Daniel Catalaa

Latino culture and healthcare

(Authored by Daniel Catalaa on October 23rd, 2013)
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If you work for a large corporation or institution in the United States, you will eventually be introduced to the notions of "culture" and "cultural differences" and there will be an expectation that you will become aware of these concepts and be sensitive to them. Yet I have found that most trainings in this area are overly generic and lack specific examples. So you listen to the cultural sensitivity presentation and when you get back on the job, for the life of you, you cannot remember what to look out for or what you could do to rescue a situation where a cultural norm, yours or the patient's, was transgressed.

It is in this spirit that I have prepared a list of key cultural topics accompanied by real life scenarios that illustrate conflicts and their resolution. Specifically, I will address how a provider who develops familiarity with both Anglo and Latino cultures can increase trust and understanding and get better results. Below, "Dominant Culture" refers to the beliefs, perspectives, ideology, superstitions, and expectations that are the most prevalent in the United States.

Author's qualifications: Daniel Catalaa has worked for 6 years with the San Francisco Bay Area Latino immigrant patient community as a Certified Medical Interpreter at California Pacific Medical Center, and lived abroad in Europe and South America for 18 years. He received health care as a patient in England, Italy, France, Argentina, and the USA, and completed a bachelors and masters degree in Cell and Molecular Biology.

COMMUNICATION STYLE

Dominant Culture: The most highly valued communication style in the USA is assertive and direct communication: If the patient needs something they need to speak up and request it. When patients state their opinions and preferences this is expected and welcomed. Replies are given as clear and unequivocal "yes" and "no"s. What you say is more important that how you say it.
Latino culture: Passive communication is the most effective style, so the patient will not openly challenge the doctor. By being non-confrontational the patient can preserve his personal relationship with the provider, and this is paramount. Showing respect and maintaining harmony are more important than getting my way. If I can maintain a good personal relation with my doctor, I am sure we can work out the rest. By the way I said "yes" or "no" (with hesitation, in a tentative way, or with enthusiasm) the provider will know where I really stand.
Scenario A: Provider announces "Mr. Garcia, you have cancer". Patient finds the provider to be a blunt communicator to the point of being uncaring. A new, life-changing diagnosis, was just blurted out in an unemotional way.
Mitigation A: Provider ramps ups slowly to disclose important news and eases into it, beating around the bush is good. For example the provider can provide a chronological summary of all things attempted to date (biopsies, chemotherapy, radiation) and how events led to the unfortunate news they are about to disclose. The patient needs to see things coming.
Scenario B: Provider asks patient if she agrees to cut back her hours at work until her back injury resolves. Patient hems and haws and eventually says "yes". However, the patient is illegally employed and is afraid of losing her job if she cannot be there every day. The provider finds the patient to be shy and a bit cagey but believes they got a straight answer. The patient does not decrease her hours and the injury gets worse.
Mitigation B: Provider pays attention to how things are said, not only to what is being said. For example, a tentative "yes" in Spanish is equivalent to a "NO (but-I-am-too-polite-to-tell-you)" in English. So it is best to fully explore any hint of hesitations by a Latino patient before moving on to the next topic or question.

COMMUNICATION CONTEXT

Dominant Culture: Communication is direct and low in context. Let's get to the point. Just the facts ma'am. Additional off-topic data quickly becomes T.M.I. (too much information). Communicating quickly and precisely is highly appreciated.
Latino culture: Communication is context-rich. The intervening narration is just as important as the punch line. You need to take in the where, what, who, how, and why to really understand what happened. It's not only about the individual elements of a story but how they are connected with each other.
Scenario A: Provider asks the patient how they broke their femur. Patient starts narrating in detail the whole day leading up to the accident. Provider is frustrated that the patient takes sooo long to say things and does not answer direct questions with direct answers. He decides to interrupt the patient and repeat the original question. Patient feels that they are being cut off and are not allowed to express themselves. Provider is seen as rude, a person ahead of themselves who cannot wait for the important information that is coming.
Mitigation A: The provider redirects the patient and rephrases his questions from open ended questions (e.g. "How did you hurt your leg?") that invite longer answers, to close-ended questions that zero into the needed information more expeditiously (e.g. "Did you hurt your leg by falling OR did you hit it with something?", "Do you want us to care for you at this hospital OR to be transferred to one near your home?")

