This week on The Huddle, we're resharing a discussion with current ADCES President, Veronica Brady, PhD, FNP-BC, BC-ADM, CDCES, FADCES. Veronica discussed the concept of unconscious bias, how it shows up in our everyday lives and in working as health care professionals, and how we can practice cultural humility to better serve the needs of people with and at risk for diabetes.
This week on The Huddle, we're resharing a discussion with current ADCES President, Veronica Brady, PhD, FNP-BC, BC-ADM, CDCES, FADCES. Veronica discussed the concept of unconscious bias, how it shows up in our everyday lives and in working as health care professionals, and how we can practice cultural humility to better serve the needs of people with and at risk for diabetes.
Intro
Welcome to ADCES' podcast, "The Huddle: Conversations with the Diabetes Care Team". In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion.
Kirsten
You've talked a little bit, too, about practicing cultural humility in reaching all people with diabetes. What is that? Can you talk a little bit about that? I'm somewhat familiar. I think the term is a little bit newer, but can you talk about cultural humility and how you practice it, and how you want to bring it to this organization?
Veronica
Absolutely. And I'll start with a little bit about, people talk about cultural competence. Cultural competence, you know, I know what I've read about what it means and what the cultural foods and activities look like for this particular population. Cultural humility is different. It is coming with an openness that says, I don't know what your needs are, but I'm going to sit and listen to you, and based on what you tell me about your culture and your needs, I'm going to humbly take that in and then I am going to come back with some ideas about how to best meet your needs. So you come in with, I don't know, I humbly ask you to tell me about you and about what you need. And then using that lens of cultural humility, I'm going to reflect back to you and be sure that I understand what your needs are.
Kirsten
How difficult is that to do? On the surface, it sounds really easy, right? But if you really think about it and how to do it well, it really means you have to forget or you have to put aside everything that you've learned, right? Which is sort of like a defense mechanism for us, right? As we move through life, we collect certain experiences sort of drive us in how we're listening or what we're doing. Do you think cultural humility is letting all of that go and listening?
Veronica
It is definitely letting all of that go. And it is also kind of taking, it's almost like walking into a room blind.
Kirsten
Mhm
Veronica
I don't see you, all I can do is hear you. I don't know what you look like. So I have no idea where you come from, whether you're black, white, green. I don't know if you have a higher weight, a lower weight. I don't know anything about you. So it's like going in the room blind and sitting in front of person just saying to them, what do you need from me? How can I be helpful today? And that is being humble. That is really looking at, or not looking at a whole person, but having the whole person tell you about their whole selves, taking it in and addressing those needs.
Kirsten
Have you, do you have any great examples you could share? I love the stories.
Veronica
I have one I'm going to share in particular because it really brought things home for me. I was in my clinical practice and I had a woman who was weight challenged. She was, in the vernacular that is commonly used, she was “morbidly obese”. And she came in, as we were talking, she said to me, “well, I've seen a number of endocrinologists and I just can't go back”. And I went, well, what's going on? She continued to tell me her story about how she had been placed on insulin. She was having a lot of episodes of hypoglycemia and she wasn't eating anything. And each person that she saw would tell her, you know, just eat less and take your insulin and you'll be fine. And so as I listened to her, I said, tell me a little bit more about kind of what's going on with your eating and the low blood sugars. And she was like, “well, I tried just eating only protein and I take…”, you know, it was a small amount of insulin, it was like 0.5 units per kilo, which was not a ton for a person with her weight. And she said, “but I take insulin and I eat food and all of sudden my blood sugars are down into the 40s”. And so as I looked at her, I thought to myself, I know what has happened to this woman. She has walked in and somebody said, “you are so overweight, you must have type 2 diabetes. And if you take your insulin and eat less, you'll be fine”. So I said, I'm going to do something. I'm going to check. I'm going to do a couple of tests. I just want to see where you are as far as your diabetes. She turned out to be GAT positive and no C-peptide. So she had type 1 diabetes. But because of her weight and the fact that they looked at her and what they saw when they looked at her, they assumed. So they weren't, that's not even being humble. That's just being, I mean, it was, some of that's our bias.
