Dental Professionals and Cultural Competency by Dr. Cathy Hung

The importance of researching and respecting diversity in dental patient and staff demographics

by Dr. Cathy Hung
Photography by Sean Micah Creative

COVID-19 has profoundly affected the human race on a physical, economical and psychological level. One tangential effect of the anxiety produced by the pandemic is that for some, fear has devolved into anger, triggering a series of unfortunate and often devastating events across the nation. We’ve witnessed xenophobic verbal and physical attacks on Asian Americans, racist threats against a Black birdwatcher in New York City’s Central Park, and anti-face-mask demonstrators showing up in grocery stores wearing Ku Klux Klan hoods and masks with swastikas on them.

As our dental practices gradually recover from the COVID-19 pandemic, there has never been a more important time for dental professionals to learn about diversity and inclusion. We are rekindling what was once taught in kindergarten: Wash your hands, stay home when you are sick, and get along with one another.

A more amalgamated American culture

In the 1940s, U.S. Census data reported the nation’s population as 89.8% white, 9.8% Black, and 0.4% other minorities such as American Indian and Native Hawaiian. By 2018, those numbers had changed significantly: The census American Community Survey estimated a population that was 72.2% white, 12.7% Black or African American, 5.6% Asian and 9.5% biracial or other demographics. Of the total U.S. population, 18.3% also identified as Latino or Hispanic in origin. (This overlap exists because, for example, a white or Black person can also be of Hispanic origin.)

The Census predicts that by 2044, America will not have any single ethnic majority—that is, none will have a 50% or greater share of the nation’s total population. Interracial marriages, illegal before 1967, are also on the climb—now around 17% of all marriages—which translates into a larger number of biracial children. America is becoming more diverse by the day, and learning about different cultures is not only a task but also a responsibility shared by health care professionals.

Financial writer Adam McCann has compared six major categories of diversity across all states in the U.S.—socioeconomic, cultural, religious, political, economic and household. The Top 5 most diverse states were, in descending order: California, Texas, Hawaii, New Jersey and New York. In general, coastal states are more diverse than inland states; this is understandable because immigrants often land along the coasts.

Even if you practice in a more homogenous geographic area, however, it’s still important to start learning how to build cultural competency. Diversity is embedded in our daily life: our friends and family, our neighbors, our working team members, and our patient base. The next generations will grow up in a more blended or amalgamated American culture, in which lines between cultures will be further blurred.

Ensuring everyone feels welcome and understood

To understand diversity and inclusion, I like to use the example of a box of loose jigsaw puzzle pieces. Each of us represents an individual loose puzzle piece, which comes in a different form, color and shape.

Diversity can include anything that sets us apart from others: race, gender, age, sexual orientation, country of origin, cultural beliefs, socioeconomic status, educational level, income, our upbringing, our ways of thinking. Walking into any shopping center in the tri-state area where I live, it’s easy to spot diversity: people of different colors, speaking different languages and often dressing differently.

Inclusion is the active act of engaging diversity, making an effort to ensure everyone feels welcome and understood. It takes work to build inclusion from diversity. For example, if you hire an assistant who speaks Spanish, do you know if he or she is from Mexico, Puerto Rico, Ecuador or another country? Getting to know this assistant’s heritage requires effort on your part but will help build trust, rapport and a better work relationship. It is a never-ending process, because our working teams will change over the course of our careers.

We must first be aware that differences exist across cultures. The word culture, in a narrow sense, often refers to something that stems from a country of origin—a subgroup of identifying characteristics based on the geographical region an individual originates from. For example, a woman with a red dot on her forehead near her eyebrows is most likely of South or Southeast Asian descent, while a man who wears a yarmulke to his appointment most likely practices Orthodox Judaism.

However, in a broader sense, culture can expand to work culture. Then, the term minority may refer not to only race or gender but also to those who exhibit characteristics that are different from mainstream culture. By being culturally aware, we can build toward more understanding and cultural competency.

Cultural competency refers to the effectiveness in communication among people with different backgrounds and ways of thinking. People with different cultural backgrounds often also have different religious beliefs or philosophies, as well as variations in educational background and socioeconomic status. They may very well speak at least one other language.

The U.S. may have immigrants from all over the world, but we also have a lot to learn from American Indian cultures. Dr. Jessica Ann Rickert, the world’s first female American Indian dentist, shared her experiences and discussed cultural competency with Dr. Howard Farran in a 2019 Dentistry Uncensored podcast. There are only 14 American Indian/Alaskan Native dental students in the United States; Rickert is working on translating patient brochures into Algonquian for Great Lakes-area Indian tribes.

Respecting commonalities—and differences

I went through my oral and maxillofacial surgery training in the South Bronx, New York, a predominantly Spanish-speaking demographic with many first-generation immigrants, mostly from the Caribbean islands and South America. I learned from my patients that although Spanish is the common shared language, Puerto Ricans, Dominicans, Ecuadorians and Colombians all have their own distinct colloquialisms. I learned not to assume that they were all “the same” just because they shared a spoken language.

On the other hand, dental professionals who have ethnic names or have completed most of their formal education abroad may be questioned by patients if the dentist’s name appears to be unfamiliar or difficult to pronounce. A young Indian dentist once confided that she had been questioned by an older white patient in her 70s.

This patient was baffled by the dentist’s name, wondered whether she could speak English well, then explained that she’d never been treated by a female dentist or anyone of Indian descent. This dentist started a conversation with the patient about her background as well as the necessary treatment, and the patient decided to continue with her because she had approached the patient with kindness. (She actually was excited to tell her neighbors about her first experience with a female dentist!)

