Cultural Competence and Type 2 Diabetes Mellitus
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Cultural Competence and Type 2 Diabetes Mellitus



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    Cultural Competence and Type 2 Diabetes Mellitus Cultural Competence and Type 2 Diabetes Mellitus Document Transcript

    • PODCAST TRANSCRIPT: CULTURAL COMPETENCEJoel Zonszein, MD, CDE, FACE, FACP: The population I see in the Bronx and again in NewYork, we love to have this very rich ethnic diversity population in the Bronx. We rarely seeHispanic patients that they are not coming from one single country, so we have patients fromDominican Republic, from Columbia, from Puerto Rico, we have Mexicans. Everyone has adifferent beliefs, different culture and that they all speak Spanish despite culture beliefs or theirapproach to their care is completely different. I think for a treating physician it is very importantto understand these different cultures and try to communicate, not to talk, but to havecommunication with patients.Certain cultures expect that type of communication, so embracing somebody, or some of thepatients, this is very welcomed by some cultures and is not welcomed by other cultures. So toknow who we are dealing, I think is important because if there is a rapport with the patient andthe patients family, I think it will be easier to treat the patient. There is nothing worse thanhaving a patient coming to a clinic to see a resident, they hardly communicate, they hardly talkto each other, they use service of interpreters through the telephone and the message isconveyed, but the communication is not there, so the patients leave and even if they told whatto do they just do not do it because they feel foreign to the health assistant, they feel foreign tothe recommendations given by the doctor, so that does not work too well. So, trying tounderstand the culture is important.Cultural competence is something that has been taking off in the last two or three years, in factwe do teach it in the medical school and we do have programs for cultural competency for ourresidents and fellows. But me being from a different country, growing up in Mexico with thedifferent culture, I realized that what we call culture competence should be called culturalincompetence because it is very difficult even if you understand a culture it is very difficult tobecome part of that culture. So I think at the end of the day what we have to do is to deal byshowing some respect to those cultures by trying to establish a communication link rather thanjust using a translator and talking, interpreters or through hospital people or family members,and again when we give directions we want to use an interpreter because often the familymember or the hospital person will not do a good job in conveying the message that needs to bedone, but for the competency part of it, again understanding of the culture will be very important.We want to find out if the patient knows how to read, if the patient likes visuals or cartoons tryingto explain something or if the patient prefers to be instructed and explain. Those are the smallissues that again often are not assessed by the physician in the brief visit with the patient in theDeveloped in collaboration with the Center for Continuing Medical Education at Albert Einstein College of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic educational facilitation by Medikly, LLC. Supported by an unrestricted educational grant from Lilly USA, LLC.
    • office. In order to provide the patient, we need to know the literacy of the patient, we need toknow their culture, we need to know their “gestalt” on disease, many of our Hispanic patientsespecially women believe diabetes is God’s will, punishment for their not being good people,some believe that diabetes can be cured by stopping sugary drinks or by eating better, they donot understands that diabetes needs to be treated with lifestyle changes with medications, andsomebody have to litigate that for months or years with the patients trying to explain to them thatdiet is just part of it and they need medication.The Asian-Americans are even more of a diverse population than the Hispanic population. AChinese is very different from a Japanese and a Korean is very different from a Chinese orJapanese, and certainly we felt that Eastern Indian population, the people from Pakistan andIndia are completely different than the Koreans, Japanese or Chinese. They all have differentlanguages, they all have different customs, we have to understand.By the way in the Southeast Asians, we see a tremendous amount of insulin resistance with nopremature cardiovascular disease and this is a very important growing section in the New Yorkarea where morbidity to mortality is very high, previously neglected that it is even higher thanthe African-American and the Hispanic population, those are much better. So, using somecultural competence to go back to the term, understanding the culture of using interpreters,having rapport, I think is very, very critical in dealing with these patients. (6.45 end)Lenora Lorenzo, DNP, APRN, FNP/ADM: When we are dealing with different populations andcultural groups that we understand the prevalence and some of the genetic kinds of implicationswithin the group, for example, the Asian and Pacific islanders can have percentages of 12% to20% as compared to 8% nationally, and I know that many of the Zuni Indians are up to 45%.Patients in American Samoa have uncontrolled diabetes of up to 45%, so it can be veryimportant factor in terms of understanding the prevalence and the risk within that group andthen understanding the culture in terms of their view or their health belief models how do theyview diabetes. If they view it is punishment, have more of a fatalistic attitude, it is going to begreater challenge than a group that sees it is an American or western type of disease that wasinflicted on them.Actually in the Asian and Pacific islanders they have no history of diabetes until westernizationand urbanization hit, so that is a real challenge for that group of patients. Understanding someof their dietary beliefs and health belief models is going to be real important. For example, inthe American Samoa culture, you have to have coconut milk with every meal, it is included inevery meal, but now they can go into the supermarket and buy a case of coconut milk that isvery concentrated and they may pour the whole can into their dish, where in the old days theyDeveloped in collaboration with the Center for Continuing Medical Education at Albert Einstein College of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic educational facilitation by Medikly, LLC. Supported by an unrestricted educational grant from Lilly USA, LLC.
    • had to climb the tree and husk the coconut, grind the coconut, squeeze the coconut through thecheese cloth in order to make the little bit to put into their dish, so get them to understanddifference in the urbanization and what has happened with westernization.I think it is really important that you understand what their culture beliefs are and do not putthem down for that or say that it is wrong because if you do, you are going to turn them off, soyou need to try and understand where they are coming from, and also it is important especially ifEnglish is their second language that either you have an interpreter ideally someone who is nota family member because you will get a clear picture of what the patient is communicating, but ifno one else is present than the family member so you can be sure that you are communicatingaccurately with the patient.The communication barrier is a huge barrier that we have to deal with. So many things toconsider in terms of culture, I think most important is that everybodys culture you cannotstereotype it, so you have to listen and really understand each individual patient and family andask them what are their beliefs, what are their concerns and then work with them on that.Developed in collaboration with the Center for Continuing Medical Education at Albert Einstein College of Medicine and Montefiore, and the American Academy of Nurse Practitioners, through a strategic educational facilitation by Medikly, LLC. Supported by an unrestricted educational grant from Lilly USA, LLC.