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OSA may provide cardioprotection
, according to researchers.
In a study of 127 patients presenting with acute coronary syndromes (ACS), median peak cardiac troponin-I (cTn-I) values were significantly higher in patients without obstructive sleep apnea, compared with OSA patients (10.7; interquartile range: 1.78-40.1, vs. 3.79; IQR: 0.37-24.3, respectively; P = .04 ). The findings were published Feb. 5 in the journal CHEST®.
The study comprised 89 OSA patients and 38 non-OSA patients who were admitted to a hospital for acute coronary syndromes. The OSA group had a median apnea-hypopnea index (AHI) of 32, while the non-OSA group had a median AHI of 4.8. There was no significant difference between the two groups in gender, age, or cardiovascular risk factors such as hypertension, diabetes mellitus, body mass index, dyslipidemia, and smoking.
The cohort was part of the Continuous Positive Airway Pressure (CPAP) in Patients With Acute Coronary Syndrome and Obstructive Sleep Apnea (ISAACC) study, a prior randomized, controlled trial that evaluated the effect of CPAP treatment on new cardiovascular events in patients with an episode of ACS and OSA, reported Alicia Sánchez-de-la-Torre, PhD, of the respiratory department at Hospital Universitari Arnau de Vilanova and Santa Maria in Catalonia, Spain, and her coauthors.
Respiratory polygraphy was performed in the first 24-72 hours after hospital admission, and patients with an AHI of at least 15 events per hour were considered to have OSA. Those with an AHI less than 15 events per hour were included in the non-OSA group.
The OSA patients were randomized to conservative or CPAP treatment. An obstructive apnea “episode” was defined as a complete cessation of airflow for 10 seconds or longer, and an episode of hypopnea was defined as a reduction in airflow for at least 10 seconds associated with a greater than 4% decrease in arterial oxygen saturation.
Blood samples were collected from patients every 6 hours until two consecutive cTn-I measurements showed a decrease, with the highest measurement considered the peak cTn-I value.
Peak cTn-I value was significantly higher in non-OSA patients than in OSA patients. Median infarct size, measured by calculating the area under the cTn-I curve, was significantly different between the two groups (451 for non-OSA patients vs. 143 in OSA patients; P = .049), wrote Dr. Sánchez-de-la-Torre and her colleagues.
As cTn-I levels decreased, there was a trend toward increased OSA severity (P = .058). In the multivariable linear regression model used to assess OSA severity, patients with severe OSA had 61% lower cTn-I levels than non-OSA patients, the authors noted.
“The effects of chronic hypoxia in individual organ systems are not well understood. While chronic sustained hypoxia as seen with COPD may lead to pulmonary hypertension, chronic intermittent hypoxia (CIH) as seen predominantly in sleep apnea has been attributed to causing widespread effects ranging from systemic hypertension to metabolic dysfunction and systemic inflammation,” noted Krishna Sundar, MD, FCCP. “Despite these associations, an increased risk of major cardiovascular events from untreated OSA is yet to be definitively established.”
In this article, a protective effect from OSA on myocardial ischemic events is demonstrated in a group of 127 consecutively admitted patients with acute coronary syndrome (ACS). While it is interesting that a high proportion of those admitted for ACS had OSA, there were no significant differences in the age, sex, BMI, usage of antihypertensive or antiplatelet agents, presence of hypertension, DM, dyslipidemia or smoking status between those with and without OSA. “OSA appeared to confer a protective effect on the size of myocardial injury with those having higher AHI values demonstrating lower peak cardiac troponin values,” said Dr. Sundar, who is an associate clinical professor of pulmonary, critical care and sleep medicine at the University of Utah.“An effect of age (mean age in this study being 64 years) and BMI (mean being 27) on the occurrence of preconditioning effects of OSA is not excluded given deleterious effects of untreated OSA on infarct size in other studies on obese or younger patients with ACS. Further understanding of molecular effects of chronic hypoxia exposure (high altitude, chronic lung disease, OSA) is required before the complex and often contradictory effects of chronic hypoxia can be affirmed as being protective or deleterious,” added Dr. Sundar, who is also medical director of the Sleep-Wake Center at the University of Utah and a member of CHEST Physician’s editorial advisory board.
According to the study’s authors, their findings “suggest that patients with higher AHI are significantly more likely to have low cTn-I levels than patients without evidence of OSA, which could imply that patients with elevated AHI, particularly those with severe OSA, may experience less severe myocardial injury.”Limitations of the study include exclusion of patients with severe ACS, exclusion of sleepy subjects, and assessment of myocardial injury using cTn-I as a biomarker, without further data to determine infarct size.
“The possible role of OSA in cardioprotection should be explored in future studies,” the authors concluded.
The authors disclosed relationships with ResMed, Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER. No other disclosures were reported.
chestphysiciannews@chestnet.org
SOURCE: Chest. 2018 Feb 5;153[2]:329-38. doi: 10.1016/j.chest.2017.06.046.
Although this study cannot definitively establish a clinically meaningful protective effect, it does provide important “preliminary evidence supporting the concept of OSA-induced cardioprotection” and challenges existing research, according to an editorial by Doron Aronson, MD, of the department of cardiology at Rambam Medical Center, Haifa, Israel, and coauthors (CHEST. 2018 Feb 153[2]:295-7. doi: 10.1016/j.chest.2017.07.036).
The results should be interpreted with caution, especially since accurate assessment of infarct size poses a challenge, they wrote.
“Myocardial infarct size is highly variable and is influenced by the duration of coronary occlusion, ST-segment elevation or non–ST elevation myocardial infarction, infarct location, residual antegrade infarct-related artery flow, collateral flow, the presence of non–culprit vessel coronary artery disease and myocardial metabolic demand,” they wrote. “Without accounting for these variables in a small study, results may be affected by variation in the characteristics of the patients.”
Though further study is needed, the findings may have “profound clinical implications regarding our therapeutic approach to patients with sleep apnea” if confirmed, the authors concluded.
Although this study cannot definitively establish a clinically meaningful protective effect, it does provide important “preliminary evidence supporting the concept of OSA-induced cardioprotection” and challenges existing research, according to an editorial by Doron Aronson, MD, of the department of cardiology at Rambam Medical Center, Haifa, Israel, and coauthors (CHEST. 2018 Feb 153[2]:295-7. doi: 10.1016/j.chest.2017.07.036).
The results should be interpreted with caution, especially since accurate assessment of infarct size poses a challenge, they wrote.
“Myocardial infarct size is highly variable and is influenced by the duration of coronary occlusion, ST-segment elevation or non–ST elevation myocardial infarction, infarct location, residual antegrade infarct-related artery flow, collateral flow, the presence of non–culprit vessel coronary artery disease and myocardial metabolic demand,” they wrote. “Without accounting for these variables in a small study, results may be affected by variation in the characteristics of the patients.”
Though further study is needed, the findings may have “profound clinical implications regarding our therapeutic approach to patients with sleep apnea” if confirmed, the authors concluded.
Although this study cannot definitively establish a clinically meaningful protective effect, it does provide important “preliminary evidence supporting the concept of OSA-induced cardioprotection” and challenges existing research, according to an editorial by Doron Aronson, MD, of the department of cardiology at Rambam Medical Center, Haifa, Israel, and coauthors (CHEST. 2018 Feb 153[2]:295-7. doi: 10.1016/j.chest.2017.07.036).
The results should be interpreted with caution, especially since accurate assessment of infarct size poses a challenge, they wrote.
“Myocardial infarct size is highly variable and is influenced by the duration of coronary occlusion, ST-segment elevation or non–ST elevation myocardial infarction, infarct location, residual antegrade infarct-related artery flow, collateral flow, the presence of non–culprit vessel coronary artery disease and myocardial metabolic demand,” they wrote. “Without accounting for these variables in a small study, results may be affected by variation in the characteristics of the patients.”
Though further study is needed, the findings may have “profound clinical implications regarding our therapeutic approach to patients with sleep apnea” if confirmed, the authors concluded.
, according to researchers.
In a study of 127 patients presenting with acute coronary syndromes (ACS), median peak cardiac troponin-I (cTn-I) values were significantly higher in patients without obstructive sleep apnea, compared with OSA patients (10.7; interquartile range: 1.78-40.1, vs. 3.79; IQR: 0.37-24.3, respectively; P = .04 ). The findings were published Feb. 5 in the journal CHEST®.
The study comprised 89 OSA patients and 38 non-OSA patients who were admitted to a hospital for acute coronary syndromes. The OSA group had a median apnea-hypopnea index (AHI) of 32, while the non-OSA group had a median AHI of 4.8. There was no significant difference between the two groups in gender, age, or cardiovascular risk factors such as hypertension, diabetes mellitus, body mass index, dyslipidemia, and smoking.
The cohort was part of the Continuous Positive Airway Pressure (CPAP) in Patients With Acute Coronary Syndrome and Obstructive Sleep Apnea (ISAACC) study, a prior randomized, controlled trial that evaluated the effect of CPAP treatment on new cardiovascular events in patients with an episode of ACS and OSA, reported Alicia Sánchez-de-la-Torre, PhD, of the respiratory department at Hospital Universitari Arnau de Vilanova and Santa Maria in Catalonia, Spain, and her coauthors.
Respiratory polygraphy was performed in the first 24-72 hours after hospital admission, and patients with an AHI of at least 15 events per hour were considered to have OSA. Those with an AHI less than 15 events per hour were included in the non-OSA group.
The OSA patients were randomized to conservative or CPAP treatment. An obstructive apnea “episode” was defined as a complete cessation of airflow for 10 seconds or longer, and an episode of hypopnea was defined as a reduction in airflow for at least 10 seconds associated with a greater than 4% decrease in arterial oxygen saturation.
Blood samples were collected from patients every 6 hours until two consecutive cTn-I measurements showed a decrease, with the highest measurement considered the peak cTn-I value.
Peak cTn-I value was significantly higher in non-OSA patients than in OSA patients. Median infarct size, measured by calculating the area under the cTn-I curve, was significantly different between the two groups (451 for non-OSA patients vs. 143 in OSA patients; P = .049), wrote Dr. Sánchez-de-la-Torre and her colleagues.
As cTn-I levels decreased, there was a trend toward increased OSA severity (P = .058). In the multivariable linear regression model used to assess OSA severity, patients with severe OSA had 61% lower cTn-I levels than non-OSA patients, the authors noted.
“The effects of chronic hypoxia in individual organ systems are not well understood. While chronic sustained hypoxia as seen with COPD may lead to pulmonary hypertension, chronic intermittent hypoxia (CIH) as seen predominantly in sleep apnea has been attributed to causing widespread effects ranging from systemic hypertension to metabolic dysfunction and systemic inflammation,” noted Krishna Sundar, MD, FCCP. “Despite these associations, an increased risk of major cardiovascular events from untreated OSA is yet to be definitively established.”
In this article, a protective effect from OSA on myocardial ischemic events is demonstrated in a group of 127 consecutively admitted patients with acute coronary syndrome (ACS). While it is interesting that a high proportion of those admitted for ACS had OSA, there were no significant differences in the age, sex, BMI, usage of antihypertensive or antiplatelet agents, presence of hypertension, DM, dyslipidemia or smoking status between those with and without OSA. “OSA appeared to confer a protective effect on the size of myocardial injury with those having higher AHI values demonstrating lower peak cardiac troponin values,” said Dr. Sundar, who is an associate clinical professor of pulmonary, critical care and sleep medicine at the University of Utah.“An effect of age (mean age in this study being 64 years) and BMI (mean being 27) on the occurrence of preconditioning effects of OSA is not excluded given deleterious effects of untreated OSA on infarct size in other studies on obese or younger patients with ACS. Further understanding of molecular effects of chronic hypoxia exposure (high altitude, chronic lung disease, OSA) is required before the complex and often contradictory effects of chronic hypoxia can be affirmed as being protective or deleterious,” added Dr. Sundar, who is also medical director of the Sleep-Wake Center at the University of Utah and a member of CHEST Physician’s editorial advisory board.
According to the study’s authors, their findings “suggest that patients with higher AHI are significantly more likely to have low cTn-I levels than patients without evidence of OSA, which could imply that patients with elevated AHI, particularly those with severe OSA, may experience less severe myocardial injury.”Limitations of the study include exclusion of patients with severe ACS, exclusion of sleepy subjects, and assessment of myocardial injury using cTn-I as a biomarker, without further data to determine infarct size.
“The possible role of OSA in cardioprotection should be explored in future studies,” the authors concluded.
The authors disclosed relationships with ResMed, Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER. No other disclosures were reported.
chestphysiciannews@chestnet.org
SOURCE: Chest. 2018 Feb 5;153[2]:329-38. doi: 10.1016/j.chest.2017.06.046.
, according to researchers.
In a study of 127 patients presenting with acute coronary syndromes (ACS), median peak cardiac troponin-I (cTn-I) values were significantly higher in patients without obstructive sleep apnea, compared with OSA patients (10.7; interquartile range: 1.78-40.1, vs. 3.79; IQR: 0.37-24.3, respectively; P = .04 ). The findings were published Feb. 5 in the journal CHEST®.
The study comprised 89 OSA patients and 38 non-OSA patients who were admitted to a hospital for acute coronary syndromes. The OSA group had a median apnea-hypopnea index (AHI) of 32, while the non-OSA group had a median AHI of 4.8. There was no significant difference between the two groups in gender, age, or cardiovascular risk factors such as hypertension, diabetes mellitus, body mass index, dyslipidemia, and smoking.
The cohort was part of the Continuous Positive Airway Pressure (CPAP) in Patients With Acute Coronary Syndrome and Obstructive Sleep Apnea (ISAACC) study, a prior randomized, controlled trial that evaluated the effect of CPAP treatment on new cardiovascular events in patients with an episode of ACS and OSA, reported Alicia Sánchez-de-la-Torre, PhD, of the respiratory department at Hospital Universitari Arnau de Vilanova and Santa Maria in Catalonia, Spain, and her coauthors.
Respiratory polygraphy was performed in the first 24-72 hours after hospital admission, and patients with an AHI of at least 15 events per hour were considered to have OSA. Those with an AHI less than 15 events per hour were included in the non-OSA group.
The OSA patients were randomized to conservative or CPAP treatment. An obstructive apnea “episode” was defined as a complete cessation of airflow for 10 seconds or longer, and an episode of hypopnea was defined as a reduction in airflow for at least 10 seconds associated with a greater than 4% decrease in arterial oxygen saturation.
Blood samples were collected from patients every 6 hours until two consecutive cTn-I measurements showed a decrease, with the highest measurement considered the peak cTn-I value.
Peak cTn-I value was significantly higher in non-OSA patients than in OSA patients. Median infarct size, measured by calculating the area under the cTn-I curve, was significantly different between the two groups (451 for non-OSA patients vs. 143 in OSA patients; P = .049), wrote Dr. Sánchez-de-la-Torre and her colleagues.
As cTn-I levels decreased, there was a trend toward increased OSA severity (P = .058). In the multivariable linear regression model used to assess OSA severity, patients with severe OSA had 61% lower cTn-I levels than non-OSA patients, the authors noted.
“The effects of chronic hypoxia in individual organ systems are not well understood. While chronic sustained hypoxia as seen with COPD may lead to pulmonary hypertension, chronic intermittent hypoxia (CIH) as seen predominantly in sleep apnea has been attributed to causing widespread effects ranging from systemic hypertension to metabolic dysfunction and systemic inflammation,” noted Krishna Sundar, MD, FCCP. “Despite these associations, an increased risk of major cardiovascular events from untreated OSA is yet to be definitively established.”
In this article, a protective effect from OSA on myocardial ischemic events is demonstrated in a group of 127 consecutively admitted patients with acute coronary syndrome (ACS). While it is interesting that a high proportion of those admitted for ACS had OSA, there were no significant differences in the age, sex, BMI, usage of antihypertensive or antiplatelet agents, presence of hypertension, DM, dyslipidemia or smoking status between those with and without OSA. “OSA appeared to confer a protective effect on the size of myocardial injury with those having higher AHI values demonstrating lower peak cardiac troponin values,” said Dr. Sundar, who is an associate clinical professor of pulmonary, critical care and sleep medicine at the University of Utah.“An effect of age (mean age in this study being 64 years) and BMI (mean being 27) on the occurrence of preconditioning effects of OSA is not excluded given deleterious effects of untreated OSA on infarct size in other studies on obese or younger patients with ACS. Further understanding of molecular effects of chronic hypoxia exposure (high altitude, chronic lung disease, OSA) is required before the complex and often contradictory effects of chronic hypoxia can be affirmed as being protective or deleterious,” added Dr. Sundar, who is also medical director of the Sleep-Wake Center at the University of Utah and a member of CHEST Physician’s editorial advisory board.
According to the study’s authors, their findings “suggest that patients with higher AHI are significantly more likely to have low cTn-I levels than patients without evidence of OSA, which could imply that patients with elevated AHI, particularly those with severe OSA, may experience less severe myocardial injury.”Limitations of the study include exclusion of patients with severe ACS, exclusion of sleepy subjects, and assessment of myocardial injury using cTn-I as a biomarker, without further data to determine infarct size.
“The possible role of OSA in cardioprotection should be explored in future studies,” the authors concluded.
The authors disclosed relationships with ResMed, Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER. No other disclosures were reported.
chestphysiciannews@chestnet.org
SOURCE: Chest. 2018 Feb 5;153[2]:329-38. doi: 10.1016/j.chest.2017.06.046.
Outpatient CAR T infusions feasible using liso-cel
SALT LAKE CITY – A CD19-directed 4-1BB chimeric antigen receptor (CAR) T cell product showed efficacy and a low rate of cytokine release syndrome and neurotoxicity in patients with aggressive lymphomas and poor prognoses, raising the possibility of outpatient administration and fewer hospitalization days in this high-risk group.
A total of 86 patients who received inpatient infusions of lisocabtagene maraleucel (liso-cel, also known as JCAR017) had a mean 15.6 days of hospitalization, compared with 9.3 days for 8 outpatient recipients, said Jeremy Abramson, MD, speaking at a top abstracts session of the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.
As of October 2017, eight patients had received liso-cel infusion as outpatients with at least 28 days of postinfusion data, Dr. Abramson said.
Although all but one required hospital admission, at a median of 5 days postinfusion (range, 4-22 days), there had been no intensive care unit admissions, and no outpatient recipients had experienced severe cytokine release syndrome (CRS) or neurotoxicity. All admitted patients presented with fever.
Among the study population, “Cytokine release syndrome was only seen in 35% of our entire dataset,” with neurologic toxicity seen in 19% of participants, Dr. Abramson said. “The majority of subjects had no CRS and no toxicity,” he said. Severe CRS occurred in 1% of the study population, and severe neurotoxicity in 12%. There were no deaths related to either complication.
Dr. Abramson reported these results from the TRANSCEND NHL 001 trial, a seamless design phase 1 pivotal trial of liso-cel enrolling patients with relapsed and refractory aggressive B cell non-Hodgkin lymphoma (NHL). Liso-cel delivers CD19-directed CD4 and CD8 CAR T cells in a 1:1 ratio, said Dr. Abramson, director of the lymphoma program at the Massachusetts General Hospital Cancer Center, Boston.
A total of 91 patients were randomized to one of the three dose-finding cohorts of the multicenter trial of liso-cel. One cohort received 5 x 107 cells in a single dose; a second cohort received the same number of cells but in two doses administered 14 days apart; the third cohort received a single dose of 1 x 108 cells.
The seamless trial design then moved to dose expansion, using the two single doses established in the dose-finding phase of the study. Ultimately, Dr. Abramson said, the third and pivotal diffuse large B-cell lymphoma (DLBCL) cohort received the higher single dose, since a dose-response relationship was seen in the earlier cohorts. No increase in cytokine release syndrome or neurotoxicity has been seen with the higher dose in patients evaluated to date.
Patients (median age, 61 years) were eligible to participate in the trial if they had relapsed or refractory DLBCL, primary mediastinal B-cell lymphoma, grade 3B follicular lymphoma, or mantle cell lymphoma. Patients with a failed prior allogeneic stem cell transplant or secondary central nervous system involvement were eligible, but all patients had to have an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2.
As the trial moved to the core pivotal phase, eligibility requirements shifted slightly to include patients with ECOG status 0 or 1, and lymphoma diagnoses narrowed to include only DLBCL not otherwise specified (NOS), transformed follicular lymphoma, and high-grade B-cell lymphoma with double- and triple-hit cytogenetics. The core group was nearing completion of accrual at the time of the presentation, which presented preliminary results from this phase of the trial.
Among the 88 evaluable patients in the initial population with DLBCL receiving any of three dose levels, the best overall response rate (ORR) was 74% (95% confidence interval, 63%-83%); 52% of these patients achieved complete response (CR; 95% CI, 41%-63%).
For patients receiving the higher dose of liso-cel, the ORR was 81% (95% CI, 62%-94%), with a 63% CR rate (95% CI, 42%-81%), bearing out the dose-response rate that had been seen earlier in the trial, Dr. Abramson said.
The median duration of response in all TRANSCEND patients was 9.2 months; the median duration of remission has not been reached, he said. “We see evidence of durable response at 3 months in all our high-risk subsets, and that includes double- and triple-hit lymphomas, double-expresser lymphomas, patients who’ve never achieved prior complete remission, and patients with refractory disease.”
“The overall results are similarly encouraging,” Dr. Abramson said, with 86% of all patients alive at 6 months. Among the complete responders, 94% are alive at the 6-month mark. “The median duration of complete responders has not been reached in this cohort,” he said.