It’s not surprising to find patients choosing doctors based on their own cultural heritage or religious affinity. Familiarity brings comfort. Years ago, when I worked as an associate in a group practice that had many Jewish patients, a few rare patients refused to see me because they expected to see the owner because he was a member of the same congregation they were.

In these types of situations, we can seek to understand the reasons behind a patient’s refusal. Gender and age bias still exist; for example, the stereotype of an older white male as the treating doctor is still a common expectation because patients don’t often envision a younger Asian woman representing what “a dentist,” or an oral and maxillofacial surgeon, would look like.

However, stereotypes can be broken through effective communication and compassion. And when language barriers exist, it’s crucial to have developed a great sense of nonverbal communication skills by understanding the cultural differences.

Putting principles into practice

How can dental professionals develop cultural competency that serves an ever-changing diverse demographic? How should we lead a diverse team and enhance inclusion within our own patient base and practice team members? Here are some of my top recommendations:

Ask open-ended questions and avoid assumptions or stereotypes.

Many times, when patients present with ethnic names that are challenging to pronounce, the best way to proceed is simply to ask them how to pronounce their name. If they have a preferred adopted American name to go by, respect that. In doubt, addressing the person formally as “Mr.,” “Mrs.” or “Miss,”or simply by asking how they would like to be identified, can never steer you wrong.

The woman I mentioned earlier with a bindi between her eyebrows could be a native of many different countries—India, Pakistan, Nepal or Bangladesh, to name a few—or a U.S.-born citizen of Southeast Asian descent. One must not automatically assume that she comes from India. Avoid “you all look the same” comments.

Use small talk to establish trust and rapport.

The more you know about the patient’s cultures, the more you may be able to quickly establish rapport. If your patient comes from the Caribbean islands and you’ve taken a cruise through the Caribbean, you can certainly start conversation there. You can also inquire about the patient’s hometown or a particular ethnic dish that might be interesting to you.

Recognize HIPAA’s limitations.

When interacting with adult patients who are not proficient in English, bear in mind that in certain cultures, a family authority figure could be the husband, father or grandfather. HIPAA is American-contexted, which lies in protecting patient privacy based on Western philosophy principles of individuality. According to HIPAA, in a situation where translation is necessary, as long as the patient identifies a particular accompanied person as the translator and does not object, you may discuss directly with the translator.

Even if translation is not necessary, in many cultures, decisions are made collectively within the family. The authority figure of the family may make decisions for the patient, even if the patient is 18 or older. If the authority figure is excluded from the discussion, it can in fact be considered as disrespectful. Therefore, frequent and transparent communication involving key persons in the family is crucial.

Research the demographics of the area you serve.

If you work in an area that has a high concentration of a specific ethnic or racial culture, read up on its customs, particularly about cultural beliefs and religious practice. When I was on staff as an attending at a local hospital with a large percentage of Jewish Orthodox patients, the hospital thoughtfully gave me a packet about Jewish customs. For example, I learned that the hospital elevator had been programmed to automatically stop at every single floor from just before sunset Friday until early Saturday evening, because operation of electrical switches is prohibited on the Jewish Sabbath.

Recognize that different values systems exist.

Different cultures may view American health care systems differently from their own; many immigrants have access to both American health care systems and that of their home country. An example would be the fee differences in dental implants—dentists in both Mexico and India usually offer lower rates. Many dentists might have experiences with patients attempting to negotiate a lower treatment fee or deciding to return to their home country for treatment. Discuss the value of your treatment and educate patients that continuity of care may become an issue, especially if complications arise.

Work on your nonverbal communication skills.

In cases where translation is needed, many nonverbal cues are still universal: Speak slowly at an eye level with a steady tone of voice, smile, and allow time for translation.

Personal distance can be greater in certain cultures, such as in many Asian, Southeast Asian and Middle Eastern cultures—especially between men and women. Typically, body contact is not a norm between two strangers, especially between those of the opposite sex. If you are a male provider treating a female patient whose husband may take the role in making decisions for her, it’s important to ask politely for permission from both husband and wife before examining the patient.

In certain cultures, speaking a louder tone of voice is considered the norm, or being passionate; in other cultures, speaking too loudly, too fast or too directly may be considered rude or intrusive.

Hitting the “restart” button

Are you regrouping your team because of COVID-19? Because many furloughs and layoffs happened during this time, it’s very possible that dental practice owners are considering hiring, or have already rehired, a different team, possibly with a different makeup in terms of diversity. If so, the time is never better to train your team to develop cultural competency, too. It’s no longer enough to recognize someone on your team simply based on a second language this person is speaking; it’s important to take extra steps to get to know your team members to know their cultural heritage.

One dentist recently told me about tension in his practice between two assistants—one from Ukraine, the other from Russia. He only knew when he hired them that they shared a language; it hadn’t occurred to him that their strong contrasting opinions about the ongoing Russo-Ukrainian War would lead to major disagreements and tension.

Filling the gaps of cross-cultural communication is an essential part of practice management. By implementing these strategies, dental professionals will increase work efficiency by organically promoting a more positive environment for team members and a friendlier atmosphere for our patients. In the long run, it will not only increase the practice profitability by increasing patient satisfaction and treatment acceptance, but also to create more cohesiveness within your team.

The same way that you would invest financially in bringing technology into your dental practice, you should invest time and efforts in introducing and embracing diversity and inclusion. The time is now.