Cultural humility in medical training: how to teach it

A resident sees a woman who refuses the proposed exam. He has heard in a class that people from that background tend to distrust hospitals and concludes that the refusal is cultural. After a few minutes of conversation, he discovers the real reason: she looks after her grandson in the afternoon and the exam was scheduled at exactly that time. The ready-made explanation nearly ended the consultation.

This is the risk that cultural humility tries to avoid. Instead of learning lists of characteristics of groups, the professional learns to ask, to listen and to revisit their own place in the relationship. This text explains what cultural humility is, how it differs from cultural competence and cultural safety, what studies show about teaching the topic and how to bring it into the curriculum and to the bedside.

Key points

• Cultural humility is a lifelong commitment to self-assessment, with attention to power in the doctor and patient relationship (Ogunyemi, 2024).
• Health inequities come from unequal power relations, not from a lack of knowledge about the other's culture (Curtis, 2019).
• Cultural awareness workshops can reinforce stereotypes when they reduce groups to lists of traits (Shepherd, 2019).
• Short interventions improved participants' perception and knowledge of the topic (Ogunyemi, 2024).
• Residents who prepared presentations on disparities reported more cultural humility (Tsuchida, 2023).
• Teaching works best when it includes reflection, practice and attention to the structures that shape care (Metzl, 2014).

Summary

• What cultural humility is
• Competence, safety and humility: what is the difference
• Why lists of traits fail and what power explains
• What studies say about teaching cultural humility
• Cultural humility in day-to-day clinical practice
• How to bring the topic into the curriculum
• Limits of the evidence
• How NEXO helps train this reasoning
• Frequently asked questions
• Take-home messages

What cultural humility is

Cultural humility is a lifelong commitment to self-assessment, to correcting power imbalances in the patient and doctor relationship and to building trusting partnerships (Ogunyemi, 2024). The focus moves away from the other and back to the professional: what they bring to the consultation, what they assume and what they do not yet know.

The term was coined in 1998 and describes a dynamic and continuous introspection aimed at reducing the power imbalance and increasing interpersonal sensitivity (Smith, 2022). The central idea is that no one becomes an expert in another person's culture. The expert in the patient's life is the patient.

This changes the kind of knowledge the doctor needs to have. Instead of memorizing what each group thinks about illness, food or death, they learn to investigate how that person, at that moment, understands what they are feeling. Culture stops being a label stuck to the patient and becomes an open question in the consultation.

Culture, here, has a broad meaning. It includes origin and ethnicity, but also religion, gender identity, sexual orientation, social class, disability, profession, age and territory. A deaf person who uses sign language, a rural worker who lives far from the service and a teenager who arrives alone at the consultation each bring their own way of living health and illness.

The authors describe three dimensions (Ogunyemi, 2024). The first is the continuous commitment to learning, self-assessment and critical reflection. The second is recognizing and addressing power imbalances. The third is institutional responsibility.

The third dimension is often forgotten. Cultural humility is an individual attitude, but also a requirement for services and schools, which define consultation time, access to interpreters and what is taught.

Competence, safety and humility: what is the difference

Three terms appear often in this discussion, and they overlap. It is worth understanding what each one emphasizes.

Cultural competence arose with the proposal of teaching knowledge and skills to care for people from different cultures. A common criticism is that the word "competence" suggests a finishing point, as if it were possible to master the other's culture.

Cultural safety shifts the focus to power. A literature review argues that professionals and services need to question power structures taken as natural and to challenge their own culture, instead of seeking competence in the culture of others (Curtis, 2019). Safety is defined by the patient: it is the patient who says whether the care was safe.

This change in who evaluates is important. A course can certify that a professional completed a module on culture, but that certification says little about how the patient felt during the consultation. Cultural safety asks the service to listen to the experience of those who were cared for and to use that listening to change practice (Curtis, 2019).

Cultural humility emphasizes the stance of permanent learner and self-assessment. It connects with the two other ideas and adds the notion of an endless process. A review in surgery proposes that competence, safety, humility and cultural dexterity are all necessary to improve the experiences and outcomes of minority groups (Smith, 2022).

