Cultural humility is as essential as anything else in the journey toward equity. Humility comes when we’re critical of ourselves and able to realize our map is only a piece of the whole territory. Miguel Ruiz, MD, inspires us with a conversation about cultural competency vs. cultural humility, seeking to understand vs. seeking to be understood, and the hospitality of the heart.
Cultural humility is as essential as anything else in the journey toward equity. Humility comes when we’re critical of ourselves and able to realize our map is only a piece of the whole territory.
Miguel Ruiz, MD, a HealthPartners hospice and palliative medicine physician, inspires us with a conversation about cultural competency vs. cultural humility, seeking to understand vs. seeking to be understood, and the hospitality of the heart.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guest: Miguel Ruiz, MD
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He's a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together, we're examining the health equity emergency,
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is Off the Charts.
Steven Jackson:
Welcome to the show. In this episode, we spoke with Dr. Miguel Ruiz. He's a HealthPartners hospice and palliative care physician.
Kari Haley:
Our conversation surrounded cultural humility. I think Dr. Ruiz did a great job comparing the differences between cultural competency, which is something that often we are taught or have a little bit more education, on versus actual cultural humility, which probably is the more important piece to having these conversations.
Steven Jackson:
Honestly, let's face it. There is no way I'm going to be competent in every person's culture. But approaching it from a standpoint of, "I don't know, but I'm willing to know," puts us ahead of the game, in terms of patient care.
Miguel Ruiz:
For me, humility is a very important concept. And just starting from the very word of humility comes from the Latin "humus." And humus means "soil." And what I think humility does and provides is a reminder, a constant awareness that we come from the same soil; of our common humanity. And actually, that's also the root for the word "humanity." So to me, when we see our patients and also our colleagues ask the human fellows, who have come from the same root that we are, from the common soil, that really helped me understand the importance of trying to meet people where they're at because they're fellow humans. Yeah, they may be patients. Yeah, they may be chiefs of departments. They may be our colleagues. But they're a person. They're a human being. And I think, when we go to our common human humanity is where we can start to understand each other and realize that they may have points to make that we may be missing.
Steven Jackson:
Dr. Ruiz, he demonstrated how going into a situation, not knowing, especially in the context of patient care, if you go into something not knowing or having the attitude of not knowing, it opens up possibilities of knowing. It opens up possibilities of truly getting to the crux of learning about your patient, their situation, which in turn can lead to the care that you're trying to give in the first place. I thought it was a brilliant conversation.
Kari Haley:
I agree. And I think a lot of it is really just approaching. He goes back to his original talk about the humility being part of "humus" and humanity and just talking to each other on the same level and being open to talking to each other on the same level. Because really ultimately, it comes down to, we're talking person to person here and to be able to relate to each other and be able to have that open mind to be able to do that.
Miguel Ruiz:
That's why having a framework by which you understand and you see an interaction with patients, for all patients, but certainly for patients from different backgrounds to yours, is helpful. And this framework I'm referring to, I have been studying and really focusing on, is the framework of cultural humility. Back to the word "humility" here; the concept of really approaching our patients from the standpoint of wanting to know, of accepting that we don't know, that we need to know. Humbly approaching that. And I don't know if it is OK to talk a little bit about this framework.
Steven Jackson:
Please do.
Miguel Ruiz:
... at this point?
Kari Haley:
Oh, yes.
Steven Jackson:
Please do. Teach us.
Miguel Ruiz:
Really... Well, no. No, no, no. Far from teaching you. Just sharing what is something that actually was developed or at least put on paper by a couple of physicians in California in the late '90s actually, in the setting of a teaching clinic and serving patients from many different cultures. And these two authors, Dr. Tervalon and Dr. Murray-Garcia, they coined this concept of "cultural humility" in contraposition to "cultural competence." And that is an important distinction to consider here because, if you think about it, competence speaks more of developing mastery and confidence in a finite set of knowledge, of principles. And we're already familiar with that, correct?
Kari Haley:
Yes.
