Wanted: “Cultural Competence” in Diabetes Care

We all know how important it is to feel like you “click” with your diabetes doctor or educator. Things never go well if the individual you’re seeing doesn’t seem to “get you.” Now imagine that they didn’t speak the same native language, and had absolutely no sense of your lifestyle, diet, mentality, or aesthetic preferences. In other words, you were being treated by someone utterly unfamiliar with your culture. How could you possibly discuss a workable diabetes regimen with no common ground?

A reader recently called my attention to a provocative article that appeared in the journal Insulin last April. It explains why “cultural competence” is key to helping patients thrive. Brace yourself. I’m going to quote extensively from this piece, which (IMHO) unlike many academic-medical articles, has some very down-to-Earth and important things to say. Redblueglasses

THE DEFINITION:
Cultural competence is defined by the American Medical Association as the knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences, self-awareness, knowledge of the patient’s culture, and adaptation of skills.

THE EVIDENCE:
Although no randomized clinical trial has been conducted to demonstrate that DM (diabetes mellitus) control and/or complications are improved by a group of health care providers with higher cultural competence compared with a group with a lower level, it appears clear that cultural competence can lead to a much more pleasant and productive health care provider–patient interaction. In the field of DM, it may be particularly relevant because disease control is greatly determined
by effective lifestyle and behavior modification
.”

I’d say so, yeah.

And furthermore:

These changes are more likely to be implemented if the patient has developed a good rapport with his or her health care provider, an aspect that can be improved through cultural competence. Some individuals have completely ignored the importance of this new area of health care practice, but it has slowly become more appealing and interesting to many.”

In fact, due to the growing number of minorities in the United States, the fact that they suffer from
higher rates of DM and its complications, and the already mentioned lower quality of DM care in these groups, the need to improve the skills of health care providers in the area of cultural competency has been more recognized than ever before.

WHO’S DOING IT:
Currently, 2 states—New Jersey and California— require physicians to obtain some annual continuing medical education credits in programs addressing cultural aspects in health care. It is anticipated that more states will join the effort to disseminate accurate information on how to improve the lives of people with DM from various cultures.”

THE BOTTOM LINE:
Patients and health care providers have a different ‘agenda’ in their mind in any given clinical encounter. Both the patient and the health care provider must become more open and receptive to the other person’s point of view regarding the disease process and treatment strategies. Ultimately, any therapeutic plan is an agreement or ‘contract’ between 2 parties. Both must recognize and acknowledge their responsibility and commitment to move forward. Unfortunately, many health care providers blame the patient for not following a treatment plan. It is disappointing to hear many professionals refer to patients as noncompliant.”

Although it is true that some patients may not adhere to their treatment plan, perhaps it is fairer and more helpful to say: ‘I have not found the best way to interact with my patient so that some specific behavioral changes occur.’”

SOME PLACES TO START:

Diabetes resource web sites with a cultural bent.

In Spanish:

http://www.diabetes.org/espanol/default.jsp

http://www.learningaboutdiabetes.org/spanishBooks.html

http://spiral.tufts.edu/

http://ndep.nih.gov/

http://www.feaed.org/

http://www.nlm.nih.gov/medlineplus/diabetes.html

http://www.joslin.org/1083_3721.asp

http://www.nei.nih.gov/nehep/espanol.asp

http://www.cdc.gov/diabetes/spanish/ndepindex.htm

http://www.diabetes.niddk.nih.gov/dm/ez.asp

http://www.dshs.state.tx.us/diabetes/patient.shtm

For African-Americans:

http://www.womenshealth.gov/minority/africanamerican/diabetes.cfm

http://www.joslin.org/3284_2183.asp

Other:

http://www.ihs.gov/medicalprograms/diabetes/index.asp — for American Indians and Alaskan natives

http://aadi.joslin.harvard.edu/intro/intro_19.asp — for Asian-Americans

http://www.lifeinsurancequotes.org/additional-resources/the-office-of-minority-health/ – covers all all “minorities”

http://www.elviradarknight.com/diabetes/minorities.html – resource list

Or you can always go have a look at David Mendosa’s big list of non-English diabetes web sites, HERE. Whatever it takes, to find your point of connection.

