Improving Provider-Patient Communication in Cross-Cultural Scenarios

Enrique Caballero, MD

Medication adherence has developed into a complex issue in diabetes, and while the instinct may be to blame the patients, some, such as Enrique Caballero, MD, suggests that perhaps physicians share some of the blame as well, mainly due to communication.

In a presentation at the American Diabetes Association’s 78^th Annual Scientific Session in Orlando, Florida, Caballero and colleagues Melinda Maryniuk, RD, CDE, and Betsy Rodriguez, RN, MSN, CDE, stressed to an audience of their peers that provider-patient communication issues need to be addressed—especially in cross-cultural situations—and may be partially responsible for the underuse of prescribed therapies.

“The quality of care provided to racial and ethnic groups is not the same,” Caballero said. “A lot of that is due to communication. It’s like trying to impose your own view on them without any considerations. We need to adapt to the culture.”

Cultural differences, whether beliefs or language barriers, according to Caballero, can easily lead to misunderstandings and mistrust of the health care provider. “Of course, many of us have to do this on a day-to-day basis. We have different health beliefs, and this is a challenge we face,” he said.

He added that these cross-cultural issues can be caused a number of factors: the language being spoken, the terminology being used, the tone of the physician, the health literacy of the patient, the level of trust between the 2, and so on. A key, he pointed out, is traversing the line between stereotyping and recognizing the specific factors that impact patients of different cultures.

To instruct the session attendees on what poor communication can look like, Maryniuk and Rodriguez, both Certified Diabetes Educators, role-played out 2 mock-interactions between a bilingual, Hispanic patient (portrayed by Rodriguez) and a provider (portrayed by Marniuk). In the first scenario, Maryniuk demonstrated a lack of active-listening to the patient, spoke quickly, and offered little additional explanation outside of relaying the required information, obviously frustrating and confusing for the patient. In the second, the scenario played out in the ideal fashion, with Maryniuk taking the time to address concerns and take into account the specific factors impacting the patient.

While the issue may be complex, the fix is often a simple one, Maryniuk said. She was part of a study that explored how just using different terminology or doing something as simple as rephrasing a sentence can affect the impact of an interaction. Instead of asking a patient why they haven’t taken their medication in a given period, note how many times they did use it in that period and ask how you can help them to improve their habit, she explained.

“Use language that is neutral, non-judgmental, and based on facts, actions, or physiology and biology,” Maryniuk said. “It needs to be free from stigma, strengths-based, respectful, and foster collaboration between the patient and the provider. But above all, it needs to be person-centered.”

The group ran through an adaptation of Kleinman’s Explanatory Model, which suggests clinicians utilize open-ended questions to better collect information from the patient—allowing for the provider to both inform and gauge their patient’s knowledge simultaneously. They also suggested the use of the ESFT—Explanation, Social Risk, Fears and Concerns, and Therapeutic Contracting—model of communication, which also focuses physicians on asking more about individual patients to gain a better understanding of the person they’re treating. Some of the suggested the questioning included the following:

• What do you think has caused your problem?
• Why do you think it started when it did?
• What do you think your sickness does to you? How does it work?
• How severe is your sickness? Will it have a short or long course?
• What kind of treatment do you think you should receive?
• What are the most important results you hope to receive from this treatment?
• What are the chief problems your sickness has caused for you?
• What do you fear most about your sickness?

For Caballero, as medicine trends toward an individualized approach, it makes sense that same goal should be applicable to how physicians communicate. His suggested objective is to have the medical community recognize that the patient-centered model of communication is an effective strategy to empower patients with diabetes in culturally diverse populations.

“The idea is not to be dogmatic,” he said. “But it is in collectively thinking about what we can do to help others.”

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