Belonging Comes With Cultural Humility

What I've Learned So Far From My Own Journey

“Belonging is having courage, being open and believing in myself and the goodness of others!” —Mukta Panda

How do you describe belonging? What allows you to experience belonging?

My life has given me the opportunity to live in many different cultures, while allowing me and requiring me to hold onto my own culture. I think not only about belonging but belonging to whom, to what, and at what cost?

To answer those questions—to be able to live in this world with no geographic boundaries whether that’s due to travel, technology, or social media—it is so important to be mindful of your own ancestral culture and the culture in which you are immersed. My journey goes from India to England to Saudi Arabia to New York to Tennessee. The people in my life are of different cultures and communities and I celebrate that fact.

The word “discrimination” was never in my vocabulary until I came to America. In the Middle East and London, I didn’t use that word. I grew up in a culture where we were always aware of and often talked about the caste system. I strived to belong from a very young age. I felt this desire for belonging as a sense of wanting to be with people. But I never felt I was being discriminated against.

I only articulated the word “discrimination” when I got to the United States. It was a very harsh word when it first popped into my brain. When I entered the workforce in the US, I felt a lack of general acceptance and a need to prove myself in a different way, beyond proving myself through good work. Only then did “discrimination” come into my mind.

As I reflect back, I find it hard to pinpoint and articulate what it was that made me feel a sense of being different. Growing up in India—which is a land of the caste system, of multiple cultures, religions, languages, food, and attire. When we moved to Goa we were different, we were from the north, yet that felt normal and accepted.

As soon as I first landed in Yonkers, I received unsolicited advice from former colleagues who had family in New York or had visited. Some warnings were explicit, some subtle, to avoid certain areas. “Do not use the subway, avoid certain stores. Be careful where you go. Keep your belongings close to you. Do not travel alone. Be careful to protect your children, they can go astray and rebel against the more conservative Indian culture.” It was as if the sense of being different was introduced then.

In the neighborhood where I lived, very few people spoke Hindi, the native Indian mother tongue, or wore the native attire of the saree or the traditional loose baggy pants called salwar with a long top called a kameez. But people were cordial and nice. This was a growing period for me. My children were almost two and four. I wanted to make sure I raised them to be comfortable in the USA but also worried that they not forget their roots and their Indian cultural heritage.

Three years later we moved to Dayton, Tennessee, a small town north of Chattanooga with even fewer Indian families. We were one of three families from India in our five-mile long city. The first time we invited some work colleagues to our home in Dayton, I was nervous, scared and tired. It was really hard enough to follow the norms and etiquette, to make sure that my family was worthy to belong. I went out and bought an ice tea maker and practiced making iced tea because I knew that was something everybody drank in Dayton. In India we drank our tea hot and with milk. I worried: Would our colleagues like the food? Would I serve the right wine and cheese? What should I wear, Indian or western? I thought I had covered all the possible points to worry about. This was the first home we ever owned. There was a small shed that stood detached but by the side of our home, basically a big unfinished room.

The guests were all in the kitchen where I had laid out the dishes in a buffet style. As we gathered around the island, I explained the various dishes, sharing their Indian names and translating the ingredients and the level of spice for the guests. After I finished, one of the female guests who was facing the kitchen window pointed to the shed asking, “What’s that building?”

“That’s an outhouse,” I replied. Outhouse is a word commonly used in India to mean a building used for storage or as an extra room to house workers. Years later I learned the American meaning of outhouse. I am cringing as I recollect this scene twenty-eight years later. My guests responded with a nod, a strange smile, but no follow-up questions. I’m not sure if they laughed behind my back, but I did get some strange looks that day.

Learning colloquial language has really served me well. I did initially ask for a “torch” when I was examining the eyes of my first patient. Luckily for me, my senior resident was a kind gentleman, so while he laughed, he was also quick to teach me. I am grateful for my ability to laugh at myself. Otherwise my residency training would’ve been hard. It took me a while to stop using words like the dustbin, the boot or trunk of the car, or to stop pronouncing certain medical terms with the emphasis on the wrong syllable. Now as I orient the non-US graduates, I have a colloquialism dictionary that I share.

These were the easier challenges. During my residency program, I became more aware of discrimination against international medical graduates. I remember being warned by another non-US senior resident two years ahead of me to be very mindful because the chief resident, a US graduate, was reviewing our patient notes behind our backs and reporting any mistakes he thought were made to the leadership. Or the rumor was that the administrative staff was instructed to keep two piles of residency applications that were submitted, one for the US graduates and one for the non-US. I have to be honest, I did not seek to validate or confirm these. The possibility was enough to instill fear and a level of distrust.