These results are notable, Dr. Abramson said, since about 90% of study participants have at least one disease risk factor that would predict median overall survival of 3-6 months.
During the period after leukapheresis while the CAR T cells were in production, patients could have ongoing treatment, but received PET scans to confirm disease before continuing enrollment in the trial and receiving liso-cel. The time from apheresis to product release for the pivotal cohort is now under 21 days, he said.
The study was supported by Juno Therapeutics, which plans to market liso-cel. Dr. Abramson reported ties with Celgene, Gilead, Seattle Genetics, Novartis, and Genentech.
SOURCE: Abramson J et al. Abstract 5.
SALT LAKE CITY – A CD19-directed 4-1BB chimeric antigen receptor (CAR) T cell product showed efficacy and a low rate of cytokine release syndrome and neurotoxicity in patients with aggressive lymphomas and poor prognoses, raising the possibility of outpatient administration and fewer hospitalization days in this high-risk group.
A total of 86 patients who received inpatient infusions of lisocabtagene maraleucel (liso-cel, also known as JCAR017) had a mean 15.6 days of hospitalization, compared with 9.3 days for 8 outpatient recipients, said Jeremy Abramson, MD, speaking at a top abstracts session of the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.
As of October 2017, eight patients had received liso-cel infusion as outpatients with at least 28 days of postinfusion data, Dr. Abramson said.
Although all but one required hospital admission, at a median of 5 days postinfusion (range, 4-22 days), there had been no intensive care unit admissions, and no outpatient recipients had experienced severe cytokine release syndrome (CRS) or neurotoxicity. All admitted patients presented with fever.
Among the study population, “Cytokine release syndrome was only seen in 35% of our entire dataset,” with neurologic toxicity seen in 19% of participants, Dr. Abramson said. “The majority of subjects had no CRS and no toxicity,” he said. Severe CRS occurred in 1% of the study population, and severe neurotoxicity in 12%. There were no deaths related to either complication.
Dr. Abramson reported these results from the TRANSCEND NHL 001 trial, a seamless design phase 1 pivotal trial of liso-cel enrolling patients with relapsed and refractory aggressive B cell non-Hodgkin lymphoma (NHL). Liso-cel delivers CD19-directed CD4 and CD8 CAR T cells in a 1:1 ratio, said Dr. Abramson, director of the lymphoma program at the Massachusetts General Hospital Cancer Center, Boston.
A total of 91 patients were randomized to one of the three dose-finding cohorts of the multicenter trial of liso-cel. One cohort received 5 x 107 cells in a single dose; a second cohort received the same number of cells but in two doses administered 14 days apart; the third cohort received a single dose of 1 x 108 cells.
The seamless trial design then moved to dose expansion, using the two single doses established in the dose-finding phase of the study. Ultimately, Dr. Abramson said, the third and pivotal diffuse large B-cell lymphoma (DLBCL) cohort received the higher single dose, since a dose-response relationship was seen in the earlier cohorts. No increase in cytokine release syndrome or neurotoxicity has been seen with the higher dose in patients evaluated to date.
Patients (median age, 61 years) were eligible to participate in the trial if they had relapsed or refractory DLBCL, primary mediastinal B-cell lymphoma, grade 3B follicular lymphoma, or mantle cell lymphoma. Patients with a failed prior allogeneic stem cell transplant or secondary central nervous system involvement were eligible, but all patients had to have an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2.
As the trial moved to the core pivotal phase, eligibility requirements shifted slightly to include patients with ECOG status 0 or 1, and lymphoma diagnoses narrowed to include only DLBCL not otherwise specified (NOS), transformed follicular lymphoma, and high-grade B-cell lymphoma with double- and triple-hit cytogenetics. The core group was nearing completion of accrual at the time of the presentation, which presented preliminary results from this phase of the trial.
Among the 88 evaluable patients in the initial population with DLBCL receiving any of three dose levels, the best overall response rate (ORR) was 74% (95% confidence interval, 63%-83%); 52% of these patients achieved complete response (CR; 95% CI, 41%-63%).
For patients receiving the higher dose of liso-cel, the ORR was 81% (95% CI, 62%-94%), with a 63% CR rate (95% CI, 42%-81%), bearing out the dose-response rate that had been seen earlier in the trial, Dr. Abramson said.
The median duration of response in all TRANSCEND patients was 9.2 months; the median duration of remission has not been reached, he said. “We see evidence of durable response at 3 months in all our high-risk subsets, and that includes double- and triple-hit lymphomas, double-expresser lymphomas, patients who’ve never achieved prior complete remission, and patients with refractory disease.”
“The overall results are similarly encouraging,” Dr. Abramson said, with 86% of all patients alive at 6 months. Among the complete responders, 94% are alive at the 6-month mark. “The median duration of complete responders has not been reached in this cohort,” he said.
These results are notable, Dr. Abramson said, since about 90% of study participants have at least one disease risk factor that would predict median overall survival of 3-6 months.
During the period after leukapheresis while the CAR T cells were in production, patients could have ongoing treatment, but received PET scans to confirm disease before continuing enrollment in the trial and receiving liso-cel. The time from apheresis to product release for the pivotal cohort is now under 21 days, he said.
The study was supported by Juno Therapeutics, which plans to market liso-cel. Dr. Abramson reported ties with Celgene, Gilead, Seattle Genetics, Novartis, and Genentech.
SOURCE: Abramson J et al. Abstract 5.
SALT LAKE CITY – A CD19-directed 4-1BB chimeric antigen receptor (CAR) T cell product showed efficacy and a low rate of cytokine release syndrome and neurotoxicity in patients with aggressive lymphomas and poor prognoses, raising the possibility of outpatient administration and fewer hospitalization days in this high-risk group.
A total of 86 patients who received inpatient infusions of lisocabtagene maraleucel (liso-cel, also known as JCAR017) had a mean 15.6 days of hospitalization, compared with 9.3 days for 8 outpatient recipients, said Jeremy Abramson, MD, speaking at a top abstracts session of the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.
As of October 2017, eight patients had received liso-cel infusion as outpatients with at least 28 days of postinfusion data, Dr. Abramson said.
Although all but one required hospital admission, at a median of 5 days postinfusion (range, 4-22 days), there had been no intensive care unit admissions, and no outpatient recipients had experienced severe cytokine release syndrome (CRS) or neurotoxicity. All admitted patients presented with fever.
Among the study population, “Cytokine release syndrome was only seen in 35% of our entire dataset,” with neurologic toxicity seen in 19% of participants, Dr. Abramson said. “The majority of subjects had no CRS and no toxicity,” he said. Severe CRS occurred in 1% of the study population, and severe neurotoxicity in 12%. There were no deaths related to either complication.
Dr. Abramson reported these results from the TRANSCEND NHL 001 trial, a seamless design phase 1 pivotal trial of liso-cel enrolling patients with relapsed and refractory aggressive B cell non-Hodgkin lymphoma (NHL). Liso-cel delivers CD19-directed CD4 and CD8 CAR T cells in a 1:1 ratio, said Dr. Abramson, director of the lymphoma program at the Massachusetts General Hospital Cancer Center, Boston.
A total of 91 patients were randomized to one of the three dose-finding cohorts of the multicenter trial of liso-cel. One cohort received 5 x 107 cells in a single dose; a second cohort received the same number of cells but in two doses administered 14 days apart; the third cohort received a single dose of 1 x 108 cells.
The seamless trial design then moved to dose expansion, using the two single doses established in the dose-finding phase of the study. Ultimately, Dr. Abramson said, the third and pivotal diffuse large B-cell lymphoma (DLBCL) cohort received the higher single dose, since a dose-response relationship was seen in the earlier cohorts. No increase in cytokine release syndrome or neurotoxicity has been seen with the higher dose in patients evaluated to date.
Patients (median age, 61 years) were eligible to participate in the trial if they had relapsed or refractory DLBCL, primary mediastinal B-cell lymphoma, grade 3B follicular lymphoma, or mantle cell lymphoma. Patients with a failed prior allogeneic stem cell transplant or secondary central nervous system involvement were eligible, but all patients had to have an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2.
As the trial moved to the core pivotal phase, eligibility requirements shifted slightly to include patients with ECOG status 0 or 1, and lymphoma diagnoses narrowed to include only DLBCL not otherwise specified (NOS), transformed follicular lymphoma, and high-grade B-cell lymphoma with double- and triple-hit cytogenetics. The core group was nearing completion of accrual at the time of the presentation, which presented preliminary results from this phase of the trial.
Among the 88 evaluable patients in the initial population with DLBCL receiving any of three dose levels, the best overall response rate (ORR) was 74% (95% confidence interval, 63%-83%); 52% of these patients achieved complete response (CR; 95% CI, 41%-63%).
For patients receiving the higher dose of liso-cel, the ORR was 81% (95% CI, 62%-94%), with a 63% CR rate (95% CI, 42%-81%), bearing out the dose-response rate that had been seen earlier in the trial, Dr. Abramson said.
The median duration of response in all TRANSCEND patients was 9.2 months; the median duration of remission has not been reached, he said. “We see evidence of durable response at 3 months in all our high-risk subsets, and that includes double- and triple-hit lymphomas, double-expresser lymphomas, patients who’ve never achieved prior complete remission, and patients with refractory disease.”
“The overall results are similarly encouraging,” Dr. Abramson said, with 86% of all patients alive at 6 months. Among the complete responders, 94% are alive at the 6-month mark. “The median duration of complete responders has not been reached in this cohort,” he said.
These results are notable, Dr. Abramson said, since about 90% of study participants have at least one disease risk factor that would predict median overall survival of 3-6 months.
During the period after leukapheresis while the CAR T cells were in production, patients could have ongoing treatment, but received PET scans to confirm disease before continuing enrollment in the trial and receiving liso-cel. The time from apheresis to product release for the pivotal cohort is now under 21 days, he said.
The study was supported by Juno Therapeutics, which plans to market liso-cel. Dr. Abramson reported ties with Celgene, Gilead, Seattle Genetics, Novartis, and Genentech.
SOURCE: Abramson J et al. Abstract 5.
REPORTING FROM THE 2018 BMT TANDEM MEETINGS
Key clinical point:
Major finding: High-risk lymphoma patients had more than 6 fewer inpatient days with outpatient CAR T infusion.
Study details: Seamless phase 1 trial initially evaluating 91 patients with relapsed/refractory diffuse large B cell lymphoma.
Disclosures: Juno Therapeutics sponsored the study. Dr. Abramson reported ties with Celgene, Gilead, Seattle Genetics, Novartis, and Genentech.
Source: Abramson J et al. Abstract 5.
MDedge Daily News: Improving wearable cardioverter defibrillators
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
, alirocumab cuts deaths in post–acute coronary syndrome patients, the ODYSSEY Outcomes trial redefines secondary cardiovascular prevention, and how walking cuts postmenopausal women’s heart failure risk.
Listen to the MDedge Daily News podcast for all the details on today’s top news.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
, alirocumab cuts deaths in post–acute coronary syndrome patients, the ODYSSEY Outcomes trial redefines secondary cardiovascular prevention, and how walking cuts postmenopausal women’s heart failure risk.
Listen to the MDedge Daily News podcast for all the details on today’s top news.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
, alirocumab cuts deaths in post–acute coronary syndrome patients, the ODYSSEY Outcomes trial redefines secondary cardiovascular prevention, and how walking cuts postmenopausal women’s heart failure risk.
Listen to the MDedge Daily News podcast for all the details on today’s top news.
A Peek at Our March 2018 Issue
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Hospital urine screening reduces TB deaths in HIV+ adults
BOSTON – Urine-based screening for tuberculosis added to standard sputum-based screening can reduce the risk of TB-associated deaths among hospitalized patients with advanced HIV compared with sputum-based screening alone, results of a randomized trial indicate.
Among 2,574 hospitalized HIV-positive patients, the rate of death at 56 days, the primary endpoint, was 21.1% for patients screened with standard-of-care sputum testing using the Xpert MTB/RIF assay, compared with 18.3% for patients screened with sputum testing and urine-sample testing by the Xpert MTB/RIF and the Determine TB-LAM urine dipstick test, reported Ankur Gupta-Wright, MBBS, MRCP, from the London School of Hygiene and Tropical Medicine.
“For every 100 patients who are HIV-positive admitted to hospital, with screening for TB using new urine-based testing in addition to sputum testing we can diagnose approximately seven extra TB case, and save approximately three lives,” he said at a briefing following his presentation of the data in a late-breaking oral abstract session.
“The findings our trial support the use of urine-based TB screening, and we hope to change how we screen for TB in HIV-positive admissions in the hospital in places with high burden of HIV and TB,” he said, speaking on behalf of colleagues in the STAMP Study.
HIV-related TB caused an estimated 400,000 deaths worldwide in 2016, and is responsible for between 32% and 67% of deaths in HIV-positive adults admit to hospitals in Africa. Yet half of all of those cases of TB are undiagnosed at the time of death, he said.
Urine based screens are easily obtained and have good diagnostic yield for disseminated TB, which is common in patients with advanced HIV, he said.
To see whether adding urine screening could increase TB diagnosis and treatment and reduce TB deaths among hospitalized HIV+ patients, the investigators enrolled 2,600 unselected HIV+ adults admitted to hospitals in South Africa and Malawi. Patients less than 18 years of age, those who had been treated for TB with the last 12 months or had received TB prophylaxis with isoniazid within the last 6 months were excluded, leaving a sample size of 2,574.
The patients were randomly assigned to standard-of-care Xpert MTB/RIF sputum screening either alone or with the addition of the two urine-based screens already described.
The overall absolute difference in risk of death at 56 days was -2.8% favoring urine screening (P = .074). As noted, this difference was only significant among patients with CD4 counts below 100/uL. Among these patients, mortality rates for nonurine screened versus screened were 35.7% vs. 28.8%, respectively (P = .036).
Baseline hemoglobin below 8 g/dl and TB suspected at admission were also predictive of better outcomes with the addition of urine-based screening.
An analysis of time to death stratified by baseline CD4 cell count also showed the advantage of urine screening for the sickest patients, with an adjusted hazard ratio for patients with CD4 counts below 100 of 0.77 (P = .047).
The urine-based screening also lead to significantly more microbiologically confirmed and clinically diagnosed TB, and more TB treatment (P less than .001 for each).
A separate cost analysis, presented in a scientific poster (CROI 2018 Abstract 1117LB), showed that the incremental cost-effectiveness ratios for the urine-based intervention were $490 per year of life save in Malawi, and $850 per year of life saved in South Africa.
The study was funded by UK AID, the UK Medical Research Council, and the Wellcome Trust. Dr. Gupta-Wright reported having no conflicts of interest to disclose.
SOURCE: Gupta-Wright, A et al. CROI 2018, Abstract 38LB.
BOSTON – Urine-based screening for tuberculosis added to standard sputum-based screening can reduce the risk of TB-associated deaths among hospitalized patients with advanced HIV compared with sputum-based screening alone, results of a randomized trial indicate.
Among 2,574 hospitalized HIV-positive patients, the rate of death at 56 days, the primary endpoint, was 21.1% for patients screened with standard-of-care sputum testing using the Xpert MTB/RIF assay, compared with 18.3% for patients screened with sputum testing and urine-sample testing by the Xpert MTB/RIF and the Determine TB-LAM urine dipstick test, reported Ankur Gupta-Wright, MBBS, MRCP, from the London School of Hygiene and Tropical Medicine.
“For every 100 patients who are HIV-positive admitted to hospital, with screening for TB using new urine-based testing in addition to sputum testing we can diagnose approximately seven extra TB case, and save approximately three lives,” he said at a briefing following his presentation of the data in a late-breaking oral abstract session.
“The findings our trial support the use of urine-based TB screening, and we hope to change how we screen for TB in HIV-positive admissions in the hospital in places with high burden of HIV and TB,” he said, speaking on behalf of colleagues in the STAMP Study.
HIV-related TB caused an estimated 400,000 deaths worldwide in 2016, and is responsible for between 32% and 67% of deaths in HIV-positive adults admit to hospitals in Africa. Yet half of all of those cases of TB are undiagnosed at the time of death, he said.
Urine based screens are easily obtained and have good diagnostic yield for disseminated TB, which is common in patients with advanced HIV, he said.
To see whether adding urine screening could increase TB diagnosis and treatment and reduce TB deaths among hospitalized HIV+ patients, the investigators enrolled 2,600 unselected HIV+ adults admitted to hospitals in South Africa and Malawi. Patients less than 18 years of age, those who had been treated for TB with the last 12 months or had received TB prophylaxis with isoniazid within the last 6 months were excluded, leaving a sample size of 2,574.
The patients were randomly assigned to standard-of-care Xpert MTB/RIF sputum screening either alone or with the addition of the two urine-based screens already described.
The overall absolute difference in risk of death at 56 days was -2.8% favoring urine screening (P = .074). As noted, this difference was only significant among patients with CD4 counts below 100/uL. Among these patients, mortality rates for nonurine screened versus screened were 35.7% vs. 28.8%, respectively (P = .036).
Baseline hemoglobin below 8 g/dl and TB suspected at admission were also predictive of better outcomes with the addition of urine-based screening.
An analysis of time to death stratified by baseline CD4 cell count also showed the advantage of urine screening for the sickest patients, with an adjusted hazard ratio for patients with CD4 counts below 100 of 0.77 (P = .047).
The urine-based screening also lead to significantly more microbiologically confirmed and clinically diagnosed TB, and more TB treatment (P less than .001 for each).
A separate cost analysis, presented in a scientific poster (CROI 2018 Abstract 1117LB), showed that the incremental cost-effectiveness ratios for the urine-based intervention were $490 per year of life save in Malawi, and $850 per year of life saved in South Africa.
The study was funded by UK AID, the UK Medical Research Council, and the Wellcome Trust. Dr. Gupta-Wright reported having no conflicts of interest to disclose.
SOURCE: Gupta-Wright, A et al. CROI 2018, Abstract 38LB.
BOSTON – Urine-based screening for tuberculosis added to standard sputum-based screening can reduce the risk of TB-associated deaths among hospitalized patients with advanced HIV compared with sputum-based screening alone, results of a randomized trial indicate.
Among 2,574 hospitalized HIV-positive patients, the rate of death at 56 days, the primary endpoint, was 21.1% for patients screened with standard-of-care sputum testing using the Xpert MTB/RIF assay, compared with 18.3% for patients screened with sputum testing and urine-sample testing by the Xpert MTB/RIF and the Determine TB-LAM urine dipstick test, reported Ankur Gupta-Wright, MBBS, MRCP, from the London School of Hygiene and Tropical Medicine.
“For every 100 patients who are HIV-positive admitted to hospital, with screening for TB using new urine-based testing in addition to sputum testing we can diagnose approximately seven extra TB case, and save approximately three lives,” he said at a briefing following his presentation of the data in a late-breaking oral abstract session.
“The findings our trial support the use of urine-based TB screening, and we hope to change how we screen for TB in HIV-positive admissions in the hospital in places with high burden of HIV and TB,” he said, speaking on behalf of colleagues in the STAMP Study.
HIV-related TB caused an estimated 400,000 deaths worldwide in 2016, and is responsible for between 32% and 67% of deaths in HIV-positive adults admit to hospitals in Africa. Yet half of all of those cases of TB are undiagnosed at the time of death, he said.
Urine based screens are easily obtained and have good diagnostic yield for disseminated TB, which is common in patients with advanced HIV, he said.
To see whether adding urine screening could increase TB diagnosis and treatment and reduce TB deaths among hospitalized HIV+ patients, the investigators enrolled 2,600 unselected HIV+ adults admitted to hospitals in South Africa and Malawi. Patients less than 18 years of age, those who had been treated for TB with the last 12 months or had received TB prophylaxis with isoniazid within the last 6 months were excluded, leaving a sample size of 2,574.
The patients were randomly assigned to standard-of-care Xpert MTB/RIF sputum screening either alone or with the addition of the two urine-based screens already described.
The overall absolute difference in risk of death at 56 days was -2.8% favoring urine screening (P = .074). As noted, this difference was only significant among patients with CD4 counts below 100/uL. Among these patients, mortality rates for nonurine screened versus screened were 35.7% vs. 28.8%, respectively (P = .036).
Baseline hemoglobin below 8 g/dl and TB suspected at admission were also predictive of better outcomes with the addition of urine-based screening.
An analysis of time to death stratified by baseline CD4 cell count also showed the advantage of urine screening for the sickest patients, with an adjusted hazard ratio for patients with CD4 counts below 100 of 0.77 (P = .047).
The urine-based screening also lead to significantly more microbiologically confirmed and clinically diagnosed TB, and more TB treatment (P less than .001 for each).
A separate cost analysis, presented in a scientific poster (CROI 2018 Abstract 1117LB), showed that the incremental cost-effectiveness ratios for the urine-based intervention were $490 per year of life save in Malawi, and $850 per year of life saved in South Africa.
The study was funded by UK AID, the UK Medical Research Council, and the Wellcome Trust. Dr. Gupta-Wright reported having no conflicts of interest to disclose.
SOURCE: Gupta-Wright, A et al. CROI 2018, Abstract 38LB.
REPORTING FROM CROI
Key clinical point: Adding urine screening for TB to sputum screening in hospitalized HIV+ patients can reduce risk for death from TB.
Major finding: Among patients with CD4 counts below 100/uL, the 56-day mortality rates was of 35.7% with sputum screening alone vs. 28.8% for combined urine and sputum screening.
