Cultural Humility

In the late 1990s, David Dunning and Justin Kruger developed a study to measure subjects’ abilities in humour, grammar, and logic, and then compared these objective measures of skill to participants’ self-reported competency in each area. The result? People who score the lowest in actual skill rankings tend to be the same people who most drastically overestimate their abilities. The phenomenon has a name: the Dunning-Kruger effect.

Dunning and Kruger observe that people “with limited knowledge in a domain suffer a dual burden: Not only do they reach mistaken conclusions and make regrettable errors, but their incompetence robs them of the ability to realize it.” (Kruger & Dunning 1999:1132) Ineptitude is blinding — it diminishes self-awareness of ineptitude itself: “incompetent individuals lack the metacognitive skills that enable them to tell how poorly they are performing, and as a result, they come to hold inflated views of their performance and ability.” (1127)

We’ll come back to the Dunning-Kruger effect in a moment. But first, a slight digression.

Around the same time of Dunning and Kruger’s study, health care institutions began making more concerted efforts to provide better services in multicultural situations. In an effort to deliver more adaptive, effective, and compassionate healthcare, ‘cultural competency’ initiatives begin springing up in hospitals, health centres, and universities around the world. What is cultural competency? Most simply, it is training that equips healthcare professionals to see their practice (and themselves) through a cultural lens, and adapt accordingly.

From a cultural perspective, no biomedical diagnosis, prognosis, or treatment ever occurs in a social vacuum. Like all human activities, medicine must always be practiced in a world of variables — amidst a fluid intersection of class, caste, ethnicity, age, gender, religion, ideology, sexuality, power, and physical and mental ability. It is impossible to separate physical health from human culture. For instance, prescribing the correct medication to a sick woman may be categorically ineffective in terms of healthcare if her husband asserts his culturally reified dominance and beats her, on religious grounds, for using pharmaceuticals. How quickly a patient will seek healthcare is massively influenced by cultural norms, stigmas, and beliefs. What every culture implicitly assumes about authority, institutions, truth, and science, largely shapes how it defines ‘health’ in the first place.

In a globalized world, virtually every clinical practice now involves cross-cultural healthcare. This makes cultural competence an increasingly important skill set for all practitioners and professionals, and it has broadly led to the realization that individual healthcare providers — doctors, nurses, etc — can only relate interculturally to the extent that they appreciate the weight of their own cultural biases and beliefs on their clinical interactions. (Practicing medicine across cultures is a bit like translating a language: the final translation can never be any better than the translator’s grasp of both languages involved.) Cultural competency, thus, requires an ever expanding self-awareness of one’s own latent assumptions.

Now the story takes an interesting turn, I think. As the need for cultural competency has grown, so have the training and resourcing opportunities. One can now earn certificates in cultural competency — become a ‘master’ of the subject. This might be all good and wonderful, but it leads to a new cultural question: is it healthy to have healthcare professionals thinking to themselves, ‘I am a now a master of cultural competency’?

This brings us back to the Dunning-Kruger effect. Applied to healthcare in a cross-cultural context, we might imagine that a true master of cultural competency would be the last person to think of themselves as a ‘master’ at all. In fact, such a person might be hesitant to even self-describe themselves with the word ‘competent’. ‘Competency’ suggests a certain level of achievement, but an appreciation for the subtleties and prevalence of culture leaves one ever-questioning their ideas about what ‘the other’ person — the patient, for instance — truly needs, wants, and believes.

Just try having a meaningful relationship with someone who assumes that they have figured out everything they will ever need to know about you.

In a cross-cultural healthcare environment, a doctor or nurse who assumes that they understand everything about you, your customs, and your background will be the most difficult to work with, which, in turn, can have clear and direct ramifications on your physical wellbeing and health outcomes.

The problem with the language of ‘competency’ was articulated cogently by Melanie Tervalon and Jann Murray-García in 1998: if by ‘cultural competence’ we mean an “active engagement in a lifelong process” of learning from others, then perhaps this outcome would be “better described as cultural humility versus cultural competence.” (Tervalon & Murray-García 1998:118) In other words, tritely: if you really want to become skilled at something, become a master of second-guessing your own presuppositions as often as you can. Get good at asking questions, listening. Cultural humility means normalizing the state of not knowing what the other person is thinking and feeling in the moment. Opposed to the notion of competency, humility does not purport to possess knowledge of the correct course: humility requires us to learn from the other.

When cultures intersect and collide, uncertainty often follows. But cultural humility is the freedom to live with this uncertainty. It allows me to say, “I do not understand why this person does what they do,” but my lack of understanding does not mean that either of us are stupid, it simply admits that I am missing certain data.

As Rousseau said, “Know how to be ignorant.” (Emile, or On Education, trans. Allan Bloom, 1979[1762]:313)

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