​Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And today, we're highlighting how language used for insulin management can really impact patient's diabetes outcomes. It's such an interesting topic. And joining me is Elisa Martinez. She's a family nurse practitioner and a certified diabetes specialist at Weill Cornell Medical Center.

Elisa, thank you so much for joining us today. So, I find this so interesting because we've all known for a long time how language—you know, they used to say names can never hurt me. But we know that language can hurt. Language can affect. Language can affect how our daughters see their body types, how we all negative self-talk. I mean, language, it really has such a big effect on so many things. So, what do we know about how language influences patient motivation and confidence when you're working with these patients every day.

Elisa Martinez: Hi, Melanie. And thank you so much. I appreciate you having me on for this. And I 1000% agree that language communicates everything that we do in our everyday life, especially in terms of your medical care. You want to make sure that the correct language is being provided to your patients so that you can motivate them to make the best outcomes, especially with a disease like diabetes where you tend to fluctuate, you go up and down. It is not the easiest disease to manage. So, supporting your patients in meeting their own goals and providing the best care possible so that they feel empowered and using the correct language and the right words. So, you want to support them in making the best outcome for themselves.

And so, each person is different. You want to meet them at a level where you can see them and you want to speak to them in a way that they can understand. And so, you know, yes, patients want to make sure that they have a competent and knowledgeable provider that's going to sit here and give them the best options for their care.

However, they also want someone that they can trust, that they can speak to, and that they can feel confident that they won't be judged, that they won't be attacked for making a wrong decision, or because their sugars are not perfect. They want someone that they can feel comfortable with, that they can feel open with, that they can say, "I need help with this" or "I want to make adjustments for that" or "This is what works best for my lifestyle." And so, using positive reinforcement, terms like motivational interviewing and therapeutic communication, like having these open-ended conversations and questions for your patients so that we can find a great middle ground in order to support them. And then, every time they even make a small adjustment towards better health, we're celebrating that. "Your A1c was 10. And now, it's nine. It's not at target yet, but I am thankful that you got it down." So, communicating and having the correct terms and saying the positive affirmations supports both yourself as a provider and your patients.

Melanie Cole, MS: That certainly is true and it really follows the path of, you know, in our lives as a whole and raising children. And that positive reinforcement has such a better outcome look than negative reinforcement. "Oh, well, your A1c only went down one point and we really needed to get down a lot more." You know, that is going to have more of that negative connotation. So when we think of speaking to our patients, and many of them are older as we know—so the technology in diabetes today is incredible and we'll get into a little bit of that language that we use. But when we think of speaking to our patients, what are some strategies you recommend clinicians use to reduce the stigma around those conversations? You mentioned about A1c and being positive about even a change in those numbers, but diabetes itself can sometimes carry a stigma because of maybe weight involvement or sedentary lifestyle, diet, these things. What are some strategies you use, Elisa, that help your patients to feel more connected to you and that they're not being judged?

Elisa Martinez: Yeah, I agree. A lot of the time, especially with my patients with type 2 diabetes, but all my patients with diabetes, they all have that stigma where, "Oh, you ate too much sugar and that's why your sugar's high." And so, the first thing I do is try and remove that stigma by saying, "Diabetes is a disease. And yes, eating too much sugar will make it worse. However, it is a disease and your body needs help to regulate these blood sugars so that we can get you to the point of health again." And just removing that and just saying, you know, "Just because you have diabetes does not mean that you don't deserve to live a normal life, just like everyone else does."

And so, I remember going on the internet one time and they said that a person with diabetes makes 1,000 more decisions per week than a person that doesn't have diabetes, right? So, someone without diabetes can pick up a cookie, eat it, and they're fine. They don't have to think twice about it. But with a person with diabetes, when they eat that cookie, they're like, "Oh, my sugar's going to go up, then I'm going to get thirsty. Then, I'm going to have to go to the bathroom. And then, I'm going to get tired, because my sugar's going to be high. And then, I'm going to have to get myself—" It is this constant thought process because you're living with a disease that affects everything. It affects your vision, it affects your activity, it affects how you feel. Many people feel like depressed because their sugars are high and they just feel down all the time. So, removing that and explaining to them, "You are craving sugar because your body's not able to use the sugar it has because you have diabetes. That's why your body needs help. And you can't use the sugar as fuel. So, we kind of need to assist your body in using the sugar that it has so that you feel better." And explaining this disease process to them so that they understand that it's not just "I'm eating too many cookies" or "I'm drinking too much soda." It is part of what's going on with their body and it is part of them having a chronic disease that constantly needs management, constantly needs observation, and constantly needs adjustments.