Data source: Randomized pragmatic trial in 2,574 HIV+ hospitalized adults in Malawi and South Africa.
Disclosures: The study was funded by UK AID, the UK Medical Research Council, and the Wellcome Trust. Dr. Gupta-Wright reported having no conflicts of interest to disclose.
Source: Gupta-Wright A et al. CROI 2018, Abstract 38LB.
Get Pocket Versions of Practice Guidelines
SVS has partnered with Guidelines Central to create a Pocket Guide version of the new AAA guidelines. Also available are pocket guides on Management of Diabetic Foot, Peripheral Arterial Disease and Venous Leg Ulcers.
SVS members can access the digital versions for free; printed guidelines vary in price. The guidelines also are available as a bundled set. Slide sets of the guidelines, useful as educational tools, also are available online.
SVS has partnered with Guidelines Central to create a Pocket Guide version of the new AAA guidelines. Also available are pocket guides on Management of Diabetic Foot, Peripheral Arterial Disease and Venous Leg Ulcers.
SVS members can access the digital versions for free; printed guidelines vary in price. The guidelines also are available as a bundled set. Slide sets of the guidelines, useful as educational tools, also are available online.
SVS has partnered with Guidelines Central to create a Pocket Guide version of the new AAA guidelines. Also available are pocket guides on Management of Diabetic Foot, Peripheral Arterial Disease and Venous Leg Ulcers.
SVS members can access the digital versions for free; printed guidelines vary in price. The guidelines also are available as a bundled set. Slide sets of the guidelines, useful as educational tools, also are available online.
Watch for QTc interval prolongation in patients taking antipsychotics
LAS VEGAS – Many potential but rare side effects, primarily arrhythmias, can occur from taking antipsychotics, according to Carrie L. Ernst, MD.
Risk factors for QT prolongation and torsades de pointes (TdP) include medications such as antiarrhythmics, many antibiotics such as macrolides and quinolones, antifungals, antiemetics, antimalarials, methadone, and antipsychotics and other psychotropics. Other risk factors include cardiac disease, electrolyte abnormalities, being female, age 65 and older, being on another medication that inhibits metabolism of the drug, genetic predisposition to prolonged QT, and impaired liver function.
All antipsychotics can cause an increase in the QT interval and can cause TdP, although some likely confer a greater risk than others. “It’s most likely not an idiosyncratic effect but rather a dose-related effect,” she said. “So the higher the dose, the more the risk.” There are some data suggesting that phenothiazines, particularly thioridazine, seem to present the greatest risk for prolonging the QTc interval. , but IV haloperidol has been linked to prolonged QTc and TdP. “It’s difficult to know whether that’s the impact of the drug or a reflection of the fact that patients on IV haloperidol are usually medically complicated patients,” Dr. Ernst noted. “Unfortunately, there is limited direct comparison data between agents. Atypicals are only implicated in TdP in rare case reports, and there is less available data for the newest atypicals.”
Two drugs have the Food and Drug Administration boxed warning for prolonged QTc and TdP: thioridazine and mesoridazine. In addition, six medications carry a warning/precaution about prolonged QTc: ziprasidone, paliperidone, IV haloperidol, iloperidone, quetiapine, and asenapine. “Even though haloperidol is not approved for IV administration, FDA created a label warning for IV haloperidol knowing that many clinicians are using it,” she said. “The label advises clinicians to use particular caution in treating patients who have high risk for QTc prolongation and TdP.”
All antipsychotics prolong the QTc by some amount, but differences exist between agents. One prospective, randomized trial showed that ziprasidone and thioridazine prolonged the QTc more than four other antipsychotic drugs (J Clin Psychopharmacol. 2004;24:62-9). “I think the important point is that nobody had a QTc over 500 milliseconds and nobody had TdP,” Dr. Ernst said. “Some data estimate that even if the QTc is 600 milliseconds, the rate of a life-threatening event is probably no more than one in 4,000, so it’s very rare.”
In a more recent meta-analysis, researchers compared 15 antipsychotics among 43,049 adults participating in 212 clinical trials (Lancet. 2013;382:951-62). They found that the following drugs were not associated with QTc prolongation, compared with placebo: lurasidone, aripiprazole, paliperidone, and asenapine. A separate meta-analysis comparing numerous different antipsychotics in children found that ziprasidone was the only one to be associated with an increased risk of QTc prolongation (J Am Acad Child Adolesc Psychiatry. 2015:54:25-36).
There are also data to suggest an association between antipsychotic use and an increased risk of ventricular arrhythmia or sudden cardiac death. The relationship between prolonged QTc and sudden cardiac death is unclear. One large retrospective cohort study found that all antipsychotics carried a 2.5-fold increased risk of sudden cardiac death, compared with the general population not taking those agents (N Eng J Med. 2009;360[3]:225-35). “Risk seemed to be dose related,” Dr. Ernst said. All antipsychotics carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Most of the deaths reported appear related to cardiovascular and infectious causes.
For patients with cardiac disease or some of the risk factors for prolonged QTc, Dr. Ernst recommends that psychiatrists order a baseline and steady state EKG, with intermittent QTc monitoring if warranted. “Closely weigh the risks and benefits and consider avoiding the antipsychotic if the baseline QTc is over 500 milliseconds,” she said. “Avoid low-potency typicals, IV haloperidol, and ziprasidone.”
For patients on IV haloperidol, she recommends obtaining a baseline and at least daily QTc, as well as electrolyte monitoring. Some guidelines suggest continuous EKG monitoring for those with baseline QTc of more than 500 milliseconds, risk factors, and/or high dose requirements. “If the QTc increases beyond 500 milliseconds, check and replete electrolytes, review the medication regimen for other agents that prolong the QTc, consider holding until the QTc is less than 500 milliseconds, consider alternative agents, and perform frequent EKG monitoring and a cardiology consult if you decide to continue,” she said.
In patients without any risk factors for prolonged QTc, there is no consensus on obtaining a baseline QTc or doing serial QTc monitoring. “Do a careful risk assessment, and if the QTc increases beyond 500 milliseconds or greater than 60 milliseconds from baseline during treatment, use the same approach as in high-risk patients,” Dr. Ernst said. “Maintain an updated medication list, and if QT prolonging medications are added or new pharmacokinetic interactions occur, approach them the same as you would a high-risk patient.”
She reported having no financial disclosures.
LAS VEGAS – Many potential but rare side effects, primarily arrhythmias, can occur from taking antipsychotics, according to Carrie L. Ernst, MD.
Risk factors for QT prolongation and torsades de pointes (TdP) include medications such as antiarrhythmics, many antibiotics such as macrolides and quinolones, antifungals, antiemetics, antimalarials, methadone, and antipsychotics and other psychotropics. Other risk factors include cardiac disease, electrolyte abnormalities, being female, age 65 and older, being on another medication that inhibits metabolism of the drug, genetic predisposition to prolonged QT, and impaired liver function.
All antipsychotics can cause an increase in the QT interval and can cause TdP, although some likely confer a greater risk than others. “It’s most likely not an idiosyncratic effect but rather a dose-related effect,” she said. “So the higher the dose, the more the risk.” There are some data suggesting that phenothiazines, particularly thioridazine, seem to present the greatest risk for prolonging the QTc interval. , but IV haloperidol has been linked to prolonged QTc and TdP. “It’s difficult to know whether that’s the impact of the drug or a reflection of the fact that patients on IV haloperidol are usually medically complicated patients,” Dr. Ernst noted. “Unfortunately, there is limited direct comparison data between agents. Atypicals are only implicated in TdP in rare case reports, and there is less available data for the newest atypicals.”
Two drugs have the Food and Drug Administration boxed warning for prolonged QTc and TdP: thioridazine and mesoridazine. In addition, six medications carry a warning/precaution about prolonged QTc: ziprasidone, paliperidone, IV haloperidol, iloperidone, quetiapine, and asenapine. “Even though haloperidol is not approved for IV administration, FDA created a label warning for IV haloperidol knowing that many clinicians are using it,” she said. “The label advises clinicians to use particular caution in treating patients who have high risk for QTc prolongation and TdP.”
All antipsychotics prolong the QTc by some amount, but differences exist between agents. One prospective, randomized trial showed that ziprasidone and thioridazine prolonged the QTc more than four other antipsychotic drugs (J Clin Psychopharmacol. 2004;24:62-9). “I think the important point is that nobody had a QTc over 500 milliseconds and nobody had TdP,” Dr. Ernst said. “Some data estimate that even if the QTc is 600 milliseconds, the rate of a life-threatening event is probably no more than one in 4,000, so it’s very rare.”
In a more recent meta-analysis, researchers compared 15 antipsychotics among 43,049 adults participating in 212 clinical trials (Lancet. 2013;382:951-62). They found that the following drugs were not associated with QTc prolongation, compared with placebo: lurasidone, aripiprazole, paliperidone, and asenapine. A separate meta-analysis comparing numerous different antipsychotics in children found that ziprasidone was the only one to be associated with an increased risk of QTc prolongation (J Am Acad Child Adolesc Psychiatry. 2015:54:25-36).
There are also data to suggest an association between antipsychotic use and an increased risk of ventricular arrhythmia or sudden cardiac death. The relationship between prolonged QTc and sudden cardiac death is unclear. One large retrospective cohort study found that all antipsychotics carried a 2.5-fold increased risk of sudden cardiac death, compared with the general population not taking those agents (N Eng J Med. 2009;360[3]:225-35). “Risk seemed to be dose related,” Dr. Ernst said. All antipsychotics carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Most of the deaths reported appear related to cardiovascular and infectious causes.
For patients with cardiac disease or some of the risk factors for prolonged QTc, Dr. Ernst recommends that psychiatrists order a baseline and steady state EKG, with intermittent QTc monitoring if warranted. “Closely weigh the risks and benefits and consider avoiding the antipsychotic if the baseline QTc is over 500 milliseconds,” she said. “Avoid low-potency typicals, IV haloperidol, and ziprasidone.”
For patients on IV haloperidol, she recommends obtaining a baseline and at least daily QTc, as well as electrolyte monitoring. Some guidelines suggest continuous EKG monitoring for those with baseline QTc of more than 500 milliseconds, risk factors, and/or high dose requirements. “If the QTc increases beyond 500 milliseconds, check and replete electrolytes, review the medication regimen for other agents that prolong the QTc, consider holding until the QTc is less than 500 milliseconds, consider alternative agents, and perform frequent EKG monitoring and a cardiology consult if you decide to continue,” she said.
In patients without any risk factors for prolonged QTc, there is no consensus on obtaining a baseline QTc or doing serial QTc monitoring. “Do a careful risk assessment, and if the QTc increases beyond 500 milliseconds or greater than 60 milliseconds from baseline during treatment, use the same approach as in high-risk patients,” Dr. Ernst said. “Maintain an updated medication list, and if QT prolonging medications are added or new pharmacokinetic interactions occur, approach them the same as you would a high-risk patient.”
She reported having no financial disclosures.
LAS VEGAS – Many potential but rare side effects, primarily arrhythmias, can occur from taking antipsychotics, according to Carrie L. Ernst, MD.
Risk factors for QT prolongation and torsades de pointes (TdP) include medications such as antiarrhythmics, many antibiotics such as macrolides and quinolones, antifungals, antiemetics, antimalarials, methadone, and antipsychotics and other psychotropics. Other risk factors include cardiac disease, electrolyte abnormalities, being female, age 65 and older, being on another medication that inhibits metabolism of the drug, genetic predisposition to prolonged QT, and impaired liver function.
All antipsychotics can cause an increase in the QT interval and can cause TdP, although some likely confer a greater risk than others. “It’s most likely not an idiosyncratic effect but rather a dose-related effect,” she said. “So the higher the dose, the more the risk.” There are some data suggesting that phenothiazines, particularly thioridazine, seem to present the greatest risk for prolonging the QTc interval. , but IV haloperidol has been linked to prolonged QTc and TdP. “It’s difficult to know whether that’s the impact of the drug or a reflection of the fact that patients on IV haloperidol are usually medically complicated patients,” Dr. Ernst noted. “Unfortunately, there is limited direct comparison data between agents. Atypicals are only implicated in TdP in rare case reports, and there is less available data for the newest atypicals.”
Two drugs have the Food and Drug Administration boxed warning for prolonged QTc and TdP: thioridazine and mesoridazine. In addition, six medications carry a warning/precaution about prolonged QTc: ziprasidone, paliperidone, IV haloperidol, iloperidone, quetiapine, and asenapine. “Even though haloperidol is not approved for IV administration, FDA created a label warning for IV haloperidol knowing that many clinicians are using it,” she said. “The label advises clinicians to use particular caution in treating patients who have high risk for QTc prolongation and TdP.”
All antipsychotics prolong the QTc by some amount, but differences exist between agents. One prospective, randomized trial showed that ziprasidone and thioridazine prolonged the QTc more than four other antipsychotic drugs (J Clin Psychopharmacol. 2004;24:62-9). “I think the important point is that nobody had a QTc over 500 milliseconds and nobody had TdP,” Dr. Ernst said. “Some data estimate that even if the QTc is 600 milliseconds, the rate of a life-threatening event is probably no more than one in 4,000, so it’s very rare.”
In a more recent meta-analysis, researchers compared 15 antipsychotics among 43,049 adults participating in 212 clinical trials (Lancet. 2013;382:951-62). They found that the following drugs were not associated with QTc prolongation, compared with placebo: lurasidone, aripiprazole, paliperidone, and asenapine. A separate meta-analysis comparing numerous different antipsychotics in children found that ziprasidone was the only one to be associated with an increased risk of QTc prolongation (J Am Acad Child Adolesc Psychiatry. 2015:54:25-36).
There are also data to suggest an association between antipsychotic use and an increased risk of ventricular arrhythmia or sudden cardiac death. The relationship between prolonged QTc and sudden cardiac death is unclear. One large retrospective cohort study found that all antipsychotics carried a 2.5-fold increased risk of sudden cardiac death, compared with the general population not taking those agents (N Eng J Med. 2009;360[3]:225-35). “Risk seemed to be dose related,” Dr. Ernst said. All antipsychotics carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Most of the deaths reported appear related to cardiovascular and infectious causes.
For patients with cardiac disease or some of the risk factors for prolonged QTc, Dr. Ernst recommends that psychiatrists order a baseline and steady state EKG, with intermittent QTc monitoring if warranted. “Closely weigh the risks and benefits and consider avoiding the antipsychotic if the baseline QTc is over 500 milliseconds,” she said. “Avoid low-potency typicals, IV haloperidol, and ziprasidone.”
For patients on IV haloperidol, she recommends obtaining a baseline and at least daily QTc, as well as electrolyte monitoring. Some guidelines suggest continuous EKG monitoring for those with baseline QTc of more than 500 milliseconds, risk factors, and/or high dose requirements. “If the QTc increases beyond 500 milliseconds, check and replete electrolytes, review the medication regimen for other agents that prolong the QTc, consider holding until the QTc is less than 500 milliseconds, consider alternative agents, and perform frequent EKG monitoring and a cardiology consult if you decide to continue,” she said.
In patients without any risk factors for prolonged QTc, there is no consensus on obtaining a baseline QTc or doing serial QTc monitoring. “Do a careful risk assessment, and if the QTc increases beyond 500 milliseconds or greater than 60 milliseconds from baseline during treatment, use the same approach as in high-risk patients,” Dr. Ernst said. “Maintain an updated medication list, and if QT prolonging medications are added or new pharmacokinetic interactions occur, approach them the same as you would a high-risk patient.”
She reported having no financial disclosures.
REPORTING FROM NPA 2018
VAM Registration Now Open
Registration and housing for the 2018 Vascular Annual Meeting are now open. Register today for VAM, June 20 to 23 in Boston, including looking over housing options. Following a full day of postgraduate courses, VESS abstracts, workshops and international programming on Wednesday, June 20, abstract-based scientific sessions will open June 21 and continue to June 23. The Exhibit Hall will be open June 21 to 22.
Catch the highlights of this year's annual meeting here.
Registration and housing for the 2018 Vascular Annual Meeting are now open. Register today for VAM, June 20 to 23 in Boston, including looking over housing options. Following a full day of postgraduate courses, VESS abstracts, workshops and international programming on Wednesday, June 20, abstract-based scientific sessions will open June 21 and continue to June 23. The Exhibit Hall will be open June 21 to 22.
Catch the highlights of this year's annual meeting here.
Registration and housing for the 2018 Vascular Annual Meeting are now open. Register today for VAM, June 20 to 23 in Boston, including looking over housing options. Following a full day of postgraduate courses, VESS abstracts, workshops and international programming on Wednesday, June 20, abstract-based scientific sessions will open June 21 and continue to June 23. The Exhibit Hall will be open June 21 to 22.
Catch the highlights of this year's annual meeting here.
Medical Marijuana Redux
There were so many developments that occurred in the first months of 2018 that could potentially affect federal health care—the government shutdown, the proposed change in rights of conscience protections for federal health care professionals (HCPs), and more debate about medical marijuana in the VA—that it was hard to pick just one topic to discuss this month. In the end I felt it was time to examine how and in what ways the new VA policy on medical marijuana may have changed.
In 2014, before I became editor-in-chief of Federal Practitioner, I wrote an article analyzing the legal and ethical conflicts that arise for VA clinicians who practice under the federal regulations that prohibit them from prescribing medical marijuana or from completing forms or providing referrals for their patients who live in states where medical marijuana is legal.2 The article summarized the events and issues that led to the VA issuing a policy on medical marijuana in 2011. When that article was written, medical marijuana had been legalized in 20 states.
Now in March 2018, 29 states have passed legislation to permit marijuana use for medical purposes.3 Prior to issuing the revised version of its medical marijuana policy, the VA rumor mill went into high gear. Anticipatory stories predicted dramatic changes from the extreme of the VA penalizing veterans who used medical marijuana to allowing doctors to prescribe it. Such massive shifts are not typical of any bureaucracy, and indeed some VA officials denied that the revision represented any substantive movement in either direction.4
VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs was issued December 8, 2017.5 In accordance with federal regulation, its issuance superceded VHA Directive 2011-04 of the same title.6 According to the directive, its emphasis on discussion with veterans was a significant policy shift. “Major changes include adding policy to support the Veteran-provider relationship when discussing the use of medical marijuana and its impact on health including Veteran-specific treatment plans.” It should be noted that the prior directive did not prohibit or even discourage such conversations, and accompanying less official guidance actually promoted them.7
Interestingly, the new directive does not instruct HCPs to ask about medical marijuana in the way questions about alcohol, tobacco, and drug use as well as many other lifestyle factors are mandated. Asking a veteran about marijuana use would be a step toward medical mainstreaming. The burden is still on the veteran to bring up the subject—not an easy thing to do in light of the fear among some veterans that the VA will curtail benefits for a veteran caught using medical marijuana.
The new directive is a minor move toward appropriate medicalization. Practitioners are advised to discuss medical marijuana use with any veteran for whom it “may have clinical relevance” or who asks about medical marijuana. This underscores the need for VA practitioners to have access to up-to-date information in order to keep up with their Internet savvy patients and combat ever proliferating myths about the panacea-like properties of medical marijuana.
But when it comes down to the devilish details, the primary rules provide no deliverance from the impasse between state and federal law. Marijuana remains a Schedule I drug under the Controlled Substances Act. For purposes of federal health care, it still is, “a substance with a high potential for abuse without a currently acceptable medical use in treatment in the United States, and lacking accepted safety for use under medical supervision.”8 Although many vocal veterans as well as some federal practitioners, HCPs in the wider medical community, and more recently a number of politicians would challenge this regulation, federal lawprohibits prescribing medical marijuana. The new VA directive is more explicit in stating that VA practitioners cannot complete forms enrolling veterans or permitting their registration in state-approved medical marijuana programs. This restriction was implicit in the prior directive but has been a continuing source of confusion for HCPs. The new directive at least clarifies these restrictions.
Another point of clinical misunderstanding had been about whether HCPs in the VA could refer patients to state-approved medical marijuana programs and what exactly referral entails. There is a direct prohibition in the new directive on making referrals, yet the term remains undefined. Nothing in the directive contradicts the right of a veteran to access their medical records for purposes of registering for state-approved programs. But the directive does forcefully restate that if a veteran appears in an HCP’s office or at the pharmacy with an authorization or registration for medical marijuana from a state-approved program, the VA will neither provide the product nor pay for its purchase elsewhere. The more rules-based form of this directive also strongly states that possession of marijuana on VA grounds even for medical purposes and with state approval is a violation of federal regulation that may be prosecuted under the Controlled Substance Act.
The new directive does clarify a question that had arisen about VA employees’ participation in state-approved medical marijuana programs. VA employees, even those who do not receive their care at the VA, are prohibited from using medical marijuana. Individuals who use marijuana for medical indications often do so daily. Considering that a person may test positive for marijuana months after regular use, a segment of VA staff may be at risk for violating federal drug-free workplace regulations.9,10
The administrative aspects of the directive are tightened, which will help clinicians know what they are supposed to do when a veteran reports medical marijuana use; it is hoped that this will bring more consistency and fairness to the process. Practitioners continue to be required to enter a veteran’s reported use of medical marijuana in the electronic medical record under the section Non-VA/Herbal Medication/Over the Counter. When HCPs discuss the use of medical marijuana with patients, the requirement to document those discussions is instructive.
