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PODCAST TRANSCRIPT:

CULTURAL COMPETENCE

Mohamed G. Atta, MD, MPH

The next issue that we would like to explore is the cultural areas in the treatment of

secondary hypoparathyroidism. As indicated before chronic kidney disease is a common

condition in the United States and according to the last estimation it was estimated that 13%

of the US population has chronic kidney disease and this will be translated into about 26

million individuals with chronic kidney disease. Obviously we know that all Americans from

all ethnic and cultural groups are affected with the disease, but if we look further we would

find that minorities are disproportionately affected. We think that it is probably related to

the fact that most two common courses affect chronic kidney disease in the United States

are diabetes and hypertension and both conditions are more in prevalent minorities such as

Latinos, African-Americans, Native-Americans and Asian-Americans compared to white

Americans.

Perhaps, major implications for those patients will develop more complications as a result of

chronic kidney disease including the secondary hypoparathyroidism, and as a result also

those minority individuals will actually have higher rates of end-stage renal disease

compared to whites. We know that the United States Renal Data System suggests that for

instance African-Americans have four-fold increase in the risk for end-stage renal disease

compared to whites. This trend is not going to get better. We know that the minorities are

growing, I am talking about specifically Latinos and Asian-Americans, in fact it is estimated

that 40% to 50% of the total US population will be comprised of those minorities by 2050

and we are not going to call them minorities anymore. There are barriers to actually treat

those patients and those barriers are driven by cultural obstacles. We think that the minority

populations face many of those obstacles to the acquisition of healthcare in general and

specifically to kidney issues. One of the problems of all chronic conditions that patients

usually is asymptomatic in the early stages of the disease, and if you look at all chronic

conditions like hypertension or diabetes or kidney disorders, those patients in general do not

have any symptoms and therefore they may delay presentation to their health care provider

to get care, and we do not have routine follow-up or routine primary care physicians to

evaluate them to find out if they have any health care issues.

We think that the barriers to the treatment of secondary hypoparathyroidism and chronic

kidney disease in patients not only include the patients, but also that provide cultural beliefs

and misalignment between the Healthcare American System and ethnic health assumptions

for instance. The approach in treating the medical condition in the United States definitely is

different from other cultures and there is lack of healthcare insurance also for many

individuals in the United States, who represent the ethnic minorities. Immigration, which is

Developed in collaboration with the Johns Hopkins University School of Medicine, through a strategic

educational facilitation by Medikly, LLC

Supported by and unrestricted educational grant from Abbott Laboratories

growing also in United States add small diversity to the socioeconomic groups and therefore

we think it’s very important for the healthcare provider and nephrologist to understand and

to overcome some of these cultural barriers, which is going to help in terms of treating

patients with this disorder.

Some examples that I would like to give with regard to cultural differences: some cultures

will think that seeking healthcare may be a luxury or an egocentric conduct, and therefore

they will not seek care except for emergency conditions only. As I indicated before, if those

conditions are chronic and usually asymptomatic in the initial phase, it is unlikely that those

individual will seek help or healthcare if they think that this is really a luxury item to their life.

Some cultures will actually not seek medical care because they believe there is association

between illness and imbalance of excesses and deficiencies. There is a lack of spiritual

strength or their disease is a punishment of immoral behaviors or they associate illness with

may be morally inferior lifestyles. These are important issues that the nephrologist and

healthcare providers should take into consideration when dealing with patients from other

cultures.

There are some ideals in other cultures that may be violated in the American healthcare

attitudes and I am talking about the idea of lifestyles and weight and may be these issues

may not be the appropriate way to approach patients from other cultures. One way of

actually approaching patients from different cultures is the questions with the patients or

the interview with the patients should actually elicit the patient perceived course of illness,

information about the complications to their illness and severity of illness. The questions

must be nonjudgmental for the most part; for instance questions with regard to those

patients may include "what you think about your problem, why did you have this problem at

this time, what you think can be done to treat this illness, and where do you think you may

find the support for your illness as well".

I am going to shift to some of the minority population that we see in our practice, specifically

the Asian-Americans, and this group of individuals are actually growing and they are very

diverse and it is a big segment now of the American population, and there are lot of cultural

issues that come with this population and it is important to understand the diversity within

the American-Asian population. We know that there are more than 50 ethnic groups and

they speak at least 100 languages, and therefore we are not going to obviously find out

about the culture of each of these different segments, but overall there are issues that we

should touch on with the Asian culture. Such as for instance the use of herbal medicine, we

know that a lot of patients from the Asian descent like to use herbs, and they think they cure

lot of disorders and at least in my experience I have seen patients who developed chronic

kidney disease and end-stage renal disease as well as liver failure as the result of the use of

some of these herbal medicine. I am not saying that all herbal medicines are bad, but at least

if we do not know the contents of these herbal plants it is very difficult for us to determine

whether those herbal medicine are responsible or not. For example, the highest prevalence

of end-stage renal disease in the world is in Taiwan and again we think it

Developed in collaboration with the Johns Hopkins University School of Medicine, through a strategic

educational facilitation by Medikly, LLC

Supported by and unrestricted educational grant from Abbott Laboratories

is related to the use of lots of herbal medicines. We have to have those type of issues in the

background when we interview a patient who has Asian culture and also was using some of

these herbal medicine and to be clear whether it is important for them to continue on these

herbal medicine, understanding that this is really their culture, but also try to educate them

about the implications some times of the use of non-regulated substance.

The other issue that comes in mind when I deal with some of these patients is the language

and sometimes it is difficult to communicate well, and so you may have to deal with them

through third party or at least try to have simple questions or sentences with them during

the interview. A closed-ended question is better than the traditional open-ended question

we are used to in the American Healthcare System. One important aspect in the Asian-

American Culture is really family obligations and family is more important than the patient

illness and therefore having a family member or involving the family in the treatment of

those patients is vital to the success in treating those chronic conditions. If there is no family

involvement, we know that the patient will not comply and adhere to treatment. So, this is

really an important message that we should convey to all health care providers; when you

are dealing patients with the Asian background, please try to involve the family in their care.