Culturally competent care: it’s a touchstone here at Tribal Health and (hopefully) any facility that serves Indigenous patients. But while there’s intense focus on the practices that support culturally intelligent care, somehow we rarely talk about the inverse. What exactly does cultural incompetence look like?
Consider the warning signs patients might detect in a provider visit. These signs may be invisible to clinicians, who think they’re conducting a helpful visit, but to the Native patient, those red flags are popping up all over the exam room. “I can tell at the first interaction,” our DEI Director Melody Lewis says. “And in the past, if a doctor’s approach was wrong, I might ghost them.”
At Tribal Health, we hear from a lot of healthcare workers who are interested in working in Tribal communities. But not everyone is prepared to work in Tribal communities. It’s not just a matter of hopping on a plane and showing up on a reservation. As a provider, you’re treating patients with a long history of colonization, underfunded healthcare resources, and violations and exploitation from the medical community. Distrust can be high.
On Team Tribal, we’re lucky to work with a stellar and compassionate group of healthcare professionals – but unfortunately, many other providers unknowingly alienate their Indigenous patients.
Red Flags in the Patient Exam Room
“The big red flag is a provider who comes across as closed minded or not open to other cultures and traditions when serving communities,” says Pamela Amiotte, who lives on the Pine Ridge reservation. “When they are unwilling to understand that Native people do come from a different cultural aspect than their own. They’re rushing patients out without being sensitive to them and how they’d like their traditions and culture incorporated into their health plan – and that can cause distrust, leading to subpar or poor care.”
Here are seven of the most common red flags.
- “White Savior Syndrome.” Let’s just get this one out of the way – because while it’s unintentional, it does happen. It’s true that many Tribal nations and Native communities are underserved. But that doesn’t mean they are to be pitied or in need of rescue. When an outside clinician is patronizing or a little too obvious in congratulating themselves on their noble selflessness, patients will sense it. Tribal nations already have considerable knowledge and insight into their healthcare needs. What they need are additional resources and staff who can complement their efforts.
- Assuming that what works for one Tribal community will work for all. Sometimes patients encounter a provider who, having served on one reservation, is now convinced they’re fluent in “Native culture.” But values, cultural practices, historical influences, and healthcare disparities are likely to differ from one Tribal nation to the next.
- Initiating treatment without acknowledging the patient as a person. This doesn’t apply in some medical emergencies, clearly, but building a personal relationship is vital for your average patient. Make the patient feel like just a number and they likely won’t return. “In Indian Country, we build the relationship first, then get to business,” Lewis says.
- Rushing the patient. Many healthcare staff wish they could spend more time with patients but just don’t have the availability. That’s the nature of the healthcare beast. But when providers cut off Native patients mid-sentence, ignore what they say, and hurry them out the door, those patients will feel disrespected and disinclined to return for a follow-up appointment. “This can be the point when ill patients become non-compliant with medication regimens, causing a decline in their health,” says Amiotte.
- An individualistic approach to medicine – as opposed to community-based. This can be a subtle flag. Most Tribal nations view their members as part of a larger whole. Healthcare workers new to Native reservations can build patient trust by learning about each area they serve, framing their services within that larger context, and involving community leaders in the facility. Awareness of local challenges and living conditions – such as lack of electricity – is also helpful.
- Unfamiliarity with trauma-centered care. Indigenous communities carry generational trauma from a variety of historical and environmental factors. Providers who aren’t familiar with trauma’s effects on behavior or practices to prevent secondary trauma can make a patient’s condition worse. At best, their clinical services will not be as effective as they could be.
- Defensiveness when corrected. It’s not uncommon for a new-to-Indian-Country healthcare worker to receive cultural guidance or even a gentle correction from patients and coworkers from the community. Someone who reacts defensively, instead of learning, will be perceived as putting their ego above the patients’ comfort.
The Path to Patient Trust
So – with all that said, what can you do to foster positive relationships between staff and patients at your facility? How can you encourage culturally intelligent care? Here are a few tips from Indigenous patients.
Practice cultural humility.
“Go in with an open heart and open mind. Lead with empathy in all things,” says Melody Lewis. “Be observant. Watch what’s happening around you, ask questions, and learn.” That includes respecting that the facility and community practices may be different from what you’re used to – and that facility staff and patients are the experts in their community.
Learn about the Tribes you’re serving.
Look up the Tribe’s history and how it’s affected their land ownership, agriculture, economy, education, and families. Ask about their top healthcare challenges and needs in their region. One Tribal nation may struggle with access to radiation treatment for their cancer patients; a facility in another nation may lack proper prenatal services. Another may struggle with opioid addiction. If your facility doesn’t already do so, engage a cultural liaison from the Tribe to identify the right cultural practices for birth, illness, recovery, and death so you don’t conflict with patient and family expectations.
Study trauma-centered care.
In addition to avoiding triggers and preventing re-traumatization, trained staff can offer patients skills and strategies to better cope with the aftermath of traumatic experiences.
Don’t take offense at mistrust.
If you feel a patient is testing you, remember they’ve probably encountered clinical discrimination before. Keep the big picture in mind as you demonstrate empathy and willingness to learn. Dealing with some “vetting” is a small price to pay to support healthcare transformation.
In the end, the most important cultural competence practice is lifelong learning. At the intersection of knowledge, culture, and treatment is the opportunity to make a difference in a patient’s life. By encouraging all facilities and healthcare workers to keep learning, we can open doors to a new world of trustworthy and culturally appropriate care.