Kirsten
Right, right.
Veronica
And that's our bias. So I guess the two things kind of go together, the cultural community and also her unconscious bias, because they treated what they saw. They didn't treat the person.
Kirsten
And thank goodness that she saw you. And we've heard these stories often, right? And if you don't see the right care provider who can take that time, who can practice that cultural humility, we're not treating people and we're not treating... The other piece that you talk a lot about is reaching or bringing something to most. Maybe you can't reach all but bringing something to most and that it sounds like what you're trying to do in your practice.
Veronica
Yeah.
Kirsten
Veronica, thank you so much for sharing that story. That was just incredible. And it reminds me of the work that we've been doing over the last year that I know is going to carry on for the next few years around bias in health care. And I know with your presidency coming up, you're really spearheading this. And I'd love to hear you talk a little bit about your vision for the work that we can do as an organization to support health care providers as they're sort of tackling bias, their personal biases maybe, and assumptions as they're dealing with patients.
Veronica
So, we spent some time as health care providers, and I know in state of Texas, and also in the state of Michigan, where I also have my nursing license, we have to go through an implicit bias training. So implicit bias and unconscious bias are basically interchangeable. But what we think about all the time is our conscious bias. And our conscious bias is, I know I don't like okra, okay? I see okra, I know what it looks like, I don't like it, I don’t like how it tastes…
Kirsten
Squash, I hate squash.
Veronica
You know, things that consciously, I am biased against it, and that's a benign example, but I'm gonna stay there. But then we come with our unconscious bias. Those things that, like me, I was being raised with eight other children, I have some unconscious biases. It's the things that I bring to the table that I don't even think about. It's the things that are unique and inherent to me. And so when I see certain things, I have a knee-jerk or a gut reaction to it. That's my unconscious bias. We often have unconscious bias about the people that we are providing care and service to. When we see certain people or in a certain place, we make an assumption. And then we decide based on that bias or that assumption, what they, as someone once put it, and it just made me almost sick to my stomach, what they need. “I know what you need, because I'm looking at you. I know what your problems are, because I already have decided. And I'm going to decide for you”. So that's our unconscious bias. Look at you, make a snap decision, and based on what I think I know, this is what you get.
So one of the ways that we show our unconscious bias the most is certainly in the area of technology. So we walk into the room and say, John Smith is, and I’ll just do this from my practice, he's an African-American gentleman, 67 years of age. He's got type 2 diabetes, he's had it for 20 years, and he's never been “in control”. And sometimes we still think like that. And so our bias says, he's never going to be any better than this. So we're basically going to leave him where he is. Because what's happened to him are the things that he's done to himself. And that really just paints John Smith into a corner. Until John Smith sees the person who realizes, “I've got an unconscious bias. I'm going to take the lens off and I'm going to listen to John Smith. I'm gonna look and hear about his whole person and the reason why he hasn't reached his glycemic targets. And then we're gonna move forward”. So what happens for John Smith, and I know John Smith, is that John Smith is eventually put on a pump with a CGM. John Smith happens to be a little bit more tech savvy than I expected him to be. Because when I looked at him, I didn't think he could do it. But when he whips out his iPhone 15, it shows me he doesn’t, he has apps on his phone and he knows how to use them. I realize, okay, John Smith can probably do this. So getting rid of that unconscious bias works in his favor because then he gets the tools that he needs.
Kirsten
This is hard though. To have cultural humility, you have to be in the position to ask questions, right? Or be comfortable asking questions. And I think most of us, I think I've read the stats that like at 18, in the United States at least, and I think globally, but in the United States at the age of 18, our society says as adults you're not supposed to ask questions anymore because that puts you in a weaker position. And I say all this because as I try to practice cultural humility just in my daily life, right, I find the easiest way to do it is to say like go to the grocery store. Like in my everyday life, I go to the grocery store and I pretend like I don't know everything. I put aside everything that I've learned about all the fruits and vegetables and the produce section. Literally, I'm not joking. And then as I walk through, I ask people questions about like, how do you tell if this pineapple is ripe? Because you know what, maybe I've been doing it the wrong way my whole life. I don't know, really? Do I really know that the way that I'm doing it is the right way? But it's really hard. It is really hard to do that. But when you do that, it's almost like, the joy you get from those conversations that you have with people, sometimes it's just putting things aside and asking questions. It's a joy that you uncover, a happiness that you uncover in other people that you never knew was there, and maybe it leaves us more open at the end.