Concept	Main emphasis	Who evaluates	Risk when poorly taught
Cultural competence	Knowledge and skills about groups	The professional and the course	Lists of traits and stereotypes
Cultural safety	Power, structures and the patient's experience	The patient	Staying only in institutional discourse
Cultural humility	Continuous self-assessment and partnership	The professional, with the patient	Becoming individual blame with no change in the service
Structural competence	Social and institutional forces that shape health	Team and service	Distance from the concrete consultation

Why lists of traits fail and what power explains

Many culture trainings begin with a description of the customs of each group. The intention is good, but the result can be the opposite of what is desired.

A critical analysis of cultural awareness workshops points out that much of the time ends up spent on stereotypes and superficial information (Shepherd, 2019). The author recalls that historical discrimination in health services happened in part precisely because clinicians had cultural stereotypes (Shepherd, 2019). Adopting supposedly typical phrases or gestures to build rapport can sound false or paternalistic.

Lists also ignore variation within each group. Two people from the same origin can have very different religions, languages, levels of schooling and life histories. Asking the patient directly is more precise than any generalization.

The same text warns of another side effect: certain information about groups can awaken only pity and reinforce the image of helpless people (Shepherd, 2019). This image gets in the way of partnership, because it places the patient in the position of someone who needs to be saved, and the doctor in the position of someone who knows everything.

Clinical reasoning also suffers. When a ready-made cultural explanation appears early, it works as an anchor and ends the investigation before its time. Refusal of a test, delay in seeking care or low adherence to treatment come to be attributed to the group, and the concrete causes stop being sought.

The same mechanism appears in diagnosis. Implicit bias leads to associating symptoms with characteristics of the group, and stigma in language changes the approach. Cultural humility works as an antidote: it replaces assumption with a question.

If the problem is rarely a lack of information, what explains inequities? The answer goes through power and the structures that surround the consultation.

Cultural humility asks the professional to look at the power they have in the consultation. They decide the time, the questions, the vocabulary, the examination and the record. The patient often arrives tired, afraid or with little information.

A review on cultural safety makes clear that health inequities come mainly from unequal power relations, unfair distribution of social determinants, marginalization, biases, unexamined privileges and institutional racism (Curtis, 2019). The problem is rarely a lack of information about the culture of the other.

Structural competency takes this idea further. The proposal trains five competencies, among them recognizing the structures that shape the clinical interaction and reframing "cultural" explanations in structural terms (Metzl, 2014). The authors also speak of structural humility, the recognition that the professional has limits in seeing and changing these forces (Metzl, 2014).

In the example from the beginning, the refusal of the exam seemed cultural and was structural: a time incompatible with the patient's life. Reframing the explanation opened up a simple solution.

The five competencies of the proposal are recognizing the structures that shape the clinical interaction, developing a language to talk about these structures, reframing cultural explanations in structural terms, observing and imagining interventions on these structures, and developing structural humility (Metzl, 2014). For the student, the third competency is usually the most useful day to day: replacing the question "what in this person's culture explains this?" with the question "what in this person's life, and in our service, explains this?".

This swap also protects against blame. When low adherence is seen as a characteristic of the group, the patient is held responsible. When it is seen as the result of difficult transport, the cost of the medication or an incompatible time, the team has something concrete to solve.

What the studies say about teaching cultural humility

The published educational interventions are, in general, short and assessed right afterwards. The results are promising, with limits that need to be stated.

A 90-minute interactive workshop brought together 133 students, residents and teachers (Ogunyemi, 2024). The workshop included a presentation on equity, exploration of the participants' own identities and case discussion. The perception score rose from 3.89 to 4.22, and the knowledge score from 0.52 to 0.67 (Ogunyemi, 2024).

A one-hour intervention for third-year students was assessed by performance in later clerkships (Khoury, 2022). The students who took part had a small improvement in supervisors' assessment of relating to patients in a respectful, careful and empathetic way (Khoury, 2022).

