10:45 –11:30am
Cultural Competency in
Diagnosing Patients
SPEAKER
Olveen Carrasquillo, MD, MPH
Presenter Disclosure Information
The following relationships exist related to this presentation:
► Olveen Carrasquillo, MD, MPH, has no financial relationships to
disclose.
Off-Label/Investigational Discussion
► In accordance with pmiCME policy, faculty have been
asked to disclose discussion of unlabeled or unapproved
use(s) of drugs or devices during the course of their
presentations.
Learning Objectives
Addressing Diabetes in the
Latino Community
► Review of the demographic, socioeconomic, cultural,
and healthcare systems factors that impact the health of
Latino patients.
► Develop effective interviewing and communication skills
to improve patient-provider communication and enhance
adherence in Latino patients.
Olveen Carrasquillo, MD, MPH
Professor of Medicine and Public Health Sciences
Chief, Division of General Internal Medicine
Division Head, Health Services Research & Policy
University of Miami, Miller School of Medicine
► Utilize culturally-tailored strategies, including
multidisciplinary collaborations, to implement communitybased treatment plans and patient education in Latino
patients.
Talk Outline
Case: VC
►Case
Patient: 62-year-old Hispanic woman
►Overview of Latinos and diabetes
Reason for visit: Needs refills of her meds
for type 2 diabetes, hypertension and cholesterol
►It’s all about effective communication
►Additional strategies for culturally and
linguistically appropriate care
Personal Medical History
 Neuropathy
 DJD
 Tension
headaches
 Depression




Reflux
Gastritis
Hypothyroidism
Anxiety




Glaucoma
IBS
Asthma
Fibromyalgia
History of medication non-adherence
DJD = degenerative joint disease
IBS = irritable bowel syndrome
Case: VC
She takes 23 medications!
Daily











Insulin glargine
Glucophage
Gabapentin
Lisinopril
HCTZ
Amlodipine
Simvastatin
Aspirin
Omeprazole
Escitalopram
Thyroxine
As Needed




Lorazepam
Acetaminophen
Naproxen
Polyethylene
glycol
Case CV: Last Visit 9
Months Ago
Non-Oral
“Natural”
 2 inhalers
 2 eye drops
 B Complex
 Uncaria
tomentosa
 Chromium
Labs (10 months ago):
 A1C: 8.6%
► Missed follow-up
 LDL-C: 115 mg/dL
appointment due to
insurance and co-pay
 SBP: 155 mmHg
issues
Plan:
 Increased glargine to 40 units ► Labs 4 months ago
 Increased simvastatin to 40 mg
 A1C: 8.7%
 Increased HCTZ to 25mg
 LDL-C: 120 mg/dL
 Follow up in 3 months
A1C: glycated hemoglobin | LDL-C: low density lipoprotein cholesterol |
SBP: systolic blood pressure | HCTZ: hydrochlorothiazide
HCTZ: hydrochlorothiazide
Case CV: Today’s Visit
Case CV: Plan
► “Just” ran out of meds
► Many other complaints
► Increase
 insulin glargine to 50 U
 amlodipine to 10 mg
 simvastatin to 80 mg
 Back pain is worse
 Still having hard stools
 Needs something stronger to “calm her nerves”
► Referrals:
(Pre new AHA guidelines)
► Nursing: flu and
pneumonia vaccinations
► Blood sugar is “doing well”
 …but ran out of strips 3 month ago






Ophthalmology
Podiatry
Nutrition
Mammography
Physical therapy
Psychiatry
 …and fasting glucose today 248 mg/dL
► Blood pressure has been “good”
 …but has not been able get blood pressure meter
 …today it is 152/86 mmHg
► Trying her best to do diet and exercise
► Nurse: Your next two patients are already here!
