Wednesday, April 09, 2008

Asking for Care, not Favors

The "voice" of the community is so important. We can learn so much when we listen to the struggles (and solutions) of the community from the community's point of view. Below is a recently published article written by one of the students who keeps me updated about her progress.

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http://virtualmentor.ama-assn.org/site/current.html
Virtual Mentor. April 2008, Volume 10, Number 4: 242-244.

Asking for Care, not Favors: Experience of Immigrants in the U.S. Medical System
Immigrant patients are often bewildered when they need to seek health care in the U.S., and that care usually comes from physicians who are unsympathetic to their plight.

Kimberly Aparicio

To this day, I get nauseated at the sight of the green cap from a bottle of Pompeian olive oil. Home remedies were the closest I got to visiting a doctor's office while growing up in inner city Dallas with an extended and ever-present Guatemalan family. For stomach aches the diagnosis was always "un empacho"—chronic indigestion—and, as much as I dreaded getting sick, my grandmother would do all she could to soothe my pains. She would start by massaging me with warm oil, then thump on my stomach to hear if it sounded hollow or obstructed. She would then pick me up by the skin of my back only to finally wrap my stomach with a tight cloth called an "ombliguero." The final step was drinking three to four teaspoons of olive oil with salt (while pinching my nose) to cleanse the digestive system.

Not many can say that their earaches were "cured" by inserting a large paper funnel into the ear with the outer tip burning to "suck out all of the bad air" that was causing the pain. By these and similar methods I managed perfect attendance throughout elementary school without ever seeing a physician. Although they arouse considerable humor now, the process of diagnosing and curing my illnesses was serious business. As I, now a medical student, reflect on those times, I realize that my attitude toward medicine was shaped not by a one-time epiphany but by the constant reminder of how different my experiences were from those of most of my classmates.

For my immigrant family there was no insurance policy, nor any savings account for emergencies—calling 911 was seen as especially wasteful because the bill would come later with a charge for the ambulance ride. As my father always said, "There is no money to get sick." What I had instead were the herbs, teas, ointments, and wonder pills from pharmacies in Mexico and Guatemala that ostensibly cured everything. Prayer for health was always a central part of my family's approach to illness. When a family member was pregnant, Parkland Hospital would deliver the baby. I grew up thinking that physicians were the people you went to when all the home remedies failed. Even trusting a physician was hard for my family, especially for my Spanish-speaking relatives, who often could not talk directly to their doctors.

When seeing a doctor did become necessary for my grandmother, I was the family translator, with the responsibility of telling the doctor her symptoms, no matter how personal, awkward, or uncomfortable it became for both of us. This arrangement was usually met with frustration by the doctor, who often responded demeaningly, as though just seeing us was doing us a favor. My grandmother never complained because she, too, felt as though he was doing her a favor. Practically, she had two options: She could either stop treatment and lose the progress she had made, or she could endure the scolding attitude from her physician because she had no where else to go.

After a certain point in her life, going to the doctor every couple of months became routine for my grandmother. When I couldn't accompany her, I would ask her what he had said about her illness, but she couldn't tell me because no one had translated for her. As she would later tell me, the trip was spent initialing some paperwork she didn't understand, sitting for hours in the waiting room, then seeing the doctor for 10 minutes only to be greeted with frustration, no explanation of her progress, and perhaps an identification bracelet as a souvenir. There was no end to this cycle, and each time it happened she missed work and spent money without learning anything about her health.

After being a long-time patient in the Parkland system and now a citizen of the United States, my grandmother recently opted to go to Guatemala for health care. She believed that doctors in the United States looked only at disease, processed her through the legality of the paperwork, and moved on. When she told me she was leaving for this reason, I couldn't help but think of the irony of it all. She rejected the health care system just as I, her trusted link to it, began the formal medical training that she had lost hope in.

Perhaps what I find most striking is that this isn't just a patient who is simply reluctant to follow doctor's orders. Rather it is a reflection of an ongoing lack of trust in the medical system on the part of the immigrant population, fueled in part by a lack of compassion, the very essence of the patient-physician relationship. While many will point out that the reasons why many immigrants are less likely to comply with medical advice are their legal status, culture, lack of education, inability to pay, and language barriers, we seem to neglect the possibility that the problems may begin at the bedside.

My experience as a medical student, as an employee in a hospital, and as an immigrant patient have provided me with valuable insight into the inadequacies of health care delivery and availability in the U.S. Having viewed the medical profession from these various perspectives, I have seen the difference in attitude that workers have toward the immigrant patient. There is not exactly a reluctance to diagnose and treat them, but bedside manner seems to be an unnecessary amenity for patients who "don't know the language and shouldn't complain because at least they're being treated." We would like to think that this attitude isn't lurking in our hospitals, but we know it is. The problem is not whether the immigrant population is receiving proper medical treatment, but the way in which we are administering it. By simply adopting the idea that "we are doing them a favor," medical systems create a barrier far greater than that posed by language difference. As a furious patient once told me after seeing her doctor, "I come here for help, not to be treated like a child for not knowing English."

What will happen in a couple of months when my grandmother returns from Guatemala, feels ill again, and goes back for treatment after having received medication and possibly even a different diagnosis from other doctors? As both her granddaughter and a medical student, this concerns me. To be sure, the immigrant population has to learn to trust the American medical system, but that trust must be earned. For their part, as the demographics of their patient population continues to change, American physicians must recognize that earning trust takes more than cold competence. No, their patients from the South will not expect their stomachs to be massaged and wrapped in ombligueros. What they will expect is to be treated with dignity and respect.


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Kimberly Aparicio is a first-year medical student at the University of Texas Southwestern Medical School and a 2006 graduate of Southern Methodist University, both in Dallas.
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