Monday, December 13, 2010

Cultural Differences

While working in a retail health clinic I walked into an exam room to see my next patient on a late Sunday afternoon. 
My patient was a 6 year old whose primary language was Spanish.  He was present with his mother who only spoke Spanish.  The 6 year old, whom I’ll call Jose, also spoke some English. 
His mother spoke to me in Spanish, “Mi nino esta es fevaro y vomito.”  (My son has a fever and is vomiting).
Knowing very little Spanish myself, I replied, “Un momento.”  (Hold on a minute).
With that I picked up the telephone and called our translation service, they would then be able to act as a translator between myself and Jose’s mom.  After letting the translation service know what language I needed, they switched me to a translator who could ask Jose’s mom in Spanish any and all questions I had for her as well as translate any questions and answers she had for me.  So during the course of our conversation Jose’s mom and I were continually handing the phone receiver back and forth between us.
I turned to Jose’s mom and asked, ‘Que problema?” (What is the problem?)
She responded, “my son has a fever, he’s been vomiting, and he has a sore throat.”
“Anything else?”
Yes, he says his head hurts, his nose has been runny and last night he started coughing.”
“How long has he been sick?”
“This is the third day, he started getting sick on Friday morning when he said his throat hurt, and the school called me later that day and asked me to come and pick him up, he was running a fever.”
“Okay.  Well it sounds as though he has the swine flu which is going around the schools like crazy right now.  But let me first ask you some more questions about any medications he’s on, allergies he may have and then I’ll do a physical exam.  After that, if need be I can also do a quick ten minute test to make sure it’s the flu and then we can talk about how to treat it.”
I had barely been able to finish relaying this information to Jose’s mom via the translator, when Jose just burst out crying and yelling in Spanish, “Mama, she said I’m going to die.  I don’t want to die!”
I immediately asked the translator (on the phone) whether she heard what Jose had said.  Thankfully the translator had heard it, and told me in English what he had said.
At this point, Jose’s mom was in tears. 
Suddenly, I had two very upset people in the exam room.  I had to do some quick thinking.
“Why all the tears?”
Jose spoke, “The TV says there are people who are dying from the swine flu.  I don’t want to die!”
“Okay, I understand.  First off, Jose we’re going to treat you with Tamiflu, the medication that we use for the swine flu.  Secondly, you are a healthy kid, you don’t have asthma or diabetes which the kids who have died have had.  It’s been the reason the kids you’ve heard about on TV have died.  Do you understand that, Jose?”

With sniffles, Jose mumbled, “I think so.”
“What part of this don’t you understand?”
“It’s just that’s all I hear on theTV.  All of these people who are dying from the flu.  I’m scared I’m going to die.”
I got up out of my seat, took a step towards Jose who was sitting on the exam table and leaned down to look Jose in the eyes.  Keeping eye contact with him, I told Jose emphatically, “You’re not going to die from the flu, Jose.  The tamiflu you’re going to take is going to take care of the flu.  The tamiflu is going to make you feel better in two days, do you understand?”
I turned to look at Jose’s mom who was trying to stifle her sniffles.  I picked up the phone receiver again and asked the translator to tell Jose’s mom what I had just explained to Jose in English, which he understood in his broken English. 
I gave the phone receiver to Jose’s mom and she listened to the translator explain to her in Spanish about the tamiflu, how Jose should take it, what to expect and about when he will begin feeling better.
I spoke to the translator, “Please make sure that Jose’s mom understands that Jose is not going to die, that he doesn’t have asthma or diabetes as the other kids who have died from the flu have had.  Therefore what she has heard on the TV is not going to affect her family.”
I gave the phone receiver back to Jose’s mom.  I watched her facial expressions relax as she heard the translator explain to her what I had just emphasized with her.
Fourty-five minutes later, Jose and his mother finally felt comfortable enough with all of their questions answered, tamiflu prescription in hand to leave the exam room.  As per usual, his mother received a call two days later as a follow-up.  She was relaxed and happy to report that he was feeling better and was going back to school tomorrow.

 Primary care clinic visits are scheduled every 15-20 minutes.  Typically within this time period a clinician is supposed to be able to proceed through the patient’s history, physical exam, treatment plan and dispense out any prescriptions the patient needs.  Most of the time this 15-20 minute time slot per patient works.  Unfortunately, usually at least once a day a clinician comes across a patient who takes longer than 15-20 minutes and then the clinician’s schedule is thrown off for the rest of the day.

It would have been unfair and rude for me to cut short Jose and his mother.  I wouldn’t have been able to pursue what was at the root of the problem with Jose and his mother.  I wouldn’t have been able to address the misinformation Jose and his mother had heard via the national/local media about the swine flu. 

Thankfully, I was also able to discuss their misinformation via a translator, which not every primary care office has access to.  I was able to make sure that they understood in words that they comprehended what to do about Jose’s flu, how to take the medication to rid his system of the flu and finally address Jose’s fear of dying.  But, alas all of this takes time, time that is not allotted on the clinic schedule.  Using a translator takes time, addressing a patient’s fears takes time, addressing misinformation takes time, doing patient education takes time.  As a clinician you never know when you are going to come across a patient who needs that extra time, and if you don’t give it to them, you are doing them a grave disservice. 

But time is the one thing that insurance companies, Medicare won’t let you bill for.  You can only bill for one patient encounter at a certain level of complexity, whether it took you 10 minutes, 20 minutes or 45 minutes like in my case.  Your re-imbursement is the same.  In specialty care, the physician can bill for procedures they have done, surgeons can bill for surgical procedures they have done, but primary care physicians who are the gatekeepers of medicine, isn’t their time just as valuable? 

What would Jose and his mother thought of me had I not spent that extra time with them?  I doubt that Jose would have taken the tamiflu, I doubt that he would have been able to calm down and not think he was going to die at any moment, and I can believe that Jose’s mom probably would have left the exam room thinking I was just another example of a rude clinician who didn’t want to talk to her because she spoke Spanish whereas I spoke English.

Primary care clinicians are the gatekeepers of medicine.  If we do our job correctly, ethically and with compassion we can prevent a lot of long-term complications in our patients by allowing them to understand their disease, what to do about it and how to address it.  If we spent the time doing appropriate patient education and counseling who knows how many patients we can spare from having open heart surgery (because they have taken their blood pressure medications, their cholesterol medications), going on dialysis because they have taken their diabetic medications and lost their extra weight, etc. 

If only the insurance companies and Medicare would also understand this, we’d all be better off.

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