When you face discrimination, your heart sinks and breaks. You try to fit in. You doubt yourself. You feel guilty and ask “what’s wrong with me?” You feel so guilty you try to improve yourself, but after a while, you realize you’re fighting a losing battle. You can build up resilience by taking a big deep breath, trying to not let it affect you. Or you can choose to retaliate—and that’s not right for me. I felt lonely as a nonwhite female and as a non-US graduate, an immigrant. In response, I built up an emotional armor-like shell that was very difficult to crack. If only we would allow our hearts to crack open to let the light in, as Leonard Cohen sings. A “broken-open heart” is more malleable and can absorb more than a broken heart.

We become insecure from a toxic culture of being watched or the perception of being watched (both are real), and that insecurity threatens our emotional and psychological safety. This illustrates how the basic need of belonging in Maslow’s hierarchy can go unmet. While health care in America is so dependent on talent from all over the globe, the political scenario does not easily value or accept non-US physicians. In fact, international medical graduates and immigrant physicians face discrimination, both at personal and policy levels. The 2017 executive order to ban immigration restricts acceptance of non-US physicians into our medical training programs. This increases our stress and burnout, dismissing (if discussed at all) how we add value with our different cultural experiences and our bilingual or multi-lingual capacity.

This year has highlighted the fragmentation of our community, especially relating to disparities in healthcare access and management. Our political scene, the COVID -19 pandemic, tensions around racism equality and justice, the climate related challenges have further highlighted these fragmentations, disparities, and discriminations and its horrific impact. Healthcare is an emotionally and physically demanding time for all health care professionals. Minorities in medicine are not only from outside the United States. Black, Latino, and Native American residents experience additional burdens secondary to race/ethnicity.

While I, too, can relate to those same challenges, other things now seem less important to me, such as feeling left out of the conversations about baseball or football. I adapted by trying to learn the American culture myself and educate my colleagues about mine. I was determined to not feel like a victim. I decided that I needed to take responsibility to learn, to seek to understand and acknowledge the new customs, to acculturate and enculturate, to strive to belong and offer belonging. Life began to improve and, by and large, I fit in with most of my colleagues.

When I first became a faculty member, I noticed the lens being used was “we have to acculturate the non-US physicians to the American culture we have to teach them how to practice medicine in the US.” I was asked to be on a team to write a curriculum document on acculturation. But to make it meaningful and to make medical students feel engaged and committed to doing their best, I believed we had to help the American medical students value the non-US.

I know that coming from a multi-cultural background, I’m value-added! I have something I bring to the table here. That was “en”-culturation, bringing us all together. I went to the dictionary and looked up the word. Enculturation brings American graduates into the fold of awareness of what the other can bring.

As a clinician and educator, I am required to ensure cultural competence training for our trainees and to embrace and incorporate diversity. Understanding this is a learning process, requiring a personal commitment to be open, transparent and sensitive. Sensitive to my own thoughts, perceptions and biases, stereotypes and intentions. A commitment to awareness and acquiring the basic knowledge and skills needed to interact effectively with people of different cultures. Our communication with each other, our learners and our patients and family’s needs to be sensitive and respectful, and it’s important that as we interact, we focus to understand the individual or family traditions, values and beliefs, and how those impact them and the healthcare we provide.

Our intentional conduct, role modeling, and interventions as educator/leaders need to be appropriate and effective for our medical students to become culturally sensitive physicians and healthcare professionals—they must have the ability to deliver the same care to people of all different cultures. More importantly this needs to be role modeled, practiced, and taught with a spirit that’s not arrogant, but reflects empathetic listening, reflecting, and expressing.

This capacity requires cultural humility, which includes a lifelong commitment to self-evaluation and self-practice. We know that cross-cultural misunderstandings play a role in perpetuating healthcare disparities. Further the diversity in the United States has increased and we know that inequities influence and impact certain cultures much more than others. In so many instances, our healthcare teams do not reflect the cultural diversity that we see in our patients.

I changed my curriculum to teach both acculturation and enculturation. All programs done together, not only for the international medical graduates (IMGs) but also the non-IMGs. A few things that have helped me along my journey (personally and as an educator, practicing clinician, and leader), start with feeling safe myself and promoting a safe space for interaction with all. A safe space is inviting, authentic, and allows each of us to feel valued and free to express our thoughts without the fear of being ridiculed. This often requires a retracing of the power balances in all relationships, including the patient-physician relationship. We need the ability to learn from each other and develop mutually beneficial non-paternalistic clinical and advocacy partnerships.

I have always held a strong belief that achieving cultural competence is not what is important; what is really necessary is cultural awareness, cultural sensitivity, and cultural humility. These require an intentional invitation, mutual respect, a mutual giving and receiving of belonging. I say it with confidence now, but it’s been a long journey to be able to have a voice and speak it. Share your voice today, it matters!

How is the coronavirus and civil unrest around racism changing the way you think of self-care, community and resilience? As this challenging time unfolds, I am posting a quote on this blog with a reflection prompt. Please join in the conversation here or on Twitter or Instagram with your thoughts or what you are doing for self-care and care of others. My book explores such ideas too: Resilient Threads: Weaving Joy and Meaning into Well-Being.