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7 Responses

  1. Rob
    Rob February 13, 2008 at 10:11 am | | Reply

    Amy-
    You make a very good point here. The cultural differences are sometimes too much to overcome and can lead to what they refer to as “noncompliance.”
    But I have seen efforts to combat this. For instance, right in your backyard at the UC San Francisco Diabetes Center, they have a Latino Program that caters specifically to LWD (Latinos with Diabetes), with bilingual AND bi-cultural specialists. This has been a huge success in its short existence and is growing quite rapidly. I work for a foundation that helped provide the start-up money for this program, and am proud to see the differences it is making in people’s lives. Thanks for bringing this to the attention of the diabetic community!

  2. Allison
    Allison February 13, 2008 at 11:14 am | | Reply

    Amy-

    You haven’t by chance read “The Spirit Catches You and You Fall Down” by Anne Fadiman, have you? We read it in my Health Communication class during my senior year in college and it speaks to the cultural differences patients have with medical professionals very well. It’s an interesting read about the Hmong people, who unlike some populations, are unable to communicate via a translator. Check it out if you can.

  3. Linda B.
    Linda B. February 13, 2008 at 9:11 pm | | Reply

    I know that understanding other cultures can help in getting good treatment,but, I must point out that sometimes, the doctor treating you who is from the same cultural background can hamper your treatment just like a doctor who may not know your culture. Why do I say this?
    My mother in law is Filipino. Her doctor is Filipino. During the past few years this doctor has been what I like to call a pill pusher. They come home with all these drugs and no training. My mother in law is a type 2 diabetic. She has uncontrolled high blood pressure, high cholesterol, and totally out of control diabetes. In the last 6 weeks she has had three strokes. Two on the left and the BIG one on the right side. During this last stroke they went to his office he looked at her and sent her home with a scrip for a CT scan and an aspiration study and told her to call a neuroligist. By the time the time they called me it was 5 hours later and she was stroking out.
    because this doctor told them it was not an emergency they sat at home while she worsened, then called us. When we found her she had facial paralysis,nospeech and no swallowing ability left. They would not go to the ER because their doctor told them not to bother it would go away. Well It didn’t. She almost died. This doctor knows the culture and the diet and the foods they eat. He was born in the Phillipines just as they were. he knows. his negligence almost killed her and her husband a year ago. He is also a type 2. Uncontrolled, high blood pressure, etc. etc. They went to see him because he was having some chest discomfort. He said it was probably nothing and sent him home with an unnecessary scrip.Two days later he had a massive heart attack followed by Quintuple bypass. He is still uncontrolled about his diabetes and his diet. He feels because he has new pipes he’s in the clear and the doctor doesn’t tell them he still could have problems. They continue to go to see this doctor because he is Filipino and will talk to them in Tagalog. They both speak perfect english, so language barriers is not an issue. they defend him to the end. The latest defense is he probably didn’t know she was having a stroke because he is just an internist. Ugh! I am banging my head against the wall right now.
    I do feel that having a better understanding of the cultures your patients come from can help in the treatment of diseases, but,negligence can happen even if they know the whole culture because they are from the same place as you. In this case their cultural loyalty seems to be killing them.

  4. camille johnson
    camille johnson February 15, 2008 at 10:04 am | | Reply

    Please tell me who/where to warn potential users.

    I need to inform you and potential users of the shortcomings of the Dexcom7 Continuous Glucose Monitor.

    I started using this device about four months ago and between failures of one kind and another, I’ve been able to use it, at most, two months. The company and the sales/educator that I worked with were very helpful on the phone and replaced most parts that failed, BUT my patience finally faced reality and that reality is: the Dexcom7 is NOT reliable or dependable and it is NOT ready for mass consumption. Not one of the parts/pieces has worked in a reliable manner and the engineering of the pieces evidently has not been tested in a manner that warrants sale to the public.

