Welcome to ReachMD. This activity, entitled “Conversations in Health Equity: Practicing Cultural Humility in Latino Populations” is provided by Prova Education.
I had this experience with a patient when I first started at my current job where she came for a diabetes appointment for follow-up. We had never met. But I did notice that she had uncontrolled diabetes. And so I did my usual, talking to her about how are you doing, how's everything going, and I couldn't quite get to her. And so we left the appointment as it was, but I did notice that she had had quite a few visits with many different providers prior to mine, and her diabetes was still not controlled. So finally, I decided after maybe the third, fourth visit that I needed to take a little more time and get to know her more. After a few visits, it turned out that she started to trust me, and she opened up as to the reason why her hemoglobin A1c wasn't going down. I assumed that she was going to tell me it was because she didn't want to use insulin, that she was afraid of something, or just didn't want to do anything about it. Well, I was very surprised to find out that she did not know how to write or read, which made a lot more sense to me of why she wasn't able to use her insulin or be able to use her glucometer.
That is such a common story that I think a lot of us in the audience, when we listen to you, Dr. Espino, are familiar with. But it is so impactful as well.
This is ReachMD, and I'm Dr. Chuck Vega.
And I’m Dr. Kareen Espino.
So welcome, colleagues. Delighted to have you join us. Let's dive right.
That story from your clinical practice highlights situations that many clinicians can relate to. What are the key messages about cultural humility that you learned on that occasion? And what are some of the specific concerns we need to keep in mind about balancing power dynamics in a clinical encounter?
Great question. I had thought that I knew, without asking her, what the answer was going to be. And that reminded me of how we need to be careful of our own biases and how we need to make sure that we don't make any generalizations about our patients. And what I mean by that is that through cultural humility, we tend to try to be open minded, we try to focus on the patient, and not necessarily a particular cultural group, which unfortunately, I did.
And so looking back, I should have, again, had the patient in mind, just try to stop, do some active listening, and try to figure out exactly where she was coming from. And the reason that's important is because as I mentioned, it took a few of the appointments for us to actually start getting to know each other. And the reason I'm saying this in terms of your question about power dynamics is because I realized that she was just going along with the plan that I thought we were both agreeing on. And unfortunately, it turned out that she didn't really have a say in the plan because I wasn't giving her the opportunity to give me the feedback to allow me to understand where she was coming from. And so I think it's very important to understand that we need to make sure we keep the patient in mind at all times. And in order to do that, we need to make sure that we do a little bit of self-reflection in terms of what our biases might be.
Yeah, those momentos de reflexión are very, very important. I see exactly what you're talking about. And it could be a variety of different things, somebody whose back pain isn't getting better, someone who consistently refuses to get vaccinations even though it's in their best interest and you've really made your case, or someone who's diabetes isn't well controlled. That moment to just step back as clinicians and say, “Okay, why is this not working the way it normally should work?” Patients are certainly depending on us for our expertise when it comes to preventive care and for treating acute illness and chronic illness, but when I see that expertise just isn't having the result that I'm looking for, it really does, I think, become really critical to take a step back and understand what might be happening, and just failure to get that buy-in from patients is a big factor. And that's a huge important issue. While certainly patients depend on our expertise, they are really the experts in their own care, and we have to respect that.
So tell us about how cultural humility, Kareen, affects shared decision-making, which is an important subject, as I just alluded to.
Yeah, you mentioned a little bit about this in terms of patients being the experts of their own bodies, of their own experiences. And I think that by putting that at the forefront of the care that we're trying to give, we want to make sure that we start practicing this cultural humility to address, as we already mentioned, power imbalance. That's a big, big issue that I see a lot in different encounters where the patients just say, “Sure, I'll do that,” or they just nod. And I think that that feeds into this paternalistic partnership, if you will, that a lot of patients and providers have, and perhaps even without knowing it. And so when we start being more open about listening to our patients, when we start doing more, as already mentioned, self-reflection of what we are thinking the answer to something may be, I think we start not only hopefully gaining the trust of our patients, but allowing them to feel comfortable not only with us, but with a clinic or the hospital setting, especially when we talk about marginalized communities who have had really horrible experiences with the medical system. And so once we get past that, hopefully we start being able to have that shared decision-making that we're hoping we're able to have with every patient.
Right, and it is empowering patients over time, right? And I'm sure that your active listening and your helping patients to find their voice makes a difference for patients one-to-one, but then for those communities writ large over time as well.
I would also just call out the fact that you mentioned body language. The person who’s nodding and smiling and seeming to understand and be with you every step of the way, look past that a little bit, because sometimes people want to please folks. We’re all biased towards good relationships and making those around us who are trying to take care of us feel better about it. But there oftentimes is some barrier. And so really try to make sure the patients are aware of the plan, do a little teach-back at the end of the session to have them describe what are those top 1 or 3 things that are important that they get out of this visit. And that's a good stepping-off point and part of that empowerment process as well.
Now there are some formal mechanisms and algorithms that we can use to enhance culturally humble care. And the U.S. Health and Human Services Office of Minority Health recommends the LEARN model as communication strategies that can be easily incorporated into clinical care. Can you tell us a little bit more about these models?
