Wednesday, 16 December 2009

Cultural Competence can make you a better Doctor

How Cultural Competence can increase your Clinical Acumen?
Mrs JM is 68 year old Indian, who came to see me. We have met along with her children and grandchildren when we did a Peer to Peer Education with her family. Apart from Type 2 Diabetes, she suffers from Rheumatoid Arthritis which has somewhat crippled her. She is mobile, walks with a stick and is very cheerful.
Here is the print out of the Blood Sugar readings over the past one month and the pattern of blood sugar as seen in the graph. She has a long list of medications, including Long and Short Acting Insulins, an oral hypoglycemia agent which she takes twice a day, a medication for BP and three other medications for her Rheumatoid Arthritis.
If you just look at this paper/graph and think of the body in terms of a machine, and not think of the patient or the society she lives in, your medical conclusions would be very different.
She dutifully takes her medications.
The pattern is thus, she wakes up with fairly normal blood sugar ( this morning it was 91 mg/dl) and then the blood sugar begins to climb throughout the morning, reaching around 300 mg/dl around 6 pm, then it comes down slowly through the night, achieving normalcy in the early morning next day.
A mechanical mind would think: she is too much breakfast and lunch; her morning regular insulin is not enough to combat the rise in blood sugar. The evening dosage is good enough to bring the blood sugar down.
They might come to the conclusion, if they only have four or five minutes to spend with the patient, that what she needs is to take more regular insulin in the morning to combat with the increasing blood sugar during the day.
Or they might conclude that the evening dosage of the long acting insulin is only enough to cover the rise in blood sugar after the evening meal and that she may need to take yet another shot in the morning of the long acting insulin.
What does Culture to do with Physiology? Does the culture interact with the medical care of this patient with Type 2 Diabetes?
If you have worked for any time with the native populations of North America, one thing you would begin to notice is that they are not very keen on eating breakfast. So this lady, like most of her generation, does not eat any breakfast, just a cup of coffee. The older Indians also eat very little for lunch, unless they are hungry and this lady usually has another cup of coffee at lunch time and at around 5 30 pm has a large supper.
Other Hours important in her daily schedule is the taking of her medications. She dutifully takes her morning medications between 10 30 and 11 am and the evening medications around the time of her supper.
Feeling reasonably comfortable that I had sleuthed the reason for her rising blood sugar during the day, we began a conversation about her life and the philosophy by which she conducts her life. The longevity among the Indians is much less than the majority population and the fact that she is nearly 70 years old itself is a credit to her determination to live well with her two disease. What will happen to all of us, I said, has already been decided by the Great Spirit, what we now hope is that our time here is without too much suffering. I know, she responded, the Great Spirit is keeping me here to do something, he has some plans for me, and I shall listen to that. She feels that her family, especially her grand children really need her, and that is the reason why she is surviving.
After a pleasant conversation about her daily life and ways of improving it, I explained the physiology of her sugar excursions, which are consistent, day after day, despite no dramatic changes in her daily behavior.
I have noticed that Indians who take Prednisone develop a kind of Insulin Resistance as well as Diabetes Type 2, which is metabolically a little different from the Type 2 Diabetes we see in the younger Indian populations. The Steroid induced Diabetes tend to be much more structural rather than metabolic, in that there is less end organ damages done and that they tend to live longer. But the effect of the Steroids is consistent and ever present with an insulin resistance which is not easily overcome. Thus her morning dosage of prednisone is overcome any efforts by the oral hypoglycemic agent and insulin. By the time evening comes around, the effects of the steroids are beginning to wear off and the insulin begins to work, bringing her blood sugar from the 300 mg/dl level to the normal level.
To decrease the number of pills she is taking, I advised her not to take the oral hypoglycemic agents twice a day, and just rely on the long acting insulin which she may now take in the morning as well. She will monitor her blood sugars as always and her next graph would give us an idea how the physiology has been altered and whether this strategy would slow down the increasing blood sugars during the day.