Lucia Novak, MSN, NP: Gaps in Diabetes Care

Health care providers must develop the ability to relate to and communicate with their patients of all backgrounds. Particularly in the United States, providers of any racial, ethnic, cultural, and socioeconomic background will encounter patients who don’t share that same background.

A study of physician empathy in a pediatric intensive care unit found that empathetic statements and opportunities to speak about emotions allowed families of pediatric patients to provide more details to the physician. Another study among patients with diabetes found that patients with physicians who had better empathy scores were significantly more likely to have good control of hemoglobin A1c (56%).

Lucia Novak spoke with MD Magazine® about some of the remaining gaps in care for patients with diabetes. She highlighted the need for more representation of racial and ethnic minorities in research, as well as the challenges for patients who are underinsured and cannot afford copays and medication.

Lastly, Novak touched on the steps providers of any background can take to reduce bias and improve their cross-cultural care. “We bring our own biases to the equation and not understanding where someone else is coming from can actually taint the waters and hurt that patient-provider relationship,” said Novak.

Where are the gaps that still remain in diabetes care?

When you look at particular gaps, like more high-risk populations over others, we have to look at our ethnic population—the different races. Unfortunately, most of the studies done here in the United States, constitute a population that is typically Caucasian more so than non-Caucasian counterparts. We need more data, we need more study subjects to participate that are of Asian, that are of Black descent, that are of Hispanic descent, because those are really the high-risk groups. They tend to have diabetes at a much higher rate than the non-Hispanic white. They also tend to have complications at a higher rate, and they tend to have higher mortality as well, when you compare them to non-Hispanic white. So, we have ethnicity and race differences that need to be addressed.

What other challenges exist for providers in managing diabetes care?

We have the underinsured. So, while we were fortunate with the Affordable [Care] Act to make sure that everyone had access to health insurance and we were able to check off that box, the type of insurance patients have—sometimes they may as well not have insurance at all because the deductible that they have to pay out of pocket before their health insurance actually kicks in is costing them way too much money and they can't afford to come to appointments, they certainly can't afford some of their medications. Again diabetes is a buy 1 get 3 free disease so you're usually contending with hypertension, dyslipidemia, underlying heart disease, and so there's other medications, other specialist appointments, other co-pays that have to be taken into consideration. And so, it makes managing a complex disease like diabetes where there is so much overlap and association with other comorbids very difficult and very costly for our patients.

What should providers keep in mind when treating patients from cultures other than their own?

Our patients that come to us from different cultural backgrounds have a different approach to their healthcare, a different approach to medication taking, a different approach to how their relationship is with the provider that's supposed to be assisting them. There's different dynamics within the family—who's allowed to speak who's not allowed to speak who has to be present at the appointment. So, our approach to our patient has to take in these cultural issues that come into play that can either be exploited in their benefit and be used to enhance the appointment or can actually act as a barrier if we don't understand what those relationships are and how to either work with them or overcome them with the patient.

How can clinicians provide more culturally aware care to patients with different backgrounds?

There are courses that are being made more available. So, I would definitely look into what's going on around you as far as educational programs that are offering some of this, maybe touching base with the colleges and universities in your area. They may have some courses that you can take even as an audit. But it's very important that whatever we do, we do, because again we bring our own biases to the equation and not understanding where someone else is coming from can actually taint the waters and hurt that patient-provider relationship and the trust that we need to establish before we can do anything, as far as managing their health.