In an emergency residency program, 32 residents prepared presentations on disparities in vulnerable populations, such as Black people, migrant rural workers, trans people and deaf people (Tsuchida, 2023). The reported responsibility to learn rose from 4.17 to 4.73, and the responsibility to be attentive to other cultures from 4.42 to 4.89 (Tsuchida, 2023).

A single 90-minute session with 35 internal medicine residents used the cultural humility and courage model to introduce spiritual care of patients (Drumright, 2024). The proposal shows that the concept applies to topics beyond ethnicity and origin, such as religion and spirituality.

The formats vary, but there are common elements. Almost all the interventions combine some theoretical content with activities in which the participant looks at their own identity and their own assumptions. The 90-minute workshop, for example, asked participants to explore their sociocultural identities and positions of power before discussing cases (Ogunyemi, 2024). The residency program, in turn, put the residents themselves in the role of those who research and teach (Tsuchida, 2023).

Cultural humility in day-to-day clinical practice

Cultural humility shows up in concrete attitudes. A teaching proposal based on acceptance and commitment therapy lists characteristics such as openness, self-awareness, absence of ego, flexibility, respect and support in interactions (Lombardero, 2023).

The same proposal highlights the stance of those who admit they do not know and are open to learning from the patient (Lombardero, 2023). This stance also makes it easier to accept when one is wrong, which serves both the relationship and the diagnosis.

A qualitative study with 11 professionals in speech therapy, occupational therapy, physical therapy and nutrition in palliative care described how they practice cultural humility (Singh, 2023). The strategies were internal, such as self-reflection, interpersonal, such as listening, and contextual, such as service support (Singh, 2023).

This finding reinforces that cultural humility is a set of observable practices, not just an intention. Asking before assuming, checking whether the explanation was understood, admitting when something in the patient's life is unknown and returning to the subject at another appointment are attitudes that can be taught, observed and corrected.

In the consultation, some questions help:

• "What do you think is causing this?"
• "Is there anything in your life, your family or your faith that I should know to care for you?"
• "What is most important to you in this treatment?"
• "Is there anything in the plan that will be hard to follow?"
• "In what language do you prefer to talk about your health?"

These questions come close to the search for ideas, concerns and expectations. When language is a barrier, a professional interpreter is part of the care. Listening to the patient's story attentively completes the picture.

Making mistakes is part of the process. At some point, the professional will use a word that hurts, assume something wrong or fail to ask what they should have. Cultural humility calls for acknowledging the mistake simply, apologizing when appropriate and adjusting the conversation. A phrase like "I think I misunderstood, can you explain it to me again?" usually opens more doors than a long justification.

The comprehension check also takes on another meaning. Asking the patient to explain the plan in their own words shows whether the guidance fits their life, not just whether they memorized what was said.

How to bring the topic into the curriculum

Cultural humility is hard to teach with lectures alone. It requires reflection on one's own identity, practice with patients and examples from those who teach.

Some strategies appear in studies and in practice:

• interactive workshops exploring one's own identities and positions of power;
• presentations prepared by the residents themselves about disparities in local populations;
• discussion of cases in which the "cultural" explanation hid a structural problem;
• written reflection after difficult consultations;
• observation and feedback on how the learner asks and listens;
• participation of patients and communities in designing the activities.

Written reflection gains strength when it is guided. The reflective portfolio helps turn the discomfort of a consultation into learning. Empathy in the consultation is also trained with practice and feedback.

The example of those who teach weighs more than any class. The hidden curriculum shows how jokes, shortcuts and comments during shift handover teach more than the official program. A preceptor who asks the patient before assuming teaches cultural humility without giving a class.

The assessment of the learner must follow this logic. Multiple-choice tests about the customs of groups measure little of what matters. Observing a consultation, asking for a written reflection and talking about how the learner handled a difficult situation say much more about real progress. The assessment by supervisors of relating to the patient in a respectful and empathetic way, used in one of the studies, is an example of a measure close to practice (Khoury, 2022).

The topic also fits into subjects that already exist. Semiology, public health, ethics, pediatrics and palliative care offer situations in which asking about the patient's beliefs, routine and priorities changes the approach. Integrating cultural humility into these moments keeps it from being isolated in a single class, remembered only on test day.