Miguel Ruiz:
The knowledge that can be demonstrable, like we do the haircut, or you do with the bar exam or whatever else. And that is a way that to demonstrate you are competent. And I think we sometimes have approached cultural and intercultural communication in such a way, where I take a little course on Latino culture. Or I do some workshops and then suddenly, I come to the conclusion that I'm an expert on African American, on Somali culture, or whatever else.
Miguel Ruiz:
So far from that, and a little bit in response to that, the idea of a cultural humility starts by stating that actually, we need to proclaim, "We don't know. We need to know."
Steven Jackson:
Nice.
Miguel Ruiz:
Because even if you are actually taking care of many Latino patients, and you are familiar with the culture, and you have lived or visited Latin countries, you don't know exactly what the patient in front of you, who is Latino, actually is all about. What are his or her priorities? What's important to them? What cultural traits are key in their life?
Miguel Ruiz:
The problem with competence is that that may lead to stereotyping, and that is something we really want to stay away from. So that first tenant of cultural humility is really a commitment, a lifelong journey to self-critique, to self-reflection, to self-awareness, as we were saying before, to say, "I need to seek to understand. I need to find out."
Steven Jackson:
This next point that Dr. Ruiz made was pretty convicting. And if I can be honest with myself, I will gladly take the blame for most of the problems that I've ever had with patient communication being on me.
Miguel Ruiz:
I think most of the problems with patient communication and interactions have to do much more with attitude of the provider than with knowledge of the provider. And I think patients do pick on that. I think if it was a knowledge issue, in terms of even cultural knowledge, it would be something that we could take a course and again, fix. But the thing is, what is our attitude? What approach? How are we coming to that encounter? What are you thinking before you get into the encounter? That I think is important. And that's what you need to adjust, both in the clinic, to a more rapid pace, in the hospital, where you may have the luxury to spend a little more time. But also there's more acuity, and sometimes that can be an impediment. So I think you need to really be flexible on how that fits best the situation you are in.
Steven Jackson:
The one thing that's highlighted in our conversation is that the concept of cultural humility is inherently patient-centered. And when you walk into a patient's room, or you walk into the clinic room, you understand immediately that there are power imbalances. And I believe that Dr. Ruiz did a great job of explaining exactly what that means.
Miguel Ruiz:
The first tenet of cultural humility, the journey, and to have that such a journey, you have to approach it with humility. You want to be looking at yourself, become a student of the patient, leave your agenda behind, and try to understand what's important to the patient. The second tenet of cultural humility has to do with identifying and recognizing power imbalances.
Steven Jackson:
I love it.
Kari Haley:
Yes. Yeah.
Miguel Ruiz:
And I think that's another point; that we are talking about patient interactions, communication, patient care.
Steven Jackson:
And I've stolen this from you, by the way. I've used this, so.
Miguel Ruiz:
It's not mine. I think I mentioned the authors, yes? Five minutes ago. But the importance, when we enter that sacred moment of an interaction with a patient, to be mindful, to not forget that power imbalances exist most of the time. I will say always. And that privilege. And I'll say here, why privilege plays a role in inpatient physician-patient interactions? It's a reality; we need to be aware of it. And not only we need to identify power imbalances in that relationship, we need to try to do something about it.
Miguel Ruiz:
Just think about it. You enter a room, and I could think of hundreds and hundreds of examples with my team. Here we are, the body of knowledge. We are in a familiar place, our hospital. And here we have this lady who just was here, visiting her daughter from Africa, who has been in Minnesota, in the U.S., For the last two months, who feels sick, but yet doesn't speak the language, or at least know well. Who is afraid because she's unfamiliar with the system. Now, let's think about this past year with COVID if who cannot have a visit from her family in the hospital. Just start thinking about the imbalances there in this interaction, in this relationship.
Miguel Ruiz:
You're feeling well, you had your coffee, and you are ready to go for the day. You got all your results of the test. You know the nurse. You know the social worker. You know how this works, this patient is there, not feeling well. Not having knowledge. In an unfamiliar place. Sick.
Steven Jackson:
That's right.
Miguel Ruiz:
You're well-dressed. You got your white coat. You're protecting yourself even. And she's there half-naked.
Steven Jackson:
Wow.
Miguel Ruiz:
And what do we do about that? How must that...
Steven Jackson:
... powerful.
