Cultural Competence, Safety, Humility, and Dexterity in Surgery.

PURPOSE OF REVIEW: As the United States' population diversifies, urgent action is required to identify, dismantle, and eradicate persistent health disparities. The surgical community must recognize how patients' values, beliefs, and behaviors are influenced by race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation, and occupation. RECENT
FINDINGS: Lately, health disparities have been highlighted during the COVID-19 pandemic. Surgery is no exception, with notable disparities occurring in pediatric, vascular, trauma, and cardiac surgery. In response, numerous curricula and training programs are being designed to increase cultural competence and safety among surgeons.
SUMMARY: Cultural competence, safety, humility, and dexterity are required to improve healthcare experiences and outcomes for minorities. Various opportunities exist to enhance cultural competency and can be implemented at the medical student, resident, attending, management, and leadership levels.

In the United States, by 2050, approximately 50% of the population will belong to a minority racial/ethnic group [1]. The United States’ increasing diversity brings opportunities and challenges for health care providers and policymakers as racial and ethnic disparities persist in today’s healthcare system and have been highlighted during the COVID-19 pandemic. To deliver competent services, the health care community must recognize how individual values, beliefs, and behaviors are influenced by race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation, and occupation.

Cultural competence is defined as the ability of individuals and institutions to effectively deliver health care services that meet patients’ socio-cultural and linguistic needs. Providers who value cultural competence aim to collaborate effectively with individuals from different cultures, improve healthcare experiences and outcomes and, most importantly, reduce health inequities and disparities.

Numerous studies across all surgical specialties have demonstrated pervasive racial and ethnic surgical disparities and exhibit the need for culturally competent surgical care:

Pediatric Surgery: Black and non-White neonates with congenital diaphragmatic hernias had a 54% and 52% increased risk of mortality, respectively, than White neonates when controlled for pertinent covariates [2].

Vascular Surgery: A study by Hughes et al. showed Black patients comprise 29% of patients undergoing a major lower extremity amputation, but only 12% of those undergoing an open surgical procedure and 10% undergoing an endovascular procedure for limb salvage compared to White patients [3].

Trauma Surgery: Numerous studies have shown increase mortality in Black, Asian, and Hispanic trauma patients when controlling for injury severity and other pertinent covariates [4-9]. Black trauma patients have been shown to have worse post-trauma functional outcomes, particularly in the traumatic brain injury population [10-13].

Cardiac Surgery: Black children undergoing cardiac surgery had 30% higher odds of referral to high-mortality hospitals, and non-White children had an adjusted 36% higher odds of mortality than their White counterparts [14]. Black and Hispanic adult patients are less likely than White patients to receive invasive cardiac procedures such as angioplasty, bypass surgery, and thrombolytic therapy when controlling for patient characteristics and socioeconomic status [15].

Perioperative Management: Several studies have demonstrated significant racial disparities in postoperative pain management, particularly in the general surgical and orthopedic literature [16, 17].

Between 2014 and 2018, White surgeons constituted 77% of the surgical workforce, while Black and Hispanic surgeons made up 2% and 3%, respectfully [18]. Accordingly, many racial inequities are associated with a failure of cultural understanding and implicit bias in cross-cultural situations. Yet, amongst surgeons who acknowledged such inequities, a majority (91.4%) believed surgical disparities were solely attributable to patient factors instead of provider factors, social determinants of health, and power structures within healthcare [19].

This article examines the meaning of cultural competency and its utility as a critical element in addressing healthcare inequities. Finally, we explore the unique role surgeons can play in providing a culturally competent environment for all patients and surgical teams.

Since the move to provide culturally competent care gained momentum during the American Civil Rights Movement in the 1960s, its terminology has seen numerous permutations [20]. It is essential to review these differences in terminology to lay the groundwork for an appropriate discussion.

Cultural Competence

In 1989, Cross et al. outlined cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professions to work effectively in cross-cultural situations.” [21] This definition is beneficial, as it puts the responsibility on both individuals and healthcare systems to shift behaviors, attitudes, and policies to improve cross-cultural interactions. Finally, cultural competency is relevant to reduce patient disparities but also to improve health care team dynamics.