NOTIONS OF TIME

Dominant Culture: Time is something to be conquered and to be used to its maximum efficiency. In the USA we show up on time, we bill by the minute, and because we live in a stable society we can schedule things months in advance.
Latino culture: Time is to be enjoyed, spent rather than saved; we spend time with those we care about. The economies and politics of our Latin American countries' are too unpredictable to nail down things for precise dates and times, being flexible is important.
Scenario A: During a clinical visit the provider shows that he cares by attempting to get the patient "out of here as soon as possible" and this is exactly what the patient is not looking for. Patient feels rushed and feels processed, rather than seen, by the doctor. Little to no time is spent building a personal relationship through small talk. Provider feels that patient is wasting time by being off-topic, providing long-winded descriptions, and talking about non-medical things.
Mitigation A: Provider explains to patient the time limitations under which he works (e.g. 15 minutes per visit) and reassures patient that, even thought their time together will be short, he cares about them. Provider suggests that patient comes prepared to each clinical visit with a small note that summarizes: 1) Updates, 2) Questions, and 3) Requests, instead of trusting their memory and winging it in them moment. This will make best use of their time together and the patient will leave with most of what they came for.

DEFERENCE

Dominant Culture: We have different backgrounds, but essentially we are all equal. As a provider, I do not need to know too much about your background because I will treat you well independent of it. I will treat you just as well as any other patient, no matter what my personal feelings are towards you. We can call each other by our first name and be informal. We address our young as we address our old so itís ok to forego formalities and jump right into the topic at hand.
Latino culture: Respect for patient: Adult patients, older patients, and those with high social status should be addressed in a respectful way at all times. It is courteous to ask about the family and to make small talk before delving into the medical facts related to the appointment. Respect for doctor: The three social roles that elicit the most deference in Latin America are teacher, priest, and doctor. So doctors are not openly challenged, rebuked, or disagreed with, even when the patient holds a different opinion.
Scenario A: Provider addresses patient by their first name who feels offended because he is being spoken to as if he was a small child even though they are an older gentleman. To their ears it sounds like "How ya doing sport?".
Mitigation A: Provider asks the patient how they prefer to be addressed (e.g. "Mr. Gutierrez" instead of "Roberto"). When in doubt always use last name.
Scenario B: Provider burst in through door and immediately starts talking about the latest lab results. Patient seeks a personal connection with provider but cannot establish one. Provider wonders what all the verbal dancing is about and why we can't just jump right into it.
Mitigation B: Provider engages patient in small talk and this builds trust. This small investment in time actually saves time, because the patient will be more compliant with treatment (he/she does not want to disappoint a provider they like) and will foster more honest disclosures by patient, for example on drug use, number of sexual partners, and embarrassing symptoms.
Scenario C: Provider believes they have reached an agreement with the patient because the patient is saying "yes" and smiling, when in fact the patient disagrees but is being deferential.
Mitigation C: Provider invites Latino patient to be more assertive and assures the patient that the doctor will not be offended by patientís questions and requests. If patient responds to a question with a lukewarm unenthusiastic "yes", the provider explores further the patients reluctance instead of moving on to the next question or topic.