Miguel Ruiz:
How must that feel? I tell the residents working with me that it's thing to, before you enter in a room, let's do the same way the surgeons in the operating room say, "Time out." "Is this the patient we think it is?" "Are we going to do their right leg?"
Steven Jackson:
That's a good question.
Miguel Ruiz:
"Is it the right or the left?" "OK."
Kari Haley:
That's very...
Miguel Ruiz:
We go through that safety, which have proven to really save lives and decrease errors and so forth. I encourage our residents, "Do a bit of a power imbalance time out before you enter to the room. Set your mind in a tone in which you're going to be looking for this. Because unless you're aware of these issues, you're not going to do much about them." Simple things as sitting down at the patient's level, as opposed to, I'm above you. Even try to be below their level. It's OK, sometimes, to be on your knee, so that they can look down on you. That's powerful.
Miguel Ruiz:
Make sure that you do bring with you a professionally-trained interpreter, if they don't speak the language. That is basic, but language discrepancy is a huge imbalance. And even when you approach them, you say, "I'm so sorry. I don't speak Somali. I apologize. Can I bring an interpreter?" You're not saying, "Hey, you don't speak English." You're saying, "I don't speak Somali, I'm sorry."
Steven Jackson:
I love it, man.
Kari Haley:
Yeah.
Steven Jackson:
That's great.
Miguel Ruiz:
That is a position of humility.
Steven Jackson:
That's great.
Miguel Ruiz:
So this humility applies to every one of these three tenants, the first tenant being: wanting to know, debunking stereotypes. Wanting to understand requires humility. Self-critique requires humility. The second tenet of identifying power imbalances requires humility. OK?
Miguel Ruiz:
I think one of the things I found most important in trying to do something about these power imbalances is to try to identify an area in which you are below, in which you, as a provider, as a doctor, as a clinician, are at a lower level than the patient is. Because they happen to have more knowledge in that area. Because of their job, their occupation. Because their life experience. They're older. They have had children. They have experience in parenting that I may not have because I'm struggling with my teenagers. Am I humble enough to say, "I see that your children come to see you here. They look like wonderful people. Would you give me a couple of tips on what you've done well to have such wonderful children?" How would that make that patient feel?
Steven Jackson:
Yeah, it sounds like it would sort of shift the power back towards them.
Miguel Ruiz:
You will elevate them...
Steven Jackson:
Yeah. That's right.
Miguel Ruiz:
... above you. You become a little vulnerable on this interaction, and you are seeking to learn from them.
Kari Haley:
I think the key points for me was that acknowledgement of that power imbalance is a key important piece. And then, the secondary piece of that would be going forward and thinking more about, how do we work on making those imbalances more equal? How do we change or flip the situation, where our patients themselves feel more empowered in the conversation and in their own health care?
Steven Jackson:
Let's tune in.
Miguel Ruiz:
So what is the third tenant of cultural humility, just to close the loop here of the three tenets, which also requires humility? Well, it's developing non-paternalistic, collaborative partnerships with the patients and the communities we serve. And that is important because, for that, you also require institutional accountability.
Miguel Ruiz:
As an organization, you need to commit that we are going to work with these communities, with these individuals, not from the, we are here, and they are there; above or the power over, but from saying, "We do provide the medical expertise, obviously. And we are a hospital. We have doctors, and there is science here. But we come to you, our community that we serve and that uses our hospital, with a humble approach of wanting to learn from you and say, 'We bring our medical expertise. You bring your cultural knowledge, your areas of expertise. And together, hopefully we put together something that helps both of us, but not in a paternalistic way.'" And I can think of many examples I've seen through the years, with patients, in which these relationships, these partnerships really give fruit to very good outcomes.
Steven Jackson:
The practice of medicine is different today than it was us back when grandma and grandpa were getting medical care. Back in the day, the doctor said something and everybody listened. And "go home and do this, do what I say." And there was maybe even a one sided-relationship there. But today it's all about partnership and collaboration. And this was really touched on very well.
Kari Haley:
I did really appreciate that he did specifically mention, too, that the collaborative partnership is not only with our patients, but with the communities that we serve as well, because I think that brings up the fact that health care is not just within the clinic walls, not just within the hospital walls, but also with out into the community.