And so, it's very frustrating. It's a very frustrating disease, especially if you don't understand what's happening and you don't know the strategies on how to manage it. And so, yes, that stigma's there. But once you empower your patients and there's just like, "Oh, well, my sugar went up this time. And what I did was I went for a walk and I drank some water. And then, my sugar came back down," or " My sugar was running high, so I decided to go up a couple units on my insulin. And now, I'm a little bit better." And so, it's like you are supporting them on making these decisions in their own life. And then, they feel empowered and they feel like they have control over their health and they feel like they can do the necessary adjustments and the necessary strategies that are needed to manage a chronic disease. But I can't take away the diabetes for them. But I can give them the skills and the tools and the things that they need to feel like they have some control. They can do something about this and they can work towards better health.

Melanie Cole, MS: Yes, very well said, Elisa. Now, one of the things we are learning more and more is that diabetes doesn't really take names. It's across cultures. It's across the board, right? So, this is a disease that affects so many different people of all ages and genders. And culturally, when we think about diverse communities, speaking to some of those communities presents an even different challenge than what we're even talking about here, because then there's the understanding and the access to care and all of these kinds of things that go into it.

So, tell us a little bit about the importance of culturally attuned communication when we think of these diverse and underserved communities and reaching out to them where they are so that they understand and can best manage their diabetes and have good access to care.

Elisa Martinez: So, this is a multifactorial answer I have to give you, because you're correct. It affects everyone, poor, rich, young, old. And so, finding the correct plan for them in their lifestyle at the moment is what we need to do.

But one of the other things is I am of Puerto Rican descent. I speak Spanish. And a lot of my patients come here and they're just so relieved that they have a provider that can speak to them in Spanish that understands them in a language that they are comfortable with. And so then, it allows them to open up and say, "Oh I can say things and I can say things better because I'm not speaking in my second language. I'm speaking in my primary language, and I can say things in a way that I feel more comfortable saying." And it assists greatly with the care that you want to provide. You want to have these conversations with these patients. And you want to see what is working for them, what is not working for them. And they cannot always say that in their language that's not their first language. So, speaking Spanish is greatly assisted.

However, you also have to look at the range of people, right? A six-year-old is not going to have the knowledge to say, "I need to count carbs and cut—" You know what I mean? So, you kind of have to break things down for each person and where they're at. Some people, I have a lady that she can't read at all. And so, I have to find pictures and different ways that I can make sure that she knows what to do in terms of her sugar and what numbers to look for and how to adjust with her diabetes in a way that she can understand it. And to be honest, she's one of the smartest people I know, but there's something there that I have to adjust for. And so because of that, she's comfortable with telling me, "I can't read, but I can do this." And so, this is how we have to go about making sure that she's doing well.

I had a guy who was from Bangladesh and kept telling me he spoke English, and he did speak English. And so, he didn't want an interpreter. And then, finally, after a couple visits, he would come back and he would be doing different instructions than what we discussed during our visits. So, I finally got him to agree to an interpreter, and you could see the little light that just opened up on him. And he was like, "Oh, I understand now." And so, it's just like you want to say things in the language that they understand. And you also want to say things in terms, right? So, not everyone is going to understand that they have CKD and they're at-risk for MI and CVD, right? So, you want to say, "Listen. It affects your kidneys because it complicates your circulation. I want to make sure you don't go on dialysis. So, let's get your sugar under control so that we can prevent complications related to diabetes." And so, just saying it in a way that they understand, in languages that they understand just opens up the gate and allows for appropriate communication regarding diabetes. And it allows the patients to feel empowered, they feel knowledgeable, and they know that they can manage it because of the way that you explained it to them and because you said it in a way that they understand.

Melanie Cole, MS: Yes. And that's so interesting, and really that is how to reach your patients in such a supportive way. Can you give us some examples of how that's supportive? You've given us a few, but can you give us some on how that improves insulin management? Because with all the technology that we touched on earlier, insulin management can be difficult. There's glucose monitors. I mean, there's all these things on the market now with our smart watches. Tell us some of the language you use every day.

Elisa Martinez: So, I will say that I'm lucky enough. I guess you could say that my daughter's a type 1 diabetic, and she was diagnosed about six years ago with type 1 diabetes. And because of that, I myself have had to learn how to do insulin pumps, to do the continuous glucose monitoring, calculate insulin manually. So because of my previous experience, I came into this role having that knowledge, and I have been able to broaden that knowledge so that I can support my patients. And so, I can initiate insulin pumps on my patients because I have certifications to do that. I can adjust their insulins because I know how to do the calculations and things like that. So, I came in with that knowledge and because of that, I've been able to speak to the patients both as a patient and as a provider. Because I was with my child managing this before I became a provider and a certified diabetes specialist.

