Cultural Competence and Type 2 Diabetes Mellitus

PODCAST TRANSCRIPT:

CULTURAL COMPETENCE
Joel Zonszein, MD, CDE, FACE, FACP: The population I see in the Bronx and again in New
York, we love to have this very rich ethnic diversity population in the Bronx. We rarely see
Hispanic patients that they are not coming from one single country, so we have patients from
Dominican Republic, from Columbia, from Puerto Rico, we have Mexicans. Everyone has a
different beliefs, different culture and that they all speak Spanish despite culture beliefs or their
approach to their care is completely different. I think for a treating physician it is very important
to understand these different cultures and try to communicate, not to talk, but to have
communication with patients.

Certain cultures expect that type of communication, so embracing somebody, or some of the
patients, this is very welcomed by some cultures and is not welcomed by other cultures. So to
know who we are dealing, I think is important because if there is a rapport with the patient and
the patient's family, I think it will be easier to treat the patient. There is nothing worse than
having a patient coming to a clinic to see a resident, they hardly communicate, they hardly talk
to each other, they use service of interpreters through the telephone and the message is
conveyed, but the communication is not there, so the patients leave and even if they told what
to do they just do not do it because they feel foreign to the health assistant, they feel foreign to
the recommendations given by the doctor, so that does not work too well. So, trying to
understand the culture is important.

Cultural competence is something that has been taking off in the last two or three years, in fact
we do teach it in the medical school and we do have programs for cultural competency for our
residents and fellows. But me being from a different country, growing up in Mexico with the
different culture, I realized that what we call culture competence should be called cultural
incompetence because it is very difficult even if you understand a culture it is very difficult to
become part of that culture. So I think at the end of the day what we have to do is to deal by
showing some respect to those cultures by trying to establish a communication link rather than
just 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 family
member or the hospital person will not do a good job in conveying the message that needs to be
done, 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 trying
to explain something or if the patient prefers to be instructed and explain. Those are the small
issues that again often are not assessed by the physician in the brief visit with the patient in the

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office. In order to provide the patient, we need to know the literacy of the patient, we need to
know their culture, we need to know their “gestalt” on disease, many of our Hispanic patients
especially 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 do
not understands that diabetes needs to be treated with lifestyle changes with medications, and
somebody have to litigate that for months or years with the patients trying to explain to them that
diet is just part of it and they need medication.

The Asian-Americans are even more of a diverse population than the Hispanic population. A
Chinese is very different from a Japanese and a Korean is very different from a Chinese or
Japanese, and certainly we felt that Eastern Indian population, the people from Pakistan and
India are completely different than the Koreans, Japanese or Chinese. They all have different
languages, 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 no
premature cardiovascular disease and this is a very important growing section in the New York
area where morbidity to mortality is very high, previously neglected that it is even higher than
the African-American and the Hispanic population, those are much better. So, using some
cultural 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 and
cultural groups that we understand the prevalence and some of the genetic kinds of implications
within the group, for example, the Asian and Pacific islanders can have percentages of 12% to
20% 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 very
important factor in terms of understanding the prevalence and the risk within that group and
then understanding the culture in terms of their view or their health belief models how do they
view diabetes. If they view it is punishment, have more of a fatalistic attitude, it is going to be
greater challenge than a group that sees it is an American or western type of disease that was
inflicted on them.

Actually in the Asian and Pacific islanders they have no history of diabetes until westernization
and urbanization hit, so that is a real challenge for that group of patients. Understanding some
of their dietary beliefs and health belief models is going to be real important. For example, in
the American Samoa culture, you have to have coconut milk with every meal, it is included in
every meal, but now they can go into the supermarket and buy a case of coconut milk that is
very concentrated and they may pour the whole can into their dish, where in the old days they



had to climb the tree and husk the coconut, grind the coconut, squeeze the coconut through the
cheese cloth in order to make the little bit to put into their dish, so get them to understand
difference 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 put
them down for that or say that it is wrong because if you do, you are going to turn them off, so
you need to try and understand where they are coming from, and also it is important especially if
English is their second language that either you have an interpreter ideally someone who is not
a family member because you will get a clear picture of what the patient is communicating, but if
no one else is present than the family member so you can be sure that you are communicating
accurately with the patient.

The communication barrier is a huge barrier that we have to deal with. So many things to
consider in terms of culture, I think most important is that everybody's culture you cannot
stereotype it, so you have to listen and really understand each individual patient and family and
ask them what are their beliefs, what are their concerns and then work with them on that.



Cultural Competence and Type 2 Diabetes Mellitus

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Cultural Competence and Type 2 Diabetes Mellitus