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Please read the case study and the article entitled, Cultural Competency vs Trauma Informed Care, posted below. Using the ideas explored in the article, please write a reflection paper describing how you might resolve the issues depicted in the case study. Mandatory Requirements: Your response must use and cite ideas taken from the article This paper must be one page double spaced, 12 point, Times New Roman You must cite and reference this assignment perfectly. Any reflection paper missing either citations or a reference list will receive a grade of zero. You are not required to cite the case study as it is my creation and not copyrighted. Inuit People and Healthcare Amanda is an Inuit woman from Nunavut whose first language is Inuktitut. Although she speaks English, she is much more comfortable expressing herself in her first language. Due to a lack of resources in her northern community, Amanda has had to relocate to Ottawa for treatment of a foot infection complicated by uncontrolled type 2 diabetes. Amanda has connected with some members of the Inuit community in Ottawa, but she still feels overwhelmed and homesick. These feelings are exacerbated by the lack of Inuktitut speakers in the hospital where she is receiving treatment. In addition, healthcare workers dismiss her request to integrate traditional Inuit healing practices into her care. Finally, her treatment is progressing very slowly and requires her to make some significant life and dietary changes. The dietary suggestions from healthcare staff do not take into consideration the traditional foods available in her community. Some Further Considerations: 1. Forced relocations and institutionalized racism have resulted in distrust toward the Canadian government and its institutions, including the healthcare industry. no 2. Often complaints of chronic pain by Indigenous peoples are met with suspicion by healthcare providers as there is a racist assumption in the healthcare industry that many Indigenous people are addicts seeking prescriptions for opiates. 3. Healthcare providers tend to dismiss different cultural perspectives about health and wellness, assuming that the Western model is the only one worthy of consideration. Trading Cultural Competency for Trauma Informed Care Uchenna Anania , Elizabeth Lanphierb,c , and Dalia Feltmand a Vanderbilt University Medical Center; b Cincinnati Children’s Hospital Medical Center; c University of Cincinnati College of Medicine; d Evanston Hospital Berger and Miller (2021) argue that cultural competency as an educational tool for physicians-in-training fails to address structural inequality and systemic oppression. Instead, it focuses on “culture” which serves as a poor surrogate for what they believe the focus should be—structural racism, implicit biases, and other forms of discrimination that contribute to health disparities. We agree that cultural competency in medical education reinforces stereotypes and assumptions about patients, their beliefs, and practices. It also posits otherness between physicians and patients, presuming physicians belong to majority identities and patients to minority identities. Moreover, evidence is lacking that cultural competence changes outcomes or care evaluations (Horvat et al. 2014). Yet Berger and Miller neglect to provide an alternative tool to replace cultural competency training and address their primary concern, health disparities. We find it unlikely that dismantling health disparities was the AAMC’S primary goal for cultural competency training (2005), given the AAMC offers curricula devoted to health disparities, housed separately from cultural competency curricula on its website. The AAMC’s cultural competency framework instead focuses on improving empathy, professionalism, and communication in patient-physician interactions. To better address aims of professionalism and interpersonal communication, while also addressing the impact of health disparities on patients, we propose replacing cultural competency training with training in trauma-informed care (TIC). A CASE EXAMPLE Vanessa is a 25-year-old Black mother visiting her 4- week-old son, Joshua, in the neonatal intensive care unit (NICU). Joshua was born prematurely at 30 weeks gestational age and is hospitalized for management of hypoglycemia (low blood glucose), jaundice, and difficulty breathing requiring oxygen and positive pressure support. He is currently receiving breastmilk via a feeding tube and is ready to start taking some milk by mouth. The attending neonatologist and a medical student greet Vanessa during her visit, and after telling Vanessa that Joshua is doing well, the neonatologist says, “we are almost out of breastmilk for Joshua in CONTACT Uchenna Anani u..i@vumc.org Pediatrics, Vanderbilt University Medical Center, 2200 Children’s Way, DOT 11137, Nashville TN 37232, USA. 2021 Taylor & Francis Group, LLC THE AMERICAN JOURNAL OF BIOETHICS 13 our freezer. Do you have more breastmilk at home? We also have our lactation support that can offer assistance. In the meantime, we will order formula as back-up.” Vanessa shares that she is having difficulty with her milk supply and says, “I think he will get formula when he goes home anyways, so sure.” Following the encounter, the medical student discusses several concerns with her attending. She wonders how to best counsel Vanessa regarding the continued benefits of breastfeeding. At the same time, she understands that breastfeeding rates, particularly after discharge from the hospital, are lowest for Black and Hispanic mothers and recognizes breastfeeding may be a sensitive topic. The neonatologist recommends providing Vanessa a brochure on breastfeeding and lactation support groups and writes the order for formula. THE “CULTURALLY COMPETENT” RESPONSE This encounter reflects one possible “culturally competent” approach to this Black mother attempting to breastfeed yet facing challenges with milk supply. The medical student recognizes that there are differential rates of breastfeeding continuation depending on race. However, framing breastfeeding rates as a “cultural” difference in which the medical student is “competent” overlooks both Vanessa’s specific needs