Medical Student Perspectives: Cultural Differences and Considerations When Working with Hispanic Patients.
The American College of Physicians has been an early proponent of the need for cultural competency, as reflected by its 2003 position paper, “Race and Ethnic Disparities in Health Care.” The Hispanic population is the fastest growing racial group in the U.S., with a projected 25% of the U.S. population being Hispanic by 2050, according to the U.S. Census Bureau’s 2000 report. This brief introduction is intended to be a framework for awareness of concepts and preferences of Hispanic patients. It bears saying that in any culture, while one size does not fit all, awareness of cultural norms is the starting point for a respectful and effective relationship.
The Language Barrier
Working with an interpreter for a non-English speaker: If translators are provided by your hospital or clinic, be sure to use their services. Their training is focused on medical Spanish and they also understand the legal framework of the situation. If a professional translator is not available, then you must fall back on a family member of the patient, if one is available. If you must use a family member as translator, you should be aware that a family member of any cultural background has limited knowledge of medical terminology and a tendency to “soften” questions or statements that he or she perceives as having potentially negative consequences. There may also be issues that the patient does not want the family member to know, so the patient may not be totally forthright in answering sensitive questions.
Working without an interpreter: If no family member is available, then your Spanish from that spring break in Cozumel back during your undergrad years will come in very handy. Have a pocket reference close by; several good ones are available, but make sure that the focus of your reference book is on medical Spanish. The best references come with pre-written dialogues that can walk you through an interview. Try to conduct an imaginary interview or two as a decision aid for choosing the right reference book.
Introducing yourself: Set the stage with a formal and polite introduction. State your name and role, then ask the patient what he or she prefers to be called. Make sure that the patient understands the flow of a visit, especially in a teaching hospital, where more than one person will be coming to talk to the patient.
Taking a history: While you are taking the patient’s history, be sure to keep in mind there is a high possibility that the patient is using botanical or herbal remedies. You should also be aware of the regional names for common ailments and symptoms.
A recent study published in the February 2006 issue of Texas Medicine found that 79% of the patients surveyed were taking an herbal remedy at the time of their visit, and a similar study found that educational background, citizenship, and work status were poor predictors of the use of botanicals. Following is a list of five of the most common herbal medicines used by Hispanics, including their potential interactions and side effects.
Manzanilla means chamomile. Chamomile is used as a tea for its sedative effects, or topically as an antiseptic, including vaginally for candidiasis. The most common side effects are allergic reactions and uterine contractions.
Aloe Vera is used topically as anesthetic or internally as a laxative due to its mildly irritant effect. Aloe Vera increases the hypoglycemic effects of antidiabetic drugs and hypokalemic effects of diuretic drugs.
Barbas de Elote means corn silk. Corn silk is ingested as a tea for urinary tract irritation; often causes inflammation of the urinary tract.
Eucaliptus Alcanfor means eucalyptus and camphor. This combination is commonly brewed as a tea or used as a liniment, similar to Vick’s Vapo Rub, for stimulating mucus clearance and circulation. Eucalyptus and camphor can be toxic if ingested in large doses, but it is commonly reported that children are given ointments such as Vick’s Vapo Rub orally for colds and fever. Eucalyptus interferes with P450 metabolism and is neurotoxic.
Common Latin Symptoms
The following are different or unusual names given to symptoms. Some are related to cultural beliefs and others are merely names that do not commonly appear in dictionaries or other resources. These terms are not diagnostic, or specific to any one cause, but rather commonly understood terms for a symptom or a suite of symptoms.
Ronchas or Comezones are boils or sites of skin irritation that have an element of itching or inflammation.
Mal de Ojo means the “Evil Eye,” an unexplained catch-all for illnesses in children. The belief that a curse can be placed on someone or transmitted by looking at the person is especially prevalent in immigrants from Haiti and the Dominican Republic.
Bilis literally means “bile.” This term can stand for either anger or acid reflux, or especially the two in conjunction. This stems from the old belief that the four humors control temperament.
Empacho means “impaction,” gastrointestinal discomfort characterized by distension and discomfort. This is frequently attributed to eating too much at one sitting or eating new foods.
Catarro is a broad term for sore throat. You must ask for a clear characterization of symptoms in order to determine what the patient means when using this term.
Gripa or Gripe is a broad term for flu-like symptoms.
Making Medical Decisions
Always ask patients who they would like to help them make any medical decisions. Often, contrary to our training, the family likes to be informed of bad news before the patient, and the best way to deal with this is to ask the patient if you can share information with the family first. Do not plant the idea of “bad news” specifically in the patient’s mind, but obtain permission for the family to be informed first while the family is present to witness the patient’s wishes. Commonly, the father is the head of the home, and family members defer to his judgment. If this is the case and the patient has agreed, include the father in decision-making and discussions at the earliest phase possible. Recognize the father’s role as the head of the household by greeting him formally and shaking his hand firmly at the beginning of each visit.
Only recently have we as physicians started to realize the importance of cultural competency in medicine. In order to ensure the quality of care and gain patient trust and compliance, we must be culturally competent. In their 1983 article in the Western Journal of Medicine, Berlin and Fowlkes suggest using the LEARN acronym to foster the ongoing improvement of cultural competency.
Listen with sympathy and understanding to the patient's perception of the problem.
Explain your perceptions of the problem and your strategy for treatment.
Acknowledge and discuss the differences and similarities between these perceptions.
Recommend treatment while remembering the patient's cultural parameters.
Negotiate agreement. It is important to understand the patient's explanatory model so that medical treatment fits in his or her cultural framework.
Council of Student Members Representative, Southwestern Region
Texas College of Osteopathic Medicine, 2009
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