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Caring For Latino Patients: When You And Your Patients Speak Different Languages, Their Health May Be At Stake. Here Are Ways You Can Overcome The Challenges.
By Barbara Weiss
April 23, 2004
ISSN: 0025-7206; Volume 81; Issue 8
Yolanda Gonzalez, a new patient, speaks almost no English. When she calls your office, a menu in both English and Spanish helps her navigate the system. A bilingual staffer makes an appointment for her and arranges for a medical interpreter to be present. In your office, signage, forms, and patient instructions written in Spanish help Yolanda understand the process. The interpreter helps you take her history and conveys your instructions. After the visit, the interpreter is paid by Yolanda's health plan, which also pays you $30 for taking the extra time to use an interpreter.
If the scenario above sounds familiar, you either work with a very enlightened health plan or you're living in dream world.
For most physicians in private practice, patients who don't speak English are handled as they've always been: Someone from the patient's family accompanies her and tries to interpret. Federal mandates say you must offer language services to patients with limited English proficiency (LEP), but, until revised recently, that mandate placed a heavy burden on individual practices to find and pay for interpreters. The language physicians are most likely to need an interpreter for is Spanish.
Hispanics/Latinos * are the fastest growing minor ity group in the country. Numbering some 37.4 million, they now represent more than 13 percent of the US population. The states with the largest concentrations of Hispanics are, in order, New Mexico, California, Texas, Arizona, Nevada, Colorado, Florida, New York, New Jersey, and Illinois. But it soon be a rare physician who doesn't see some Hispanic patients in the office.
A cover story in Business Week last month (March 15) proclaimed that Latinos are "a key catalyst of economic growth" with $625 billion dollars in disposable income last year. Additional good news is that in many ways Latino patients tend to be in relatively good health. They have a higher life expectancy at birth than non-Hispanic Whites, and a lower infant mortality. On the other hand, a disproportionate number of Hispanics live below the poverty line, and they're far more likely than any other group to have no health insurance. According to a report by The Commonwealth Fund, Hispanics are more likely to rely on community or public clinics as their regular source for care. More than half of those who are uninsured don't have a primary care physician and thus no access to preventive services.
There's also evidence that Latinos receive less effective care than non-Hispanic Whites. The National Healthcare Disparities Report shows that Hispanics are less likely to get blood pressure and cholesterol screenings, counseling and treatment for some cardiac risk factors, and recommended immunizations for influenza and pneumococcal disease. They're nearly twice as likely to develop diabetes as non-Hispanic Whites and are hospitalized for long-term diabetic complications more often.
Not all the same
It's important to recognize, however, that Latino patients may vary greatly. They can have Native American, African, or European ancestry. Latinos hail from such disparate regions as Cuba, Mexico, Puerto Rico, and--more recently--Central and South America. Their health often varies according to their country of origin.
Mexicans and Puerto Ricans, for example, have far higher rates of diabetes than non-Hispanic Whites, but Cubans and other Latinos are at only slightly elevated risk. Most Hispanic patients are less likely to develop COPD than Whites (perhaps because fewer of them smoke), but Puerto Ricans are an exception. Asthma is quite low among Mexicans, somewhat higher among Cubans and some other Latinos, and highest for Puerto Ricans.
Health may be further affected by income, age, generational status, and even by the number of years a Latino has lived in America. For the most part, with more acculturation, Latinos increase their education, income, occupational status, and fluency in English. Not all of the changes are beneficial, however. For instance, the longer they live in America, the more Latinos decrease their fiber consumption and increase their use of alcohol and cigarettes. Often, then, foreign-born Latinos are healthier than their American-born cohorts.
To Latino patients who don't have good English skills, our health system can seem impenetrable. In an incident reported in Medical Economics in 1984 (and still referred to in cultural competency circles), a patient was brought into an ED in Florida accompanied by his Hispanic mother and girlfriend, who told the doctors and ED workers that he was "intoxicado"--by which they meant nauseous. The staff, who spoke no Spanish, assumed the man was drunk or on drugs. Two days later, still undiagnosed, he experienced respiratory arrest and was found to have multiple hematomas and brain stem compression. Left a quadriplegic, he sued the hospital, the paramedics, and the physicians involved in his case and was awarded a settlement that could eventually reach more than $70 million dollars.
Physicians don't like to acknowledge that patients' inability to speak English could produce great disparities in healthcare. Yet study after study seems to prove that it does. A recent article in Pediatrics, for example, showed that during health visits with patients who have limited English proficiency, inadequate interpretation led to an average of 31 mistakes a visit, nearly two-thirds of which could have adversely affected the patient.
And don't think that two years of rusty high school Spanish--or even the Spanish you or a staff person learned as a child--will be enough to fall back on, especially when it's necessary to explain complicated medical procedures or discuss end-of-life issues with Hispanic patients.
