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Guest Perspective: Exploring the Cultural Evolution

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By Dr. Anthony Palatta, Senior Director for Educational Program Development, ADEA
Anthony Palatta

Before assuming my current responsibilities eight months ago, I served as the cultural competency instructor at a dental school. In that role, I found that helping students learn about culture is often fraught with resistance. Faculty members are often frustrated as well, and who can blame them. Not only is the term “culture” defined in various ways, but we have yet to develop an empirical way to assess whether or not a student is culturally competent.  

Nonetheless, according to the most recent Commission on Dental Accreditation (CODA) standards, “dental school graduates must be competent in managing a diverse patient population and have the interpersonal and communications skills to function successfully in a multicultural work environment.” With each dental school having its own unique student body, geography, faculty and patient pool, teaching cultural competency becomes decidedly challenging, especially for those seeking a one-size–fits-all approach.

What’s a dental school to do?

Let’s begin by defining culture. In social anthropology, and at its most basic level, culture is simply “a system of symbols of a social group which are shared, learned and passed on from generation to generation.” But more important than what culture is, is what culture does: culture influences how people perceive the world around them and helps guide their interactions with others. As Harvard professor and scholar Dr. Arthur Kleinman was able to show, people perceive and experience health and sickness through a cultural lens, for example, one person’s chicken soup is another person’s penicillin. In other words, culture is inseparable from the person.

We also know that cultural competency is essential in reducing health disparities—a priority for our profession—and that incorporating cultural competency into patient care improves patients’ compliance and satisfaction with treatment. This is crucial for both students and faculty to understand because it makes the case for why cultural competency is germane to dental education and necessary for excellence in patient care. Put another way, if we are teaching our students to treat the whole patient, shouldn’t culture be part of their patient evaluations?

Yes! And I would add that in the years that I taught cultural competency to hundreds of students, I came to realize that our typical definitions of culture tend to be far too narrow. In my view, the definition of culture can and should be expanded to include all the identities that people may express such as gender, age, religion, socio-economic status and ability, to name a few. The list is endless.

Most of my former students, and several of my colleagues, had the misunderstanding that cultural competency was strictly about our perceptions of race and ethnicity. Although it is indisputable that race and ethnicity have the most impact on perpetuating health disparities in the United States, discussions about race in the first session of a cultural competency course can prove to be difficult, even uncomfortable, for faculty to teach and for students to experience. Creating a safe environment where all students can express their opinions is essential for learning to occur.

For this reason, I focused the first lecture of my cultural competency course on an identity that all students share and feel comfortable discussing: the dental student culture. This is a guaranteed way to warm up the class. Within minutes, students shared examples of stereotypes (“faculty think we want the easy way out and never study”), biases (“people think I couldn’t get into med school”) and even discrimination (“I know the med school library won’t let me study there because they don’t like dental students”). We then moved on to issues of gender, age and ability, among others, building the students’ cultural acumen and comfort level with biases and assumptions to the point that they felt more secure about sharing their perceptions of race in a group setting.

Cultural competency courses often overlook the fact that culture is as much a part of the practitioner’s world as it is of the patient’s. To fully appreciate the perceptions of the “other” (those different than oneself), individuals must first understand their own cultural beliefs and assumptions. Just as the patient views health through her own cultural lens, so does the practitioner. In other words, cultural competency education must begin with self-exploration of the practitioner’s assumptions about health and other cultures. We cannot assume that the health care practitioner simply leaves his biases outside the operatory or has no biases at all. We are all human.

As we established earlier, culture is inextricably a part of who we are. Each culture comes with a particular point of view inherent to our being, and often an implicit assumption that we know better than others and that their ways of thinking are not as good as our own or are even totally wrong. The key point, then, that we want our students to understand? Although we all have biases and stereotypes, the culturally competent dentist is aware of these assumptions, can identify when they are interfering with her patient care and chooses not act upon them. Unfortunately, many cultural competency courses fail to address this essential element.

Recently Barbara Miller, D.D.S., Executive Director, Recruitment and Admissions, and Lavern Holyfield, D.D.S., Director, Faculty Development, both at Texas A&M University Baylor College of Dentistry, surveyed dental school deans to assess their perspectives on their institutions’ cultural competency courses. The researchers asked respondents about six domains in which cultural competency can be taught and assessed: health disparities, community strategies, self-reflection, cross-cultural communication, interpreters and dental culture. Respondents rated lowest their ability to teach and assess the self-reflection and the culture of dentistry domains. The community strategies domain, which entails sending students outside the dental school to outreach programs where they encounter diverse populations of patients, ranked the highest.

This sounds good, but community service--without a self-reflective component--can actually undermine our efforts to produce culturally competent practitioners. If students’ assumptions about other cultures are not addressed prior to these community-based encounters, their biases may actually be reinforced.

Here are some of my best practices for utilizing a community outreach program as a vehicle to improve student cultural competency. First the program should include a pre-visit discussion of the population to be treated. Topics could include students’ preconceptions about the population, observations that challenge their assumptions and guidance on what students should be attuned to while at the site. A group discussion in which students can share with each other what they learned about other cultures and differing perceptions of health should follow the experience. I would also ask students to write a brief reflective essay in which they could explore their own biases that surfaced during the outreach experience. Students should view underserved populations not with pity or with a savior mentality but with respect for other cultures and with the intent to incorporate oral health care education in a culturally appropriate way.

Although outreach sites can be fertile ground for cultural competency education, one does not need to travel far to engage students in cultural experiences. By expanding the definition of culture in my program, I was able to utilize the school environment, other students and the patient pool as effective teaching tools. Among the projects I gave my students were “explore the campus and identify ways in which we are not culturally competent and what we can do to improve” and “interview a classmate or patient of a different culture than your own and compare your initial assumptions to what you learned.” Self-reflection papers were also quite effective, especially when I allowed them to be anonymous. I would hand them out randomly and have students read them to one another in small groups. It’s been my experience that anonymity results in more revealing reactions from the students and gives them the opportunity to address their biases in a safe environment.

Cultural competency can also be easily embedded in any interprofessional education (IPE) activity since the goals of IPE are for students to communicate effectively and work collaboratively in teams. Teaching cultural competency and interprofessional collaboration together also addresses two accreditation standards in one program. And one last tip: do not overlook the resources provided by your parent institution. Most, if not all universities have an office of diversity that offers training in cultural competency. I enrolled in an eight-session cultural competency program at my university, and from that experience I gained a wealth of knowledge that I applied to my own programming. I also had several university experts come to the dental school campus and speak to our students.

Just as cultural competency is an evolutionary process composed of various overlapping stages of personal development, so too should be our approach to teaching culture. We as educators can evolve by broadening our definition of culture and engaging our students in all the identities they bring to the profession by linking culture classes to health disparities and patient satisfaction, by capitalizing on outreach opportunities and other experiential programs and by having our students self-reflect. By utilizing all the resources our schools and universities offer, cultural competency education can be an effective and transformative experience for our students and our profession. 

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