A narrow focus on cultural competency alone, however, has been criticized as it risks promoting a static understanding that centers on ‘otherness,’ perpetuates stereotypes, and ignores power differentials [22]. The unintended consequence of a limited focus on cultural competence positions the responsibility for poor health solely with the affected individuals or communities. As a result, this focus diminishes the impact of health professionals, the health care system, and broader socioeconomic structures on surgical health disparities seen today. Cultural competence is therefore considered essential but not adequate without cultural safety.

Cultural Safety

Cultural safety is concerned with deconstructing traditional power dynamics between the medical profession, patients and communities, to reduce bias and improve equity within the workforce and health care environments. Cultural safety asserts that health care and socioeconomic systems have created and perpetuated health inequities, and therefore attempts to address inequities by examining, critiquing, and dismantling those structures [22-24]. Cultural safety also affirms that it is not lack of cultural awareness driving health inequities but the direct result of unequal cultural power dynamics, unfair distribution of social determinants of health, marginalization, unexamined privilege, and institutional racism [25]. Thus, cultural safety creates a shift in focus, requiring the surgeon and healthcare system to learn about their beliefs and role in contributing to systemic health inequities, rather than focusing on the individual patient.

Cultural Humility

Cultural humility, a term coined in 1998, defines a dynamic lifelong introspection aiming to address power imbalance and enhance interpersonal sensitivity [26]. The term may be viewed as a muted rendering of cultural safety, adopting cultural competence and cultural safety benefits while choosing the more discreet word, humility. The choice of terminology also helps to create an appropriate mindset for HCPs engaging in cross-cultural situations. Inevitably, errors and missteps will occur in any attempt at building a productive and safe environment for HCPs and patients from minority groups. Humility leaves enough flexibility for surgeons to grow from mistakes and develop an ongoing commitment to learning about different cultures, intersectionality, and their own implicit biases. As such, many have embraced cultural humility as a supplement or replacement term for cultural competence [27].

Cultural Dexterity

Like humility, the semantics of dexterity provides many benefits. Surgeons use manual dexterity to apply their knowledge to patient care while navigating the unique circumstances of each surgical case [28]. Likewise, cultural dexterity allows surgical teams to apply socio-cultural awareness, emotional intelligence, and interpersonal skills in cross-cultural settings. It promotes adaptability over mastery, allowing surgeons to adjust to the unique needs of an individual patient [29]. While humility helps to create a flexible mindset, dexterity presents the idea of a personal toolbox that stores mental and physical skills related to providing culturally competent care.

Cultural Awareness

The preceding definitions depend on the surgical teams’ ability to recognize the culture and interpret cross-cultural interactions. The National Center for Cultural Competence defines cultural awareness as being observant and conscious of similarities and differences among and between cultural groups [30]. Cultural awareness often requires individuals to become culturally self-aware: a critical understanding of how one’s culture shapes their personality, beliefs, and biases. In becoming more cognizant about culture’s influence on the self, surgeons must be prepared to be more sensitive and alert to other cultures. Without cultural awareness, the application of cultural competence, safety, humility, and dexterity become virtually meaningless Table 1.

Table 1

Cultural competence and nomenclature

Nomenclature	Definition
	Benefits	Limitations
Cultural competence	“A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professions to work effectively in cross-cultural situations.” [21]
	- Places responsibility on individuals and healthcare systems; - Focuses on patient interactions and health care team dynamics	- Risks promoting a static understanding that centers on ‘otherness,’ perpetuates stereotypes, ignores power differentials. [22]
Cultural safety	Asserts that health care and socioeconomic systems have created and perpetuated health inequities, and therefore attempts to address inequities by examining, critiquing, and dismantling those structures. [22–24]
	- Pays attention to cultural power dynamics, social determinants of health, marginalization, privilege, and institutional racism; - Requires surgeons and healthcare systems to examine their role in contributing to systemic health inequities
Cultural humility	Defines a dynamic lifelong introspection aimed at addressing power imbalance and enhance interpersonal sensitivity. [26]
	- Helps to create an appropriate mindset for HCPs engaging in cross-cultural situations; - Embraced as a supplement or replacement term for cultural competence. [27]
Cultural dexterity	Allows surgical teams to adapt and apply sociocultural awareness, emotional intelligence, and interpersonal skills in cross-cultural settings
	- Promotes adaptability over mastery; - Develops the framework of a personal toolbox that stores mental and physical skills related to providing culturally competent care
Cultural awareness	Observes similarities and differences among and between cultural groups by recognizing culture and interpreting cross-cultural interactions. [30]
	- Requires individuals to become culturally self-aware - Process of being more sensitive and alert to other cultures