Nor are family members always a good choice as medical interpreters. The patient may hesitate to talk frankly about gynecological problems, sexually transmitted diseases, domestic violence, or other private matters in front of a family member, especially a child.
There are a number of ways that physicians and their staffs can learn medical Spanish, but many of them require baseline knowledge. At Walker's Point/Clarke Square Community Clinics in Milwaukee, for instance, FP Mauricio Palencia and his colleagues offer a "mini-immersion course" sponsored by Aurora Health Care and the University of Wisconsin Medical School. Participants must have at least two years of substantial exposure to Spanish. During a one- or two-week program, they spend most of their time in the clinic interviewing patients under the supervision of Palencia and his staff. They also have a chance to visit Hispanic families from the neighborhood.
Interpreters can help
If you can't attain a working knowledge of medical Spanish, ideally you should hire medical interpreters and translators. Title VI of the Civil Rights Act of 1964 mandates that physicians provide meaningful access to their programs, services, and activities for patients with limited English. Health plans that contract with Medicaid and the State Children's Health Insurance Program are often required to provide language assistance and translated materials for enrollees.
Unfortunately, most of the state and federal programs that require medical interpreters don't pay for them, so the AMA has lobbied the Office for Civil Rights to relax its regulations, with some success. (See "The translator mandate gets easier," Feb. 6, 2004, available at www.memag.com.) The rules have been made more flexible and now take into consideration a practice's resources and the number of LEP patients it's likely to see. Nevertheless, the rules remain amorphous, says New Jersey healthcare attorney Steve Kern.
A handful of states have obtained federal matching funds to provide language services to Medicaid and SCHIP enrollees, but for the most part, neither Medicare nor Medicaid pays for interpreters. Nor do they reimburse providers for the extra time such services require. "It's similar to the issue of sign language for hearing-impaired patients," says Susan Hogeland, executive VP of the California Academy of Family Physicians. "The money comes directly out of the doctors' pockets."
Some health systems that serve LEP patients are working to resolve this problem. Kaiser Permanente, for example, provides in-house telephonic and face-to-face interpreters at no cost to patients or physicians. The Alameda Alliance for Health, which Hogeland identifies as one of the most forward-looking plans in this regard, goes even further. Scenarios like the one at the beginning of this article actually take place at Alameda's program in Northern California, which is the brainchild of Chief Financial Officer and General Counsel Kelvin Quan.
"When the patient makes an appointment, we arrange for an interpreter to be there," says Quan. "The interpreter will even call the patient the night before and let him know she's coming. This decreases the rate of no-shows. We pay the cost of a two-hour visit directly to the interpreter, so the physician doesn't have to bill and wait for reimbursement. We pay $30 to physicians when they use face-to-face interpreters, and $20 when they use telephonic translations through our system."
Such systems may be ideal, but few practices have the financial resources to match them. Moreover, working with medical interpreters requires some training. An inexperienced physician taking a history from a Latina, for instance, might tend to look at the interpreter and address all questions to him ("Ask her where it hurts"). To the patient, that looks like you're ignoring her.
What to do?
Even without the finances of a health system like Alameda behind you, there are many things you can do to improve your cultural competency. Lots of Spanish-language resources are available, many for free. (For a detailed list, see our Web-based supplement to this article that discusses resources for caring for Hispanic patients, available at www.memag.com.)
Here are some suggestions from experts in multicultural care on how you can make your practice more accessible to your Hispanic patients:
* Take a self-assessment test to find out how sensitive you are to cultural competency issues. The National Center for Cultural Competence at Georgetown University offers one on its Web site, at www.georgetown.edu/research/gucdc/nccc/nccc11.html.
* Consider hiring a bilingual staff person the next time a slot opens up.
* Make signs and documents like appointment reminders bilingual, and obtain "I speak--" cards to identify patients' language needs. Look for patient education materials written in Spanish.
* Look into government and medical association programs that focus on Hispanic health. The National Heart, Lung, and Blood Institute, for example, has an initiative on Latino cardiovascular health resources (Salud para su Corazon). You can find information about it at www.nhlbi.nih.gov/health/prof/heart/latino/latin_pg.htm.
* Find out if your managed care organizations, hospitals, and community-based organizations have medical interpreter services you can use. Federal, state, and county departments of health are potential sources of funding.
Many experts make a strong financial case for health plans to offer accessible services to LEP patients: More patients will be attracted; quality measures, such as patient satisfaction, will be higher; overall costs of unnecessary testing and hospitalizations can be avoided. For the private physician, however, the economic rationale is murkier. Providing language services is expensive and so far remains largely unfunded.