    It is hard to know exactly what part has failed, but according to the various people I have talked to at customer service, the sensor, the transmitter, the receiver, and the connection cable have all failed. Also [and one of my biggest peeves] the blood test strips rarely work. It is normal that 4-6 (read $4-$6) strips are used before one “works” and displays a glucose level. The management level response to this is that “Dexcom is not responsible for the test strips. Dexcom does not manufacture the test strips.” The OneTouch Ultra Test Strips” are used by other monitors without problems and I don’t believe the test strips are at fault. The Dexcom monitor that “reads” or fails to read the strip, is at fault.

    As a Type1 diabetic, I need my monitor to give me reliable information at all times. The Dexcom7 does not succeed. Please help distribute this information to all persons considering this device.

  5. CALpumper
    CALpumper February 15, 2008 at 11:01 am | | Reply

    This is great information and Linda’s post is very scary too.

    As a child I had an American Female Pediatric Endo. Good fit. What I found was key to my relationship with her….honesty. She told me how many children hide or lie about their bt’s. I told her, why lie, if I give you the information you need then you can help me.

    After her I saw an American Male Endo as an adult. We were not a good fit, he had different agendas and opinions on treatments. After trying his way, getting worse and him being adamant about it working, I left.

    Then I moved onto an Indian Female Endo. Although our cultures were very different, important to me was she was a woman. As I was growing and changing with my disease, even in my 20s, she was very helpful. The best thing she did for me was listen, provide information and empower me to guide her.

    My latest is a Pakistan Male Endo. I have become very knowledgeable about how my body reacts to certain things and learned some medical jargon. This helped develop a good communication with my Endo as he did not need to explain things to me, he could talk “straight” and I would tell him Yes or No to therapies, drugs, tests etc.

    Every Endo I have had is a very different person (where they grew up, what they believe, where/how they got their degree, research concentration). Each has an opinion. So as a patient be vigilant and proactive. Tell your Endo who You are! What you are about! Be honest, upfront. This is Your life and if you do not think something will work, or if you do, tell them. And if you are not comfortable with them, find someone else.

    Through the years Endo’s have listened to me, not, tested, tried things, believed it was only one way for all diabetics so it has to be that way for me. I have encountered it all. So you have the choice, listen to your body and find an Endo that fits or just believe what your Endo tells you. (from experience, doctors do not know everything! what they say is not the end all be all, not the only way) I appreciate my current Endo because he can admit that he has no idea why some things work for a time then don’t. That means a lot to me because He is being honest too!

    These days with technology, research. Find what works for you and work it!

  6. Bek
    Bek November 5, 2008 at 3:07 pm | | Reply

    Great points…
    I would like to also point out that diabetes in and of itself is a culture..
    This disease and the management of it are more ingrained in my daily life than any cultural aspects…

    I can only imagine how much less frustrating, and more effective, some of my medical experiences would have been had the medical professionals I was dealing with (from pharmaceutical and med technology reps to nutritionists, and even my own doctor) had cultural competence in regards to various medical issues… In my case, cultural competence in regards to diabetes (specifically type 1…most of them seem to have quite a bit of understanding about type 2) and chronic pain management have been proven, time and time again, to be two areas where the “pros” have textbook knowledge and no concept of what life with the disease is like-and that can cause a huge communication problem and lead to compliance issues and patient frustration…

    Sure, I’d rather have a doctor that understands my actual cultural heritage and norms (to a degree), but I’d much rather have a doctor who understands that managing this disease goes beyond testing x times/day and shooting up x times/day and that this disease, and the management of this disease, do not exist in a bubble.

    Just my 2 cents (ok make that 2.5 :-)

  7. Devin
    Devin July 28, 2013 at 10:16 am | | Reply

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