Dr. Melanie Tervalon is outspoken about being humble. The Oakland pediatrician and community activist wants doctors to loosen the reins of power, become more self-reflective, and do a better job of listening. Too often, even the most well intended physician overlooks the wisdom of true experts in the health care setting—the patients themselves.
“The story of the person across from you is the story you need to pay attention to,” counsels Tervalon.
Known as “cultural humility,” Tervalon’s approach aims to ensure that increasingly diverse populations of patients get the high-quality and respectful care they deserve. It was introduced 20 years ago at Children’s Hospital and Research Center Oakland as part of Tervalon’s pioneering Multicultural Curriculum Program for doctors-in-training at the innercity institution.
“It was time to turn on its head who was the teacher and who was the student,” says Tervalon, who has long championed health equity and other social justice causes. As a consultant and Children’s Hospital professor, she gives talks and training on cultural humility and a number of multicultural health issues.
Cultural humility encourages physicians to politely ask about the needs and practices of those seeking treatment— and to avoid assumptions or snap judgments based on gender, ethnicity, economic status, or other aspects of a patient’s identity. Doctors are coached to commit to ongoing learning and self-critiques. Not surprisingly, the concept runs into occasional resistance from a target audience not known for its meekness.
“Often I find that physicians recoil a bit from the term humility,” Tervalon says. “We use the term to remind us to not be so arrogant or prideful or really think that we have to be all-knowing and all-knowledgeable…which of course we can’t be.”
The curriculum program at Children’s ran for a decade. Parents, community members, and historians were invited to attend and lead informational forums about various cultural groups. The project gained national recognition and was reproduced in other medical centers and workplaces. “To our knowledge, there wasn’t anything like it in the country,” says Tervalon.
Advocating for change, often loudly, is a familiar role for her. Over the course of her career, she’s donned the hats of clinician, health strategist, educator, and adviser to grapple with such thorny problems as racial and ethnic health disparities, childhood obesity, and HIV/AIDS prevention and education.
“I was not raised to be quiet,” says Tervalon.
Indeed: Tapped as a commencement speaker at her graduation from the UCSF School of Medicine, Tervalon unleashed a blistering attack on the racism, classism, and sexism she’d witnessed during training. Her May 1980 address became known as “The Speech.” She related how a second-year resident had used a racial epithet to describe an African American patient and cited how another resident presented a dying white alcoholic, jaundiced and bloated by failing organs, as “the yellow pumpkin.”
“We have often felt dehumanized, ashamed, and unable to call our teammates colleagues,” she told the audience.
Reflecting on that experience, Tervalon says, “I had no idea what medical school would be like. When I got there, I was horrified.”
Dr. Vicki Alexander, who has known Tervalon for 40 years, praises her friend’s courage to speak out against injustice. “Melanie would stand up and call it what it was,” says Alexander, the retired director of the City of Berkeley’s maternal child and adolescent health program.
Tervalon gives credit to her strongly identified African American family in Philadelphia. Her mother was a school teacher, and her father a policeman. “My mother taught me to read when I was three and was going to make sure all the doors were open to me,” she says.
Heavily recruited by Ivy League colleges, Tervalon accepted Radcliffe’s offer in 1969. She immersed herself in a thicket of demonstrations demanding the establishment of a campus center honoring W.E.B. Du Bois, Harvard’s first African American doctoral recipient. When her freshman-year activism earned her a suspension, she headed west and didn’t return. Landing in the Bay Area, she threw herself into progressive political activities. Tervalon joined a Cuba solidarity brigade, managed the Oakland office of Black Panther leader Angela Davis’s defense committee, and at one point shared housing with Davis.
Davis asked her what she wanted to do with her life, which spurred Tervalon to return to school. After getting a bachelor’s degree in genetics at Berkeley, she made a beeline to UCSF for her medical degree. By becoming an MD, Tervalon wanted to serve the black community and gain a solid platform for her activism. An interest in public health led her back to Berkeley after residency. She studied maternal and child health at the School of Public Health from 1983 to 1984, and completed a health policy fellowship at UCSF in 1989.
Two years later, a horrific incident—the beating of black motorist Rodney King in Los Angeles— sparked the cultural humility project. Tervalon was working as an attending physician at Children’s when King’s beating caused simmering racial tensions among the ethnically mixed staff to boil over. Many nonwhite workers felt patronized by white physicians and were troubled by the treatment of patients of color.
A hospital executive asked her and other staff members to sort out the turmoil. With the administration’s blessing, Tervalon and others organized the educational sessions, which attracted enthusiastic crowds of staff and local residents. At gatherings highlighting the backgrounds of African Americans, Latinos, Asians, whites, and other groups, speakers shared historical facts, health practices, poetry, and their past hospital experiences.
Many stories emerged. Among them was a cautionary tale related by a distraught African American mother. She had brought her son to Children’s one night for an asthma attack and left feeling as if she was under a cloud of suspicion. The white medical student examining her son had mistaken scars on his body for evidence of past abuse. He began questioning the boy until discovering the origin of the marks: They were lingering reminders of the major surgery the child had undergone as a fragile premature baby. By this time, the mother felt mistrusted and mistrustful.
For Tervalon, the visit clearly illustrated the need for cultural humility. “We have to check ourselves, check our biases,” she says. Practitioners should be “respectfully curious” of patients and their families, and take time to “listen in ways we haven’t before.” Cultural humility also calls for doctors to become community advocates and for hospitals to provide institutional support.
The program had a powerful impact at Children’s, she says. Communications improved. The hospital introduced language and translation services for non-English speaking patients. And many interns and residents who embraced the principles of cultural humility are “scattered around the country now,” she says.
Jann Murray-Garcia MD, MPH ’94, a fellow pediatrician who helped develop the concept, says cultural humility offered an alternative to the prevailing emphasis that doctors acquire cultural “competence” in their patient interactions. Learning to care for patients from different backgrounds should be an ongoing process, she says, rather than the mastery of a set of facts. “This was not about ten things you do with a Cambodian patient,” says Murray-Garcia, who calls Tervalon “one of the most talented, self-sacrificing and powerful people” she knows.
Fittingly, Tervalon is more humble: “I feel as though I have made a small, important contribution to the work of making change.”