You know, the LEARN model, as you mentioned, is a good framework, specifically for what it stands for, which is Listening, Explaining, Acknowledging, Recommending, and Negotiating health information instructions. I think the key here is that they remind us that we need to listen with empathy, which is very important, especially given the type of jobs that healthcare providers have; they can be very difficult, especially with not having enough time, sometimes we tend to not listen with empathy. So that's a good reminder. And of course, we want to make sure we acknowledge and discuss any differences that there may be. And then when they talk about negotiating an agreement, I think it goes back to what you and I already mentioned, which is the shared decision-making. We want to make sure that whatever plan we come up with is mutually agreeable by both the provider and the patient, as well.
And then, of course, power. We talked a little bit about power dynamics. And then we want to make sure that we understand the patient's concerns and fears, where they're coming from. And last but not least, make sure that we start having a level of trust with the patient to make sure that we recognize that trust is not something inherent but must be earned, and thus trying to practice cultural humility.
Yeah, great points. It’s nice to have that North Star. And trust is the number one quality that particularly people of color in United States look to from their healthcare providers. So trust is so, so important.
For those of you who are just tuning in, you're listening to ReachMD. I'm Dr. Chuck Vega.
So I'm delighted to be joined today by Dr. Kareen Espino, who is a graduate of our Program in Medical Education for the Latino Community [PRIME-LC]. And this is a 5-year curriculum that we have here at the University of California Irvine School of Medicine that promotes leadership and achievement in promoting health and equity among Latinos. And so, Kareen, I know you graduated just a few years ago, but do you want to just talk briefly about your experience in the program?
Doing PRIME-LC was my goal when I was applying to medical school. I knew that that was going to be the perfect program for me, given not only the dual degree program opportunity, but also the type of people that ended up going to the program, which were very conscientious about helping the Latino community in many different ways. In addition to not only being good clinicians, I know that the graduates ended up coming out with a very forward thinking when it comes to helping the Latino community in California. And so I wanted to be part of that. And so I'm really happy that I got to do that.
We're delving deeper into practical clinical tips to address the needs of diverse Latino populations.
So Kareen, are there any specific techniques or practical tips you would recommend for our listeners who are keen to improve their clinical practice, particularly thinking about Latino patients?
Yeah, thanks for the question. I think that the first step is already being taken, which is listening to this podcast. I think it's really important to be open to try new things in your practice. And obviously, trying to be someone who's culturally humble when it comes to practicing, specifically with the Latino population, is very important.
I think, open-ended questions, sometimes we forget to do that. And so I think sometimes we might think that by doing open-ended questions we might spend more time than we want with a patient, but I have actually found that you spend a little less time if you're able to use the open-ended questions.
The other thing, of course, is – we've already mentioned this – just being an active listener, very, very important. And then make sure that we focus on the patient, right? We want to make sure that we are able to trust their experience, right, their lived experiences. And this is not only about patients who perhaps have a different culture, but also patients with limited English proficiency, right? So I think trying to practice those things, as well as trying to give yourself some time to have that momento de reflexión, that self-reflection, as you mentioned, Chuck, is very, very important. And it can be hard to do this type of work. Having this lifelong process of self-reflection, self-critique, can be challenging, so making sure that you have a support group or someone else that you can talk about how difficult this may be, I think, is very helpful.
And I can speak as somebody who's just a few years further along in their practice career than you are that actually that self-reflection is – there's a real richness in there and that you're constantly learning and improving. It's called “practice” for a reason, because we haven't perfected it; we're still practicing. And every patient is quite different. And sometimes that connection is not made immediately. It's great when it is, and of course, you want to use all those qualities that Kareen espoused to to make that connection as soon as possible. But those little moments where you're learning something new and having a different skill set, and especially when you see a good result, which is better patient outcomes and a healthy patient relationship, boy, that's really outstanding. And I find that very sustaining moving forward and worth the extra effort.
Before we wrap up, Kareen, what's your take-home message for our audience?
I think it's very important for you to continue to be open. Be open to new suggestions, new ideas, like you are with cultural humility. I think it's really important for you to be patient with yourself, not only about continuing to learn or starting to learn about cultural humility, but just be patient with yourself at all times. Of course, we already know that, like you mentioned, we're still practicing, practicing medicine, and it's not easy. But we all know we went into this career because we love it and we love helping patients.
But the other thing that I would say is make sure that you definitely try to remember that we don't want to generalize. I think that's really important, not just for the Latino population but other marginalized groups. I think generalizations can get us in trouble as not only everyday people, but as physicians. And so the more we continue to focus on an individual instead of a cultural group and try to master a list of, I don't know, a list of – what would you say? – differences or peculiar beliefs that you think a group has, again, go back to just focusing on an individual patient.
Great. Unfortunately, that's all the time we have for today. But I want to thank our audience for listening in. I know how busy you are, so hopefully you found this session helpful. Of course, thank you, Dr. Kareen Espino, for sharing your expertise and insight. You are certainly an inspiration to me and to many others, and certainly your patients as well. And I hope our enthusiasm for this subject translates to the broader audience. Take care, everyone.
Thank you. Goodbye.
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