and circumstances as a patient, and broader systemic considerations influencing disparate breastfeeding rates. The medical team may infer that Vanessa will not continue breastfeeding because it is statistically less common among Black mothers. Plus, Vanessa indicated that her milk supply is low, and she will likely resort to formula at home. But by assuming breastfeeding is a “sensitive topic” to discuss further with Vanessa because she is a Black mother, the medical team members do not fully assess Vanessa’s lactation difficulties and her breastfeeding goals. While attempting to be “culturally competent,” the medical team may inadvertently reinforce racial disparities in breastfeeding rates by failing to assess and support Vanessa in breastfeeding if this is her goal. Framing lower rates of breastfeeding among Black mothers as a cultural difference does not appreciate systemic influences on breastfeeding rates as one of several health disparities affecting Black newborns. Black women are more likely to deliver prematurely, especially at extremely early gestational ages, and be at higher risk for prematurity-related comorbidities (Arnolds et al. 2020). One such complication, necrotizing enterocolitis, is higher in formual TRAUMA-INFORMED CARE Trauma-informed care is grounded in the realization that trauma is pervasive, and commits to recognizing signs of trauma, responding to trauma, and resisting re-traumatization by applying trauma-informed principles (SAMHSA 2014). TIC principles include: safety; trust; peer support; inclusivity and collaboration; empowerment and choice; and attention to identity, history, difference, bias, and stereotype (SAMHSA 2014; Lanphier and Anani 2021). Fundamentally, TIC reframes how we react to others. Instead of asking, “what is wrong with them?” TIC teaches that we ask, “what is going on for them?” TIC embraces curiosity about the experience of another, rather than make assumptions about the experience, identity, or culture of someone else. The TIC literature defines “trauma” broadly to include not only experiences like adverse childhood events or actual or perceived threats of death or sexual violence, but also collective and historical traumas including social, ethnic, or gender-based oppression and structural racism (Lanphier and Anani 2021). In this way, TIC is attuned to intersectional identities and their impacts on individuals. Asking what is going on for someone invites their own narrative about their experience, rather than the assumption of what another’s “culture” and experience might be (Lanphier and Anani 2019). 14 OPEN PEER COMMENTARIES TIC can therefore serve as a concrete, teachable model for interpersonal communication and professionalization. Focusing attention on learning about the individual patient allows TIC to avoid the pitfalls of assumptions and stereotypes presented by “cultural competency.” TIC methods allow the discovery of harms suffered due to implicit bias, microaggressions, and other types of racism, elements Betence model. Lastly, TIC not only applies to patient-clinician interactions, but also holds for peer and mentortrainee relationships. It can be deployed within medical education to better support diverse trainees, addressing not only social determinants of health and health disparities experienced in the world, but also disparities in the medical workforce and learning environment (Brown 2021). A TRAUMA-INFORMED RESPONSE By asking what is going on for Vanessa, we move away from making “culturally competent” inferences about Vanessa and her experiences. We build a partnership with Vanessa by safely and supportively showing curiosity about her particular situation. For example, a trauma-informed neonatologist might, after hearing Vanessa relate her low milk supply, inquire about what is going on for her. Being cognizant of racial disparities in breastfeeding in a trauma-informed way may inform some of the neonatologist’s questions, help identify opportunities for peer support connections, and pay special attention to systemic barriers to breastfeeding for Black women in the United States (Cartagena et al. 2021). But a trauma-informed approach also means engaging Vanessa in conversation, empowering her voice, and enabling her choices. Vanessa could share that she lacks an effective breast pump, flexibility to pump while at work, and peer support and breastfeeding role models. Rather than a generalized handout, the neonatologist could connect Vanessa to hospital resources to help with insurance approval for an adequate pump, engage a lactation consultant to help develop a modified pumping schedule around work constraints, and facilitate connections with other NICU breastfeeding mothers in Vanessa’s community. Leading by example, physician educators can teach students effective methods for screening for trauma and attuning to intersectional identities through TIC. Not only will this improve partnerships in healthcare when physicians and patients have different identity markers, but TIC training can also improve partnerships when patients and physicians are presumed “culturally” similar, but have divergent, specific histories that inform their experience surrounding healthcare. Additionally, trauma-informed medical education (TIME) can support partnerships challenged by the racial and ethnic mismatch common across many patient-provider relationships in the United States currently, revealing concrete examples of structural racism and potential biases in order to combat them (Brown et al 2021; Levy-Carrick et al. 2019) Ultimately, using a TIC based curriculum in medical training and education teaches medical learners skills necessary to promote a safe, supportive, and traumainformed space for patients and medical professionals alike, while inviting them to advocate for health equity at the bedside and beyond. ORCID Uchenna Anani http://orcid.org/0000-0002-0886-2786 Elizabeth Lanphier http://orcid.org/0000-0001-9888-1253 REFERENCES Arnolds, M., R. Gandhi, M. Famuyide, and D. Feltman. 2020. Racial disparities in preemies and pandemics. The American Journal of Bioethics 20 16 OPEN PEER COMMENTARIES Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may p

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