Why your patient won't let you touch her

In this ethnically diverse country of ours, patients with health care customs and practices quite different from Western medicine's are looking for doctors who understand their needs. Will you be one of them?

By Elizabeth A. Pector, MD, FP/Naperville, IL and Gil L. Solomon, MD, FP/West Hills, CA

Although one of us practices in Illinois and the other in California, we both see many patients who aren't native to the United States, or who were born here but have very different cultural backgrounds. That fact enriches our practices, but also complicates them.

Indeed, whether it's overcoming language barriers or dealing with different expectations about health care, practicing good multicultural medicine can be challenging. It requires patience, an open mind, and a willingness to learn about unfamiliar traditions and folkways. Increasingly, it also requires knowledge of the law. But the payoffs—in a larger, more rewarding, and safer practice—are worth the time and effort.

Overcoming language and other cultural barriers

Language is often the biggest multicultural hurdle doctors have to overcome.

The easiest way is to use one of the patient's family members as translator. But doing so is something you need to think twice about. For one thing, you could end up violating federal guidelines, which mandate competent translation services for patients with limited English proficiency (see "Don't let translation rules leave you speechless").

Using family members as translators poses other problems as well. With no health care background, they may misrepresent our questions, or they may feel awkward posing potentially embarrassing—but medically important—questions. And you might feel awkward asking them to.

That can lead to incomplete, or even dangerous, care. We know of an Hispanic man who's 10-year-old son regularly served as translator. When the need arose to prescribe a beta blocker, the FP felt it would embarrass both the child and the father if she discussed impotence as a possible side effect—so she didn't raise the issue.

Like language differences, a clash of cultural norms can complicate patient encounters, especially in the diagnosis of psychiatric disorders. Depression and anxiety, for example, are largely Western concepts. In non-Western countries, both the concepts and the treatment—typically some combination of counseling, behavioral therapy, and prescription drugs—are generally unfamiliar or where they are recognized may be considered signs of weakness. That results in a Catch-22-like situation in which patients resist treatment for psychiatric maladies even though they may be more prone to these maladies because they're far from family and familiar surroundings.

Such patients tend to express their problems in medical terms and present with medical complaints. Middle-aged Hispanic women, for instance, might complain "Me duele"—I hurt. Similarly, elderly Chinese women and other immigrants tell their doctors of headaches, dizziness, chest and stomach pain, backaches, and overall body soreness.

But tactful probing usually reveals trouble of some kind—and underlying depression. Perhaps the patient is trying to cope with a child's defiance, estrangement, or involvement with drugs, or maybe the patient's spouse is verbally, emotionally, or even physically abusive. Such patients often resist being treated for depression. Still, identifying the cause of their ailments can prevent misguided interventions.

Many immigrants from war-torn nations carry the psychological scars that come from witnessing brutality. One Cambodian immigrant we know of survived the massacres of the genocidal Pol Pot regime. Now in his 30s, he matter-of-factly explained how the systematic killing of some 2 million people obliterated Khmer history, culture, and language. He grieves for his lost heritage. Treating patients like these requires an extra effort—and a special sensitivity to their plight.

To learn more about cross-cultural issues, check out www.diversityrx.org. The site is supported by the National Conference of State Legislatures, Resources for Cross Cultural Health Care, and the Henry J. Kaiser Family Foundation.

A patient-friendly office for all patients

Cultural differences invite misunderstandings in front and back office alike.

It's easy to become upset, for example, when foreign-born patients walk in without appointments. Are they being rude or inconsiderate? Not necessarily. In many countries, appointment systems don't exist. Ailing patients simply go to the doctor's office and wait to be seen, often for hours.

Similarly, patients from other lands may find it odd, even disconcerting, when we recommend an over-the-counter medication for their common cold. They expect us to provide some form of active treatment or at least a prescription, and our low-key approach confounds their expectations of good medical care. We needn't cater to these expectations, but we should stand ready to explain our course of action.

Comprehensive family care may also prove difficult because of cultural barriers. A female FP, for instance, may be allowed to treat the women members of a Muslim family, but not the men. Fortunately, as Muslim men become acculturated into Western society, their reluctance to be seen by female doctors diminishes. Not so Muslim women, in our experience. They steadfastly resist seeing male physicians for intimate exams.

Other roadblocks arise in reproductive care. In California, a community-based family planning program ran into trouble when Hispanic husbands opposed to birth control objected. It wasn't until the women learned effective ways of standing up to their husbands that the program was able to continue.

Some cultural traditions flatly contradict Western notions of autonomy, confidentiality, and informed consent. We've known patients who've insisted on step-by-step family involvement in the development of diagnosis and treatment plans. Others prefer that we communicate solely with selected family members, such as the patriarch, leaving the patient herself out of the loop. If you're uncertain, ask the patient whether test results should go to her or to a designated family member.