Those looking for a relaxation in the VA’s clinical approach will find little to cheer about. But there are a few rays of hope for those HCPs and patients trying to do the best they can in this catch-22 situation. First, the VA has stood firm that veterans cannot be excluded from other types of VA medical care due to their use of medical marijuana. “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.”5 The directive specifically acknowledges the clinical areas in which veteran medical marijuana use has been the most contentious: PTSD, substance use, and pain management. It also encourages HCPs to review potential drug interactions and how marijuana use may affect other types of medical or psychiatric care. These 3 areas also are the object of intensified congressional pressure and veteran service organization lobbying for the VA to not only incorporate these modalities into VA care, but also to expand research.11
Second, the phrase “modifying treatment plans,” which understandably makes patients and their advocates apprehensive, is qualified. To those clinicians who would prefer, either because of concerns of professional liability or personal belief, to have a black-and-white stance on the use of medical marijuana, the directive mandates that they must deal with the gray. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis.”5
Third, those modifications cannot be unilateral pronouncements, but must be the result of shared decisions making and mutual discussion. The only ground on which a practitioner can exercise any degree of soft paternalism is when the use of medical marijuana and treatment for another condition represents an evidence-based threat to the health and safety of the veteran. “Providers need to
Overall the policy has no big surprises, leaving those who hoped the revision would bring a softening of the VA’s institutional position and federal law frustrated. Those who sought a strengthening of VA policy based on those same regulations regarding the use of medical marijuana will be equally thwarted. And those clinicians who are just trying to do the right thing as HCPs who work for the federal government and for their patients who are interested only in relief from their most troubling ailments, will stay right where they were, suspended over the ethical chasm that medical marijuana generates between state and federal law.
1. Curie M. Pierre Curie With Autobiographical Notes. Kellogg C, Kellogg V, trans. New York: Macmillan; 1923.
2. Geppert CMA. Legal and clinical evolution of Veterans Health Administration policy on medical marijuana. Fed Pract. 2014;31(3):6-12.
3. National Conference of State Legislators. State Medical Marijuana Laws. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx Updated February 15, 2018. Accessed March 2, 2018.
4. Shane L. VA refutes rumors of new policy on medical marijuana. https://www.militarytimes.com/veterans/2017/12/19/va-refutes-rumors-of-a-new-policy-on-medical-marijuana. Published December 19, 2017. Accessed March 2, 2018.
5. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs. December 8, 2017.
6. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2011-004, Access to Clinical Programs for Veterans Participating in State-Approved Marijuana Programs, dated January 31, 2011 (rescinded).
7. U.S. Department of Veterans Affairs, Veterans Health Administration. Clinical considerations regarding veteran patients who participate in state-approved medical marijuana programs. Washington, DC; 2010. [Nonpublic document.]
8. 21 U.S.C. 801 et al, the Controlled Substances Act.
9. Welch SA. The pharmacology of cannabinoids. In: Principles of Addiction Medicine: The Essentials. Cavacuiti CA, ed. Philadelphia, PA: Lippincott-Williams & Wilkins; 2011:62.
10. U.S. Department of Veterans Affairs. VA Handbook 5383.2, VA drug-free workplace plan. https://www.va.gov/vapubs/search_action.cfm?dType=2. Published April 11, 1997. Accessed March 2, 2018.
11. Zezima K. VA says it won’t study medical marijuana’s effect on veterans. The Washington Post. https://www.washingtonpost.com/news/post-nation/wp/2018/01/16/va-says-it-wont-study-medical-marijuanas-effect-on-veterans/?utm_term=.9d554109d135. Published January 16, 2018. Accessed March 2, 2018.
There were so many developments that occurred in the first months of 2018 that could potentially affect federal health care—the government shutdown, the proposed change in rights of conscience protections for federal health care professionals (HCPs), and more debate about medical marijuana in the VA—that it was hard to pick just one topic to discuss this month. In the end I felt it was time to examine how and in what ways the new VA policy on medical marijuana may have changed.
In 2014, before I became editor-in-chief of Federal Practitioner, I wrote an article analyzing the legal and ethical conflicts that arise for VA clinicians who practice under the federal regulations that prohibit them from prescribing medical marijuana or from completing forms or providing referrals for their patients who live in states where medical marijuana is legal.2 The article summarized the events and issues that led to the VA issuing a policy on medical marijuana in 2011. When that article was written, medical marijuana had been legalized in 20 states.
Now in March 2018, 29 states have passed legislation to permit marijuana use for medical purposes.3 Prior to issuing the revised version of its medical marijuana policy, the VA rumor mill went into high gear. Anticipatory stories predicted dramatic changes from the extreme of the VA penalizing veterans who used medical marijuana to allowing doctors to prescribe it. Such massive shifts are not typical of any bureaucracy, and indeed some VA officials denied that the revision represented any substantive movement in either direction.4
VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs was issued December 8, 2017.5 In accordance with federal regulation, its issuance superceded VHA Directive 2011-04 of the same title.6 According to the directive, its emphasis on discussion with veterans was a significant policy shift. “Major changes include adding policy to support the Veteran-provider relationship when discussing the use of medical marijuana and its impact on health including Veteran-specific treatment plans.” It should be noted that the prior directive did not prohibit or even discourage such conversations, and accompanying less official guidance actually promoted them.7
Interestingly, the new directive does not instruct HCPs to ask about medical marijuana in the way questions about alcohol, tobacco, and drug use as well as many other lifestyle factors are mandated. Asking a veteran about marijuana use would be a step toward medical mainstreaming. The burden is still on the veteran to bring up the subject—not an easy thing to do in light of the fear among some veterans that the VA will curtail benefits for a veteran caught using medical marijuana.
The new directive is a minor move toward appropriate medicalization. Practitioners are advised to discuss medical marijuana use with any veteran for whom it “may have clinical relevance” or who asks about medical marijuana. This underscores the need for VA practitioners to have access to up-to-date information in order to keep up with their Internet savvy patients and combat ever proliferating myths about the panacea-like properties of medical marijuana.
But when it comes down to the devilish details, the primary rules provide no deliverance from the impasse between state and federal law. Marijuana remains a Schedule I drug under the Controlled Substances Act. For purposes of federal health care, it still is, “a substance with a high potential for abuse without a currently acceptable medical use in treatment in the United States, and lacking accepted safety for use under medical supervision.”8 Although many vocal veterans as well as some federal practitioners, HCPs in the wider medical community, and more recently a number of politicians would challenge this regulation, federal lawprohibits prescribing medical marijuana. The new VA directive is more explicit in stating that VA practitioners cannot complete forms enrolling veterans or permitting their registration in state-approved medical marijuana programs. This restriction was implicit in the prior directive but has been a continuing source of confusion for HCPs. The new directive at least clarifies these restrictions.
Another point of clinical misunderstanding had been about whether HCPs in the VA could refer patients to state-approved medical marijuana programs and what exactly referral entails. There is a direct prohibition in the new directive on making referrals, yet the term remains undefined. Nothing in the directive contradicts the right of a veteran to access their medical records for purposes of registering for state-approved programs. But the directive does forcefully restate that if a veteran appears in an HCP’s office or at the pharmacy with an authorization or registration for medical marijuana from a state-approved program, the VA will neither provide the product nor pay for its purchase elsewhere. The more rules-based form of this directive also strongly states that possession of marijuana on VA grounds even for medical purposes and with state approval is a violation of federal regulation that may be prosecuted under the Controlled Substance Act.
The new directive does clarify a question that had arisen about VA employees’ participation in state-approved medical marijuana programs. VA employees, even those who do not receive their care at the VA, are prohibited from using medical marijuana. Individuals who use marijuana for medical indications often do so daily. Considering that a person may test positive for marijuana months after regular use, a segment of VA staff may be at risk for violating federal drug-free workplace regulations.9,10
The administrative aspects of the directive are tightened, which will help clinicians know what they are supposed to do when a veteran reports medical marijuana use; it is hoped that this will bring more consistency and fairness to the process. Practitioners continue to be required to enter a veteran’s reported use of medical marijuana in the electronic medical record under the section Non-VA/Herbal Medication/Over the Counter. When HCPs discuss the use of medical marijuana with patients, the requirement to document those discussions is instructive.
Those looking for a relaxation in the VA’s clinical approach will find little to cheer about. But there are a few rays of hope for those HCPs and patients trying to do the best they can in this catch-22 situation. First, the VA has stood firm that veterans cannot be excluded from other types of VA medical care due to their use of medical marijuana. “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.”5 The directive specifically acknowledges the clinical areas in which veteran medical marijuana use has been the most contentious: PTSD, substance use, and pain management. It also encourages HCPs to review potential drug interactions and how marijuana use may affect other types of medical or psychiatric care. These 3 areas also are the object of intensified congressional pressure and veteran service organization lobbying for the VA to not only incorporate these modalities into VA care, but also to expand research.11
Second, the phrase “modifying treatment plans,” which understandably makes patients and their advocates apprehensive, is qualified. To those clinicians who would prefer, either because of concerns of professional liability or personal belief, to have a black-and-white stance on the use of medical marijuana, the directive mandates that they must deal with the gray. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis.”5
Third, those modifications cannot be unilateral pronouncements, but must be the result of shared decisions making and mutual discussion. The only ground on which a practitioner can exercise any degree of soft paternalism is when the use of medical marijuana and treatment for another condition represents an evidence-based threat to the health and safety of the veteran. “Providers need to
Overall the policy has no big surprises, leaving those who hoped the revision would bring a softening of the VA’s institutional position and federal law frustrated. Those who sought a strengthening of VA policy based on those same regulations regarding the use of medical marijuana will be equally thwarted. And those clinicians who are just trying to do the right thing as HCPs who work for the federal government and for their patients who are interested only in relief from their most troubling ailments, will stay right where they were, suspended over the ethical chasm that medical marijuana generates between state and federal law.
There were so many developments that occurred in the first months of 2018 that could potentially affect federal health care—the government shutdown, the proposed change in rights of conscience protections for federal health care professionals (HCPs), and more debate about medical marijuana in the VA—that it was hard to pick just one topic to discuss this month. In the end I felt it was time to examine how and in what ways the new VA policy on medical marijuana may have changed.
In 2014, before I became editor-in-chief of Federal Practitioner, I wrote an article analyzing the legal and ethical conflicts that arise for VA clinicians who practice under the federal regulations that prohibit them from prescribing medical marijuana or from completing forms or providing referrals for their patients who live in states where medical marijuana is legal.2 The article summarized the events and issues that led to the VA issuing a policy on medical marijuana in 2011. When that article was written, medical marijuana had been legalized in 20 states.
Now in March 2018, 29 states have passed legislation to permit marijuana use for medical purposes.3 Prior to issuing the revised version of its medical marijuana policy, the VA rumor mill went into high gear. Anticipatory stories predicted dramatic changes from the extreme of the VA penalizing veterans who used medical marijuana to allowing doctors to prescribe it. Such massive shifts are not typical of any bureaucracy, and indeed some VA officials denied that the revision represented any substantive movement in either direction.4
VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs was issued December 8, 2017.5 In accordance with federal regulation, its issuance superceded VHA Directive 2011-04 of the same title.6 According to the directive, its emphasis on discussion with veterans was a significant policy shift. “Major changes include adding policy to support the Veteran-provider relationship when discussing the use of medical marijuana and its impact on health including Veteran-specific treatment plans.” It should be noted that the prior directive did not prohibit or even discourage such conversations, and accompanying less official guidance actually promoted them.7
Interestingly, the new directive does not instruct HCPs to ask about medical marijuana in the way questions about alcohol, tobacco, and drug use as well as many other lifestyle factors are mandated. Asking a veteran about marijuana use would be a step toward medical mainstreaming. The burden is still on the veteran to bring up the subject—not an easy thing to do in light of the fear among some veterans that the VA will curtail benefits for a veteran caught using medical marijuana.
The new directive is a minor move toward appropriate medicalization. Practitioners are advised to discuss medical marijuana use with any veteran for whom it “may have clinical relevance” or who asks about medical marijuana. This underscores the need for VA practitioners to have access to up-to-date information in order to keep up with their Internet savvy patients and combat ever proliferating myths about the panacea-like properties of medical marijuana.
But when it comes down to the devilish details, the primary rules provide no deliverance from the impasse between state and federal law. Marijuana remains a Schedule I drug under the Controlled Substances Act. For purposes of federal health care, it still is, “a substance with a high potential for abuse without a currently acceptable medical use in treatment in the United States, and lacking accepted safety for use under medical supervision.”8 Although many vocal veterans as well as some federal practitioners, HCPs in the wider medical community, and more recently a number of politicians would challenge this regulation, federal lawprohibits prescribing medical marijuana. The new VA directive is more explicit in stating that VA practitioners cannot complete forms enrolling veterans or permitting their registration in state-approved medical marijuana programs. This restriction was implicit in the prior directive but has been a continuing source of confusion for HCPs. The new directive at least clarifies these restrictions.
Another point of clinical misunderstanding had been about whether HCPs in the VA could refer patients to state-approved medical marijuana programs and what exactly referral entails. There is a direct prohibition in the new directive on making referrals, yet the term remains undefined. Nothing in the directive contradicts the right of a veteran to access their medical records for purposes of registering for state-approved programs. But the directive does forcefully restate that if a veteran appears in an HCP’s office or at the pharmacy with an authorization or registration for medical marijuana from a state-approved program, the VA will neither provide the product nor pay for its purchase elsewhere. The more rules-based form of this directive also strongly states that possession of marijuana on VA grounds even for medical purposes and with state approval is a violation of federal regulation that may be prosecuted under the Controlled Substance Act.
The new directive does clarify a question that had arisen about VA employees’ participation in state-approved medical marijuana programs. VA employees, even those who do not receive their care at the VA, are prohibited from using medical marijuana. Individuals who use marijuana for medical indications often do so daily. Considering that a person may test positive for marijuana months after regular use, a segment of VA staff may be at risk for violating federal drug-free workplace regulations.9,10
The administrative aspects of the directive are tightened, which will help clinicians know what they are supposed to do when a veteran reports medical marijuana use; it is hoped that this will bring more consistency and fairness to the process. Practitioners continue to be required to enter a veteran’s reported use of medical marijuana in the electronic medical record under the section Non-VA/Herbal Medication/Over the Counter. When HCPs discuss the use of medical marijuana with patients, the requirement to document those discussions is instructive.
Those looking for a relaxation in the VA’s clinical approach will find little to cheer about. But there are a few rays of hope for those HCPs and patients trying to do the best they can in this catch-22 situation. First, the VA has stood firm that veterans cannot be excluded from other types of VA medical care due to their use of medical marijuana. “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.”5 The directive specifically acknowledges the clinical areas in which veteran medical marijuana use has been the most contentious: PTSD, substance use, and pain management. It also encourages HCPs to review potential drug interactions and how marijuana use may affect other types of medical or psychiatric care. These 3 areas also are the object of intensified congressional pressure and veteran service organization lobbying for the VA to not only incorporate these modalities into VA care, but also to expand research.11
Second, the phrase “modifying treatment plans,” which understandably makes patients and their advocates apprehensive, is qualified. To those clinicians who would prefer, either because of concerns of professional liability or personal belief, to have a black-and-white stance on the use of medical marijuana, the directive mandates that they must deal with the gray. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis.”5
Third, those modifications cannot be unilateral pronouncements, but must be the result of shared decisions making and mutual discussion. The only ground on which a practitioner can exercise any degree of soft paternalism is when the use of medical marijuana and treatment for another condition represents an evidence-based threat to the health and safety of the veteran. “Providers need to
Overall the policy has no big surprises, leaving those who hoped the revision would bring a softening of the VA’s institutional position and federal law frustrated. Those who sought a strengthening of VA policy based on those same regulations regarding the use of medical marijuana will be equally thwarted. And those clinicians who are just trying to do the right thing as HCPs who work for the federal government and for their patients who are interested only in relief from their most troubling ailments, will stay right where they were, suspended over the ethical chasm that medical marijuana generates between state and federal law.
1. Curie M. Pierre Curie With Autobiographical Notes. Kellogg C, Kellogg V, trans. New York: Macmillan; 1923.
2. Geppert CMA. Legal and clinical evolution of Veterans Health Administration policy on medical marijuana. Fed Pract. 2014;31(3):6-12.
3. National Conference of State Legislators. State Medical Marijuana Laws. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx Updated February 15, 2018. Accessed March 2, 2018.
4. Shane L. VA refutes rumors of new policy on medical marijuana. https://www.militarytimes.com/veterans/2017/12/19/va-refutes-rumors-of-a-new-policy-on-medical-marijuana. Published December 19, 2017. Accessed March 2, 2018.
5. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs. December 8, 2017.
6. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2011-004, Access to Clinical Programs for Veterans Participating in State-Approved Marijuana Programs, dated January 31, 2011 (rescinded).
7. U.S. Department of Veterans Affairs, Veterans Health Administration. Clinical considerations regarding veteran patients who participate in state-approved medical marijuana programs. Washington, DC; 2010. [Nonpublic document.]
8. 21 U.S.C. 801 et al, the Controlled Substances Act.
9. Welch SA. The pharmacology of cannabinoids. In: Principles of Addiction Medicine: The Essentials. Cavacuiti CA, ed. Philadelphia, PA: Lippincott-Williams & Wilkins; 2011:62.
10. U.S. Department of Veterans Affairs. VA Handbook 5383.2, VA drug-free workplace plan. https://www.va.gov/vapubs/search_action.cfm?dType=2. Published April 11, 1997. Accessed March 2, 2018.
11. Zezima K. VA says it won’t study medical marijuana’s effect on veterans. The Washington Post. https://www.washingtonpost.com/news/post-nation/wp/2018/01/16/va-says-it-wont-study-medical-marijuanas-effect-on-veterans/?utm_term=.9d554109d135. Published January 16, 2018. Accessed March 2, 2018.
1. Curie M. Pierre Curie With Autobiographical Notes. Kellogg C, Kellogg V, trans. New York: Macmillan; 1923.
2. Geppert CMA. Legal and clinical evolution of Veterans Health Administration policy on medical marijuana. Fed Pract. 2014;31(3):6-12.
3. National Conference of State Legislators. State Medical Marijuana Laws. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx Updated February 15, 2018. Accessed March 2, 2018.
4. Shane L. VA refutes rumors of new policy on medical marijuana. https://www.militarytimes.com/veterans/2017/12/19/va-refutes-rumors-of-a-new-policy-on-medical-marijuana. Published December 19, 2017. Accessed March 2, 2018.
5. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs. December 8, 2017.
6. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2011-004, Access to Clinical Programs for Veterans Participating in State-Approved Marijuana Programs, dated January 31, 2011 (rescinded).
7. U.S. Department of Veterans Affairs, Veterans Health Administration. Clinical considerations regarding veteran patients who participate in state-approved medical marijuana programs. Washington, DC; 2010. [Nonpublic document.]
8. 21 U.S.C. 801 et al, the Controlled Substances Act.
9. Welch SA. The pharmacology of cannabinoids. In: Principles of Addiction Medicine: The Essentials. Cavacuiti CA, ed. Philadelphia, PA: Lippincott-Williams & Wilkins; 2011:62.
10. U.S. Department of Veterans Affairs. VA Handbook 5383.2, VA drug-free workplace plan. https://www.va.gov/vapubs/search_action.cfm?dType=2. Published April 11, 1997. Accessed March 2, 2018.
11. Zezima K. VA says it won’t study medical marijuana’s effect on veterans. The Washington Post. https://www.washingtonpost.com/news/post-nation/wp/2018/01/16/va-says-it-wont-study-medical-marijuanas-effect-on-veterans/?utm_term=.9d554109d135. Published January 16, 2018. Accessed March 2, 2018.
Approaches to Enhancing Patient-Centered Communication In Caring For Hispanic/Latino Patients With Diabetes
From the University of Texas at El Paso, El Paso, TX.
Abstract
- Objective: To demonstrate the applied use of recommended cultural competency communication tools.
- Methods: An overview of several cultural competency tools is presented and vignettes are used to demonstrate the use of these tools with Hispanic patients with diabetes.
- Results: Three communication mnemonic instruments, ie, BELIEF, ETHNIC, and BATHE, may be useful for engaging health professionals in patient-centered communication with their Hispanic patients and shared decision making. Health professionals can also employ nonjudgmental probing as part of engaging patients in setting diabetes treatment goals.
- Conclusion: Health professionals are in an influential position to leverage a patient- and culture-centered communication style to improve communication with Hispanic patients. Using mnemonic tools can help facilitate this communication and improve health professionals’ understanding on how cultural and social factors influence diabetes management in this population.
Key words: Hispanic/Latino; diabetes; patient-centered communication; cultural-competency.
The 2017 American Diabetes Association (ADA) Standards of Medical Care recommend that health professionals engage in a patient-centered communication style with patient to facilitate shared decision-making and improve diabetes outcomes. The ADA defines patient-centered communication as “a style that uses active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care” [1]. One of the main goals of using patient-centered communication is to create a collaborative, personal, and non-judgmental relationship with patients. These guidelines, however, provide less direction on the type of communication skills training that would facilitate this type of communication, particularly as it relates to ethnic/racial minority groups most at risk for diabetes and related complications.
