Monday, February 5, 2007

Your Doctor and You – Sick and Speaking No English, Fifteen in a Series

Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tossed to me:
I lift my lamp beside the golden door.

Inscription on Statute of Liberty

The Language Barrier and Health Plans

The language gap between cultures is even causing a litigation stir. As many as 10 percent of California HMO members speak no or little English. Recently a 53 year old Spanish speaking self-employed scrap-metal dealer filed a lawsuit against Wellpoint, Inc., for failing to explain in Spanish that his pre-existing chest pain made him uninsurable.

Wellpoint cancelled his contract after he had an operation unclogging his arteries. This left the patient and his wife with a $130,000 debt which they could not pay(”Language Becoming an Issue for Health Insurers. A Spanish-Speaking Couple is Sueing Blue Cross, Saying that It Should Not have Yanked a Policy That it Wrote in English,“Los Angeles Times, March 20, 2006).

Hospitals Step Up

From business and patient satisfaction standpoints, hospitals understand the importance of cultural competence. They’re employing diversity coordinators, seeking diversity training for executive and patient care employees, and hiring more interpreters. Those hospitals prepared for cultural diversity are better equipped for more effective care for immigrants.

Cultural awareness is also very much on the medical establishment’s mind. The American Medical Association, the American College of Physicians, and the American College of Cardiology are among the many medical societies that have launched initiatives to improve cultural competency and care of diverse populations.

Becoming Culturally Competent Physicians

What can physicians do to become culturally competent? The fundamentals are:

• Immerse yourself in the culture.

• Get a foreign-born physician or nurse adviso.

• Read a book on the subject (Bigby, J, Cross-Cultural Medicine, American College of Physicians, 2003.

• Be sensitive to culture differences.

Heed these tips for improving the relationship:

1. Get an interpreter.

2. Be more formal with patients from another culture.

3. Maintain a greater distance between doctor and patient throughout the relationship.

4. Use the patient's last name when addressing him or her.

5. Don’t be insulted if patients fail to look you in the eye or ask questions about treatment. In many cultures, looking you in eye and asking questions is disrespectful.

6. Don’t make any assumptions about the patient's ideas about maintaining health, or the cause of illness or means to prevent or cure it.

7. Don’t dismiss beliefs not held by Western biomedicine. Patients may be afraid to tell Western caregivers that they’re visiting a folk healer or a taking an alternative medicine.

8. Don’t discount beliefs in the supernatural. If the patient believes that the illness has been caused by the evil eye, the patient isn’t likely to take any responsibility for his or her cure.

9. Inquire indirectly about the patient's belief in the supernatural or use of nontraditional cures.

10. Try to engage the entire family in the treatment. In many cultures, medical decisions are made by the immediate family or the extended family.

11. Be restrained in relating bad news or explaining in detail complications that may result from a particular course of treatment. "The need to know" is a unique American trait.

12. Whenever possible, incorporate into the treatment plan the patient's folk medication and folk beliefs that are not specifically contradicted.

Hints for Immigrant Patients

If you’re a foreign-born patient new to this country and speak poor English, bring a family member who has been in America awhile and who speaks good English. Have the doctor write out the diagnosis and treatment plan. If possible find an American doctor born in your country or one who understands your language. If your friends or family doesn’t know of such a doctor, call the local hospital or medical society. They may be an able to help.

I would add, learn English and encourage your family to become integrated into American society. This will come naturally for second generation children of immigrants, but encouragement by health care professionals may speed the process of assimilation among the first generation too.

The unexpected acceleration of immigration to the U.S. is stressing our health system and helping create a shortage of physicians. A significant percentage of U.S. physicians, an estimated 25 percent, are now foreign-born. Many immigrants are uninsured and have difficult times gaining access and treatmen.

The issue of “cultural competence” of U.S. health professionals is said to complicate the problems and process of access and assimilation. Shall we cross over to their culture, or they to ours? The question will be answered in one generation. In the meantime, we must improvise a task of assimilating at which Americans are among the best in the world.

Cultural Diversity Growth

This furious growth and the cultural diversity accompanying immigration creates problems for hospitals and doctors, who often must hire numerous translators to deal with patientt from these different countries.

According the Census Bureau, by the year 2000, almost 50 million people in the U.S. were from different ethnic backgrounds. In 1940, 70 percent of immigrants were from Europe. By 1992, the immigrant pool had changed. Fifteen percent came from Europe, 37 percent came from Asia and 44 percent came from Latin America and the Caribbean.
Generalist physicians can now expect more than 40 percent of their patients to be from minority cultures (All information above from U.S. Census Bureau).

The Contribution of Foreign Born U.S. Physicians

Ironically, the number of foreign-born doctors practicing in the U.S will be invaluable in ameliorating the physician shortage.

Wrapping Up

Immigrants are an essential element in the vitality, vibrancy, and prosperity of the American dream and our vision of ourselves as a “melting pot for free people.” Unfortunately, the rapid influx of illegal immigrants has tainted the dream and created tensions because the new immigrants don’t “melt” into the American mainstream by becoming taxpayers and buying health insurance. Instead they retain their languages and customs and remain in the shadows of society. These characteristics create economic and culture strains in the health care marketplace.

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