Summary of relevant definitions, benefits, and limitations of terms used interchangeably or in lieu of cultural competence

Despite its drawbacks, cultural competence remains the dominant terminology used in current publications, medical education, and clinical settings [31-34]. However, the authors note that cultural competence is often used interchangeably and appropriates meaning from terms such as cultural humility, cultural awareness, and cultural dexterity.

Cultural Competence and the Delivery of Surgical Care

Cultural safety and competency are necessary components in addressing unacceptable health inequities, which disproportionately impact minority groups. Quality surgical care for patients is not limited to performing excellent surgery but requires making sound and culturally competent clinical judgments in a safe and inclusive clinical environment. Data shows that some parts of the community receive lesser-quality care according to the surgeon’s standards and have lower health outcomes [4, 6, 35, 36]. The credibility of medical institutions rely on the public’s trust [22, 37]. As leaders in the clinical and hospital settings, surgeons are uniquely positioned to advocate for surgical teams and healthcare system policies to eliminating health inequity. Surgeons can set the tone for delivering culturally competent operative and perioperative patient care.

Additionally, there is a clear need for culturally competent leadership in surgery. While more recently, medical schools and training programs are recruiting more women, racial and ethnic minorities, the slow surgical pipeline (with training spanning over a decade for many surgical specialties) does not lend itself to adjusting quickly [38-40]. These factors are compounded by slower career progression seen from medical school into residency and through associate professor to full professor, which show rapidly declining proportions of women and minorities in each advancing level. While many inspirational and aspiring young surgeons actively address surgical disparities and surgical cultural competence, the surgical community cannot just depend on trainees and young surgeons to provide this leadership. Effecting meaningful change needs to come from senior surgical leaders to change the culture of surgical residencies and departments to help minority surgeons thrive and deliver better surgical care to diverse patient groups.

A critical step is linking the objective of cultural competence and safety to achieving health equity. This first step requires understanding that health inequities for Black, Indigenous, and People of Color (BIPOC) are unacceptable outcomes. Second, cultural competence must be a continuous reflective process, requiring ongoing self-assessment. Third, cultural competence requires a constant reassessment of power structures and privilege, taking meaning from cultural safety. Therefore, cultural competence should not be limited to formal training curricula but also aligned across all training/practice environments, systems, structures, and policies [22].

The Individual

In its most basic form, culturally competent care is rooted in patient/provider interactions. The individual surgeon and surgical team members can still modify their behavior, evaluate their biases, and enhance the quality of their interactions with patients. Several guidelines include:

Embracing a lifelong approach for gaining cultural competency. Just as culture continues to evolve, cultural competency does not have a discrete endpoint. Individuals can continually improve their cultural dexterity and awareness to meet the needs of their patients better.

Adopting an open mentality fosters growth, curiosity, and humility when learning about one’s own culture and others. For example, surgical providers can use the ASSESS acronym to engage an appropriate mindset in cross-cultural interactions: Ask questions in a humble, safe manner; Seek self-awareness; Suspend judgment; Express kindness and compassion; Support a safe and welcoming environment, and Start where the patient is. [41]

Magnifying an individual’s impact through advocacy. Reaching out to family, friends, colleagues, and institutions can exponentially affect the number of individuals who seek to learn about cultural competency and integrate those practices in daily life.

The Surgical Team (and Team Dynamics)

We can similarly apply individual guidelines on cultural competence to surgical teams. An attitude shift gains more support if they become the behavioral norm within a group, and advocacy is more impactful when supported by a larger group.[42] As the recruitment, retention, and promotion of Black, Indigenous, and People of Color (BIPOC) in surgery improve, ensuring a culturally safe work environment is imperative. As such, certain cultural practices to encourage in teams are:

Open communication. Good team-based communication fosters mutual respect, transparency, and productive feedback. Communication helps team members recognize implicit biases and institutionalize privilege, benefiting from a trusted outside perspective. Additionally, colleagues can be more receptive to feedback and avoid repeating mistakes in cross-cultural interactions.