The US Hispanic/Latino population, in particular, is a group that is burdened by the diabetes epidemic, with a prevalence that is 130% higher than non-Hispanic whites [2]. It is widely known that certain social determinants of health, like socioeconomic status, social injustices, poor access to health care, food insecurity, or living in environments that do not support health behaviors, all contribute to health disparities for Hispanics/Latinos [3]. Understanding how Hispanics/Latinos cope with these social determinants of health is important for health care professionals, and a patient-centered communication style is an ideal approach for active listening and eliciting information about the social barriers/challenges that may influence diabetes self-care. However, there is some evidence that suggests this approach is not fully used by health care professionals when communicating with Hispanics/Latinos with diabetes, and Hispanics/Latinos continue to be more likely to experience disparities in the quality of diabetes care they receive compared to non-Hispanic whites [4–9]. One of the identified contributors to these disparities is the poor communication between physicians and Hispanic/Latino patients [10–16]. Given that health care professionals are the primary source of health care and diabetes information for Hispanics/Latinos, it is important for health professionals to enhance their patient-centered communications skills to improve the quality of care that is provided to this population [12].
Cultural Competence and Patient-Centered Communication
Not all health professional communication skills are perceived as unsatisfactory by Hispanic/Latino patients with diabetes. In fact, Hispanics/Latinos report a positive provider-patient clinical interaction when health professionals display cultural competency skills [15,17–20]. Moreover, evidence suggest that Hispanic/Latino patients with diabetes reported better quality of care and improved self-management behaviors with a culturally competent provider [18–20]. Cultural competency is described as “understanding and responding effectively to the cultural and linguistic needs brought by the patient to the health care encounter” and “valuing diversity, provider self-assessment, managing dynamics of differences, acquiring and institutionalizing knowledge, and adapting to diversity and the cultural context of individuals served” [9,11,12]. One approach for gaining cultural competency skills is to understand how the disease process is conceptualized within a culture and how that influences a patient’s own theory about their disease etiology, prognosis, and outcome [21]. This approach is known as culture-centered in the health communications literature and may be useful when communicating with Hispanic/Latino patients with diabetes because there is extensive literature describing unique indigenous Latin American explanatory models for diabetes [22–26].
Language Discordance in Physician-Patient Communication
The process of patient-physician communication includes “attending to one another and begin interpreting one another’s verbal and nonverbal” interactions [9]. A conventional assumption regarding the disparities in diabetes care quality for Hispanic/Latino patients is that it stems from language discordant patient-physician interactions, which result in errors in the provision of diabetes information and treatment instructions regarding medications and self-care behaviors [9]. While language is a contributing factor, the US Census reports that over half of US Hispanics/Latinos are bilingual and speak English “very well” [27]. Thus, other underlying mechanisms must be contributing to patient-physician miscommunication and suboptimal diabetes outcomes. Moreover, the findings from studies of patient-physician language concordance and diabetes management are inconsistent. For example, language concordance between Hispanic/Latino patients and physicians is associated with improvement in HbA1c but not self-care behaviors (ie, healthy eating, self-monitoring, medicine adherence, exercise) [20]. Thus, there is need to move beyond spoken language to address elements of interpersonal communication around diabetes care through addressing cultural health beliefs and explanatory models of diabetes.
Cultural Explanatory Models of Diabetes
Explanatory models for diabetes among Hispanics/Latinos are diverse and often include a biomedical framework (eg, obesity, unhealthy eating, sedentary lifestyle, genetics); however, there is one unique indigenous belief that continues to be held within this population. Specifically, there is a cultural belief that diabetes is caused by strong or negative emotions, like fright sickness (susto), stress (estres), anger (coraje), or nerves (nervios) [22–26]. Although this cultural belief has been in existence long before scientific evidence has shown the bi-directional relationship between stress/depression and diabetes, the integration of emotions in diabetes self-management in patient-provider communication has not been standardized [28–31]. Health professionals’ interest in how patients view their own disease process may help build rapport with patients. Enhancing health professionals’ cultural competency skills can be a critical first step for improving patient-provider communication. For instance, it can (1) present an opportunity to integrate cultural belief systems into diabetes care for Hispanics/Latinos, (2) open the door for other important conversations about Hispanic/Latino patients’ psychosocial and familial environment and identify barriers or motivators in diabetes self-management, and (3) build rapport and trust between the health professional and patient.
Additionally, inquiring about emotional beliefs or emotions about diabetes in general can help improve the patient-provider relationship, giving Hispanic/Latino patients a sense that their provider cares about their feelings and emotional well-being. For example, in a study conducted by Concha et al, a Hispanic/Latino male patient with diabetes expresses his appreciation of his doctor for attending to his emotional problems and suggests that his diabetes is in control because of the encouragement he receives from the doctor [22].
…I believe the doctors..can encourage one with ..diabetes… I am very grateful to God before anything that till today I have my sugar controlled. I am a diabetic, but controlled. And Dr. [name omitted], he’s a blessing from God. He knows my body like my mother….Because whatever little thing, he attends to me, he gives me a lot of encouragement with my emotional problems. He sent me to a counselor, I have a specialist for my problem with my urinary tracts. I have attention, I have all the attention from the doctor…
Inquiring about emotional well-being may also be beneficial because Hispanics/Latinos with diabetes have reported that they would feel more comfortable talking to a professional about personal problems compared to Hispanics/Latinos without diabetes [32]. Having a physical illness may provide an opportunity for these patients to discuss stress or depression in tandem with diabetes to diminish any possible stigma or shame associated with having a mental health problem. It is important for health care providers to be aware of emotional or social problems that may be negatively influencing diabetes self-care behaviors.
Models of Effective Cross-Cultural Communication
Cultural competency training for health professionals is one strategy for reducing health disparities and ensuring that racial/ethnic populations receive “equitable, effective, and culturally appropriate clinical care” [9,11,12,33]. The Association of American Medical Colleges’ guide for cultural competence education in medical school cites several models of effective cross-cultural communication for physicians and/or physician assistants [34]. I describe 3 communication tools below that may help health care professionals initiate conversations and aid them in understanding how to better manage sociocultural and environmental issues that may impede patients’ ability to manage diabetes. For each tool, a vignette is offered that illustrates how the tool may be used in communicating with Hispanic/Latino patients.
BELIEF
The BELIEF instrument (Dobbie 2003) is a teaching tool designed to elicit patients’ health beliefs and to assist preclinical medical students or medical professionals in understanding how explanatory models of a disease influence patient engagement in care. The BELIEF instrument is straightforward and can be easily implemented into clinical case vignettes and or role-play as part of cultural competency training [35]. The specific questions corresponding to the BELIEF prompts are
- B: Beliefs about health (What caused your illness/problem?)
- E: Explanation (Why did it happen at this time?)
- L: Learn (Help me understand your belief/opinion)
- I: Impact (How is this illness/problem impacting your life?)
- E: Empathy (This must be very hard for you)
- F: Feelings (How are you feeling about it?)
Vignette 1
The following vignette is a conversation between a Spanish-speaking Hispanic women, a language interpreter, and medical professional. The patient, Mrs. Chavez, has come into the clinic for the third time after experiencing symptoms due to hypoglycemia. Mrs. Chavez believes stress may have something to do with her hypoglycemia but is not quite sure how. By using the BELIEF mnemonic, the medical professional is able to ask more about the stress that led into a discussion about how stress actually influenced her eating and medication intake behaviors. Through this probing, the medical professional was able to identify the possible cause of her hypoglycemia and work with Mrs. Chavez on finding a solution every time she experiences the stressful event. The vignette also demonstrates how interpreters may share cultural information that may clarify problems.
Medical Professional: Mrs. Chavez, I see you are here again for hypoglycemia. Can you tell me what has happened? Do you have your medications with you today?
Interpreter: Sra. Chavez, entiendo que está aquí nuevamente por hipoglucemia. ¿Puedes decirme qué ha pasado? ¿Tiene sus medicamentos con usted hoy?
Mrs. Chavez: Si, me ha sentido débil y mareado.
Interpreter: Yes I have felt faint and dizzy?
Medical Professional: Have you been taking your metformin as prescribed?
Interpreter: ¿Ha estado tomando su metformin según lo recetado?
Mrs. Chavez: Si (YES).
Medical Professional: We might have to consider adjusting your dosage.
Interpreter: Es posible que tengamos que considerar ajustar su dosis.
Mrs. Chavez privately to the Interpreter: ¿no es posible que las emociones o nervios puedan causar algo? He escuchado que este puede ser el problema?
Interpreter to Mrs. Chavez: Déjame preguntarle al doctor, si?
Let me ask the doctor, yes? (Mrs. Chavez, nods in agreement)
Interpreter to Medical Professional: She is asking if emotions or nervousness could be the cause. She has heard that this could be the problem.
Medical Profesional to Interpreter: What does she mean?
Interpreter: There is a cultural belief that stress or nerves can cause diabetes or affect diabetes. You may want to ask about this.
Medical Professional: Yes emotions like stress can cause changes in you glucose. (Beliefs) Do you believe that some emotions are causing your hypoglycemia?
Interpreter: Sí, las emociones como el estrés pueden provocar cambios en la glucosa. ¿Crees que algunas emociones están causando tu hipoglucemia?
Mrs. Chavez: (Shrugs shoulders).
Medical Professional: I see here in your records, that the other two times you had hypoglycemica were 1 month and 3 months ago. (Beliefs) What do you think caused these events and (Explanation) why do you think it happened during these times?
Interpreter: Veo aquí en sus registros que las otras dos veces que tuvo hipoglucemia fueron hace 1 mes y 3 meses. ¿Qué crees que causó estos eventos y por qué crees que sucedió durante estos tiempos?
Mrs. Chavez: Pues, no sé.
Interpreter: Well I don’t know.
Medical Professional: (Learn) Help me understand what you think happened 3 and 1 month ago and this month that may have caused your glucose to drop. What was happening emotionally during these times? Do you remember?
Interpreter: Ayúdame a entender lo que piensas que sucedió hace 3 y 1 meses y este mes, puede haber causado que tu glucosa baje. ¿Qué estaba pasando emocionalmente durante este tiempo? ¿Te acuerdas?
Mrs. Chavez: Hmm. Pues, hace 3 meses fui a visitar a mi madre y hace 1 meses fui a visitar a mi hermano al norte.
Interpreter: Hmm. Well 3 months ago I went to visit my mother and 1 months ago I went to visit my brother up north.
Medical Professional: (Learn) How were those trips for you. Did you have fun? What types of emotions were you feeling during these trips?
Interpreter: ¿Cómo fueron esos viajes para ti? ¿Te divertiste? ¿Qué tipo de emociones sentías durante estos viajes?
Mrs. Chavez: Pues, yo estaba muy estresado durante mis viajes.
Interpreter: Well, I was very stressed during my trips.
Medical Professional: (Learn) Would you like to share why you were stressed? What was happening for you to feel so stressed?
Interpreter: ¿Te gustaría compartir por qué estabas estresado? ¿Qué estaba pasando para que te sientas tan estresado?
Mrs. Chavez: Bueno, tenemos muchos problemas familiares y conflictos. Hay muchos argumentos familiares y se vuelve estresante.
Interpreter: Well we have a lot of family problems and conflict. There are a lot of family arguments and it gets stressful.
Medical Professional: (Impact) How do you think this has affected your glucose?
Interpreter: ¿Cómo crees que esto ha afectado tu glucosa?
Mrs. Chavez: No lo sé.
Interpreter: I don’t know.
Medical Professional: (Learn) Do you think the stress maybe led you to forget to take your medication or affected your eating?
Interprter: ¿Crees que el estrés puede llevarte a olvidarte de tomar tu medicación o afectó su alimentación?
Mrs. Chavez: Pues si y no comí. Estaba demasiado estresado para comer. Raramente comí mientras estaba allí. Estaba tan estresado que no tenía apetito.
Interpreter: Well yes and I didn’t eat. I was too stressed to eat. I rarely ate while I was there. I was so stressed i did not have an appetite.
Medical Professional: (Empathy) Mrs. Chavez, that must have been very hard for you. I’m sorry you have had to feel this way. (Feelings) Is this how you feel everytime you visit your family?
Interpreter: Sra. Chávez, eso debe haber sido muy difícil para usted. Lamento que hayas tenido que sentirte de esta manera. ¿Es así como te sientes cada vez que visitas a tu familia?
Mrs. Chavez: Sí, todos se involucran en los problemas familiares y es muy estresante visitarlos, pero tengo que ir a ayudar a mi madre porque mi hermano está enfermo y no puede ayudarla. Soy el único que está cerca y mis otros hermanos discuten sobre lo que debería hacer. Tengo que estar ahí. Tengo que visitar.
Interpreter: Yes, everyone gets involved in the family problems and it is very stressful to visit but I have to go to help my mom because my brother is sick and can’t help her. I’m the only one close by and my other siblings argue about what I should do. I have to be there. I have to visit.
Medical Profesional: (Empathy) Yes, that must be very difficult for you. Okay, now I understand what is happening. Your visits are necessary but it seems like the stress is affecting your eating patterns and whether you remember to take your metformin. How do you feel if we come up with a plan for when you visit your family now that we know what might be causing your hypoglycemia? Do you think it is a good idea to take high glucose snacks or candy and have them with you on the trip so when you feel dizzy or faint you can eat them?
Interpreter: Sí, eso debe ser muy difícil para ti. De acuerdo, ahora entiendo lo que está pasando. Sus visitas son necesarias, pero parece que el estrés está afectando sus patrones de alimentación y si recuerda tomar su metformina. ¿Cómo se siente si elaboramos un plan para su familia ahora que sabemos lo que podría estar causando su hipoglucemia? ¿Cree que es una buena idea tomar refrigerios con alto contenido de glucosa o dulces y llevarlos consigo durante el viaje para que cuando se sienta mareado o desmayado pueda comerlos?
Mrs. Chavez: Sí, por supuesto. Ni siquiera me di cuenta de eso hasta ahora que hablamos sobre eso. Tienes razón, no he estado comiendo bien cuando lo visito. Me siento terrible cuando estoy allí como si quisiera desmayarme.
Interpreter: Yes of course. I didn’t even really realize that until now that we talked about it. You are right, I haven’t been eating right when I visit. I feel terrible when I am there like I want to faint.
Medical Professional: Mrs. Chavez, sometimes it is helpful to talk about our stress and problems we encournter in life, just to talk through it. Is this something you would be interested in? If so, we can arrange for you to come talk to the social worker.
Interpreter: Sra. Chavez, a veces es útil hablar sobre nuestro estrés y los problemas que alegramos en la vida, solo para hablar sobre ello. ¿Esto es algo que te interesaría? Si tu quieres, podemos hacer arreglos para que vengas a hablar con el trabajador social.
Mrs. Chavez: Tal vez, no estoy seguro, pero tal vez
Interpreter: Maybe, I’m not sure but maybe.
Medical Professional: Okay, you let me know if this is something you would like to do. You can call and let us know and I’ll ask again during our next visit and see how you are dealing with the stress when you visit your family.
Interpreter: De acuerdo, dime si esto es algo que te gustaría hacer. Puede llamar y dejarnos saber, y volveré a preguntar durante nuestra próxima visita y verá cómo lidia con el estrés cuando visita a su familia.
ETHNIC
The ETHNIC interviewing tool (Levin SJ 2000) can be used to explore cross cultural issues and facilitate collaboration during clinical encounters and is designed for clinical students or health professionals permitted to diagnose and provide therapeutic interventions [36]. The specific questions corresponding to the ETHNIC prompts:
- E: Explanation (How do you explain your illness?)
- T: Treatment (What treatment have you tried?)
- H: Healers (Have you sought any advice from folk healers?)
- N: Negotiate (mutually acceptable options)
- I: Intervention (agreed on)
- C: Collaboration (with patient, family, and healers)
Vignette 2
The second vignette is a discussion between a conscientious patient, Mrs. Rodriguez, and her doctor. Mrs. Rodriguez is determined to keep her glucose levels within optimal range by eating healthy and living a natural lifestyle. Included in her natural lifestyle is the use of herbs from her garden and herbal supplements sold to her by her neighbor. Because her numbers have been in the normal range she discontinues her prescribed medication to rely on natural products. However, a trip with family members interrupts her daily routine, which is replaced with fast foods and little rest. Upon returning from her trip her glucose levels increase and she cannot decrease her glucose numbers.
Medical Professional: Good morning Mrs. Rodriguez. I see you are here today for high blood sugar because of your diabetes. (Explanation) Can you share why you think you have recently had higher numbers than normal?
Mrs. Rodriguez: Good morning Doctor. Yes, I am usually very good with my numbers but lately they have gone up and I know why.
Medical Professional: Yes, that is good that you have had your glucose managed. (Explanation) What has caused your numbers to go up Mrs. Rodriguez?
Mrs. Rodriguez: All this American food. I went on a trip to visit my daughter and all we did was eat out, hamburgers, fast food restaurants. They do not cook at home and we were always doing something so I could not cook. It was terrible, all we did was keep busy out and about, I was tired. I spent so much money on food that has chemicals. Look at me now. I can’t seem to get my numbers down.
Medical Professional: Oh, I understand. Yes, a trip can sometimes mess with our routine. (Treatment) Since you have been good at managing your glucose in the past what have you been doing now to get your glucose in normal range?
Mrs. Rodriguez: Well I have been doing the same thing I have always been doing. Eating healthy, resting, gardening, and praying.
Medical Professional: Gardening? That’s really nice. What do you garden?
Mrs. Rodriguez: Oh I love gardening. I plant all types of herbs, vegetables, flowers.
Medical Professional: That is so good Mrs. Rodriguez. I wish I had more time to garden. Do you use your own vegetable and herbs when you cook?
Mrs. Rodriguez: Haha. Yes of course. That is why my sugar was fine before I went on this trip. I rely on my garden to keep me healthy.
Medical Professional: There are so many herbs that are helpful for diabetes. (Treatment) Do you use any to help with your diabetes?
Mrs. Rodriguez: Well yes, in fact, I do. I know you doctors don’t like us to use our herbs but I do. And that was what keeps my sugars normal.
Medical Professional: Oh Mrs. Rodriguez, yes sometimes you hear doctors say this but some herbs are helpful. We just like to know what other things our patients do so we know how to make sure your medications work with certain herbs. (Treatment) I know many people use nopal (cactus), do you eat nopal?
Mrs. Rodriguez: ¿Como no? (of course). I eat them all the time. I make my morning licuado (drink); a little bit of parsley, oregano, oatmeal, lemon, nopal mixed with milk and yogurt.
Medical Professional: (Treatment) Sounds good, what else do you use?
Mrs. Rodriguez: Oh you know other things. Apple cider, cinnamon, cayenne.
Medical Professional: All from your garden?
Mrs. Rodriguez: Yes.
Medical Professional: (Treatment) Do you use any type of herbal supplements from stores or online?
Mrs. Rodriguez: My neighbor sells supplements specifically for diabetes. I started to use a natural supplement with cinnamon, vitamin D, and fish oil. All very natural.
Medical Professional: (Healer) Oh does your neighbor also have diabetes?
Mrs. Rodriguez: No, she sells products. But she sells to many people with diabetes and the supplement works. We get together and she tells us about how they work.
Medical Professional: Do you know the name of this supplement Mrs. Rodriguez?
Mrs. Rodriguez: Oh, gluco…something, it has a heart in the name. But I read the ingredients and it has only natural ingredients. (An FDA banned supplement for false claims)
Medical Professional: Oh I see. I may be familiar with that. Can you bring the supplement along with the medications I have prescribed? I just want to make sure there is not interaction between the two. To get your glucose back to normal I want to make sure we think of every possible situation that could be causing your high numbers. (Treatment) How have you been taking the supplement and the prescribed medications?
Mrs. Rodriguez: Well, I have not refilled your prescription. I was doing so well with my numbers, I’d rather go natural than take all those chemicals.
Medical Professional: Oh, I see Mrs. Rodriguez. Okay, you have done so well controlling your glucose before your trip and now we are in a situation where your numbers are not coming down so let’s try to figure this out. I’d like to learn more about this supplement, so for our next visit can you bring in your supplements so I can take a look at it? (Negotiate) We can then talk about the benefits or cautions. But in the meantime I’d like you to refill your medication and take as followed to see if that helps your sugars. (Negotiate) What do you think? Is this possible?
Mrs. Rodriguez: Oh Doctor, I just don’t like taking chemicals.
Medical Professional: I understand Mrs. Rodriguez. You did take them to start when you first came in for diabetes, is this correct?
Mrs. Rodriguez: Well yes but, I slowly got off them.
Medical Professional: I know it’s difficult to take medications every day but they can help in addition to your healthy eating. I know you are concerned about medications but for now we have to focus on getting your numbers down or your diabetes could become worse and we don’t want you to get there. Do you agree? (Negotiating process)
Mrs. Rodriguez: Well, I am concerned about my numbers.
Medical Professional: (Intervention) Okay well let’s try to get back to where you were before the trip. Let’s get you back on the medication and let’s see if this helps. (Negotiate) For the next visit would you be willing to bring any supplements you are taking along with the medication? (Collaboration) We can talk about the benefits and cautions for the medications and supplements. How does this sound?
Mrs. Rodriguez: Well, I am here to fix my numbers. I have everything I take in a box so I can bring that.
Medical Professional: Yes that would be great. (Collaboration) We can both talk about your daily routine and what have you learned about the supplement, any information or papers that you have, in addition to the medication I prescribed.
Mrs. Rodriguez: Yes I can do that.
Medical Professional: Thank you Mrs. Rodriguez. (Intervention) Also, I’ll have the nurse call you today or tomorrow and you can give her the name of the supplement and she’ll make sure the drug store has a refill for you. Would this work for you Mrs. Rodriguez?
Mrs. Rodriguez: Yes Doctor. You can call me. I’ll have the list ready.
BATHE
Unlike the BELIEF and ETHNIC instruments, the BATHE mnemonic (Lieberman 1999)
- B: Background (What is going on in your life?)