An example activity helps to make it concrete. After a clinic session, the preceptor asks each student to choose a consultation in which an assumption turned out to be wrong. The group discusses what led to the assumption, which question could have prevented it, and what in the service made the situation harder, such as a lack of an interpreter or a short consultation. In a few minutes, the conversation touches on the three dimensions of cultural humility: self-assessment, power and institutional responsibility.

Patient participation in teaching also broadens learning. Hearing from a person what it was like to be cared for, what made them feel respected and what made them give up on coming back often leaves a stronger impression than a text on the subject. This participation needs to be careful, with preparation, fair payment when possible, and freedom for the person to share only what they want.

Schools and residency programs can also look at themselves. Who teaches, who is invited to speak, which cases appear in exams and how patients are described in materials all send messages about who matters. Reviewing these points is part of the institutional responsibility that cultural humility calls for.

The common thread across these proposals is to treat cultural humility as a daily practice, revisited throughout training, and not as the topic of a single class. Each consultation offers a new chance to ask, listen and learn from the person being cared for.

Limits of the evidence

Most studies measure self-report and knowledge right after the intervention (Ogunyemi, 2024). Few follow participants for months, and almost none measure patient outcomes.

Samples are small and come from specific programs (Tsuchida, 2023). The observed effect on behavior, when measured, was small (Khoury, 2022). This calls for longer interventions, integrated into the curriculum and assessed in clinical practice.

There is also the risk of turning the topic into an individual responsibility alone. Without changes in the service, such as adequate consultation time, interpreters and channels for hearing patients, the professional's humility runs into structures that they cannot change alone (Curtis, 2019).

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by looking for the code in ICD-10.

The limits of using the game are described on the NEXO Economy page. If you research the teaching of clinical reasoning, the page for Researchers explains how to get in touch. Professionals who write or review cases find information under Curator and Creators, and institutions can learn about the proposal on the partnerships page. Practicing differential diagnosis with clues and looking for the right code in ICD-10 complete this training.

Frequently asked questions

What is cultural humility?

It is a continuous commitment to self-assessment, to correcting power imbalances in the relationship with the patient, and to building trusting partnerships (Ogunyemi, 2024).

What is the difference between humility and cultural competence?

Cultural competence emphasizes knowledge about groups, and humility emphasizes the stance of a learner and self-assessment. Reviews argue that the concepts complement each other (Smith, 2022).

What is cultural safety?

It is an approach that places power at the center and defines the safety of care by the patient's experience (Curtis, 2019).

Do short workshops work?

They improve perception and knowledge right afterward (Ogunyemi, 2024). The effect on behavior was small when measured (Khoury, 2022).

Why are lists of cultural traits a problem?

They spend time on stereotypes and can reinforce the discrimination they aim to combat (Shepherd, 2019).

How can you practice cultural humility in the consultation?

Ask what the patient thinks is happening, what matters to them and what could make the plan harder. Admit what you do not yet know and be open to learning (Lombardero, 2023).

Take-home messages

• Cultural humility is a continuous process of self-assessment and partnership, with no finish line.
• Inequities come from power and structures, more than from a lack of knowledge about the other.
• Lists of cultural traits can reinforce stereotypes and hide concrete problems.
• Asking the patient about their ideas, priorities and difficulties is more accurate than assuming.
• Short workshops help, but the lasting effect depends on reflection, practice and example.
• Responsibility also lies with the service, which defines time, interpreters and listening.

Want to train clinical reasoning by hearing each clue before concluding? Play the case of the day on NEXO.

References

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2. Drumright B, Sacro Y, Nussbaum A. Enriching Spiritual Care in Medical Residents Through Cultural Humility and Courage. MedEdPORTAL. 2024. PMID 39070542. DOI 10.15766/mep_2374-8265.11423.
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8. Singh H, Haghayegh AT, Shah R, et al. A qualitative exploration of allied health providers' perspectives on cultural humility in palliative and end-of-life care. BMC Palliat Care. 2023. PMID 37434238. DOI 10.1186/s12904-023-01214-4.
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