HLTH 2110 Week 4 Case Study Example

The Question Nobody Asked About Insulin: A Case Analysis Tracing Each Assumption in One Diabetes Visit to the Moment It Entered the Encounter

Student Name

Walden University

HLTH 2110: Behavioral and Cultural Issues in Healthcare

Instructor Name

Month Day, Year

The Question Nobody Asked About Insulin: A Case Analysis Tracing Each Assumption in One Diabetes Visit to the Moment It Entered the Encounter

The Case

Mrs. Ortega, a composite patient described for analysis, is a 54-year-old woman with type 2 diabetes who has used long-acting insulin for two years. She prefers to speak Spanish. At a routine visit, her hemoglobin A1c was 10.4%, up from 7.8% nine months earlier. The clinician, who does not speak Spanish, used a telephone interpreter. Asked whether she was taking her insulin, Mrs. Ortega said yes. The clinician noted that two years earlier she had been "reluctant to start insulin," wrote "suspect nonadherence related to cultural beliefs about insulin," increased her dose by 20% and referred her to a group class on insulin myths. Five weeks later she was admitted to the hospital with very high blood glucose and dehydration. During the admission, a social worker learned that Mrs. Ortega had lost her job-based insurance seven months earlier and had been using her insulin every other day to make each vial last. The higher dose meant her supply ran out sooner.

This analysis treats the clinician's inference, not the patient's behavior, as the object of study. It asks where each assumption entered the encounter and what question would have tested it.

Tracing the Assumptions

Table 1

Assumptions in the Encounter and the Moment Each Entered

Each row's last column is a question that could have been asked in under a minute and that would have changed the plan.

The Old Note

The first assumption entered before Mrs. Ortega spoke. A note from two years earlier described her as reluctant to start insulin. That was true at the time, and she had since started and used insulin. Carrying the old description forward framed the visit around reluctance before any new information arrived. The note was accurate history; the error was in reading it as a current fact.

The Closed Question

The second assumption entered with the question "Are you taking your insulin?" The question invites a yes. Mrs. Ortega was taking insulin, on alternate days, so her answer was truthful. The question could not distinguish full doses daily from half the doses, and the clinician did not follow up. Schillinger et al. (2003) found that when physicians assessed patients' recall and comprehension, a practice often called teach-back, patients with diabetes had better glycemic control, suggesting that checking what the patient actually does closes gaps that a yes or no answer leaves open.

The Cultural Explanation

The third and most consequential assumption entered when the clinician wrote "cultural beliefs about insulin." At that point, an explanation was supplied for a behavior nobody had described. Kleinman and Benson (2006) warn against exactly this use of culture: treating it as a set of beliefs attached to an ethnic group and applying it to an individual without asking. Kleinman et al. (1978) proposed that clinicians elicit the patient's own explanatory model with simple questions, such as what the patient thinks is happening and what problems the illness or its treatment has caused. Asking Mrs. Ortega what had been hardest about her insulin would have produced an answer about cost, not belief.

The inference also fits a broader pattern. According to a systematic review, unconscious bias related to race and ethnicity is common among clinicians and is associated in some studies with poorer communication and treatment decisions (Hall et al., 2015). This case does not show bias in the clinician; it shows how readily an ethnic or cultural explanation can fill a gap that a question should have filled.

The Plan

The fourth assumption entered with the plan. Increasing the dose assumed the patient could obtain more insulin. Referral to a class on insulin myths assumed that misinformation was the problem. Both actions followed logically from the cultural explanation, and both made things worse. A higher dose shortened the time each vial lasted, and the class addressed a problem Mrs. Ortega did not have.

What Was Missing: The Cost Question

Cost-related insulin underuse is not rare. Surveying patients of a diabetes center at a city academic medical center, researchers found that about one in four said that, within the past year, cost had led them to take less insulin than their prescription called for (Herkert et al., 2019). A clinician aware of that figure would treat cost as a likely explanation for a rising A1c in any patient using insulin, and would ask about it routinely. The question "Have you had trouble paying for or getting your insulin?" takes seconds to ask, does not depend on the patient's language or culture and would have redirected the plan toward insurance, assistance programs or a less expensive insulin.

What the Case Shows

The failure in this encounter was not a lack of interpreter services; an interpreter was present. Nor was it, as far as the record shows, a lack of care or effort. It was a chain of inferences, each reasonable on its face, that began with an old note and ended with a plan built on an explanation no one had checked. Each link could have been tested by a question. The most important missing question concerned cost, and it was missing because a cultural explanation had already been supplied.

Conclusion

In Mrs. Ortega's visit, culture was used to explain a behavior that was actually a response to cost. The assumptions entered at identifiable moments: when an old note was read, when a closed question was asked, when an explanation was written down and when a plan was made. A clinician who treats their own inferences as hypotheses, and asks the question that would test each one, is less likely to supply an explanation the patient was never given the chance to correct.

References

Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. American Journal of Public Health, 105(12), e60-e76. https://doi.org/10.2105/AJPH.2015.302903

Herkert, D., Vijayakumar, P., Luo, J., Schwartz, J. I., Rabin, T. L., DeFilippo, E., & Lipska, K. J. (2019). Cost-related insulin underuse among patients with diabetes. JAMA Internal Medicine, 179(1), 112-114. https://doi.org/10.1001/jamainternmed.2018.5008

Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Medicine, 3(10), Article e294. https://doi.org/10.1371/journal.pmed.0030294

Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2), 251-258. https://doi.org/10.7326/0003-4819-88-2-251

Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., Leong-Grotz, K., Castro, C., & Bindman, A. B. (2003). Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine, 163(1), 83-90. https://doi.org/10.1001/archinte.163.1.83