- A: Affect (How do you feel about what is going on?)
- T: Trouble (What troubles you most?)
- H: Handling (How are you handling that?)
- E: Empathy (This must be very difficult for you)
Vignette 3
The last vignette features Mr. Gonzalez, who typically shows a positive outlook on life when visiting his doctor. He is a patient who would not necessarily discuss his emotions if not asked specific questions about his emotional well-being.
Medical Professional: Hello Mr. Gonzalez. (Background) How are you doing today? What’s new? What’s going on in your life lately?
Mr. Gonzalez: Hey, Doctor! I’m good you know just living day to day.
Medical Professional: Good. (Affect) So how is your diabetes treating you day to day? How are you feeling with life and managing your diabetes?
Mr. Gonzalez: Ah well you know, just dealing with it as best as I can.
Medical Professional: Ah okay. As best as you can. (Troubles) What troubles you the most about managing diabetes?
Mr. Gonzalez: Well you know the aches and pains. But what can I do.
Medical Professional: (Affect) How do you feel about those aches and pains?
Mr. Gonzalez: Well it does limit me. I can’t move as well as I use to.
Medical Professional: (Handling) Hmm. I see. How are you handling those aches and pains? What are you doing to relieve it?
Mr. Gonzalez: I do my best with pain cream.
Medical Professional: (Empathy) Pains and aches, that must be difficult. (Affect) How do the aches and pains make you feel?
Mr. Gonzalez: Ahh, Doc, it’s not the same. You know I can’t do the same things anymore.
Medical Professional: (Background) What do you mean? What is not the same anymore?
Mr. Gonzalez: This diabetes, I’m not the same person. I use to be able to be there for my family and community and now I feel like I can’t be there for them the way I use to. I use to be the strong one for my family, helping those in need, and now I’m limited, my body is limited.
Medical Professional: (Affect) How do you feel about that? How does it make you feel emotionally and physically?
Mr. Gonzalez: Bad. I feel bad about it.
Medical Professional: Bad emotionally or physically?
Mr. Gonzalez: Both
Medical Professional: I see. (Handling) How are you dealing with the emotional part of it?
Mr. Gonzalez: I don’t know. I don’t know how.
Medical Professional: (Empathy) Dealing with diabetes and how it makes your body feel can be very emotionally distressing. It is common to feel this way but I want to make sure we also work on how you feel emotionally or how your emotions is affecting your diabetes.
Conclusion
Three mnemonic tools have been suggested to initiate patient-centered and culture-centered communication with patients. Beyond the use of these instruments, there are 2 key skills that are essential for engaging a Hispanic/Latino patient. The first is a non-judgmental, warm communication approach, and the second is astute probing. Once when I was interpreting for a Spanish-speaking Hispanic/Latino patient and English-speaking doctor, the patient expressed to me that she felt that the medical professionals “tienen una cultura fría” (“have a cold culture”), and she did not feel comfortable sharing more about herself because of it. It is also important for medical professionals to be aware of a patient’s doublespeak as a way to share enough information but not all information to keep from being judged by medical professionals. Thus, non-judgmental probing can uncover important information that may be useful for collaborative goal setting and treatment decisions.
The management of diabetes is multifaceted and complex, particularly for populations who face social barriers and challenges. The Hispanic/Latino population is more likely to encounter disparities in access to quality health care and disparities in social determinants of health compared to non-Hispanic whites [4–9]. Therefore, it is important for health professionals to engage Hispanic/Latino patients in self-care by eliciting information that best facilitates collaborative goal setting. Health professionals are in an influential position to leverage a communication style that is empathetic, trusting, and open, setting the tone for a positive patient-physician encounter and, in turn, positive patient outcomes [18–20].
Corresponding author: Jeannie Belinda Concha, PhD, MPH, Dept. of Public Health Sciences, The University of Texas at El Paso, 500 W. University Ave., El Paso, TX 79968, jeannie@utep.edu.
Funding support: Support for this research was provided by the Office of Research and Sponsored Projects at The University of Texas at El Paso.
Financial disclosures: None.
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From the University of Texas at El Paso, El Paso, TX.
Abstract
- Objective: To demonstrate the applied use of recommended cultural competency communication tools.
- Methods: An overview of several cultural competency tools is presented and vignettes are used to demonstrate the use of these tools with Hispanic patients with diabetes.
- Results: Three communication mnemonic instruments, ie, BELIEF, ETHNIC, and BATHE, may be useful for engaging health professionals in patient-centered communication with their Hispanic patients and shared decision making. Health professionals can also employ nonjudgmental probing as part of engaging patients in setting diabetes treatment goals.
- Conclusion: Health professionals are in an influential position to leverage a patient- and culture-centered communication style to improve communication with Hispanic patients. Using mnemonic tools can help facilitate this communication and improve health professionals’ understanding on how cultural and social factors influence diabetes management in this population.
Key words: Hispanic/Latino; diabetes; patient-centered communication; cultural-competency.
The 2017 American Diabetes Association (ADA) Standards of Medical Care recommend that health professionals engage in a patient-centered communication style with patient to facilitate shared decision-making and improve diabetes outcomes. The ADA defines patient-centered communication as “a style that uses active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care” [1]. One of the main goals of using patient-centered communication is to create a collaborative, personal, and non-judgmental relationship with patients. These guidelines, however, provide less direction on the type of communication skills training that would facilitate this type of communication, particularly as it relates to ethnic/racial minority groups most at risk for diabetes and related complications.
The US Hispanic/Latino population, in particular, is a group that is burdened by the diabetes epidemic, with a prevalence that is 130% higher than non-Hispanic whites [2]. It is widely known that certain social determinants of health, like socioeconomic status, social injustices, poor access to health care, food insecurity, or living in environments that do not support health behaviors, all contribute to health disparities for Hispanics/Latinos [3]. Understanding how Hispanics/Latinos cope with these social determinants of health is important for health care professionals, and a patient-centered communication style is an ideal approach for active listening and eliciting information about the social barriers/challenges that may influence diabetes self-care. However, there is some evidence that suggests this approach is not fully used by health care professionals when communicating with Hispanics/Latinos with diabetes, and Hispanics/Latinos continue to be more likely to experience disparities in the quality of diabetes care they receive compared to non-Hispanic whites [4–9]. One of the identified contributors to these disparities is the poor communication between physicians and Hispanic/Latino patients [10–16]. Given that health care professionals are the primary source of health care and diabetes information for Hispanics/Latinos, it is important for health professionals to enhance their patient-centered communications skills to improve the quality of care that is provided to this population [12].
Cultural Competence and Patient-Centered Communication
Not all health professional communication skills are perceived as unsatisfactory by Hispanic/Latino patients with diabetes. In fact, Hispanics/Latinos report a positive provider-patient clinical interaction when health professionals display cultural competency skills [15,17–20]. Moreover, evidence suggest that Hispanic/Latino patients with diabetes reported better quality of care and improved self-management behaviors with a culturally competent provider [18–20]. Cultural competency is described as “understanding and responding effectively to the cultural and linguistic needs brought by the patient to the health care encounter” and “valuing diversity, provider self-assessment, managing dynamics of differences, acquiring and institutionalizing knowledge, and adapting to diversity and the cultural context of individuals served” [9,11,12]. One approach for gaining cultural competency skills is to understand how the disease process is conceptualized within a culture and how that influences a patient’s own theory about their disease etiology, prognosis, and outcome [21]. This approach is known as culture-centered in the health communications literature and may be useful when communicating with Hispanic/Latino patients with diabetes because there is extensive literature describing unique indigenous Latin American explanatory models for diabetes [22–26].
Language Discordance in Physician-Patient Communication
The process of patient-physician communication includes “attending to one another and begin interpreting one another’s verbal and nonverbal” interactions [9]. A conventional assumption regarding the disparities in diabetes care quality for Hispanic/Latino patients is that it stems from language discordant patient-physician interactions, which result in errors in the provision of diabetes information and treatment instructions regarding medications and self-care behaviors [9]. While language is a contributing factor, the US Census reports that over half of US Hispanics/Latinos are bilingual and speak English “very well” [27]. Thus, other underlying mechanisms must be contributing to patient-physician miscommunication and suboptimal diabetes outcomes. Moreover, the findings from studies of patient-physician language concordance and diabetes management are inconsistent. For example, language concordance between Hispanic/Latino patients and physicians is associated with improvement in HbA1c but not self-care behaviors (ie, healthy eating, self-monitoring, medicine adherence, exercise) [20]. Thus, there is need to move beyond spoken language to address elements of interpersonal communication around diabetes care through addressing cultural health beliefs and explanatory models of diabetes.
Cultural Explanatory Models of Diabetes
Explanatory models for diabetes among Hispanics/Latinos are diverse and often include a biomedical framework (eg, obesity, unhealthy eating, sedentary lifestyle, genetics); however, there is one unique indigenous belief that continues to be held within this population. Specifically, there is a cultural belief that diabetes is caused by strong or negative emotions, like fright sickness (susto), stress (estres), anger (coraje), or nerves (nervios) [22–26]. Although this cultural belief has been in existence long before scientific evidence has shown the bi-directional relationship between stress/depression and diabetes, the integration of emotions in diabetes self-management in patient-provider communication has not been standardized [28–31]. Health professionals’ interest in how patients view their own disease process may help build rapport with patients. Enhancing health professionals’ cultural competency skills can be a critical first step for improving patient-provider communication. For instance, it can (1) present an opportunity to integrate cultural belief systems into diabetes care for Hispanics/Latinos, (2) open the door for other important conversations about Hispanic/Latino patients’ psychosocial and familial environment and identify barriers or motivators in diabetes self-management, and (3) build rapport and trust between the health professional and patient.
Additionally, inquiring about emotional beliefs or emotions about diabetes in general can help improve the patient-provider relationship, giving Hispanic/Latino patients a sense that their provider cares about their feelings and emotional well-being. For example, in a study conducted by Concha et al, a Hispanic/Latino male patient with diabetes expresses his appreciation of his doctor for attending to his emotional problems and suggests that his diabetes is in control because of the encouragement he receives from the doctor [22].
…I believe the doctors..can encourage one with ..diabetes… I am very grateful to God before anything that till today I have my sugar controlled. I am a diabetic, but controlled. And Dr. [name omitted], he’s a blessing from God. He knows my body like my mother….Because whatever little thing, he attends to me, he gives me a lot of encouragement with my emotional problems. He sent me to a counselor, I have a specialist for my problem with my urinary tracts. I have attention, I have all the attention from the doctor…
Inquiring about emotional well-being may also be beneficial because Hispanics/Latinos with diabetes have reported that they would feel more comfortable talking to a professional about personal problems compared to Hispanics/Latinos without diabetes [32]. Having a physical illness may provide an opportunity for these patients to discuss stress or depression in tandem with diabetes to diminish any possible stigma or shame associated with having a mental health problem. It is important for health care providers to be aware of emotional or social problems that may be negatively influencing diabetes self-care behaviors.
Models of Effective Cross-Cultural Communication
Cultural competency training for health professionals is one strategy for reducing health disparities and ensuring that racial/ethnic populations receive “equitable, effective, and culturally appropriate clinical care” [9,11,12,33]. The Association of American Medical Colleges’ guide for cultural competence education in medical school cites several models of effective cross-cultural communication for physicians and/or physician assistants [34]. I describe 3 communication tools below that may help health care professionals initiate conversations and aid them in understanding how to better manage sociocultural and environmental issues that may impede patients’ ability to manage diabetes. For each tool, a vignette is offered that illustrates how the tool may be used in communicating with Hispanic/Latino patients.
BELIEF
The BELIEF instrument (Dobbie 2003) is a teaching tool designed to elicit patients’ health beliefs and to assist preclinical medical students or medical professionals in understanding how explanatory models of a disease influence patient engagement in care. The BELIEF instrument is straightforward and can be easily implemented into clinical case vignettes and or role-play as part of cultural competency training [35]. The specific questions corresponding to the BELIEF prompts are
- B: Beliefs about health (What caused your illness/problem?)
- E: Explanation (Why did it happen at this time?)
- L: Learn (Help me understand your belief/opinion)
- I: Impact (How is this illness/problem impacting your life?)
- E: Empathy (This must be very hard for you)
- F: Feelings (How are you feeling about it?)
Vignette 1
The following vignette is a conversation between a Spanish-speaking Hispanic women, a language interpreter, and medical professional. The patient, Mrs. Chavez, has come into the clinic for the third time after experiencing symptoms due to hypoglycemia. Mrs. Chavez believes stress may have something to do with her hypoglycemia but is not quite sure how. By using the BELIEF mnemonic, the medical professional is able to ask more about the stress that led into a discussion about how stress actually influenced her eating and medication intake behaviors. Through this probing, the medical professional was able to identify the possible cause of her hypoglycemia and work with Mrs. Chavez on finding a solution every time she experiences the stressful event. The vignette also demonstrates how interpreters may share cultural information that may clarify problems.
Medical Professional: Mrs. Chavez, I see you are here again for hypoglycemia. Can you tell me what has happened? Do you have your medications with you today?
Interpreter: Sra. Chavez, entiendo que está aquí nuevamente por hipoglucemia. ¿Puedes decirme qué ha pasado? ¿Tiene sus medicamentos con usted hoy?
Mrs. Chavez: Si, me ha sentido débil y mareado.
Interpreter: Yes I have felt faint and dizzy?
Medical Professional: Have you been taking your metformin as prescribed?
Interpreter: ¿Ha estado tomando su metformin según lo recetado?
Mrs. Chavez: Si (YES).
Medical Professional: We might have to consider adjusting your dosage.
Interpreter: Es posible que tengamos que considerar ajustar su dosis.
Mrs. Chavez privately to the Interpreter: ¿no es posible que las emociones o nervios puedan causar algo? He escuchado que este puede ser el problema?
Interpreter to Mrs. Chavez: Déjame preguntarle al doctor, si?
Let me ask the doctor, yes? (Mrs. Chavez, nods in agreement)
Interpreter to Medical Professional: She is asking if emotions or nervousness could be the cause. She has heard that this could be the problem.
Medical Profesional to Interpreter: What does she mean?
Interpreter: There is a cultural belief that stress or nerves can cause diabetes or affect diabetes. You may want to ask about this.
Medical Professional: Yes emotions like stress can cause changes in you glucose. (Beliefs) Do you believe that some emotions are causing your hypoglycemia?
Interpreter: Sí, las emociones como el estrés pueden provocar cambios en la glucosa. ¿Crees que algunas emociones están causando tu hipoglucemia?
Mrs. Chavez: (Shrugs shoulders).
Medical Professional: I see here in your records, that the other two times you had hypoglycemica were 1 month and 3 months ago. (Beliefs) What do you think caused these events and (Explanation) why do you think it happened during these times?
Interpreter: Veo aquí en sus registros que las otras dos veces que tuvo hipoglucemia fueron hace 1 mes y 3 meses. ¿Qué crees que causó estos eventos y por qué crees que sucedió durante estos tiempos?
Mrs. Chavez: Pues, no sé.
Interpreter: Well I don’t know.
Medical Professional: (Learn) Help me understand what you think happened 3 and 1 month ago and this month that may have caused your glucose to drop. What was happening emotionally during these times? Do you remember?
Interpreter: Ayúdame a entender lo que piensas que sucedió hace 3 y 1 meses y este mes, puede haber causado que tu glucosa baje. ¿Qué estaba pasando emocionalmente durante este tiempo? ¿Te acuerdas?
Mrs. Chavez: Hmm. Pues, hace 3 meses fui a visitar a mi madre y hace 1 meses fui a visitar a mi hermano al norte.
Interpreter: Hmm. Well 3 months ago I went to visit my mother and 1 months ago I went to visit my brother up north.
Medical Professional: (Learn) How were those trips for you. Did you have fun? What types of emotions were you feeling during these trips?
Interpreter: ¿Cómo fueron esos viajes para ti? ¿Te divertiste? ¿Qué tipo de emociones sentías durante estos viajes?
Mrs. Chavez: Pues, yo estaba muy estresado durante mis viajes.
Interpreter: Well, I was very stressed during my trips.
Medical Professional: (Learn) Would you like to share why you were stressed? What was happening for you to feel so stressed?
Interpreter: ¿Te gustaría compartir por qué estabas estresado? ¿Qué estaba pasando para que te sientas tan estresado?
Mrs. Chavez: Bueno, tenemos muchos problemas familiares y conflictos. Hay muchos argumentos familiares y se vuelve estresante.
Interpreter: Well we have a lot of family problems and conflict. There are a lot of family arguments and it gets stressful.
Medical Professional: (Impact) How do you think this has affected your glucose?
Interpreter: ¿Cómo crees que esto ha afectado tu glucosa?
Mrs. Chavez: No lo sé.
Interpreter: I don’t know.
Medical Professional: (Learn) Do you think the stress maybe led you to forget to take your medication or affected your eating?
Interprter: ¿Crees que el estrés puede llevarte a olvidarte de tomar tu medicación o afectó su alimentación?
Mrs. Chavez: Pues si y no comí. Estaba demasiado estresado para comer. Raramente comí mientras estaba allí. Estaba tan estresado que no tenía apetito.
Interpreter: Well yes and I didn’t eat. I was too stressed to eat. I rarely ate while I was there. I was so stressed i did not have an appetite.
Medical Professional: (Empathy) Mrs. Chavez, that must have been very hard for you. I’m sorry you have had to feel this way. (Feelings) Is this how you feel everytime you visit your family?
Interpreter: Sra. Chávez, eso debe haber sido muy difícil para usted. Lamento que hayas tenido que sentirte de esta manera. ¿Es así como te sientes cada vez que visitas a tu familia?
Mrs. Chavez: Sí, todos se involucran en los problemas familiares y es muy estresante visitarlos, pero tengo que ir a ayudar a mi madre porque mi hermano está enfermo y no puede ayudarla. Soy el único que está cerca y mis otros hermanos discuten sobre lo que debería hacer. Tengo que estar ahí. Tengo que visitar.
Interpreter: Yes, everyone gets involved in the family problems and it is very stressful to visit but I have to go to help my mom because my brother is sick and can’t help her. I’m the only one close by and my other siblings argue about what I should do. I have to be there. I have to visit.
Medical Profesional: (Empathy) Yes, that must be very difficult for you. Okay, now I understand what is happening. Your visits are necessary but it seems like the stress is affecting your eating patterns and whether you remember to take your metformin. How do you feel if we come up with a plan for when you visit your family now that we know what might be causing your hypoglycemia? Do you think it is a good idea to take high glucose snacks or candy and have them with you on the trip so when you feel dizzy or faint you can eat them?
Interpreter: Sí, eso debe ser muy difícil para ti. De acuerdo, ahora entiendo lo que está pasando. Sus visitas son necesarias, pero parece que el estrés está afectando sus patrones de alimentación y si recuerda tomar su metformina. ¿Cómo se siente si elaboramos un plan para su familia ahora que sabemos lo que podría estar causando su hipoglucemia? ¿Cree que es una buena idea tomar refrigerios con alto contenido de glucosa o dulces y llevarlos consigo durante el viaje para que cuando se sienta mareado o desmayado pueda comerlos?
Mrs. Chavez: Sí, por supuesto. Ni siquiera me di cuenta de eso hasta ahora que hablamos sobre eso. Tienes razón, no he estado comiendo bien cuando lo visito. Me siento terrible cuando estoy allí como si quisiera desmayarme.
Interpreter: Yes of course. I didn’t even really realize that until now that we talked about it. You are right, I haven’t been eating right when I visit. I feel terrible when I am there like I want to faint.
Medical Professional: Mrs. Chavez, sometimes it is helpful to talk about our stress and problems we encournter in life, just to talk through it. Is this something you would be interested in? If so, we can arrange for you to come talk to the social worker.
Interpreter: Sra. Chavez, a veces es útil hablar sobre nuestro estrés y los problemas que alegramos en la vida, solo para hablar sobre ello. ¿Esto es algo que te interesaría? Si tu quieres, podemos hacer arreglos para que vengas a hablar con el trabajador social.
Mrs. Chavez: Tal vez, no estoy seguro, pero tal vez
Interpreter: Maybe, I’m not sure but maybe.
Medical Professional: Okay, you let me know if this is something you would like to do. You can call and let us know and I’ll ask again during our next visit and see how you are dealing with the stress when you visit your family.
Interpreter: De acuerdo, dime si esto es algo que te gustaría hacer. Puede llamar y dejarnos saber, y volveré a preguntar durante nuestra próxima visita y verá cómo lidia con el estrés cuando visita a su familia.
ETHNIC
The ETHNIC interviewing tool (Levin SJ 2000) can be used to explore cross cultural issues and facilitate collaboration during clinical encounters and is designed for clinical students or health professionals permitted to diagnose and provide therapeutic interventions [36]. The specific questions corresponding to the ETHNIC prompts:
- E: Explanation (How do you explain your illness?)
- T: Treatment (What treatment have you tried?)
- H: Healers (Have you sought any advice from folk healers?)
- N: Negotiate (mutually acceptable options)
- I: Intervention (agreed on)
- C: Collaboration (with patient, family, and healers)
Vignette 2
The second vignette is a discussion between a conscientious patient, Mrs. Rodriguez, and her doctor. Mrs. Rodriguez is determined to keep her glucose levels within optimal range by eating healthy and living a natural lifestyle. Included in her natural lifestyle is the use of herbs from her garden and herbal supplements sold to her by her neighbor. Because her numbers have been in the normal range she discontinues her prescribed medication to rely on natural products. However, a trip with family members interrupts her daily routine, which is replaced with fast foods and little rest. Upon returning from her trip her glucose levels increase and she cannot decrease her glucose numbers.
