The Role of Culturally Competent Trauma-Informed Medical Deliverance in Surgical Settings
As a medical field, we often emphasize the importance of delivering culturally, socially, individually competent medical care within primary health settings, whether that be within patients’ medical home, their family physician’s office, or during consultations with specialists. However, it is imperative to recognize the shift in this delivery in the context of surgical practice, too, both during extensive consultation appointments as well as before, during, and after the operating room. Cultural competency is defined as “the ability of healthcare providers and the healthcare system to communicate effectively with and provide quality healthcare to patients from diverse sociocultural backgrounds.”[1] Furthermore, Culturally-Sensitive Trauma-Informed Care (CSTIC) refers to healthcare professionals’ capacity for providing assessments and interventions that acknowledge, respect, and integrate patients’ cultural values, beliefs, and practices in a trauma informed manner.[2] It is imperative, then, that such capacities retain great significance in the practice of delivering holistic, all-encompassing healthcare in surgical settings, pertinent to patients’ physical, mental, cognitive, religious and spiritual, and emotional health.[3]
Holistic healthcare pertains to whole-body health advocacy, whereby a patient’s entire well-being is accounted for, regardless of the cause for their visit. A patient’s cultural background, personal experiences, and traumas comprise a large part of their identity, and therefore the foundations of their complete wellbeing. It is important to account for these factors in a surgical setting as the relationship fostered between surgeons and their patients is paramount for comfortable, patient-centered care during tremendously difficult and daunting periods in the patient’s life (and doctor’s life, too). This appreciation for and care of the patient’s complex identity encompasses not only a deep recognition and accommodation of their beliefs, customs, and values, but also a capacity for meaningful communication regardless of sociocultural barriers that might exist. Such efforts allow for the establishment of rapport between the patient and physician, ensuring adequate information is conveyed and retained for genuine understanding and appropriate consent on both sides.[4] Patient outcomes, unique intersectional needs, and educational incentives are all at the forefront of supporting and sustaining culturally competent, trauma informed care that is implemented meaningfully.
Patient outcomes drive many quantitative studies that have been and continue to be underway. This pertains to pharmacological and surgical interventions, disease prognosis, and comorbidities, to name only a few areas of medical research. It has also been well documented that disparities on the basis of race and ethnicity continue to exist contemporarily, in various sectors of healthcare, calling for improved training in cultural competency.[5] However, many of these studies have also reported low survey response rates pertaining to the education aspect of cultural competency, leading to elusive results. Alternatively, when it comes to actual practice, many studies do show that disparities exist in healthcare provision in various areas of medicine. A study in the realm of pediatric surgery, for instance, showed that Black and non-White neonates with congenital diaphragmatic hernias had a 54% and 52% increased risk of mortality, respectively, than White neonates.[6] Another study showed that while Black patients comprise about 29% of patients undergoing major extremity amputation, they receive dramatically fewer limb salvage procedures (only 12% of patients undergoing open surgical procedure and 10% of patients undergoing an endovascular procedure).[7] In response to such harrowing health disparities highlighted in recent years, numerous training programs have restructured their curricula to increase sociocultural competency teachings in and outside of their programs for the betterment of our patients, as well as our physicians and surgeons.
Another component of holistic surgical deliverance that is socioculturally cognizant in nature is patient-centered care. While we often take this care to be founded on accommodating language barriers, being aware of patients’ cultural, racial, ethnic, and religious backgrounds, and understanding the desires that they have which may or may not align with the physician’s vision, trauma informed care is a major component of competent care that must also be addressed. Research suggests that ethnocultural factors can influence the biopsychosocial experience of trauma and subsequent traumatic stress reactions, which may very well be found in surgical settings for many patients.[8] It has also been evidenced in the literature that it is not the objective severity of trauma, but the experience of that trauma, that influences stress responses in the future.[9] This is imperative in the context of caring for immigrant, refugee, Indigenous, marginalized populations who may or may not have traumatic experiences pertinent to medicine or otherwise. Surgical intervention is already a vulnerable and frightening experience for most, which may be exacerbated by sociocultural barriers or traumatic factors. It is imminent that continued awareness is brought to this paramount topic and that we continue to foster an environment that encourages continued education, growth, and collaboration within the field of culturally competent healthcare deliverance, regardless of medical or surgical specialty.
[1] Campbell, Alex, Maura Sullivan, Randy Sherman, and William P. Magee. “The Medical Mission and Modern Cultural Competency Training.” Journal of the American College of Surgeons 212, no. 1 (January 1, 2011): 124–29. https://doi.org/10.1016/j.jamcollsurg.2010.08.019.
[2] “Culturally-Sensitive Trauma-Informed Care | Patient Centered Care and Trauma Informed Care for Pediatric Patients - Healthcare Toolbox.” Accessed June 8, 2024. https://www.healthcaretoolbox.org/culturally-sensitive-trauma-informed-care.
[3] Shah, Sagar S., Francisco B. Sapigao, and Maria B. J. Chun. “An Overview of Cultural Competency Curricula in ACGME-Accredited General Surgery Residency Programs.” Journal of Surgical Education 74, no. 1 (January 1, 2017): 16–22.https://doi.org/10.1016/j.jsurg.2016.06.017.
[4] Smith, Charlotte B., Laura N. Purcell, and Anthony Charles. “Cultural Competence, Safety, Humility, and Dexterity in Surgery.” Current Surgery Reports 10, no. 1 (2022): 1–7. https://doi.org/10.1007/s40137-021-00306-5.
[5] Shah, Sagar S., Francisco B. Sapigao, and Maria B. J. Chun. “An Overview of Cultural Competency Curricula in ACGME-Accredited General Surgery Residency Programs.” Journal of Surgical Education 74, no. 1 (January 1, 2017): 16–22. https://doi.org/10.1016/j.jsurg.2016.06.017.
[6] Sola, Juan E., Steven N. Bronson, Michael C. Cheung, Beatriz Ordonez, Holly L. Neville, and Leonidas G. Koniaris. “Survival Disparities in Newborns with Congenital Diaphragmatic Hernia: A National Perspective.” Journal of Pediatric Surgery 45, no. 6 (June 2010): 1336–42.https://doi.org/10.1016/j.jpedsurg.2010.02.105.
[7] Hughes, Kakra, Christopher Boyd, Tolulope Oyetunji, Daniel Tran, David Chang, David Rose, Suryanarayan Siram, Edward Cornwell, and Thomas Obisesan. “Racial/Ethnic Disparities in Revascularization for Limb Salvage: An Analysis of the National Surgical Quality Improvement Program Database.” Vascular and Endovascular Surgery 48, no. 5–6 (2014): 402–5. https://doi.org/10.1177/1538574414543276.
[8] “Culturally-Sensitive Trauma-Informed Care | Patient Centered Care and Trauma Informed Care for Pediatric Patients - Healthcare Toolbox.” Accessed June 1, 2024. https://www.healthcaretoolbox.org/culturally-sensitive-trauma-informed-care.
[9] Ethnocultural Aspects of Posttraumatic Stress Disorder: Issues, Research, and Clinical Applications. Ethnocultural Aspects of Posttraumatic Stress Disorder: Issues, Research, and Clinical Applications. Washington, DC, US: American Psychological Association, 1996.https://doi.org/10.1037/10555-000.