Overview of US Hispanic Population
32 million in 2000 | 54 million in 2013
The Big 3
Newer groups
Mexicans
64%
Puerto Ricans 9.4%
Cubans
3.7%
Salvadorans
Dominicans
Guatemalan
Columbians
3.8%
3.1%
2.3%
1.8%
► Follow up in 3 months; labs 1 week prior
► Further address her “other issues” at next visit
Will any of this have any impact on her diabetes?
Disparities in Access to Care
Health Insurance Coverage, 2006
40%
33%
30%
20%
20%
15%
11%
10%
>60% of Latinos in US are US born.
Some Latinos in US 100 years before the pilgrims arrived!
Source: US Census Bureau; 2013 American Community Survey
0%
Non‐Hispanic
White
Black
Shah NS, Carrasquillo O. Health Affairs. 2006:25(6):1612-1619.
Asian
Hispanic
Latino paradox Theories
Latino Paradox
► “Healthy immigrant;” “salmon” hypotheses
►Many studies link poverty to poor health.
► Strong social/family networks
►Latinos are poorer than African Americans...
► Low tobacco and alcohol
► Religiosity
►…but they have lower overall mortality rates,
death from cancer and heart disease, infant
mortality than African Americans and whites.
► Traditional healing practices
► Traditional diet
► Less access to health care leads to improved health??
Why is this?
Challenges to Caring for Patients with
Diabetes (Latinos and non-Latinos)
The Latino Gene?
► There is no Latino SNP!
 Latinos as a genetic group not consistent with modern concepts
of biology and evolution
► Average of 6 meds needed to
reach ABC targets
► Latinos very genetically heterogeneous
 Puerto Ricans very different from Mexicans
 Mexican Spaniards very different from Mayans
 Mexicans in SF very different from Mexicans in DF
► At least 4 visits per year just
for diabetes care
 Cubans in Miami very different from Cubans in Miami
► Many tests, labs, supplies, etc.
► Latinos great group to do genetic research





Some conditions more prevalent
Large families
We know where they live
Can track down the ones abroad!!
Epigenetics
A1C
Blood Pressure
Cholesterol
Ophthalmology
Podiatry
Nutrition
CDE
► Guidelines continue to evolve
SNP = single nucleotide polymorphism
Non-Adherence to First Prescription
Antihypertensives
Challenges to Modify Health
Behaviors
► Lack of time/process to screen for inadequate health
behaviors.
► Prescribing behavior change does not work.
Lipid lowering agents
► No reimbursement for behavior change efforts.
Pain medications
► Intensive interventions often are required.
► Sustainability not proven.
Antidiabetics
0
10
20
30
40
50
60
Percent
Fischer MA et al. J Gen Intern Med. 2010; 25(4):284-90.
Source: Haynes RB, et al. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD000011
Other Challenges: Patients don’t
live in the clinic
Physicians need to be creative about reaching them
Biggest Challenge:
Social Determinants of Health
Social determinants of health are the circumstances in
which people are born, grow up, live, work, and age, as
well as the systems put in place to deal with illness.
These circumstances are in turn shaped by a wider set of
forces: economics, social policies, and politics.
Med Care Res Rev. Oct 2007; 64(5 Suppl): 7S–28S.
Social Determinants of Health
► Poverty
► Education
► Housing
► Environment (incl. access
parks, healthy food)
► Political Empowerment
Most important
components of
health status.
Can they be
addressed at health
care / health care
delivery level?
Back to VC and Her Care
►Diabetes is very complicated to
manage in anyone
►Needs lots drugs and lots of things
►Guidelines on what is “High Quality
Diabetes Care” keep changing
►Many perverse incentives in system
 Fee-for-service: Do much more
 Uninsured or Capitation: Do too little
► Social Inequities
Other Challenges for VC
because She Is Hispanic
► Being Latina
 More likely to have diabetes mellitus
 More likely to be low income
 More likely to have difficulties with access to care
 More likely not to speak English
 More likely to have other social barriers
► All this plus all the other known barriers to providing high
quality care to patients with diabetes
Does she stand a chance?
