What Exactly Are We Measuring?

Evaluating Sexual and Gender Minority Cultural Humility Training for Oncology Care Clinicians

Ash Alpert, MD; Charles Kamen, PhD; Matthew B. Schabath, PhD; Lauren Hamel, PhD; Julia Seay, PhD; Gwendolyn P. Quinn, PhD


J Clin Oncol. 2020;38(23):2605-2609. 

In This Article

Future Directions for SGM Cultural Humility Training in Oncology

Thus far, we have argued that cultural humility serve as a framework for SGM-focused training in oncology and for multilevel evaluations of such training with attention to structural change. Most importantly, we advocate for the creation of SGM oncology cultural humility training and patient-centered measurement tools in partnership with SGM patients who have had cancer, particularly people of color, those who are working class, and those with other intersecting marginalized identities.[6,41–44] Partnerships between community stakeholders and clinicians have the potential to decrease hierarchic power dynamics between patients and physicians and improve relationships. The Betancourt et al[38] model offers several patient-level measures that could be cocreated in collaboration with SGM stakeholders. For example, SGM patients with cancer have outlined domains that contributed to their satisfaction with care: entering clinical spaces that acknowledge their identities, being assured of safe and respectful treatment, and interacting with providers who engage in patient-centered communication. Patient-derived components of satisfaction should be measured after cultural humility training. Additional patient-level measures should include whether SGM oncology patients remain in care, which is particularly germane in situations where SGM patients might leave care because of mistreatment. Additional metrics of SGM cultural humility training in oncology should be derived in partnership with stakeholders. Setting goals of training and developing relevant measurement tools should be a continuous, context-dependent, and iterative process.

The question for future studies to answer is how can providers who have been trained to be more culturally humble with SGM patients, directly improve their patients' health? An SGM patient who feels understood and accepted may be more likely to disclose important facts about their health and behaviors, allowing their clinician to make more timely diagnoses and/or more relevant treatment recommendations. Moreover, a patient who feels accepted by their clinician may be more likely to stay in care and experience less cancer-related distress. Future studies should evaluate the association between particular cultural humility trainings, practice and systemic changes, and SGM patient satisfaction, engagement, and outcomes based on assessments created in collaboration with community stakeholders. The results of such studies should be provided to stakeholders and researchers to be used in a process of continuous growth and quality improvement.

Training is unlikely to be sufficient in changing the climate of care for SGM people. We also recommend that health care policies reinforce individual and system changes. For example, we strongly recommend that cancer centers provide incentives (eg, pay increases) based on SGM and other marginalized patients' engagement and satisfaction with care. Additionally, we recommend the National Cancer Institute (NCI) include in its assessment of eligibility for NCI designation (1) the satisfaction, engagement, and outcomes of SGM and other marginalized patient populations compared with nonmarginalized patient populations, and (2) the satisfaction, retention, and promotion/rank of SGM and other marginalized clinicians and administrators.

ASCO and the National Institutes of Health have classified SGM persons as a population experiencing health disparities.[39,45] Despite this designation, and the many health disparities experienced by SGM patients with cancer, the field of SGM cultural humility in oncology is in its infancy. Although there is much promise in improving structural, organizational, and clinical aspects of oncology care to meet the needs of SGM patients, more work is needed in developing frameworks for evaluation and specific measures of change. To build medical systems that are truly inclusive of marginalized people, we must be committed to radical change in our individual relationships and systems. These changes must be visualized and developed by marginalized patients and clinicians hand in hand with our allies with an eye toward achieving the ultimate goal of reducing discrimination and eliminating health disparities.