RELIGION AND PHILOSOPHY

Dominant Culture: Free will is king and science can perform miracles when we consent to it, so the patient is expected to be actively involved in their care. At an emotional level, death is not seen as a natural phenomenon of life, it's an aberration and technology can help us to fight it and postpone it at all costs.
Latino culture: Philosophy hinges heavily on a blend of Christianity and fatalism. We are here for a finite amount of time and when itís time for us to go, itís time to go. The body is just a vessel used to prepare the soul for its eternal afterlife. Therefore, Latino patients may throw in the towel to soon when some effort on their part would have made a difference. This same tendency to accept outcomes and just let things happen however is beneficial when facing terminal diagnosis where medicine has reached its limits and only comfort care can be offered. Pain and illness can be seen as tests of faith. If I endure them without cursing out my god, there may be a spiritual reward later.
Scenario A: Provider informs family that the chemotherapy has shrunk the tumor but has not removed it. Patient and family are accepting of what appears to be a terminal diagnosis and are ready for palliative care. Provider is puzzled: Why doesn't the patient want to go through another round of chemotherapy? Why aren't they fighting this tooth-and-nail? Family consents to further treatment but after a while they start thinking that all these "heroic measures" (resuscitation, life support, etc.) make no sense. Just let him go in peace.
Mitigation A: Provider explains where personal involvement, insistence, and determination by the patient will make a difference and when none of these will help. If provider can only increase the length of life but not the quality of life, they can offer comfort care sooner in the course of events.

DECISION MAKING

Dominant Culture: The patient is a free moral agent and is the executor of all decisions. The patient is in control. The provider will explain risk and benefits and the patient will pull the trigger on whether to proceed or not. The patient keeps their family updated, but ultimately all decisions rest in the patient's hands.
Latino culture: The doctor's "opinion" is seen more as a medical imperative/directive and carries a lot of weight. The thinking is that the doctor knows best and I will follow his recommendations. I have no reason to second guess him, he is the professional and I trust his expertise. Also, my decisions affect my family of which I am an integral part of so I am going to consult with my husband/wife and adult children regarding what to do. Latino families are large and tight-knit so the patient is always thinking how his/her actions will affect others members.
Scenario A: Patient is bewildered because they are asked to make medical decisions (e.g. proceed or not with a surgery, chose what type of anesthesia to receive) when they have no medical training. Patient thinks "The doctor studied these things, so why doesn't he tell me what to do? Besides that, I need to talk things over with my husband". The provider is thinking: "Why canít the patient make up her mind? After all, I explained everything clearly. This is her body, she does not need anybody elseís permission to make a decision. What's the hold up?"
Mitigation A: Provider will be more directive with Latino patients actively suggesting the preferred option among those presented. Provider may say "Of the options discussed, based on my years of experience, I think that increasing the Prograf and postponing a second transplant is the way to go here" instead of "We could do A, B, C, or D; what would you like to do?". Provider will allow time for patient to consult with family and extended home support network before an important decision is made, even if they are not present on day of consultation. After all patient may need to arrange for somebody to drive them, shop for groceries, babysit, take time off work, pick up mediation, etc.

POLARIZED GENDER ROLES

Dominant Culture: Men and women are essentially the same when it comes to basic legal rights, equal pay for equal work, and engaging in similar levels of responsibility, opportunity, and recognition. The male and female roles are interchangeable and it is socially acceptable to be a career woman as it is to be a stay-home dad.
Latino culture: Each gender is specialized into roles that are only moderately flexible. Men are expected to be the heads of household, bread-winners, discipline enforcers, and ultimate decision makers on important decisions. Though many Latin women are receiving more education and are active in the workforce they are still expected to have a supportive, nurturing, domestic, child-rearing role.
Scenario A: A dietitian trains a diabetic man on how to fix nutritious and balanced meals but he is never around the kitchen and does not buy the food for the household. Because the wife was not present for the training, eating habits do not change.
Mitigation A: The dietitian invites both husband and wife to the training. In recognition that the wife runs the household, she is educated regarding food purchases, preparation, portion size, and insulin storage.
Scenario B: In an effort to be politically correct, a pediatrician asks the father (instead of the mother) what the baby's eating and sleeping habits are but he just looks confused and returns a blank stare back.
Mitigation B: For a more fluid communication, the provider uses their understanding of established gender roles and directs questions relating to young children first to the mother.
Scenario C: A pediatric surgeon asks a mother if she wants to proceed with her child's heart valve replacement. She asks for more time because she needs to consult with her husband first. Because the husband was not present nor was he part of the conversation, a new appointment needs to be set up and precious time is lost.
Mitigation C: To reach a consensus faster on important decisions involving surgery, financial expenses, end-of-life matters, risky or experimental procedures, the provider will consult and involve the main male family authority figure, be it the father, husband, or eldest son.