Next 35 Minutes: How Can Providers
Really Help VC?
► Effective communication
► Cultural and linguistic competence
► Need a multidisciplinary team
 Clinical diabetes educators (CDEs)
 Nutrition
Community Health Workers
 Nursing
(CHWs)
 Social workers
 Can help address some of
+
social determinants
 Linkage to community
resources and facilitators
Strategies that Work for Latino
Patients
#1: Good Physician-Patient communication
► Effective communication is essential in
establishing a diagnosis and treatment
plan.
► Doctors’ interpersonal and communication
skills are highly correlated with improved
health outcomes and health care quality.
► Ineffective communication skills are
associated with malpractice claims and
suits and medical errors.
► True for Latinos and non-Latinos!
Traditional communication approach with
VC: To promote change, we often….
Give them Knowledge ► If people just know
enough, then they will change.
Give them Insight ► If you can just make people
see, then they will change.
Give them Hell ► If you can just make people feel
bad or afraid enough, they will change.
Stewart et al. CMAJ. 1995:1;152(9):1423-33.
Levinson et al. 1997:19;277(7):553-9.
Something like this….
Doctor:
Your diabetes is getting worse and that increases your
chances for complications in the future. Have you been
taking your medications as they were prescribed?
Patient:
Mostly yes.
Doctor:
Do you recall any changes in your diet or weight?
Patient:
I do not think so.
Effective Communication Strategies:
OARS
Open-ended questions
Affirming
Reflective listening
Summarizing
Usual approach continues
Doctor:
Have you been sick or have you traveled and eaten
more outside your home.
Patient:
Not really.
Doctor:
Well, your A1C is worse and it is very important to keep
it below 7% to avoid complications like kidney disease
or blindness. I see that you are on maximal doses of oral
medications so at this point I recommend adding insulin.
I will explain your regimen and the nurse is going to
teach you how to inject the medication.
Open-Ended Questions
►Cannot be answered with yes or no
►Allow to understand patient’s perspective,
readiness, preferences
Example:
How do you feel about your diabetes?
?
Affirming
Reflective Listening: Goals
►Reassuring statements
►Allows to convey empathy, set the tone,
build rapport and support self efficacy
► Understanding
 Show that you are listening
 Clarify meaning
 Get into the patient’s perspective
► Validating/affirming
Example:
I am impressed with your commitment to
lose weight… I know is really difficult..
+
► Reducing resistance
► Encourage discussion
 Struggles/priorities
 Change talk
Reflective Listening
Reflective Listening
Levels of reflection: “I’ve got to stop eating out so much or
I’ll never lose weight and will end up on insulin.”
Levels of reflection: “I’ve got to stop eating out so much or
I’ll never lose weight and will end up on insulin.”
 Repeating – “You’ve got to stop eating out so much to
lose weight and avoid insulin.”
 Reflection of feeling – “The idea of injecting yourself
is scary.”
 Rephrasing – “You can avoid insulin if you lose
weight.”
 Reflecting unspoken content – “For you insulin
means that things are getting worse.”
 Paraphrasing – “Eating at home more could have
some real positive health benefits.”
 Double-sided – “You enjoy eating at McDonald’s, yet
it is leading to weight gain and increasing your risk of
diabetes.”
Effective Communication:
Getting Patients to Use Change Talk
►Speech that favors movement in the
direction of change
►Opposite of sustain talk
►Specific to a target behavior or set of
target behaviors
►Not past tense
Change Talk: DARNCT
►Desire:
 I would really like to lower my blood sugar.
►Ability:
 I can probably figure out a way to remember my
morning meds.
►Reasons:
 I want to be able to provide for my family.
Change Talk: DARNCT
►Need:
 If I’m going to get my blood sugar under control, I
have to make some changes.
►Commitment:
 This week I’m going to make sure I will take my
medications.