Miguel Ruiz:
Clinicians, physicians for the most, I think we are biased towards data. You're right. We are scientists. We want to see the numbers because we've learned, through the history, that sometimes perceptions can be misleading and misguiding us and so forth. And yet I think this is a pendulum that we may have gone a little bit toward the heavier reliance on numerical, quantitative data than perhaps we should. [crosstalk 00:16:41] And I want to say that the feel of phenomenological research, the lived experience of individuals is also scientific. That qualitative quality improvement is also a science and that non-quantifiable numerical processes and information should also be science and is also science, in my mind. That we cannot measure it doesn't mean that doesn't exist. Tell me, how can you measure pain?
Kari Haley:
We tried that.
Miguel Ruiz:
We tried, and we failed.
Kari Haley:
Yes.
Steven Jackson:
Yes.
Miguel Ruiz:
And yet, is pain real?
Steven Jackson:
Very real.
Miguel Ruiz:
How do you measure love?
Steven Jackson:
On a scale of... I'm joking.
Miguel Ruiz:
And you're right.
Steven Jackson:
How big can you open arms?
Miguel Ruiz:
With your hands. So, there's so many things that we cannot measure numerically and that we know are real and are there. I think-
Steven Jackson:
It's a great point.
Miguel Ruiz:
... it goes back to the fact that we need to really listen to patients. Because no matter what the data says, in terms of numbers for... and by the way, numerical quantitative data continues to show that there are significant discrepancies by race, ethnicity, language, etc. So I think now we have a body of evidence, in the quantitative world, of the disparities. So there is a problem. There is a problem. But I think part of the solution and the assessment is really to sit down. Small focus groups, small groups, conversation, where patients hopefully are able to tell us how they feel. And realizing that at the end of the day, regardless of what numbers say... And again, I'm a physician, I'm all for numbers.
Kari Haley:
Yes.
Steven Jackson:
Sure.
Miguel Ruiz:
I like to believe things that are demonstrable, if possible. But I think we have to be careful that we don't fall into that because then we start losing the heart.
Steven Jackson:
There's no doubt that data is needed to inform our medical decision-making as well as coming up with prognoses and things like that. But I agree wholeheartedly that sometimes we rely too much on data and miss out on the value of the qualitative aspects of care, which I think are equally important.
Kari Haley:
Dr. Ruiz did a great job summarizing that difference between the data, the hard facts that we as clinicians often use, and how we can mix in those other pieces that are not necessarily measurable, like compassion or empathy, into our patient care.
Steven Jackson:
I think just because it's not measurable, doesn't mean it's not important. In fact, qualitative data is the nonverbal communication of information, and it's very important. The last points of our conversation were powerful and humbling, and I believe there was a proverbial mic drop as Dr. Ruiz finished up with talking about how we should seek to understand more so than seeking to be understood.
Kari Haley:
As we listen to this last piece, I really think that if listeners are able to really just sit with this quote that he does, because it really is powerful.
Miguel Ruiz:
Yeah. I'm just thinking about something that Ibram Kendi says, which is: "Being an anti-racist requires persistent self-awareness, constant self-critique, regular self-examination." And-
Steven Jackson:
I love it.
Miguel Ruiz:
And to me, humility comes when you realize that you need to... you are critical to yourself. You have to constantly realize that you may not have it all together, that you actually may not know some of the factors that are leading this patient to think the way they're thinking or to do or to say what they said or to perceive you in the ways they did. You are humble enough to realize that your map is not the territory. You have just one view of the territory, but you don't have the whole picture. That requires humility.
Steven Jackson:
That's great.
Miguel Ruiz:
To think that... Seeking to understand before you want to be understood. And and in doing...
Steven Jackson:
I got to write that down. That's awesome.
Miguel Ruiz:
And in doing so you realize that, oh, perhaps there's another way to look at this situation that I wasn't aware. Or perhaps this patient is responding in such a way because this and this and this happened before to them, with such a doctor with such a situation in such a health care. Oh, boy. If I would have been on that situation...
Steven Jackson:
Off the Charts is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy with creative by Peggy Arnson, Tina Long, Tim Myers, and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.