MEDICAL LITERACY AND JARGON

Dominant Culture: The US has compulsory primary and secondary education for its citizens and has a 99% literacy rate. The use of medical terms is pervasive in the news and public health educational campaigns. Some technical medical terms have become mainstream.
Latino culture: The Latino community that immigrates is not a cross-section of society. Educated and wealthy individuals and those with stable socio-economic conditions have no incentive to leave their countries of origin and come to the States. So most of those who come have, at best, some primary education.
Scenario A: Provider explains a necessary procedure and used terms like "endoscopy", "biopsy", and "pathologist". The patient looks confused and the interpreter has to repeat things several times.
Mitigation A: Provider adapts their speaking register based on patient's educational level. Use first 2-3 minutes of small talk to gauge patient's educational level and medical literacy. Keep your register high for educated patients and simplify the message for all others. Instead of saying "During the endoscopy we are going to take biopsies of polyps and send them to the pathologist", change it to "We are going to use a small camera to look at the inside of your stomach. We will take samples of any abnormal tissue that we find and will study them"
Scenario B: At the Ambulatory Surgery Unit, the anesthesiologist asks the patient whether they would like general, local, or monitored anesthesia. Patient is surprised by question and does not know what to choose. Mitigation B: Anesthesiologist explains the differences and advantages of each type of anesthesia by using layman terms, e.g. ": You will be awake/asleep, you will feel something/nothing, you can talk to us/will have a breathing tube". Only after this explanation does he invite a choice to be made.

HEALTH CARE SYSTEM

Dominant Culture: The US healthcare system is a multi-billion dollar industry that is hyper-specialized and has a heavy legalistic focus that requires the signing of numerous forms, releases, and consents, and the documentation of every step of care delivery.
Latino culture: Health care in Latin America relies mostly on public hospital and clinics complemented by some private enterprise. Medicine is for the most part socialized and has many fewer specialties and sub-specialties. Preventive medicine is well developed, but other types of care are much more advanced in the US.
Scenario A: A patient presents through the Emergency Room and is admitted. During his week-long stay he meets no less than 30-40 different staff and providers each carrying different titles: doctors, surgeons, social workers, admitting clerks, financial counselors, therapists, nurses, and medical assistants. Patient has no clue as to the role of each person and does not know who to speak to for what.
Mitigation A: When providers introduce themselves they will constantly repeat what their roles is, rather than just providing their name and title. For example instead of just saying "Hi, I am Jessica, your physical therapist", the therapist adds "I am here to help you to get out of bed, exercise, and get strong again". A neurologist could explain "I am a specialist of the brain and will visit you over the next couple of days to make sure the swelling in the head is going down."
Scenario B: Patient is repeatedly asked for his name and date of birth, over and over again. Patients start losing confidence in staff and asks himself "Don't they know who I am? Why do they keep loosing track of my information?"
Mitigation B: The provider explains the processes used and the reasons for them, for example that patients are purposely identified and re-identified at various stages. This is a safety precaution and is not due to a lapse of memory.
Scenario C: Patient is offered different services that he seems to need (interpreting services, oxygen delivered to his home, etc.), but inexplicably turns them down. Unbeknownst to the provider, the patient recently received a $3,000 ambulance bill and is reluctant to agree to any more services. A charge like that is tantamount to financial exploitation and would never have occurred in his country.
Mitigation C: The cost of any service is explained, specially if there will be out-of-pocket expenses. If a free service is turned down, the patient is reminded that it there is no associated cost.