►Taking steps:
 I have already started taking my blood sugar
medications before breakfast.
New Buzz Word:
Motivational Interviewing
► “Client-centered, directive method for
enhancing intrinsic motivation to change
by exploring and resolving ambivalence”
► “Clinical method of guiding patients to make
changes in the interest of their health by eliciting
the patient’s own motivation for change”
► Works in all populations
► Particularly effective in minority populations
Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. Vol 2nd ed. New York, NY: 2002.
Guiding Principles of Motivational
Interviewing: RULE
R
Resist the “righting reflex”
U
Understand your patient’s motivations
L
Listen to your patient
E
Empower your patient
 Resistance is a natural reaction to persuasion.
 Facilitate patient’s “arguments” for change.
 Elicit patient’s values, goals, and concerns.
 It is the patient’s reasons that will lead to change.
 More listening, less talking
 Communicate understanding and acceptance of patient’s
experience
 Give patient an active role
 Elicit and support patient’s ideas and solutions
 Support self-efficacy and hope
Motivational Interviewing Approach
Doctor:
Your diabetes is getting worse and that increases your
chances for complications in the future. What are your
thoughts about why your sugar levels may be higher?
Patient:
Well, I lost my job 6 months ago, so I was not as consistent
with my diet for a period of time. I ate what was available.
Thankfully, I got a job now but I have to wake up early and
sometimes miss breakfast. Those days I tend not to take my
morning diabetes medications because I am afraid of getting
a low sugar.
Doctor:
I can see you have been through challenging times, any other
changes in your diet and physical activity during this period?
Conversation Continues...
Conversation Continues…
Patient:
I think I am doing pretty good with lunch and dinner, but
I must confess I have milk and cookies before going to
bed and since I go to work early I usually skip breakfast
and my morning medications.
Doctor:
It seems that on one hand we have found possible
reasons for the blood sugar increase, like the skipping
of the morning dose, but on the other you feel you are
doing the best you can under the circumstances.
Patient:
That is correct.
Doctor:
We need to figure out together how to approach your
worsening diabetes. We could brainstorm strategies to
improve the way you take your medication and maintain
a healthy diet or we could talk about adding other
medications such as insulin. What are your thoughts
about your options?
Patient:
Well, I am not to fond of needles, can we talk a bit more
about what could I do to better take my medications and
exercise more.
Motivational Interviewing Language
Doctor:
What are some reasons for you to make this change?
Patient:
Well, taking my medications will help me get a handle on my
diabetes and for me it is important to not get sicker. I want to
be there for my family, see my grandchildren grow up.
Doctor:
You have very good reasons to try to improve the way you
take your medications and diabetes (reflective listening) if you
were to try to make changes to accomplish this, how would
you go about it in a way that is manageable? (open ended)
Patient:
I leave my breakfast ready the night before, set up an alarm
10 minutes early and take my morning medications when I
brush my teeth.
Motivational Interviewing Language
“Why do you think your diabetes is
not controlled?”
Open-ended question
Change talk: Need
“Even though it is going to be a
sacrifice, do you feel the
improvement in blood glucose is
worth it?”
Reflective listening
Open-ended question
► Tried to find out what the patient thinks the
cause was (patients usually have a theory)
► Not confrontational
► Empathetic, encouraging
► Elicited patient preferences/values
► Gave patient choices
► Helped patient to develop his own plan
Clinical Outcomes of Motivational
Interviewing
►Decrease BMI
►Higher abstinence rates for tobacco and
substance abuse
►Improved adherence
Open-ended question
Can MI improve Medication
Adherence?
Mean medication possession ratio by randomized arm
Motivational Interviewing Summary
► Achieve collaborative, nonjudgmental interactions
► Establish a partnership in which physician offers
expertise
0.78
P=0.01
0.76
► Used open ended questions
►Improved control of cardiovascular risk factors
“I’ve got to wake up earlier to have
breakfast and take my pills”
“What are the best three reasons for
you to make this change?”
