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.