OSCE Case 2

Clinical Scenario:

            A.R. is a 51-year-old Hispanic male with PMHx of uncontrolled Type 2 Diabetes Mellitus who presents to his PCP complaining of fatigue and bilateral lower extremity pain. A.R. immigrated to the United States from the Dominican Republic about two years ago with his wife and three children. He was born and raised in a rural village in the Dominican Republic where herbs are used as the primary means for managing medical conditions. A.R.’s symptoms started around 5 months ago, but he did not seek medical care until his wife insisted. Prior to this, A.R. was self-medicating by consuming a tea made of nettle, ginger, and dandelion.  He tells his PCP that he works 60 hours a week as a butcher at their local meat market, but he cannot take time off work because he needs to take care of his family. He states that it is his duty to be strong and continue “pushing forward”. A.R. speaks some English, but he is not fluent, so he prefers Spanish.

Cultural Factors:

Use of Herbal Medicine: Traditional herbal remedies are significant in Dominican culture. Medicinal knowledge is passed down from one generation to another, and it is common for villages to have traditional healers who use herbal remedies to help others manage their chronic conditions. Traditional healers possess extensive knowledge on the herbs, plants, flowers, and roots that grow on the land and are well-respected figures in their community. A.R. may have consulted a highly regarded healer from his village in the Dominican Republic about his symptoms.

Language Barrier: A.R.’s preferred language is Spanish. To effectively communicate with his PCP, interpretation services must be available to him if his PCP does not speak Spanish.

Unique Beliefs/Considerations:

Machismo: Machismo is a value which emphasizes  the importance of masculinity, strength, and responsibility as provider. A.R. admits to engaging in 60-hour work weeks to provide for his family which may have led to a delay in seeking care. There is a strong sense of pride in men who practice machismo, specifically that they must be brave and self-sufficient even when they do not feel well. A.R. expresses that he feels he must “push forward” despite his symptoms because it is his obligation to do so as a man.

Financial Situation: A.R. immigrated to the United States about two years ago. It is possible that he is working extensive hours not only to support his immediate family, but to help his family in the Dominican Republic as well. It is common in many cultures to “send money back home” to help with necessities such as food, electricity, and water. The U.S. dollar is more valuable in the Dominican Republic, and it is possible that A.R. allocates some of his money towards relatives who live there.

Areas of Potential Conflict:

Medical vs. Herbal Management: A.R. has uncontrolled T2DM and new onset fatigue and lower extremity pain. It is important to explain the benefits of lifestyle modification and possible pharmacotherapy without discounting A.R.’s beliefs on traditional medicine. Completely dismissing his cultural practices may discourage him from adhering to medical advice.

Work Demands vs. Health Needs: Because A.R. has such a strong belief in his duty to provide for his family, he may not prioritize his health. The clinician can initiate the conversation by acknowledging and even commending A.R. for his stellar work ethic then transition into the importance of resting and taking time off to recover when needed.

Machismo vs. Vulnerability: A.R. may oppose medical intervention because it opposes his machismo views.

Expected Skills:

Language Access: The clinician should offer interpreter services once A.R. confirms his preferred language. This is done to facilitate effective communication between A.R. and the medical team. Interpretation services may be provided over the phone or via video on a tablet or other smart device.

Confidentiality: The clinician should emphasize confidentiality. Confidentiality should be emphasized at the beginning of each visit.

Respect for Cultural Practices: If the clinician is not familiar with the health benefits of the herbs that A.R. is consuming, this is a great opportunity to establish rapport with the patient by asking questions and actively listening. Engaging in this manner can make A.R. feel more comfortable and he will be more agreeable to adhering to medical advice. If possible, the clinician can try to develop a treatment plan that allows A.R. to use his herbals as a supplement for disease management.

Empathy: When addressing A.R.’s health needs, the clinician should acknowledge his hard work and dedication to his family. By doing this, the clinician is addressing A.R.s cultural beliefs which strengthens the patient-provider relationship.

Collaboration: If necessary, the clinician should not hesitate to reach out to other health professionals.

Patient Education:

Type 2 Diabetes Mellitus: T2DM is an endocrine disorder in which the body’s cell become less responsive to insulin, leading to increased blood sugar levels. First-line treatment for T2DM is lifestyle modifications such as improvement in diet and exercise. Pharmacotherapy with Metformin may be initiated if lifestyle modifications are unsuccessful.

Herbal Remedies: Herbal remedies can be used as adjunct therapy to pharmacologic treatment so long as there are no interactions. Many times, patients are under the impression that taking herbal supplements in conjunction with their prescription medication is harmless. This, however, is not true. A common plant that is used for a wide variety of illnesses is St. John’s Wort. This medication possesses serotonergic properties and can induce serotonin syndrome if taken with another serotonergic drug such as citalopram. The clinician should make A.R. aware of any interactions that may arise if he initiates pharmacotherapy and wants to continue drinking herbal tea.

Importance of Seeking Timely Care: Although it is important for A.R. to provide for his family, it is equally as important to take care of himself. The clinician can suggest a treatment plan that is tailored around his work schedule and encourage him to seek care in a timely manner. 

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