What Was Different with
Motivational Interviewing?
► Understand patient’s values, motivations, preferences
and readiness
0.74
0.72
► Evoke within the patient arguments for change
0.7
► Allow patient to find own reasons
0.68
0.66
DVD
Palacio A, et al. J Gen Int Med. 2015. In Press.
MINT
► Respect patient autonomy and right to choose
How About Cultural Competence?
Culture: A pattern of learned, integrated beliefs, values,
and behavior that are shared within a group
 Not just race, ethnic background or country of origin
 Includes language, styles of communication,
practices, customs and views on roles and
relationships as these shape the way we see the
world.
Competence: having the capacity to function effectively,
Evolved Model of Cultural
Competence
IT IS NOT only earlier practice of “do’s and don’ts for X
patient,” as it could lead to stereotyping/oversimplification
of culture.
IT IS NOT making assumptions or generalizations about
patients on the basis of their background.
IT IS NOT only physician language ability—although it is
as an individual or as an organization, within the context of
needs, beliefs, behaviors presented by consumers/patients.
a good start!
How Not to Teach about Caring for
Latino Patients: Empacho
How Not to Teach about Caring for
Latino Patients: Susto
Caused by bolus of undigested food somewhere
in the intestinal tract
► Variety of symptoms
► Treatment includes:
include:
 Dietary restrictions
 Indigestion
 Herbal teas
 Vomiting
 Abdominal massage
with warm oil
 Lack of appetite
 Pinching the skin on
 Diarrhea or constipation
the back and pulling it
until it pops
Cultural Competence Is…
► Implementation of principles of patient-centered care
► Exploration, empathy and responsiveness to patient’s
needs, values, and preferences
How can we do this for Latino patients?
Same as everyone else!!
Strategy #1: Effective Communication
A “fright sickness” caused by a frightening or traumatic experience
that temporarily scares a person’s spirit from their body
► Symptoms include:
 Chill
 Lethargy
 Anxiety
 Depression
 Insomnia
 Irritability
► Treatment includes:
 Herbal teas
 Covering the face with a
cloth and sprinkling holy
water
 Spitting a mouthful of water
or alcohol into the patient’s
face unexpectedly
 Cleansing ceremonies
called limpieza
Cross Cultural Competence
Strategy #2: Know Your Community
► Know your population: Collect data on patients’ race,
ethnicity, primary language
► Know basics of politics/history/cultural markers or
festivities of significance of your community’s
background
► Know about and try to understand social determinants
and barriers to care in your community
Know (and Have Staff From) Your
Community
► Social resources in the community
► Adult day programs
► Pharmacies with free or low cost drugs
► Glucometers available and cost of strips
► Blood pressure meters that are available
► Parks programs and low cost gyms
► Behavioral resources (e.g. smoking cessation)
► Community based organizations
► Legal resources
Interpreter or Not?
► When translation is needed, use certified interpreters.
► Why?
 Patient may be reluctant to discuss certain issues.
 Result in large numbers of errors
• Omission, addition, role exchange
► Whom should not be used
 Staff are often not appropriate - unless certified.
 Friends or family are not appropriate.
 Do not use children!!!
Linguistically Appropriate Services
► A culturally diverse staff that reflects the communities
served
 Staff can be certified interpreters
 Staff can also be trained in effective cross cultural
communication
► Signage and instructional literature in target languages
and consistent with cultural norms
 No Mexican cookbooks for Puerto Ricans
Cross Cultural Competence Strategy #3:
Linguistically Appropriate Services
For the 20% of Latinos who do not speak English well…….
► Assures the provision of appropriate services
► Reduces the incidence of medical errors resulting from
misunderstandings due to language or cultural
incongruences
► Improves efficiency of care by reducing unnecessary
diagnostic testing and inappropriate use of services
Working with Interpreters
► If have large # of patients speaking a certain language,
consider having certified interpreter in house.