Also, keep in mind that some patients come from cultures in which one's word is one's bond. So when you ask for written permission prior to a procedure, you might need to explain that you aren't questioning their trustworthiness or character; you're simply obeying the law.

If patients travel back to their native countries, it's important for you to know what they're likely to encounter—and how that will affect their health. The CDC's Health Information for International Travel at www.cdc.gov/travel/yb can help refresh your medical school knowledge of rare and exotic bugs. (It also comes in handy when native-born patients travel outside the country.)

End-of-life care requires special sensitivity

Cultural differences can also make discussions about organ donation, advance directives, and hospice planning difficult. A Midwestern orthodox Jewish family we know, for example, is determined to keep a comatose family member alive. They have nearly exhausted their collective resources to provide him with round-the-clock home nursing, a Clinitron bed, and even a hyperbaric chamber.

The doctors, nurses, and therapists who've cared for him, in and outside the hospital, viewed the all-out effort as irrational and wasteful. Finally, a specialist involved in the case who happens to be Jewish explained the family's reasoning. In doing all they could to keep their relative alive, he explained, they were adhering to their strict interpretation of Jewish end-of-life law.

For caregivers, knowing that fact didn't significantly diminish the day-to-day treatment challenges, but it put the family's actions in their proper perspective. To find out more about end-of-life care and cultural differences, go to www.lastacts.org.

These are just some of the ways that practicing good multicultural medicine can help you and your patients. You might also consider hiring staffers who more closely mirror your town's ethnic composition. At the very least, both you and your staff should familiarize yourselves with the cultural mores of the major ethnic groups in your area.

Increasingly, ethnic patients will seek out culturally savvy doctors. With some knowledge and a little effort, you could be the doctor they select.

For more on cross-cultural medicine, please see "From fingersticks to chopsticks" in this issue.

Don't let translation rules leave you speechless

Socorro Placencia's daughter usually accompanied her on visits to FP Gil Solomon's office in West Hills, CA. But on this visit, the Medicare patient was sitting alone in the exam room.

"Tell me about your chest pain," Solomon said, sitting on the rolling stool. His patient's blank expression indicated he'd have to rephrase the question.

"The nurse wrote that you're having chest pains," he said. "When did they start?"

The elderly patient attempted to answer, but Solomon couldn't tell whether her complaint was coronary, musculoskeletal, or gastrointestinal in nature. Frustrated, he tried reaching Mrs. Placencia's daughter at work, but couldn't.

Then he remembered: The federal government requires doctors who receive federal monies—meaning anyone who treats Medicare or Medicaid patients—to provide translators for non-English speaking patients. He instructed his staff to call a translation service, but was stunned to learn the translators charge $2.50 a minute. Conscious of the law, he nevertheless elected to conduct the remainder of the exam nonverbally.

"Does it hurt when I press?" he asked his patient. Mrs. Placencia grimaced and squirmed, then reached up to pull his hand off her rib cage. Further tests showed her heart tones were normal, with no acute changes in her ECG. Despite lingering doubts, Solomon wrote "costochondritis" in the chart and sent his patient home.

Solomon's diagnosis proved correct, but what if it hadn't? What if Mrs. Placencia had died that night from a massive heart attack? The fact that Solomon hadn't hired a translator—or, at the very least, called one of the Filipino record clerks who work above his office—would have worked against him. "I'd probably be facing a malpractice suit—and possibly other legal action for violating my patient's civil rights," he says.

Following an executive order signed by President Clinton on Aug. 11, 2000, federal agencies, including the Department of Health and Human Services, scrambled to assure improved access to services for people with limited English proficiency. The HHS guidelines, the first to be published, set out minimum standards for all providers participating in Medicare and Medicaid or receiving any federal assistance from HHS. These include an assessment of local language needs, the drafting of a written language-access policy, staff training, and program monitoring.

Beyond this, doctors must choose from among a number of language-assistance options, de-pending upon practice size and population need. They may hire bilingual staff, contract with an office- or telephone-based interpreter service, or enter into a formal arrangement with a voluntary community service agency. Again depending upon circumstances, doctors may also be responsible for translating "vital documents" like applications, consent forms, and benefit notices for patients with limited English proficiency.

Guideline compliance will be accessed on a case-by-case basis, according to the HHS Office for Civil Rights, which is responsible for enforcement. The Office promises to focus its compliance efforts on larger covered entities—hospitals, managed care organizations, state agencies. But it will also review smaller practices or individual physicians if there's been a patient complaint. Doctors who refuse to initiate corrective actions voluntarily can ultimately be suspended from participating in Medicare and Medicaid.

While acknowledging their potential benefit to patients, physicians say the guidelines impose burdensome new costs, especially for doctors participating in the already squeezed Medicaid program. The AMA has asked for a moratorium pending review by the Bush administration.

—Wayne J. Guglielmo, Senior Editor

Gil Solomon, Elizabeth Pector. Why your patient won't let you touch her.

Medical Economics

2002;11:47.