
- Do our staff and leadership reflect the communities/populations we serve?
- How do we, as an organization, engage with the larger community to ensure community voice in our work? What organizations are already doing this well?
- What experiences of inequity or suboptimal care is this patient likely to have encountered at my health institution?
- Where would I go to find out the reputation my institution has in the community?
Research suggests that cognitive stressors, including those associated with clinicians’ internal states (e.g., stress, burnout, fatigue, hunger) and characteristics of the clinical environment (e.g., overcrowding, patient load, competing demands, excessive noise) increase implicit bias and stereotyping behavior.2,3 On the other hand, clinicians who experience higher levels of positive emotion during clinical encounters are more likely to view patients in terms of their individual attributes and less likely to categorize people in terms of their racial, ethnic, or cultural group.4
Some emotional states and environmental factors may be difficult to change, especially the further away one is from the decision-making power at the workplace. However, being aware that stress and negative emotions may increase stereotyping can make clinicians more vigilant about when their interactions with patients are likely to be biased. When time and circumstances allow, clinicians can use stress-reducing techniques, such as mindfulness meditation—even for brief, one-minute or less episodes while working—to recognize and regulate their emotions, increase empathy and compassion, and reduce the impact of implicit bias on their behavior.3
Laboratory studies instructing subjects to adopt another person’s perspective and situation have been shown to reduce bias toward a range of stigmatized groups and to inhibit the activation of unconscious stereotypes and prejudices.4 While clinicians may never fully comprehend an individual patient’s perspective, spending a moment in each clinical encounter imagining themselves “in the patient’s shoes” or as a member of one’s family can increase empathy and interest in the patient’s welfare, ultimately improving the effectiveness of the clinical interaction.
When clinicians build partnerships with patients—leveling power imbalances and reframing the interaction as one between collaborating equals on the “same team”— and patients may become more open and engaged.1,4 Clinicians should aim to find common ground with patients, reaching agreement about their respective roles, the nature of the medical problems and other priorities, the goals of treatment, and the likelihood of follow-through given the patient’s current life circumstances and challenges.
Through partnerships with communities, clinicians can better understand the factors informing community health priorities, research activities, and advocacy efforts and build on the existing assets of communities. By honoring the expertise that exists in communities and partnering with community members and organizations in a “mutually beneficial, non-paternalistic, and respectful” manner, clinicians can begin to address the larger social factors that affect their patients’ health.1
Dr. Shani Buggs and Dr. Nicole Kravitz-Wirtz from the UC Davis Violence Prevention Research Program contributed to this content.
Click to view references
- Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved.
- The impact of cognitive stressors in the emergency department on physician implicit racial bias. Academic Emergency Medicine.
- Mindfulness practice: A promising approach to reducing the effects of clinician implicit bias on patients. Patient Education and Counseling.
- Reducing racial bias among health care providers: Lessons from social-cognitive psychology. Journal of General Internal Medicine.
- Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Processes & Intergroup Relations.
- Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS.
- Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systemic review. American Journal of Public Health.
- Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press.
- Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Medicine.
- Association of race and ethnicity with management of abdominal pain in the emergency department. Pediatrics.
- Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016. MMWR Morb Mortal Wkly Report.
- Overcoming weight bias in the management of patients with diabetes and obesity. Clinical Diabetes.
- Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000-2007. American Journal of Public Health.
- From mastery to accountability: Cultural humility as an alternative to cultural competence. Social Work Education.
- Protests focus on over-policing. But under-policing is also deadly. The Washington Post.
- Risk of being killed by police use of force in the United States by age, race-ethnicity, and sex. PNAS.
- Racism and research: The case of the Tuskegee Syphilis Study. The Hastings Center Report.
- Bad Medicine: The Harm That Comes From Racism. The New York Times.
- Disproportionate sterilization of Latinos under California’s eugenic sterilization program, 1920-1945. American Journal of Public Health.
- The Indian Health Service and the sterilization of Native American women. American Indian Quarterly.
For more information, see these peer-reviewed articles.
Tervalon, M. & Murray-García, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved.
Fisher-Borne, M., Cain, J. M., & Martin, S. L. (2014). From mastery to accountability: Cultural humility as an alternative to cultural competence. Social Work Education.
Burgess, D., van Ryn, M., Dovidio, J., & Saha, S. (2007). Reducing racial bias among health care providers: Lessons from social-cognitive psychology. Journal of General Internal Medicine.
Omeish, Y., & Kiernan, S. (2020). Targeting bias to improve maternal care and outcomes for Black women in the USA. EClinicalMedicine.
Betz, M. E., & Wintemute, G. J. (2015). Physician counseling on firearm safety: A new kind of cultural competence. JAMA.
Additional Resources on Cultural Humility & Implicit Bias
Cultural Humility: People, Principles and Practices
This 30-minute documentary by San Francisco State professor Vivian Chávez mixes poetry with music, interviews, archival footage, and images of community, nature and dance to explain what Cultural Humility is and why we need it.
Excuse Me, Your Bias is Showing
Episode 10 of EM Pulse, a podcast produced by UC Davis Emergency Medicine, discusses racism and implicit bias in emergency health care.
The Danger of a Single Story
In this TED Talk, novelist Chimamanda Adichie tells the story of how she found her authentic cultural voice and warns that if we hear only a single story about another person or country, we risk a critical misunderstanding.