 Speak to the patient directly, using a normal tone of
voice. Do not scream!!
 Ask one question at a time
 Avoid slang or technical terms
► Phone interpretation not ideal but much better than none
 Cost effective
 May miss non-verbal communication cues
Additional Cross Cultural
Strategies:
► Try to understand how the patient understands his or her
illness, using skills in interpreting both verbal and
nonverbal cues.
► Use different methods for eliciting patients’
understanding of illness/their condition or explanatory
model of illness (ask patient what they think is going on,
what caused it, etc).
► The role of family in decision-making must be
acknowledged when discussing a treatment plan, and
specifically in the contexts of chronic disease
management and end-of-life issues.
Staff: Community Health Workers (CHWs)
Promotores de Salud” = “Promoters of Health”
Health Navigators | Outreach Workers
Roles/Scope of CHW Practice
► Bridging/cultural mediation between communities and the
health and social service system:
 Help filling forms
► Community members without formal health care education
who serve as a link between patients and providers
 Finding programs, housing and food banks, legal etc.)
► Have long been used in Latin-America as an integral part of
their health care delivery system
► Providing culturally appropriate basic health education and
information
► Share the same ethnicity, socio-economic status, cultural
norms, and communicate in the language of the community
► Navigating people to get the services they need (provide
insurance enrollment assistance/connectors to care)
► Providing informal counseling and social support
► Providing basic clinical/chronic disease management tasks
(taking blood pressure, help w nutrition and physical activity,
etc.)
Miami Healthy Heart Initiative:
Project Overview
► A clinical research of 300 poorly controlled Latino
diabetic patients
► To determine if at 12 months, the Community Health
Worker intervention results in improvements in:
 Cholesterol
CHW Intervention
► Home visits
► Clinic visits
► Social services
► Group walks
► Group education:
 Blood pressure
 Sugar mapping
 Blood sugar control
(A1C)
 Nutrition labels
 How to eat healthy on a budget
 Managing depression
 Open dialogue with physician
Mostly Non-Medical Services
Do CHWs Work?
Results: Outcomes (unpublished data)
► Health Insurance and coverage navigation
Difference*
P value
Difference**
SBP
-3.91
(-8.28 to 0.46)
0.08
-4.62
(-9.01 to -0.24)
0.04
LDL
-8.13
(-18.57 to 2.30)
0.12
-8.21
(-18.74 to 2.32)
0.13
A1C
-0.52
(-0.94 to -0.09)
0.02
-0.51
(-0.94 to -0.08)
0.02
► Legal (housing, immigration)
► Behavioral
► Job training, resumes, placement
► SNAP, WIC, free phones
► Family based approach, help all
P value
* adjusted only for baseline values
** adjusted for adjust age, BMI, CS, gender, education, and depression
A1C: glycated hemoglobin | LDL-C: low density lipoprotein cholesterol | SBP: systolic blood pressure
Can CHWs Be Part of Your Staff?
► Many training materials and programs exist
► States beginning develop certification programs
► Often cost-effective strategy for mid-to large health
provider systems
Addressing Diabetes in the Latino
Community: Key Points
► Caring for patients with diabetes is hard.
► Caring for Latino patients with diabetes is even harder.
Provider-level strategies:
► Effective
communication
Office-level strategies:
► Culturally and
linguistically
appropriate care
System-level strategies:
► Professional and nonprofessional health
workers
Summary: How Can We
Help VC?
► What can the provider do:
 Watch you tube videos of encounters using
Motivation Interviewing (MI)
 Consider MI training for providers & staff
 Practice effective communication strategies
► Culturally and linguistically appropriate care
► Recognize one needs a multidisciplinary team
 Social workers, CDEs, nurses, nutritionists
• Many are trained in motivational interviewing
 CHWs
• Linkage to community resources and facilitators
• Can help address some of social determinants