A white woman stands in front of a cultural site with her hands pressed together.

When Competence Harms Patients

Three weeks and a day, and I’ll be in New York City for medical school. I just resigned from the best gap year job I could have asked for — marketing, communications, and graphic design at Central Texas’s oldest safety net clinic — and so I have a bit of free time before embarking on my big adventure.

I want to dedicate a bit of this free time to blogging, and so I am challenging myself: write every day until I move to New York City, about whatever makes sense on that day. Try to hit at least 250 words, but aim for 500.

Why?

It all has to do with being a better physician. It seems silly, but I have a hard time finding time to blog. One of the reasons for that is that I am a compulsive editor, and so blogging takes a huge investment of time. I recently wrote about how I overcame my compulsive editor when writing the first draft of my novel, but that required that I handwrite everything. Handwriting a blog isn’t blogging — it’s journaling. And, as much as I love to do that, it kind of defeats the purpose of having a more public space to express my thoughts about medicine. 🙄

The desire to edit is compounded by the knowledge that whatever I write for a blog might actually be read by someone else. I used to be terrified of other people reading my writing, which made no sense — I’ve wanted to “be a writer” for longer than I’ve wanted to be a physician! Why was I terrified?

It wasn’t because I was afraid of criticism. I’m a writing tutor — I can’t be afraid of others critiquing my writing because I critique others’ writing all the time. In fact, I critique my own writing twice as harshly. I appreciate honest criticism because it makes my writing better — I’m not terrified of it at all.

Honestly, I can’t think of any other explanation than the fact that reading someone else’s writing is, in my opinion, and intimate experience. Reading someone else’s unfiltered writing — writing that hasn’t been compulsively edited a thousand times — is even more intimate. To allow someone to read my writing is to allow myself to be vulnerable. I can’t say that I have a problem with vulnerability, but in this particular instance, this type of vulnerability is very uncomfortable.

That means the fact that I am choosing to write every day for 21 days is significant. There’s not much editing you can do to a piece of writing that you intend to publish in a few hours. It is very similar to letting someone read your diary. It’s terrifying. But, for someone like me, it’s necessary to become a better physician.

It’s necessary because of how I want to be a physician. I grew up in a world without medical infrastructure — without most kinds of infrastructure, in fact — and I recognize that I only stand where I am because of privileges not everyone in my hometown had. I want to be a part of delivering health care to people without access, because I believe the right to health is unalienable. I’m not sure exactly what work that would entail yet — I am interested in psychiatry, but also neglected diseases like sickle cell, but also the complex needs of queer youth without parental support — but I do know that this kind of work requires a healthy dose of vulnerability.

Why?

Well, vulnerability breeds humility.

Doctors often come to the table from a place of competence. Competence, in and of itself, is not bad. But people who are smart and know they are smart — who have decades of training and experience, and years of people telling them the work they do makes the good, important people — often are not humble. Always-assumed competence and a lack of humility do not bode well for working with a diverse group of patients, especially those who have been traumatized or marginalized for most of — or all of — their life.

The best example I can give is a buzzword: cultural competence. Medical programs around the nation want to graduate ranks of culturally competent physicians, which are physicians who understand the social norms of different racial and ethnic populations in order to deliver effective health care (the definition should also include non-ethnic or racial populations, like LGBTQIA+, but often doesn’t). Examples of cultural competence might include recognizing that some cultures find eye contact to be disrespectful or difficult, or that some cultures are more family- or community-oriented than individualistic.

However, the idea that you can be competent in someone else’s culture is, at best, arrogant. To assume that you can be competent in someone else’s culture — and not just one culture, but all cultures you may come into contact with as a physician — assumes that culture is something that can be reduced to bullet points.

I cannot even begin to describe to you the ins and outs of the individualistic, boot-strap-pulling, wildly religious & conservative culture of my hometown. How can I expect to comprehend multiple other cultures and all of their intricacies?

Furthermore, I may have grown up in my hometown’s culture, and it has certainly influenced me in tremendous ways, but not in the ways you’d expect at all. So how could I expect to predict how someone else’s culture will influence how they act in the exam room?

I am not the only one who finds the idea of cultural competence to be ill-fitting for the goals it wants to achieve. Significant literature has been written on an alternative: cultural humility. Cultural humility is always open to the “other” person. It recognizes, first, that you cannot be competent in someone else’s culture and, therefore, cannot know what parts of someone’s cultural identity is important to them. It’s focused on being humble, instead of focusing on achieving a level or knowledge or competence. You can’t possibly know how the patient sitting in front of you will feel or respond to certain things, so you approach every interaction as a chance to learn about the person, their identity, and what effective health care looks like to them.

Humility in this capacity requires vulnerability. Although I consider myself an empathetic person, always eager to learn about the person I am speaking to or working with, I have been looking for ways to force myself to be vulnerable. Forcing myself to be vulnerable will help me grow as a person and become more comfortable navigating spaces in which I am incompetent. It will, I hope, make me a better physician — or at least minimize the always-assumed competence that often harms patients.

Currently, my approach to spaces in which I am incompetent is to be quiet and listen so that I will become more competent. While this is a valid approach in some cases, being a physician means that I will still have to work and achieve goals in situations where I will never be competent in someone else’s culture, life, and identity. Forcing myself to be vulnerable, I think, is the first step to becoming more comfortable navigating these spaces. I don’t want to start working on this vulnerability only when I first start seeing patients, of course. I want to work on it now, to hopefully minimize future harm.

Writing daily, and allowing people to read my barely-edited, imperfect thoughts, is a first step to becoming comfortable while vulnerable. Is it the best first step? I have no idea. But I just wrote 1250 words for a blog post where my minimum was 250 and my goal was 500, so it’s a doable first step. Honestly, that’s all I ask for. 💜

Photo on Foter.com

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