Each September, the Hector P. Garcia Committee solicits applications from UTMB students for the Hector P. Garcia, M.D. Cultural Competence Award.
The award celebrates Garcia, a distinguished 1940 graduate of the School of Medicine and civil rights champion. It also recognizes the student whose essay best demonstrates both cultural competency and a commitment to providing quality health care to all. On Friday, Sept. 19, third year medical student, Matthew Edwards won the award for writing a moving essay about his journey to becoming a culturally competent physician. His essay is featured below.
A Medical Student’s Lesson in Humility
By Matthew Edwards
I met with a close family friend, an elderly man named John, during Thanksgiving weekend of my second-year of medical school. He had just been diagnosed with hypertension and hyperlipidemia, and I had just completed a ten-week course in cardiovascular and pulmonary medicine. John informed me that his doctor prescribed him a statin, an angiotensin receptor blocker (ARB), and a number of lifestyle modifications. Seemingly frustrated, he asked me why I thought his doctor prescribed these medications and whether I thought they really worked. “The doctor told me that Blacks have a higher rate of high blood pressure,” he said, as I nodded approvingly. He paused for a moment, struggling, before uttering words that caught me unawares: “But as I think back to my parents and grandparents who lived without all these medications, and … I wonder if ‘medicine’ is really on my side.”
Suddenly my knowledge of the cardiovascular system seemed to matter very little. Until this moment in my medical education, I had always felt comfortable with issues of race and terms like cultural competence. After all, I was raised in a medically underserved community and grew up in a family of fairly modest means. As sociology major in college, I was familiar with the history of American medicine, the legacy of the Tuskegee “experiment,” and the role that race and socio-economic factors played in creating health disparities. I had grappled with concepts such as implicit bias, “us vs. them,” and in-groups and out-groups in term papers and small group discussions. Moreover, I had positive experiences treating patients from various racial, ethnic, and socioeconomic backgrounds not only as a student-clinician treating medicine and gynecology patients at UTMB’s St. Vincent’s Student-Run Free Clinic and Frontera de Salud, but also in my clinical curriculum in medical school.
Yet I found myself struggling to relate to John’s concerns. I thought it was well-understood how far medical ethics and the doctor-patient relationship had come since the 1960s. Moreover, it seemed obvious to me that a person with hypertension and elevated lipids would see the utility of medication and lifestyle modification. My experience with John forced me to question: what exactly is cultural competence, if not the ability to relate to and function with people of different cultures and backgrounds? I assumed that my race, background, and life experiences made me uniquely poised to relate to different individuals, especially those with backgrounds similar to my own. Moreover, it was something that had been affirmed by mentors, medical school interviewers, and advisors.
My own experience with the culture of medicine has shaped the way I view the human condition. It has allowed me to reconcile the simultaneous resiliency and precariousness of the human body. As a species, we are able to withstand devastating trauma and still recover some semblance of normal function. Yet seemingly benign disturbances in physiology can dramatically shorten life. For example, my increasing knowledge of the cumulative insults at the molecular level enable me to better understand how years of uncontrolled hypertension or high blood sugar frequently have more disastrous impacts on the body systems in the long-term than the acute effects of a few years of reckless activity in adolescence or early adulthood. These same strengths and vulnerabilities are what unite us, regardless of cultural, ethnic, religious, or socioeconomic groups. I now understand cultural competency through the lens of the uniting human condition rather than the lens of individual differences. Disparities along lines of race, gender, language, and socioeconomic status only heighten these deleterious effects.
I now realize that no single experience makes an individual culturally competent. Cultural competence is not an artifact of an individual’s background, or even the result of months or years of cumulative, passive experience. It is a continual process of learning from patients, much like any other aspect of medicine. It requires a willingness to engage in introspection and acknowledge one’s beliefs and biases. For me, it requires a conscious effort to continually reevaluate my own experiences as they have undoubtedly changed over time. Moreover, medical training and medical practice engender their own cultures distinct from socio-economics, politics, religion, or ethnicity—cultures that emphasize reason and decision-making filtered through and modified by clinical and personal experience. The earlier we as clinicians realize this, the better we are positioned to address the needs of an increasingly diverse population.
Although John and I had shared many other conversations about medicine, culture, and history, this one felt different. It felt different because while I most likely could explain the clinical pathogenesis of hypertension and hyperlipidemia in more detail than John likely cared to know, I had only lived a fraction of his life. A product of the baby-boomer generation, having grown up during the Civil Rights era, and having lived through experiences I only read in history books, John was infinitely more qualified to teach me about on the matter.
I listened, said very little, and encouraged John to keep speaking. Throughout the conversation John seemed troubled by the doctor’s mention of race. Yet, physicians are taught to think in terms of probability—both in terms of what diseases are most frequent in a population as well as those that affect particular populations disproportionately. Though crude, these cognitive shortcuts are an important part of clinical decision-making. We are taught to be vigilant for signs of preventable disease, especially given their prevalence in underrepresented communities.
Patients like John do not, however, see themselves merely as members of a group with a higher likelihood of a particular disease. They do not see race and culture and age as fixed discrete determinants. Although medical students are taught to use facts like race and socioeconomic status and gender in our clinical reasoning, we are not always taught how to express these facts to our patients in a way that is sensitive to their history and the collective memory. I do not think that John objected so much to the fact that race was a feature in his discussion with his doctor as much as he resented how it was used— as a sort of prima facie explanation for why he needed to change his lifestyle. I think John may have come away with a different outlook on this situation if his physician had taken a few seconds to become familiar with John’s background and frame his subsequent comments in a culturally appropriate context.
By the end of our conversation, John seemed to be more at peace with his physician’s recommendation. Yet I genuinely believe that I was the one who gained the most from the experience: I had a personal lesson on the importance of humility and self-reflection in all facets of the doctor-patient relationship, especially with matters of culture and background. My encounter with John humbled me, and taught me that no single feature my life—be it race, gender, socioeconomic background, or education—endowed me with cultural competence. Rather, cultural competence is a life-long process, one that is continually refined by wisdom and shaped by experience.