How do we, as hospitalists, win the hearts and minds of patients, families, and care team members whom we do not know? What are the obstacles that we face when encountering patients and gaining the trust needed to improve patient care and patient experience?
With these questions in mind, the Cultural Humility Work Group, part of SHM’s Practice Management Committee, set out to develop a simple, universal framework to provide a foundation for strengthening communication skills and raising awareness of the basic tenets of cultural humility. According to Tervalon and Murray-Garcia, cultural humility is defined as a “process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. It requires humility in how physicians bring into check the power imbalances that exist in the dynamics of physician-patient communication by using patient-focused interviewing and care, and it is a process that requires humility to develop and maintain mutually respectful and dynamic partnerships with communities” (Tervalon, M. & Murray-García, J. “Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education.” J Health Care Poor Underserved. 1998;9[2]:117-25).
Dr. Aziz Ansari
To begin, the work group set out to identify where the root of communication breakdowns lies. As we pulled the literature review together, the Sabin and Greenwald study (2011) reverberated with us. It concluded that a physician’s implicit (or unconscious) attitudes and stereotypes are associated with treatment recommendations. Unconscious biases became the focal point of our project given the realization that treatment is being affected without many physicians even knowing it (Am J Public Health. 2012 May;102(5):988-95).
How do we win this battle? The first step is to simply be aware that everyone is a victim of unconscious biases. Once we come to this (often uncomfortable) realization, we must make a conscious effort to change our mindset and make conscious decisions to not allow these biases to manifest.
Practicing cultural humility is extremely important in this process. It puts everyone on the same platform because there is no “minority,” “majority,” or “ethnicity” associated with it. It takes away the need to know everything about a certain culture and encourages us to approach every patient encounter acknowledging that we will humble ourselves, learn what is important to the patient, and leave having learned something from the interaction.
The work group developed “The 5 Rs of Cultural Humility” as a simple tool for hospitalists to incorporate into their practice. The first four Rs (Reflection, Respect, Regard and Relevance) are extrinsically focused, while the 5th R (Resiliency) is intrinsic. Our theory posits that, if you attain the first 4 Rs in every interaction, these will serve to build on and develop your own personal resiliency. Here are the 5 Rs:
- Reflection – Hospitalists will approach every encounter with humility and understanding that there is always something to learn from everyone.
- Respect – Hospitalists will treat every person with the utmost respect and strive to preserve dignity at all times.
- Regard – Hospitalists will hold every person in their highest regard while being aware of and not allowing unconscious biases to interfere in any interactions.
- Relevance – Hospitalists will expect cultural humility to be relevant to the patient and apply this practice to every encounter.
- Resiliency – Hospitalists will embody the practice of cultural humility to enhance personal resilience and globally focused compassion.
The content will be available as a downloadable pocket card that can be easily referenced on rounds and shared with colleagues. Our hope is to achieve heightened awareness of effective interaction. In addition to the definitions of each of the Rs, the card will feature questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.
The card will be printed and disseminated at Hospital Medicine 2017, and the 5 Rs will be discussed in a few sessions: “Making ‘Everything We Say and Do’ a Positive Patient Experience” in the Practice Management track on Thursday, May 4, and during a 20-minute “MEDtalk” in Product Theater 1 on May 3, at 10:15 a.m.
Keep on the lookout for future blog posts, where you’ll read about the 5 R’s in action through vignettes and a deeper dive into each aspect.
For more information and the downloadable pocket card, visit www.hospitalmedicine.org/5Rs.
Dr. Ansari is associate professor and associate division director of hospital medicine at Loyola University Medical Center, Maywood, Ill., and serves on SHM’s Cultural Humility Work Group.