But can I ask you one thing from your story you were telling? What I got was believe in people. And so was it John Smith, you said, yeah, the 57-year-old with the iPhone 15? I love that. I guess, my iPhone is cracked and old and like, you know, and I... But you believed in him, right? And when you believe in people, they can fly, right?
Veronica
Yeah. And you have to give people the opportunity to tell you what they need. And your example about putting aside what you know about the fruit, it's putting aside what you know about people. That's the humble piece of it. And allowing them to tell you it's being teachable and not judgmental. I once had somebody say to me, I was in a room, I was doing something and I looked at the person, they did something that unconsciously I was like, “oh my God, really?” The person looked at me and I said, “don't worry, I'm not judging you”. And he said, “yes, you are”. And it really stuck with me because I was. I didn't say a word to him. It just, it made have been an eye roll. I don't think so. I feel good about not rolling my eyes, but it must have been, there was something in my posture that said, I judged you and found you wanting. So I try to be really, and we should be very careful about how we walk into a room and you kind of like, you know, cause all the situations we walk into are not the most desirable.
Kirsten
No, no.
Veronica
But we have to learn to kind of take a step back from ourselves, kind of watch our faces, our posture, and allow the person, be humble enough to allow that person to tell you what it is they needed in that time and space. And people often say to me, “I only got 15 minutes with a person”. So that means in that 15 minutes, you got to walk in there and ask the number one question. And I have a mentor, his number one question is, he walks in, he says who he is, and he says, “what can I do for you today?” And that's his opener. And his opener is amazing because it's one of those like the person will say things like, well, some people say, “All I need is a prescription refill”. Or it's, you know, “I got this thing on my toe or my blood sugars have been crazy”. It's whatever that thing is. But it gives them an opportunity to tell what their thing is. As an early practitioner, I walk in the room because I know what your A1C is before I get in the room. I know who you are because I read your demographic sheet. So I know exactly what I'm about to encounter when I walk in the room. So I'm all set for it. I know I need to increase your insulin doses. You know, I already know what I need to do before I ever knock on the door to let you know I'm coming in. That has changed for me over the years because the things that I plan to do when I walk in the room, when I start to ask that one question. And your one question may not be, what can I do for you today? It may be something else. But you ask that one question, and all of this over here kind of goes out the window. Because the driver of what's going on in the labs is very different from what I expected it to be. It could be, I ran out of money. I don't have any insulin. It could be, my family members were in a car accident. You never know what that thing is. So before we walk in and as we look at people, just take the lens off and listen.
Kirsten
Boy, after this conversation, you know, I'm going to head into this next year taking the lens off. That's going to be what I remember from this conversation. Veronica, I absolutely love these conversations. I wish they happened a lot more. Can I offer you any words you would like to leave people as we close this out?
Veronica
Cultural humility and unconscious bias, it takes work. It's not like we will all as diabetes care and education specialists walk into our places of work in the next day and have it all together. But it is consciously making that effort. And I think that we will gain so much from the people that we have been blessed and privileged to care for. And I encourage all of us as we bring that passion for diabetes and caring for people with diabetes and at risk for diabetes, that we think about these conversations. So thank you.
Kirsten
Absolutely. And I can guarantee that you have a whole membership that is ready to work with you on this really important work. I, for one, am right behind you. So thank you so much for this conversation. I hope we can do this more.
Veronica
Thank you, Kirsten.
Kirsten
Thank you for listening to this episode of The Huddle. Make sure to download the resources discussed on today's episode. You can find them linked in the show notes. And remember, being an ADCES member gets you access to many resources, education, and networking opportunities. Learn about the many benefits of ADCES membership at adces.org/join. The information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a health care professional. Please consult your health care professional for any medical questions.