Introduction:
Cultural humility has emerged as a complex, politically attuned branch of culturally informed practices1 that foreground diversity or multiculturalism - broadly defined - as a core value of contemporary health care delivery and education2. Understandings of cultural humility vary across context and authors, although a constellation of key attributes have emerged since its conceptualization by Melanie Trevalon and Jann Murray Garcia in the late 1990’s2. Cultural humility has been described as an ethically engaged, context specific3, and dynamic set of professional practices attuned to the impact of social and cultural determinants of health on marginalised populations’ health outcomes and associated social and economic opportunities and capacities4,3. Critical reflection on the health care provider’s own socially situated personal and professional self-identities and knowledges5,2 is understood as a core means of assessing the myriad ways in which structural relations of power manifest in the clinical encounter, including prejudices and stereotypes held by clinician and patient alike6,3. Attention has been variously focused on the health practitioner’s investments in ”egoless practice”1 and ”not knowing”2. These practices, in turn, are understood to be essential components of an epistemological stance in the face of the patient’s situated knowledges about their own embodied and culturally informed health experiences6.
These definitions weight on different aspects of professionalism, and perhaps more specifically, on professional values7. Authors variously emphasize the need for an ongoing learning and refinement of skills, such as respect for cultural difference and decentring Eurocentric normative values1, openness to new ideas1 and interrogation of personal biases and assumptions5. In speaking to the need for cultural humility in health professions’ education, Chang, Simon, and Dong8 propose a comprehensive framework that extends beyond the dyad of healthcare provider-patient. By drawing attention to concentric social influences such as families, communities and institutions that make the clinical relationship both possible and effective, their expanded definition advances a call for a complex understanding of culture and a call for the integration of a spectrum of situated knowledges in clinical practices. In this re-articulated calculous, effective healthcare is seen as the product of an assemblage of social interactions, social contexts, and differentially held ways of knowing and being.
To be sure, cultural humility, understood as a social process conducive to the radical rethinking of power relations1 and vulnerabilities inhering in the professional spaces of health practices is a needed and welcomed advance. And yet, despite these refinements, current frameworks of cultural humility, including Chang et al’s model, lack capacity to accommodate shifts that have been occurring in contemporary biomedical cultures. More complex models are required that are attuned to how advances in biomedical, communications and information technologies are increasingly transforming the very material and cultural conditions of health care delivery, and thus how power manifests in clinical encounters. Attention, in other words, needs to be broadened beyond a structural accounting of the experiences of those with marginalised social identities to encompass a less straightforward, and yet potentially richer investigation into the workings of power activated in the wake of shifts towards highly technologised biomedical practices. A case in point, is conceiving of a cultural humility framework that is able to grapple with how health care providers conceive of, and manage decision making in the face of two incommensurate knowledge systems that present in the clinical encounter. On the one hand, practitioners are mandated to consistently apply Evidence Based Medicine models of clinical care. These models are facilitated and supported by a suite of decision-making technologies and data management systems; computer technologies such as Electronic Health Records (EHRs) facilitate flows of what has been deemed essential information directly into the space of the clinic. In this sense, their presence is both material and discursive, effecting new means of decision making and new levels of professional accountability. On the other, health practitioners are expected to perform culturally sensitive, value-driven and patient-centered practice. Under this model, clinicians are expected to engage with the patient as a unique social and biological individual9. While the former focuses on population-level logics, the later focuses on clinicians’ ability to comprehend and adjust according to patients’ experiential knowledges, socio-cultural contexts and investments in self-care that too have become technologically mediated10. The complexity of knowing demanded by the emergence of contemporary technologies-driven health decision making and care delivery systems requires new methods of observation, new ways of analysing health phenomena and health bodies and new ways of examining our place as practitioners, researchers and educators in practices of health care delivery.
In this paper, we offer a two-pronged intervention in the cultural humility literature. At a first level of analysis, we suggest the need to broaden understandings of culture and associated workings of power to accommodate the effects of biomedicine’s technologising turn11.A second level of intervention suggests the need to broaden the availability of methodological tools to analyse and evaluate the multidimensionality of technologies12,13and their agentic effects in healthcare encounters. Through a selective reading of feminist neo-materialism theories, we introduce a framework for cultural humility expanding analytical sight-lines beyond hierarchical relationships and dichotomies that privilege the human (practitioner or patient) as sole actants in the clinical exchange. Rather, in our reformulation, practices of care are approached as dynamic material-discursive events entangling big-data driven knowledges and interventions, pharmacological technologies and technologised material instruments and devices, diseases, and the bodies/subjectivities of health care providers and patients.
We first examine the social-material circumstances that have given rise to a need for new approaches to doing culturally humble, power-attuned health care work. We then introduce what we propose is a more ”diffractive ”14 reformulation of cultural humility detailing the framework’s key working assumptions and propositions. We then extract lessons learned from piloting a visual, neomaterialist methodology in New York and adapt these learnings to the context of technologised practices of clinical care. Drawing from a case illustration grounded in our visual data, we consider the implications for assessment if a cultural humility framework is methodologically attuned to the clinical encounter as a discontinuous, discursive-material process producing multiple, contingent data moments and objects for analysis. We conclude the paper by highlighting the framework’s capacity for critically engaging evaluative inquiry as an ethical practice that attends to the forms of patient and clinician accountability and responsibility emerging in the clinical encounter.