Medical Professional: Good morning Mrs. Rodriguez. I see you are here today for high blood sugar because of your diabetes. (Explanation) Can you share why you think you have recently had higher numbers than normal?
Mrs. Rodriguez: Good morning Doctor. Yes, I am usually very good with my numbers but lately they have gone up and I know why.
Medical Professional: Yes, that is good that you have had your glucose managed. (Explanation) What has caused your numbers to go up Mrs. Rodriguez?
Mrs. Rodriguez: All this American food. I went on a trip to visit my daughter and all we did was eat out, hamburgers, fast food restaurants. They do not cook at home and we were always doing something so I could not cook. It was terrible, all we did was keep busy out and about, I was tired. I spent so much money on food that has chemicals. Look at me now. I can’t seem to get my numbers down.
Medical Professional: Oh, I understand. Yes, a trip can sometimes mess with our routine. (Treatment) Since you have been good at managing your glucose in the past what have you been doing now to get your glucose in normal range?
Mrs. Rodriguez: Well I have been doing the same thing I have always been doing. Eating healthy, resting, gardening, and praying.
Medical Professional: Gardening? That’s really nice. What do you garden?
Mrs. Rodriguez: Oh I love gardening. I plant all types of herbs, vegetables, flowers.
Medical Professional: That is so good Mrs. Rodriguez. I wish I had more time to garden. Do you use your own vegetable and herbs when you cook?
Mrs. Rodriguez: Haha. Yes of course. That is why my sugar was fine before I went on this trip. I rely on my garden to keep me healthy.
Medical Professional: There are so many herbs that are helpful for diabetes. (Treatment) Do you use any to help with your diabetes?
Mrs. Rodriguez: Well yes, in fact, I do. I know you doctors don’t like us to use our herbs but I do. And that was what keeps my sugars normal.
Medical Professional: Oh Mrs. Rodriguez, yes sometimes you hear doctors say this but some herbs are helpful. We just like to know what other things our patients do so we know how to make sure your medications work with certain herbs. (Treatment) I know many people use nopal (cactus), do you eat nopal?
Mrs. Rodriguez: ¿Como no? (of course). I eat them all the time. I make my morning licuado (drink); a little bit of parsley, oregano, oatmeal, lemon, nopal mixed with milk and yogurt.
Medical Professional: (Treatment) Sounds good, what else do you use?
Mrs. Rodriguez: Oh you know other things. Apple cider, cinnamon, cayenne.
Medical Professional: All from your garden?
Mrs. Rodriguez: Yes.
Medical Professional: (Treatment) Do you use any type of herbal supplements from stores or online?
Mrs. Rodriguez: My neighbor sells supplements specifically for diabetes. I started to use a natural supplement with cinnamon, vitamin D, and fish oil. All very natural.
Medical Professional: (Healer) Oh does your neighbor also have diabetes?
Mrs. Rodriguez: No, she sells products. But she sells to many people with diabetes and the supplement works. We get together and she tells us about how they work.
Medical Professional: Do you know the name of this supplement Mrs. Rodriguez?
Mrs. Rodriguez: Oh, gluco…something, it has a heart in the name. But I read the ingredients and it has only natural ingredients. (An FDA banned supplement for false claims)
Medical Professional: Oh I see. I may be familiar with that. Can you bring the supplement along with the medications I have prescribed? I just want to make sure there is not interaction between the two. To get your glucose back to normal I want to make sure we think of every possible situation that could be causing your high numbers. (Treatment) How have you been taking the supplement and the prescribed medications?
Mrs. Rodriguez: Well, I have not refilled your prescription. I was doing so well with my numbers, I’d rather go natural than take all those chemicals.
Medical Professional: Oh, I see Mrs. Rodriguez. Okay, you have done so well controlling your glucose before your trip and now we are in a situation where your numbers are not coming down so let’s try to figure this out. I’d like to learn more about this supplement, so for our next visit can you bring in your supplements so I can take a look at it? (Negotiate) We can then talk about the benefits or cautions. But in the meantime I’d like you to refill your medication and take as followed to see if that helps your sugars. (Negotiate) What do you think? Is this possible?
Mrs. Rodriguez: Oh Doctor, I just don’t like taking chemicals.
Medical Professional: I understand Mrs. Rodriguez. You did take them to start when you first came in for diabetes, is this correct?
Mrs. Rodriguez: Well yes but, I slowly got off them.
Medical Professional: I know it’s difficult to take medications every day but they can help in addition to your healthy eating. I know you are concerned about medications but for now we have to focus on getting your numbers down or your diabetes could become worse and we don’t want you to get there. Do you agree? (Negotiating process)
Mrs. Rodriguez: Well, I am concerned about my numbers.
Medical Professional: (Intervention) Okay well let’s try to get back to where you were before the trip. Let’s get you back on the medication and let’s see if this helps. (Negotiate) For the next visit would you be willing to bring any supplements you are taking along with the medication? (Collaboration) We can talk about the benefits and cautions for the medications and supplements. How does this sound?
Mrs. Rodriguez: Well, I am here to fix my numbers. I have everything I take in a box so I can bring that.
Medical Professional: Yes that would be great. (Collaboration) We can both talk about your daily routine and what have you learned about the supplement, any information or papers that you have, in addition to the medication I prescribed.
Mrs. Rodriguez: Yes I can do that.
Medical Professional: Thank you Mrs. Rodriguez. (Intervention) Also, I’ll have the nurse call you today or tomorrow and you can give her the name of the supplement and she’ll make sure the drug store has a refill for you. Would this work for you Mrs. Rodriguez?
Mrs. Rodriguez: Yes Doctor. You can call me. I’ll have the list ready.
BATHE
Unlike the BELIEF and ETHNIC instruments, the BATHE mnemonic (Lieberman 1999)
- B: Background (What is going on in your life?)
- A: Affect (How do you feel about what is going on?)
- T: Trouble (What troubles you most?)
- H: Handling (How are you handling that?)
- E: Empathy (This must be very difficult for you)
Vignette 3
The last vignette features Mr. Gonzalez, who typically shows a positive outlook on life when visiting his doctor. He is a patient who would not necessarily discuss his emotions if not asked specific questions about his emotional well-being.
Medical Professional: Hello Mr. Gonzalez. (Background) How are you doing today? What’s new? What’s going on in your life lately?
Mr. Gonzalez: Hey, Doctor! I’m good you know just living day to day.
Medical Professional: Good. (Affect) So how is your diabetes treating you day to day? How are you feeling with life and managing your diabetes?
Mr. Gonzalez: Ah well you know, just dealing with it as best as I can.
Medical Professional: Ah okay. As best as you can. (Troubles) What troubles you the most about managing diabetes?
Mr. Gonzalez: Well you know the aches and pains. But what can I do.
Medical Professional: (Affect) How do you feel about those aches and pains?
Mr. Gonzalez: Well it does limit me. I can’t move as well as I use to.
Medical Professional: (Handling) Hmm. I see. How are you handling those aches and pains? What are you doing to relieve it?
Mr. Gonzalez: I do my best with pain cream.
Medical Professional: (Empathy) Pains and aches, that must be difficult. (Affect) How do the aches and pains make you feel?
Mr. Gonzalez: Ahh, Doc, it’s not the same. You know I can’t do the same things anymore.
Medical Professional: (Background) What do you mean? What is not the same anymore?
Mr. Gonzalez: This diabetes, I’m not the same person. I use to be able to be there for my family and community and now I feel like I can’t be there for them the way I use to. I use to be the strong one for my family, helping those in need, and now I’m limited, my body is limited.
Medical Professional: (Affect) How do you feel about that? How does it make you feel emotionally and physically?
Mr. Gonzalez: Bad. I feel bad about it.
Medical Professional: Bad emotionally or physically?
Mr. Gonzalez: Both
Medical Professional: I see. (Handling) How are you dealing with the emotional part of it?
Mr. Gonzalez: I don’t know. I don’t know how.
Medical Professional: (Empathy) Dealing with diabetes and how it makes your body feel can be very emotionally distressing. It is common to feel this way but I want to make sure we also work on how you feel emotionally or how your emotions is affecting your diabetes.
Conclusion
Three mnemonic tools have been suggested to initiate patient-centered and culture-centered communication with patients. Beyond the use of these instruments, there are 2 key skills that are essential for engaging a Hispanic/Latino patient. The first is a non-judgmental, warm communication approach, and the second is astute probing. Once when I was interpreting for a Spanish-speaking Hispanic/Latino patient and English-speaking doctor, the patient expressed to me that she felt that the medical professionals “tienen una cultura fría” (“have a cold culture”), and she did not feel comfortable sharing more about herself because of it. It is also important for medical professionals to be aware of a patient’s doublespeak as a way to share enough information but not all information to keep from being judged by medical professionals. Thus, non-judgmental probing can uncover important information that may be useful for collaborative goal setting and treatment decisions.
The management of diabetes is multifaceted and complex, particularly for populations who face social barriers and challenges. The Hispanic/Latino population is more likely to encounter disparities in access to quality health care and disparities in social determinants of health compared to non-Hispanic whites [4–9]. Therefore, it is important for health professionals to engage Hispanic/Latino patients in self-care by eliciting information that best facilitates collaborative goal setting. Health professionals are in an influential position to leverage a communication style that is empathetic, trusting, and open, setting the tone for a positive patient-physician encounter and, in turn, positive patient outcomes [18–20].
Corresponding author: Jeannie Belinda Concha, PhD, MPH, Dept. of Public Health Sciences, The University of Texas at El Paso, 500 W. University Ave., El Paso, TX 79968, jeannie@utep.edu.
Funding support: Support for this research was provided by the Office of Research and Sponsored Projects at The University of Texas at El Paso.
Financial disclosures: None.
From the University of Texas at El Paso, El Paso, TX.
Abstract
- Objective: To demonstrate the applied use of recommended cultural competency communication tools.
- Methods: An overview of several cultural competency tools is presented and vignettes are used to demonstrate the use of these tools with Hispanic patients with diabetes.
- Results: Three communication mnemonic instruments, ie, BELIEF, ETHNIC, and BATHE, may be useful for engaging health professionals in patient-centered communication with their Hispanic patients and shared decision making. Health professionals can also employ nonjudgmental probing as part of engaging patients in setting diabetes treatment goals.
- Conclusion: Health professionals are in an influential position to leverage a patient- and culture-centered communication style to improve communication with Hispanic patients. Using mnemonic tools can help facilitate this communication and improve health professionals’ understanding on how cultural and social factors influence diabetes management in this population.
Key words: Hispanic/Latino; diabetes; patient-centered communication; cultural-competency.
The 2017 American Diabetes Association (ADA) Standards of Medical Care recommend that health professionals engage in a patient-centered communication style with patient to facilitate shared decision-making and improve diabetes outcomes. The ADA defines patient-centered communication as “a style that uses active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care” [1]. One of the main goals of using patient-centered communication is to create a collaborative, personal, and non-judgmental relationship with patients. These guidelines, however, provide less direction on the type of communication skills training that would facilitate this type of communication, particularly as it relates to ethnic/racial minority groups most at risk for diabetes and related complications.
The US Hispanic/Latino population, in particular, is a group that is burdened by the diabetes epidemic, with a prevalence that is 130% higher than non-Hispanic whites [2]. It is widely known that certain social determinants of health, like socioeconomic status, social injustices, poor access to health care, food insecurity, or living in environments that do not support health behaviors, all contribute to health disparities for Hispanics/Latinos [3]. Understanding how Hispanics/Latinos cope with these social determinants of health is important for health care professionals, and a patient-centered communication style is an ideal approach for active listening and eliciting information about the social barriers/challenges that may influence diabetes self-care. However, there is some evidence that suggests this approach is not fully used by health care professionals when communicating with Hispanics/Latinos with diabetes, and Hispanics/Latinos continue to be more likely to experience disparities in the quality of diabetes care they receive compared to non-Hispanic whites [4–9]. One of the identified contributors to these disparities is the poor communication between physicians and Hispanic/Latino patients [10–16]. Given that health care professionals are the primary source of health care and diabetes information for Hispanics/Latinos, it is important for health professionals to enhance their patient-centered communications skills to improve the quality of care that is provided to this population [12].
Cultural Competence and Patient-Centered Communication
Not all health professional communication skills are perceived as unsatisfactory by Hispanic/Latino patients with diabetes. In fact, Hispanics/Latinos report a positive provider-patient clinical interaction when health professionals display cultural competency skills [15,17–20]. Moreover, evidence suggest that Hispanic/Latino patients with diabetes reported better quality of care and improved self-management behaviors with a culturally competent provider [18–20]. Cultural competency is described as “understanding and responding effectively to the cultural and linguistic needs brought by the patient to the health care encounter” and “valuing diversity, provider self-assessment, managing dynamics of differences, acquiring and institutionalizing knowledge, and adapting to diversity and the cultural context of individuals served” [9,11,12]. One approach for gaining cultural competency skills is to understand how the disease process is conceptualized within a culture and how that influences a patient’s own theory about their disease etiology, prognosis, and outcome [21]. This approach is known as culture-centered in the health communications literature and may be useful when communicating with Hispanic/Latino patients with diabetes because there is extensive literature describing unique indigenous Latin American explanatory models for diabetes [22–26].
Language Discordance in Physician-Patient Communication
The process of patient-physician communication includes “attending to one another and begin interpreting one another’s verbal and nonverbal” interactions [9]. A conventional assumption regarding the disparities in diabetes care quality for Hispanic/Latino patients is that it stems from language discordant patient-physician interactions, which result in errors in the provision of diabetes information and treatment instructions regarding medications and self-care behaviors [9]. While language is a contributing factor, the US Census reports that over half of US Hispanics/Latinos are bilingual and speak English “very well” [27]. Thus, other underlying mechanisms must be contributing to patient-physician miscommunication and suboptimal diabetes outcomes. Moreover, the findings from studies of patient-physician language concordance and diabetes management are inconsistent. For example, language concordance between Hispanic/Latino patients and physicians is associated with improvement in HbA1c but not self-care behaviors (ie, healthy eating, self-monitoring, medicine adherence, exercise) [20]. Thus, there is need to move beyond spoken language to address elements of interpersonal communication around diabetes care through addressing cultural health beliefs and explanatory models of diabetes.
Cultural Explanatory Models of Diabetes
Explanatory models for diabetes among Hispanics/Latinos are diverse and often include a biomedical framework (eg, obesity, unhealthy eating, sedentary lifestyle, genetics); however, there is one unique indigenous belief that continues to be held within this population. Specifically, there is a cultural belief that diabetes is caused by strong or negative emotions, like fright sickness (susto), stress (estres), anger (coraje), or nerves (nervios) [22–26]. Although this cultural belief has been in existence long before scientific evidence has shown the bi-directional relationship between stress/depression and diabetes, the integration of emotions in diabetes self-management in patient-provider communication has not been standardized [28–31]. Health professionals’ interest in how patients view their own disease process may help build rapport with patients. Enhancing health professionals’ cultural competency skills can be a critical first step for improving patient-provider communication. For instance, it can (1) present an opportunity to integrate cultural belief systems into diabetes care for Hispanics/Latinos, (2) open the door for other important conversations about Hispanic/Latino patients’ psychosocial and familial environment and identify barriers or motivators in diabetes self-management, and (3) build rapport and trust between the health professional and patient.
Additionally, inquiring about emotional beliefs or emotions about diabetes in general can help improve the patient-provider relationship, giving Hispanic/Latino patients a sense that their provider cares about their feelings and emotional well-being. For example, in a study conducted by Concha et al, a Hispanic/Latino male patient with diabetes expresses his appreciation of his doctor for attending to his emotional problems and suggests that his diabetes is in control because of the encouragement he receives from the doctor [22].
…I believe the doctors..can encourage one with ..diabetes… I am very grateful to God before anything that till today I have my sugar controlled. I am a diabetic, but controlled. And Dr. [name omitted], he’s a blessing from God. He knows my body like my mother….Because whatever little thing, he attends to me, he gives me a lot of encouragement with my emotional problems. He sent me to a counselor, I have a specialist for my problem with my urinary tracts. I have attention, I have all the attention from the doctor…
Inquiring about emotional well-being may also be beneficial because Hispanics/Latinos with diabetes have reported that they would feel more comfortable talking to a professional about personal problems compared to Hispanics/Latinos without diabetes [32]. Having a physical illness may provide an opportunity for these patients to discuss stress or depression in tandem with diabetes to diminish any possible stigma or shame associated with having a mental health problem. It is important for health care providers to be aware of emotional or social problems that may be negatively influencing diabetes self-care behaviors.
Models of Effective Cross-Cultural Communication
Cultural competency training for health professionals is one strategy for reducing health disparities and ensuring that racial/ethnic populations receive “equitable, effective, and culturally appropriate clinical care” [9,11,12,33]. The Association of American Medical Colleges’ guide for cultural competence education in medical school cites several models of effective cross-cultural communication for physicians and/or physician assistants [34]. I describe 3 communication tools below that may help health care professionals initiate conversations and aid them in understanding how to better manage sociocultural and environmental issues that may impede patients’ ability to manage diabetes. For each tool, a vignette is offered that illustrates how the tool may be used in communicating with Hispanic/Latino patients.
BELIEF
The BELIEF instrument (Dobbie 2003) is a teaching tool designed to elicit patients’ health beliefs and to assist preclinical medical students or medical professionals in understanding how explanatory models of a disease influence patient engagement in care. The BELIEF instrument is straightforward and can be easily implemented into clinical case vignettes and or role-play as part of cultural competency training [35]. The specific questions corresponding to the BELIEF prompts are
- B: Beliefs about health (What caused your illness/problem?)
- E: Explanation (Why did it happen at this time?)
- L: Learn (Help me understand your belief/opinion)
- I: Impact (How is this illness/problem impacting your life?)
- E: Empathy (This must be very hard for you)
- F: Feelings (How are you feeling about it?)
Vignette 1
The following vignette is a conversation between a Spanish-speaking Hispanic women, a language interpreter, and medical professional. The patient, Mrs. Chavez, has come into the clinic for the third time after experiencing symptoms due to hypoglycemia. Mrs. Chavez believes stress may have something to do with her hypoglycemia but is not quite sure how. By using the BELIEF mnemonic, the medical professional is able to ask more about the stress that led into a discussion about how stress actually influenced her eating and medication intake behaviors. Through this probing, the medical professional was able to identify the possible cause of her hypoglycemia and work with Mrs. Chavez on finding a solution every time she experiences the stressful event. The vignette also demonstrates how interpreters may share cultural information that may clarify problems.
Medical Professional: Mrs. Chavez, I see you are here again for hypoglycemia. Can you tell me what has happened? Do you have your medications with you today?
Interpreter: Sra. Chavez, entiendo que está aquí nuevamente por hipoglucemia. ¿Puedes decirme qué ha pasado? ¿Tiene sus medicamentos con usted hoy?
Mrs. Chavez: Si, me ha sentido débil y mareado.
Interpreter: Yes I have felt faint and dizzy?
Medical Professional: Have you been taking your metformin as prescribed?
Interpreter: ¿Ha estado tomando su metformin según lo recetado?
Mrs. Chavez: Si (YES).
Medical Professional: We might have to consider adjusting your dosage.
Interpreter: Es posible que tengamos que considerar ajustar su dosis.
Mrs. Chavez privately to the Interpreter: ¿no es posible que las emociones o nervios puedan causar algo? He escuchado que este puede ser el problema?
Interpreter to Mrs. Chavez: Déjame preguntarle al doctor, si?
Let me ask the doctor, yes? (Mrs. Chavez, nods in agreement)
Interpreter to Medical Professional: She is asking if emotions or nervousness could be the cause. She has heard that this could be the problem.
Medical Profesional to Interpreter: What does she mean?
Interpreter: There is a cultural belief that stress or nerves can cause diabetes or affect diabetes. You may want to ask about this.
Medical Professional: Yes emotions like stress can cause changes in you glucose. (Beliefs) Do you believe that some emotions are causing your hypoglycemia?
Interpreter: Sí, las emociones como el estrés pueden provocar cambios en la glucosa. ¿Crees que algunas emociones están causando tu hipoglucemia?
Mrs. Chavez: (Shrugs shoulders).
Medical Professional: I see here in your records, that the other two times you had hypoglycemica were 1 month and 3 months ago. (Beliefs) What do you think caused these events and (Explanation) why do you think it happened during these times?
Interpreter: Veo aquí en sus registros que las otras dos veces que tuvo hipoglucemia fueron hace 1 mes y 3 meses. ¿Qué crees que causó estos eventos y por qué crees que sucedió durante estos tiempos?
Mrs. Chavez: Pues, no sé.
Interpreter: Well I don’t know.
Medical Professional: (Learn) Help me understand what you think happened 3 and 1 month ago and this month that may have caused your glucose to drop. What was happening emotionally during these times? Do you remember?
Interpreter: Ayúdame a entender lo que piensas que sucedió hace 3 y 1 meses y este mes, puede haber causado que tu glucosa baje. ¿Qué estaba pasando emocionalmente durante este tiempo? ¿Te acuerdas?
Mrs. Chavez: Hmm. Pues, hace 3 meses fui a visitar a mi madre y hace 1 meses fui a visitar a mi hermano al norte.
Interpreter: Hmm. Well 3 months ago I went to visit my mother and 1 months ago I went to visit my brother up north.