So, in terms of the language, it's always a conversation. What are their goals in their life? And what are their limitations? And what can they do and how can I support them? So, many times, we start them off small. So, I'll say, "Why don't we put the little sensor on your arm?" I do not call it a continuous glucose monitor. I say, "Let's put the little sensor on your arm. It's going to check your fluid. It's going to give me numbers and it's going to give me a good amount of information that can tell me whether I need to give you insulin before meals or adjust your basal insulin, which is your 24-hour insulin." And so just saying that like, "All right, let's just try this and let's just see if it works. And it's just a little sensor. We stick it on your arm, you leave it there. And then you come back and we'll talk about it. And so, starting small and getting them used to the diabetes technical things. Once they have the sensor and they're used to it, then I can move up. I can say, "Oh, do you want to smart pen? And this can help you adjust your insulin," or "Are you tired of giving yourself injections? I can recommend the insulin pump." And so, you're building a rapport with your patients definitely. And you're definitely seeing what would be best for them when you're having these conversations with them. And you're just adjusting your language to a way where they can understand what you're saying.

So, yesterday, actually, I had a lady. She is from the Dominican Republic. She has severe diabetes, like she's had multiple complications because of poor diabetes management. And so, I just spoke to her for an hour, literally about how to put on a CGM, how I can look at the information. And within that conversation, she communicated with me saying, "I'm so tired of all these shots and I forget." And then, I threw out the insulin pump and she's like, "Oh my gosh, that would be amazing. Please give me this insulin pump."

And so, most people are not that quick to jump on the diabetes technology bandwagon. A lot of people need like that little introduction, getting comfortable with it. And then, I can gradually, like add smart pens, add insulin pumps if needed, speak about their data online and tell them how this is good and how this is bad. But the majority of the time, my patient's need some time to adjust, understand the disease process, understand what they can do to make sure that their diabetes is under control. And then, they'll be more open to other ways of managing their diabetes slowly but surely.

Melanie Cole, MS: This has been such great information, Elisa. And I think it's something that not all providers tend to think about. They give out medications, they give out instructions. But they don't think about how they're talking about these things and the stigma and the language that they're using. So, it's really such a great topic to discuss.

As we wrap up, i'd like your best advice about how health systems can train their teams to use more empowering communication practices, to be more uplifting and use that positive reinforcement. Give us your best advice here.

Elisa Martinez: So definitely, motivational interviewing techniques, therapeutic communication obviously. But I just happened to be listening this morning to an audio book, the Let Them Theory by, Mel Robbins, I think is her name. When I was listening to this morning, she gave a great example of how to speak to people in your life to promote the best changes, but you're still empowering them and allowing them to make their decisions. She said it was the A, B, C method.

So, the first thing would be, A, you want to ask open-ended questions. So, "Oh, it sounds like you're having difficulty with bringing your sugar down after meals." And then, you allow your patients and, answer the question. And then, at that point is when I insert my little bit of education and then tell them what their options are in terms of addressing that. And so then, once we come up with a plan B, B is you just back off. You observe and you allow them to implement or do nothing and just allow them to do what they need to do if they want to do it.

And then, finally, C is celebrate. So, let's say they did implement the strategies that we discussed. However, they only did it half of the time. "You know what? Great job, you did it half of the time. Next time, I want to see you do it more. And let's get these numbers better," or "If this isn't working for you, what can we do?"

And so, It's just simple. A, B, C, right? Like, you can remember that. Everyone can remember that. But it is a form of motivational interviewing. You are leaving it open to the patient, allowing them to make their own decisions, and then providing positive feedback when they do the good things, even if it's something small, even if they're not at target. You're still saying, "Thank you for the effort. Thank you for putting in the work. Thank you for following up. Even if you didn't do anything, you still came into the doctor and you still decided to put the effort to come and see your doctor today and have this discussion with me. So, thank you so much. You're doing great. Let's do this now." And so you want to motivate your patients. You want them to feel empowered. You want them to feel like they're making these decisions on their own, and you want to make sure that they not only are knowledgeable on their own care, but that they understand why they're doing things and they understand why the doctor's telling them to do these things. And so, they kind of listen a little bit better when they have the motivation to do it because they understand why.

Melanie Cole, MS: Really very well said. That's so true. Thank you so much, Elisa, for joining us today. And Weill Cornell Medicine continues to see our patients in-person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health.

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