Expectations/Standards. Progress can be more effective when individuals work as a team. By setting expectations, a team can create a sense of shared responsibility, maintain greater focus, and leave less room for misunderstandings. Explicit expectations can also help standardize patient care across providers.

Inter-professional approach. As previously touched upon, surgeons occupy a privileged leadership position within the surgical team. A partnership with other HCPs such as nurses, physician associates, and physical therapists can promote culturally safe and aware care from all aspects of the patient experience.

Academic Centers/Institutions

Any institution that provides patient care, from larger academic centers to smaller private practices, can initiate effective, culturally competent policies and behaviors. Institutional leadership can set the tone on issues such as health inequities and diversity and inclusion. They can also create and enforce standards, implement training requirements, and provide resources for their staff. Possible methods for action include:

Training. The Provider Awareness and Cultural Dexterity Toolkit for Surgeons (PACTS) could be introduced to standardize cultural competency training for all current staff. Lee et al. noted that institutional support, participant engagement, and clear applicability to surgical practice are essential for this curricula to be successful. [43]

Policy changes. Potential changes include updating the code of conduct to include cultural humility, promoting an open-door policy to facilitate reporting, applying the rules swiftly and equally to all staff members, and increasing representation in the hiring process.

Surgical Volunteerism: Opportunities to live and work outside your home culture facilitate cultural self-awareness—a necessary first step for achieving cultural humility and dexterity.

Physician Training Programs: Medical School, Residency and Fellowship

Physician training programs must prioritize values to help create the next generation of culturally dexterous providers. This is the most sustainable way to ensure progress and eliminate current health disparities. Key areas of focus should include:

Recruiting diverse and multicultural students. The surgical workforce is missing appropriate representation of minorities. While pipeline programs and recruitment efforts have made headway, much progress is still required to overcome the current deficit and build programs that facilitate retention, growth, and leadership opportunities [38, 44].

Curriculum Changes. The American Association of Medical Colleges (AAMC) made cultural competence a core competency for pre-medical students. The Accreditation Council for Graduate Medical Education (ACGME) also made cross-cultural education a general competency for medical students and residents [45, 46]. Teachings should emphasize its ongoing, self-reflective nature and recognize how power imbalances and provider behavior impact health inequities Table 2.

Table 2

Phased approach to cultural competence training

Level	Cultural competence
Individual	- Embrace a lifelong approach for gaining cultural competency; - Use the ASSESS acronym to engage an appropriate mindset in cross-cultural interactions; [41] - Advocate to engage family, friends, colleagues, and institutions
Surgical team	- Promote team-based communication that fosters mutual respect, transparency, and productive feedback; - Set expectations for culturally aware teamwork and patient care; - Partner with others to promote culturally safe and aware care from all aspects of the patient experience
Academic centers/institutions	- Introduce the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS; [43] - Update policies relevant to cultural humility, reporting, and increasing representation in the hiring process; - Create opportunities for providers to live and work outside their home culture and to facilitate cultural self-awareness
Physician training programs	- Recruit diverse and multicultural learners; - Emphasize self-reflective learning, power imbalances, and the impact of provider behavior on health inequities in program curriculum

Summary of strategies to promote culturally competent care and health equity targeted at different levels in the healthcare system

Conclusion

Surgeons must continue to care about cultural competence with each patient encounter, and mastering measures to improve cultural competence will help alleviate healthcare disparities and improve health care outcomes in surgical patient populations. Efforts must begin early in the pipeline to attract qualified racial, ethnic, and gender minorities to the field; actively improve the surgical culture to retain and promote highly motivated and skilled competent minorities in surgery; and advocate for culturally competent healthcare policy to improve the access and outcomes for surgical care nationwide. Cultural competence must be required for all surgeons and surgical trainees, regardless of race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation. Various opportunities exist to enhance cultural competency at the medical student, resident, attending, management, and leadership levels.