Indeed, the strongest economic motive for the individual physician is probably risk management. The law demands that you comply with Title VI of the Civil Rights Act. Legal experts tend to agree that the chances of a private physician being prosecuted or even terminated from Medicare or Medicaid programs under Title VI are quite limited. What's not limited, however, is the liability risk you run when an LEP patient doesn't understand your directions or a procedure well enough to give you an informed consent. The recent HHS clarification simply establishes" 'a new recognized standard' of your obligation to the LEP patient," explains attorney Steven Kern, "and a new cause of action for malpractice."
But besides reducing risk, improving your cultural competence can lead to the kind of high-quality medicine all practitioners would like to believe they practice. "It creates a better physician-patient relationship, better compliance with the therapeutic regimen, and fewer medical errors," concludes Kelvin Quan.
* Note patients' language needs as soon as they contact you.
* Consider hiring bilingual staffers when a position is open.
* Look for signage, appointment reminders, and patient educational materials written in Spanish. Many are available free on the Web.
* Look for programs that focus on Hispanic health--for example, cardiovascular programs that focus on "heart healthy" Latino recipes.
* Try to avoid using members of the patient's family or even members of your staff to interpret. Whenever possible, use professionally trained medical interpreters.
If, like most US physicians, you speak little or no Spanish, the cultural gap between you and your Latino patients could be wide. You'll need to become aware of the beliefs and customs some of them may bring to your office.
Latinos form a very diverse community, of course, and it's important not to stereotype your patients. But for many of them, the family bond (familismo) is very strong. Often a large, extended family is involved in the patient's diagnosis and treatment. "The family matriarch, the grandmother, is the healer," says Robert Graham, a clinical research fellow in Integrative Medicine at Harvard Medical School. "She has all the wisdom about folk beliefs." On the other hand, the male head of the family may ultimately make all the decisions, notes Graham, whose family is part Hispanic.
Like most of your patients, Latinos value simpatia (a polite, pleasant manner) and personalismo (a warm, personal relationship) in their healthcare providers. But they often expect an authoritative manner and professional dress from their physician, whom they regard with respeto (respect). Other attitudes, such as fatalismo (fatalism), can undermine a therapeutic relationship; you may have to work hard to convince your patients that they can take charge of their own health.
Your Hispanic patients may also have their own views on what makes them sick and what can heal them. Folk traditions point to negative emotions, natural phenomena, magic, or an imbalance between hot and cold as the culprits that cause disease. (See the box on page 38.)
For this reason, you may want to respectfully ask them what they think caused their illness and whether they're taking any folk medicine for it. Robert Graham asks his patients to bring to his office whatever medication they use. Rather than forbid the use of home remedies, he tries to create a therapeutic alliance with the patient that will result "in a treatment plan that incorporates both my belief systems and theirs."
Diet is a particularly big issue, says Mauricio Palencia, an assistant professor at the University of Wisconsin Medical School who works at the university's family health clinic in Milwaukee. Latino families may frequent fast food chains because they can't afford more expensive restaurants. And Hispanic grocery stores, which tend to have cheaper prices than chain supermarkets, don't promote healthy foods.
"Breakfast might be a few tortillas [up to 300 calories each] with meat or perhaps chicharron [fried pork skin]," Palencia says. "Not a healthy diet for a diabetic." His clinic's Spanish-speaking nurse suggests healthier alternatives, and Palencia himself has gone into neighborhood Hispanic grocery stores to read food labels so he can suggest lower-fat options.
Hispanic folk beliefs about health and illness
Hispanic patients may believe these maladies affect their children, and, sometimes, themselves:
* Empacho is a stomach condition associated with vomiting, diarrhea, anorexia, bloating, and cramps. Many Hispanics believe it's caused when food or saliva gets stuck to the walls of the intestines or stomach. Parents may treat it with herbal teas or abdominal massage with warm oil. Less often, they may use azarcon or greta--potentially toxic substances that contain lead--as laxatives.
* Mal de ojo (evil eye) supposedly comes from a spell or an iii wish and heats the child's blood, causing fever, diarrhea, vomiting, and a gassy stomach. Many parents believe it can be cured by a healer or with herbs purchased at a botica (herb shop).
* Mollera Caida (fallen fontanelle) is believed to result when the breast or bottle is removed too rapidly or the child is tossed around. Symptoms include fever, diarrhea, and fussiness. "Cures" include pushing up the soft palate with the thumb to push out the fontanelle, pulling the child's hair, or positioning the child upside down.
* Susto occurs after a frightening experience, causing nightmares, insomnia, diarrhea, fever, and loss of appetite. Cures include prayers and other religious practices.
* Viento is a cold wind that causes muscular pain. The most traditional approach is "cupping," which involves putting a lit candle on the muscle and placing a cup directly over it until all the oxygen burns away and a vacuum is created, pulling the air (and the viento) out of the body.
* Some people prefer the term "Hispanic;" others use "Latino." For purposes of convenience, we have used them interchangeably in this article.