Medical Professional: (Learn) How were those trips for you. Did you have fun? What types of emotions were you feeling during these trips?
Interpreter: ¿Cómo fueron esos viajes para ti? ¿Te divertiste? ¿Qué tipo de emociones sentías durante estos viajes?
Mrs. Chavez: Pues, yo estaba muy estresado durante mis viajes.
Interpreter: Well, I was very stressed during my trips.
Medical Professional: (Learn) Would you like to share why you were stressed? What was happening for you to feel so stressed?
Interpreter: ¿Te gustaría compartir por qué estabas estresado? ¿Qué estaba pasando para que te sientas tan estresado?
Mrs. Chavez: Bueno, tenemos muchos problemas familiares y conflictos. Hay muchos argumentos familiares y se vuelve estresante.
Interpreter: Well we have a lot of family problems and conflict. There are a lot of family arguments and it gets stressful.
Medical Professional: (Impact) How do you think this has affected your glucose?
Interpreter: ¿Cómo crees que esto ha afectado tu glucosa?
Mrs. Chavez: No lo sé.
Interpreter: I don’t know.
Medical Professional: (Learn) Do you think the stress maybe led you to forget to take your medication or affected your eating?
Interprter: ¿Crees que el estrés puede llevarte a olvidarte de tomar tu medicación o afectó su alimentación?
Mrs. Chavez: Pues si y no comí. Estaba demasiado estresado para comer. Raramente comí mientras estaba allí. Estaba tan estresado que no tenía apetito.
Interpreter: Well yes and I didn’t eat. I was too stressed to eat. I rarely ate while I was there. I was so stressed i did not have an appetite.
Medical Professional: (Empathy) Mrs. Chavez, that must have been very hard for you. I’m sorry you have had to feel this way. (Feelings) Is this how you feel everytime you visit your family?
Interpreter: Sra. Chávez, eso debe haber sido muy difícil para usted. Lamento que hayas tenido que sentirte de esta manera. ¿Es así como te sientes cada vez que visitas a tu familia?
Mrs. Chavez: Sí, todos se involucran en los problemas familiares y es muy estresante visitarlos, pero tengo que ir a ayudar a mi madre porque mi hermano está enfermo y no puede ayudarla. Soy el único que está cerca y mis otros hermanos discuten sobre lo que debería hacer. Tengo que estar ahí. Tengo que visitar.
Interpreter: Yes, everyone gets involved in the family problems and it is very stressful to visit but I have to go to help my mom because my brother is sick and can’t help her. I’m the only one close by and my other siblings argue about what I should do. I have to be there. I have to visit.
Medical Profesional: (Empathy) Yes, that must be very difficult for you. Okay, now I understand what is happening. Your visits are necessary but it seems like the stress is affecting your eating patterns and whether you remember to take your metformin. How do you feel if we come up with a plan for when you visit your family now that we know what might be causing your hypoglycemia? Do you think it is a good idea to take high glucose snacks or candy and have them with you on the trip so when you feel dizzy or faint you can eat them?
Interpreter: Sí, eso debe ser muy difícil para ti. De acuerdo, ahora entiendo lo que está pasando. Sus visitas son necesarias, pero parece que el estrés está afectando sus patrones de alimentación y si recuerda tomar su metformina. ¿Cómo se siente si elaboramos un plan para su familia ahora que sabemos lo que podría estar causando su hipoglucemia? ¿Cree que es una buena idea tomar refrigerios con alto contenido de glucosa o dulces y llevarlos consigo durante el viaje para que cuando se sienta mareado o desmayado pueda comerlos?
Mrs. Chavez: Sí, por supuesto. Ni siquiera me di cuenta de eso hasta ahora que hablamos sobre eso. Tienes razón, no he estado comiendo bien cuando lo visito. Me siento terrible cuando estoy allí como si quisiera desmayarme.
Interpreter: Yes of course. I didn’t even really realize that until now that we talked about it. You are right, I haven’t been eating right when I visit. I feel terrible when I am there like I want to faint.
Medical Professional: Mrs. Chavez, sometimes it is helpful to talk about our stress and problems we encournter in life, just to talk through it. Is this something you would be interested in? If so, we can arrange for you to come talk to the social worker.
Interpreter: Sra. Chavez, a veces es útil hablar sobre nuestro estrés y los problemas que alegramos en la vida, solo para hablar sobre ello. ¿Esto es algo que te interesaría? Si tu quieres, podemos hacer arreglos para que vengas a hablar con el trabajador social.
Mrs. Chavez: Tal vez, no estoy seguro, pero tal vez
Interpreter: Maybe, I’m not sure but maybe.
Medical Professional: Okay, you let me know if this is something you would like to do. You can call and let us know and I’ll ask again during our next visit and see how you are dealing with the stress when you visit your family.
Interpreter: De acuerdo, dime si esto es algo que te gustaría hacer. Puede llamar y dejarnos saber, y volveré a preguntar durante nuestra próxima visita y verá cómo lidia con el estrés cuando visita a su familia.
ETHNIC
The ETHNIC interviewing tool (Levin SJ 2000) can be used to explore cross cultural issues and facilitate collaboration during clinical encounters and is designed for clinical students or health professionals permitted to diagnose and provide therapeutic interventions [36]. The specific questions corresponding to the ETHNIC prompts:
- E: Explanation (How do you explain your illness?)
- T: Treatment (What treatment have you tried?)
- H: Healers (Have you sought any advice from folk healers?)
- N: Negotiate (mutually acceptable options)
- I: Intervention (agreed on)
- C: Collaboration (with patient, family, and healers)
Vignette 2
The second vignette is a discussion between a conscientious patient, Mrs. Rodriguez, and her doctor. Mrs. Rodriguez is determined to keep her glucose levels within optimal range by eating healthy and living a natural lifestyle. Included in her natural lifestyle is the use of herbs from her garden and herbal supplements sold to her by her neighbor. Because her numbers have been in the normal range she discontinues her prescribed medication to rely on natural products. However, a trip with family members interrupts her daily routine, which is replaced with fast foods and little rest. Upon returning from her trip her glucose levels increase and she cannot decrease her glucose numbers.
Medical Professional: Good morning Mrs. Rodriguez. I see you are here today for high blood sugar because of your diabetes. (Explanation) Can you share why you think you have recently had higher numbers than normal?
Mrs. Rodriguez: Good morning Doctor. Yes, I am usually very good with my numbers but lately they have gone up and I know why.
Medical Professional: Yes, that is good that you have had your glucose managed. (Explanation) What has caused your numbers to go up Mrs. Rodriguez?
Mrs. Rodriguez: All this American food. I went on a trip to visit my daughter and all we did was eat out, hamburgers, fast food restaurants. They do not cook at home and we were always doing something so I could not cook. It was terrible, all we did was keep busy out and about, I was tired. I spent so much money on food that has chemicals. Look at me now. I can’t seem to get my numbers down.
Medical Professional: Oh, I understand. Yes, a trip can sometimes mess with our routine. (Treatment) Since you have been good at managing your glucose in the past what have you been doing now to get your glucose in normal range?
Mrs. Rodriguez: Well I have been doing the same thing I have always been doing. Eating healthy, resting, gardening, and praying.
Medical Professional: Gardening? That’s really nice. What do you garden?
Mrs. Rodriguez: Oh I love gardening. I plant all types of herbs, vegetables, flowers.
Medical Professional: That is so good Mrs. Rodriguez. I wish I had more time to garden. Do you use your own vegetable and herbs when you cook?
Mrs. Rodriguez: Haha. Yes of course. That is why my sugar was fine before I went on this trip. I rely on my garden to keep me healthy.
Medical Professional: There are so many herbs that are helpful for diabetes. (Treatment) Do you use any to help with your diabetes?
Mrs. Rodriguez: Well yes, in fact, I do. I know you doctors don’t like us to use our herbs but I do. And that was what keeps my sugars normal.
Medical Professional: Oh Mrs. Rodriguez, yes sometimes you hear doctors say this but some herbs are helpful. We just like to know what other things our patients do so we know how to make sure your medications work with certain herbs. (Treatment) I know many people use nopal (cactus), do you eat nopal?
Mrs. Rodriguez: ¿Como no? (of course). I eat them all the time. I make my morning licuado (drink); a little bit of parsley, oregano, oatmeal, lemon, nopal mixed with milk and yogurt.
Medical Professional: (Treatment) Sounds good, what else do you use?
Mrs. Rodriguez: Oh you know other things. Apple cider, cinnamon, cayenne.
Medical Professional: All from your garden?
Mrs. Rodriguez: Yes.
Medical Professional: (Treatment) Do you use any type of herbal supplements from stores or online?
Mrs. Rodriguez: My neighbor sells supplements specifically for diabetes. I started to use a natural supplement with cinnamon, vitamin D, and fish oil. All very natural.
Medical Professional: (Healer) Oh does your neighbor also have diabetes?
Mrs. Rodriguez: No, she sells products. But she sells to many people with diabetes and the supplement works. We get together and she tells us about how they work.
Medical Professional: Do you know the name of this supplement Mrs. Rodriguez?
Mrs. Rodriguez: Oh, gluco…something, it has a heart in the name. But I read the ingredients and it has only natural ingredients. (An FDA banned supplement for false claims)
Medical Professional: Oh I see. I may be familiar with that. Can you bring the supplement along with the medications I have prescribed? I just want to make sure there is not interaction between the two. To get your glucose back to normal I want to make sure we think of every possible situation that could be causing your high numbers. (Treatment) How have you been taking the supplement and the prescribed medications?
Mrs. Rodriguez: Well, I have not refilled your prescription. I was doing so well with my numbers, I’d rather go natural than take all those chemicals.
Medical Professional: Oh, I see Mrs. Rodriguez. Okay, you have done so well controlling your glucose before your trip and now we are in a situation where your numbers are not coming down so let’s try to figure this out. I’d like to learn more about this supplement, so for our next visit can you bring in your supplements so I can take a look at it? (Negotiate) We can then talk about the benefits or cautions. But in the meantime I’d like you to refill your medication and take as followed to see if that helps your sugars. (Negotiate) What do you think? Is this possible?
Mrs. Rodriguez: Oh Doctor, I just don’t like taking chemicals.
Medical Professional: I understand Mrs. Rodriguez. You did take them to start when you first came in for diabetes, is this correct?
Mrs. Rodriguez: Well yes but, I slowly got off them.
Medical Professional: I know it’s difficult to take medications every day but they can help in addition to your healthy eating. I know you are concerned about medications but for now we have to focus on getting your numbers down or your diabetes could become worse and we don’t want you to get there. Do you agree? (Negotiating process)
Mrs. Rodriguez: Well, I am concerned about my numbers.
Medical Professional: (Intervention) Okay well let’s try to get back to where you were before the trip. Let’s get you back on the medication and let’s see if this helps. (Negotiate) For the next visit would you be willing to bring any supplements you are taking along with the medication? (Collaboration) We can talk about the benefits and cautions for the medications and supplements. How does this sound?
Mrs. Rodriguez: Well, I am here to fix my numbers. I have everything I take in a box so I can bring that.
Medical Professional: Yes that would be great. (Collaboration) We can both talk about your daily routine and what have you learned about the supplement, any information or papers that you have, in addition to the medication I prescribed.
Mrs. Rodriguez: Yes I can do that.
Medical Professional: Thank you Mrs. Rodriguez. (Intervention) Also, I’ll have the nurse call you today or tomorrow and you can give her the name of the supplement and she’ll make sure the drug store has a refill for you. Would this work for you Mrs. Rodriguez?
Mrs. Rodriguez: Yes Doctor. You can call me. I’ll have the list ready.
BATHE
Unlike the BELIEF and ETHNIC instruments, the BATHE mnemonic (Lieberman 1999)
- B: Background (What is going on in your life?)
- A: Affect (How do you feel about what is going on?)
- T: Trouble (What troubles you most?)
- H: Handling (How are you handling that?)
- E: Empathy (This must be very difficult for you)
Vignette 3
The last vignette features Mr. Gonzalez, who typically shows a positive outlook on life when visiting his doctor. He is a patient who would not necessarily discuss his emotions if not asked specific questions about his emotional well-being.
Medical Professional: Hello Mr. Gonzalez. (Background) How are you doing today? What’s new? What’s going on in your life lately?
Mr. Gonzalez: Hey, Doctor! I’m good you know just living day to day.
Medical Professional: Good. (Affect) So how is your diabetes treating you day to day? How are you feeling with life and managing your diabetes?
Mr. Gonzalez: Ah well you know, just dealing with it as best as I can.
Medical Professional: Ah okay. As best as you can. (Troubles) What troubles you the most about managing diabetes?
Mr. Gonzalez: Well you know the aches and pains. But what can I do.
Medical Professional: (Affect) How do you feel about those aches and pains?
Mr. Gonzalez: Well it does limit me. I can’t move as well as I use to.
Medical Professional: (Handling) Hmm. I see. How are you handling those aches and pains? What are you doing to relieve it?
Mr. Gonzalez: I do my best with pain cream.
Medical Professional: (Empathy) Pains and aches, that must be difficult. (Affect) How do the aches and pains make you feel?
Mr. Gonzalez: Ahh, Doc, it’s not the same. You know I can’t do the same things anymore.
Medical Professional: (Background) What do you mean? What is not the same anymore?
Mr. Gonzalez: This diabetes, I’m not the same person. I use to be able to be there for my family and community and now I feel like I can’t be there for them the way I use to. I use to be the strong one for my family, helping those in need, and now I’m limited, my body is limited.
Medical Professional: (Affect) How do you feel about that? How does it make you feel emotionally and physically?
Mr. Gonzalez: Bad. I feel bad about it.
Medical Professional: Bad emotionally or physically?
Mr. Gonzalez: Both
Medical Professional: I see. (Handling) How are you dealing with the emotional part of it?
Mr. Gonzalez: I don’t know. I don’t know how.
Medical Professional: (Empathy) Dealing with diabetes and how it makes your body feel can be very emotionally distressing. It is common to feel this way but I want to make sure we also work on how you feel emotionally or how your emotions is affecting your diabetes.
Conclusion
Three mnemonic tools have been suggested to initiate patient-centered and culture-centered communication with patients. Beyond the use of these instruments, there are 2 key skills that are essential for engaging a Hispanic/Latino patient. The first is a non-judgmental, warm communication approach, and the second is astute probing. Once when I was interpreting for a Spanish-speaking Hispanic/Latino patient and English-speaking doctor, the patient expressed to me that she felt that the medical professionals “tienen una cultura fría” (“have a cold culture”), and she did not feel comfortable sharing more about herself because of it. It is also important for medical professionals to be aware of a patient’s doublespeak as a way to share enough information but not all information to keep from being judged by medical professionals. Thus, non-judgmental probing can uncover important information that may be useful for collaborative goal setting and treatment decisions.
The management of diabetes is multifaceted and complex, particularly for populations who face social barriers and challenges. The Hispanic/Latino population is more likely to encounter disparities in access to quality health care and disparities in social determinants of health compared to non-Hispanic whites [4–9]. Therefore, it is important for health professionals to engage Hispanic/Latino patients in self-care by eliciting information that best facilitates collaborative goal setting. Health professionals are in an influential position to leverage a communication style that is empathetic, trusting, and open, setting the tone for a positive patient-physician encounter and, in turn, positive patient outcomes [18–20].
Corresponding author: Jeannie Belinda Concha, PhD, MPH, Dept. of Public Health Sciences, The University of Texas at El Paso, 500 W. University Ave., El Paso, TX 79968, jeannie@utep.edu.
Funding support: Support for this research was provided by the Office of Research and Sponsored Projects at The University of Texas at El Paso.
Financial disclosures: None.
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21. Duta MJ. Communicating about culture and health: Theorizing culture-centered and cultural sensitivity approaches. Commun Theory 2007;17:304–28.
22. Concha JB, Mayer SD, Mezuk B, Avula D. Diabetes causation beliefs among Spanish speaking patients. Diabetes Educ 2015:42:116–25.
23. Arcury TA, Skelly AH, Gesler WM, et al. Diabetes meanings among those without diabetes: explanatory models of immigrant Latinos in rural North Carolina. Soc Sci Med 2004;59:2183–3.
24. Daniulaityte R. Making sense of diabetes: cultural models, gender and individual adjustment to type 2 diabetes in a Mexican community. Soc Sci Med 2004;59:1899–912.
25. Poss J, Jezewski MA. The role and meaning of susto in Mexican American’s explanatory model of type 2 diabetes. Med Anthropol Q 2002;16:360–77.
26. Weller SC, Baer RD, Pachter LM, et al. Latino beliefs about diabetes. Diabetes Care 1999;22:722–8.
27. United States Census Bureau. Language use. Accessed Sept 2017 at https://www.census.gov/topics/population/language-use/about.html.
28. Mezuk B, Albrecht S, Eaton WW, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care 2008;31:2383–90.
29. Li C, Ford ES, Strine TW, Mokdad AH. Prevalence of depression among US adults with diabetes. Diabetes Care 2007;31:105–7.
30. Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2006;24:1069–78.
31. Li C, Barker L, Ford ES, et al. Diabetes and anxiety In US adults: findings from the 2006 Behavioral Risk Factor Surveillance System. Diabetes Med 2008;25:878–81.
32. Concha JB, Mezuk B, Duran B. Culture-centered approaches: the relevance of assessing emotional health for Latinos with type 2 diabetes. BMJ Open Diab Res Care 2015;3.
33. Bentancourt JR, Green AR, Carillo Je, Park ER. Cultural competence and health care: Key perspectives and trends. Health Affairs 2015;24:499–506.
34. Association of American Medical Colleges. Cultural Competence Education 2005. Accessed Feb 2016 at https://www.aamc.org/download/54338/data/.
35. Dobbie AE, Medrano M, Tysinger J, Olney C. The BELIEF Instrument: A preclinical teaching tool to elicit patients’ health beliefs. Family Med 2003;35:316–9.
36. Levin SJ, Like RC, Gottlieb JE. ETHNIC: A framework for culturally competent ethical practice. Patient Care 2003;34:188–9.
37. Stuart MR, Leibermann JR. The fifteen-minute hour: applied psychotherapy for the primary care physician. New York: Praeger.
38. Pace EJ, Somerville NJ, Enyoha C, et al. Effects of a brief psychosocial intervention on inpatient satisfaction: a randomized control trial. Fam Med 2017;49:675–8.
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19. Kutob RM, Bormanis J, Crago M, et al. Assessing culturally competent diabetes care with unannounced standardized patients. Fam Med 2013;45:400–8.
20. Weller SC, Baer RD, Garcia de Alba Garcia J, Salcedo Rocha AL. Are differences between patient and provider explanatory models of diabetes associated with patient self-management and glycemic control? J Health Care Poor Underserved 2013:24;1498–510.
21. Duta MJ. Communicating about culture and health: Theorizing culture-centered and cultural sensitivity approaches. Commun Theory 2007;17:304–28.
22. Concha JB, Mayer SD, Mezuk B, Avula D. Diabetes causation beliefs among Spanish speaking patients. Diabetes Educ 2015:42:116–25.
23. Arcury TA, Skelly AH, Gesler WM, et al. Diabetes meanings among those without diabetes: explanatory models of immigrant Latinos in rural North Carolina. Soc Sci Med 2004;59:2183–3.
24. Daniulaityte R. Making sense of diabetes: cultural models, gender and individual adjustment to type 2 diabetes in a Mexican community. Soc Sci Med 2004;59:1899–912.
25. Poss J, Jezewski MA. The role and meaning of susto in Mexican American’s explanatory model of type 2 diabetes. Med Anthropol Q 2002;16:360–77.
26. Weller SC, Baer RD, Pachter LM, et al. Latino beliefs about diabetes. Diabetes Care 1999;22:722–8.
27. United States Census Bureau. Language use. Accessed Sept 2017 at https://www.census.gov/topics/population/language-use/about.html.
28. Mezuk B, Albrecht S, Eaton WW, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care 2008;31:2383–90.
29. Li C, Ford ES, Strine TW, Mokdad AH. Prevalence of depression among US adults with diabetes. Diabetes Care 2007;31:105–7.
30. Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2006;24:1069–78.
31. Li C, Barker L, Ford ES, et al. Diabetes and anxiety In US adults: findings from the 2006 Behavioral Risk Factor Surveillance System. Diabetes Med 2008;25:878–81.
32. Concha JB, Mezuk B, Duran B. Culture-centered approaches: the relevance of assessing emotional health for Latinos with type 2 diabetes. BMJ Open Diab Res Care 2015;3.
33. Bentancourt JR, Green AR, Carillo Je, Park ER. Cultural competence and health care: Key perspectives and trends. Health Affairs 2015;24:499–506.
34. Association of American Medical Colleges. Cultural Competence Education 2005. Accessed Feb 2016 at https://www.aamc.org/download/54338/data/.
35. Dobbie AE, Medrano M, Tysinger J, Olney C. The BELIEF Instrument: A preclinical teaching tool to elicit patients’ health beliefs. Family Med 2003;35:316–9.
36. Levin SJ, Like RC, Gottlieb JE. ETHNIC: A framework for culturally competent ethical practice. Patient Care 2003;34:188–9.
37. Stuart MR, Leibermann JR. The fifteen-minute hour: applied psychotherapy for the primary care physician. New York: Praeger.
38. Pace EJ, Somerville NJ, Enyoha C, et al. Effects of a brief psychosocial intervention on inpatient satisfaction: a randomized control trial. Fam Med 2017;49:675–8.