The Census of 1990 reported the total population of the state of North Carolina as 6,632,448. Of this, roughly 1% or 76, 745 were Hispanic. Between 1990 and 1998 the total population of the state increased by 13.8%. During the same time, the total Hispanic population of North Carolina increased by 110.1%. In the community of Chapel Hill, where the University of North Carolina has its medical school, the newest elementary school, which opened its doors the current academic year, has a larger percentage of Spanish speaking children than any other ethnic group. In Siler City, where the Klan met in protest, 41% of the children in the local elementary school are Spanish speakers. In the eastern counties of the state, the last hurricane season destroyed entire farming communities, precisely where thousands of Hispanic migrant workers earned their livelihood. Within this context of growth and challenge, the health care community has rushed to find solutions for the problems of communication that naturally arise in situations where cultures come in contact.
The North Carolina Area Health Education Center Program, based at the University of North Carolina at Chapel Hill School of Medicine, recently received a $498,000 grant from the Duke Endowment to fund the AHEC Spanish Language and Cultural Training Initiative: Improving Access and Quality of Care for Latinos in North Carolina. Community organizations of all kinds offer translation and interpreting services at cost or through volunteers. The University of North Carolina system is promoting service-learning curricula and is involved at the highest administrative levels in developing outreach programs to support the organizations working with the Spanish speaking population. But this willingness of organizations and individuals is often hampered by lack of information. What does the new arrival need? What previous experiences with medical care may color the relationship between Spanish speaking patients and the US providers?
Our immediate problems stem from the newness of the experience. There is no blueprint for the effort to accommodate a large population who not only speaks a language other than English, but can be expected to place a high value on its native culture and defend its diversity. Research in the United States has focused so far mostly on Spanish speaking populations in large urban centers, unlike the towns and cities of North Carolina. Our health care providers, teachers of language and program developers need more specific descriptions and pertinent guidance regarding the character and experiences of the Spanish speaking individual in distress.
This study is an effort to repair the information void. Although all Hispanic cultures are unique, they share a language and some fundamental cultural beliefs that stem from a common Spanish heritage. The choice of Puerto Rico as study site was predicated on the most recent common history of the island and the United States. Puerto Rico is a Commonwealth of the United States, a political status which resulted in the development on the island of a health care system patterned after the US standard of care and support. Puerto Rico has both Medicare and Medicaid, private insurers, and a Department of Public Health originally patterned after the US Department of Health and Human Services. In 1966 the Recinto de Ciencias Médicas was created by law as an independent unit of the University of Puerto Rico, the island's public university system. This institution is accredited by the
Commission on
Higher Education, Middle
States Association of Colleges and Schools, and the Association of
American
Medical Colleges1.
Doctors in Puerto Rico are licensed through the United States Medical
Licensing
Examination Board. As a result, the Puerto Rican patient sees the
same clinical procedures and professional strategies that are found in
comparable practices in the United States. Our hypothesis
is
that differences in the doctor-patient relationship will be due to the
culture. The goal of the study
The primary goal of this study is to shed light on the nature of the doctor-patient relationship, which we see as the core of the entire health care experience. It is documented that a patient's culture can shape his concept of disease, treatment, and perception of illness, and that it can affect the interactions with the caregiver (Molina 1994, 25). Cultural differences can alter the approach that a physician uses with a patient. What is respectful to a non-Hispanic physician may not be to a Hispanic patient. For example, published studies indicate that the man of a Hispanic household, and not the patient, should be addressed directly by the physician in order to respect the social structure(Coreil 1990, 3-27). Other studies suggest that a physician caring for a Hispanic patient should always be aware of the use of home remedies, and should question that patient specifically (Angell and Kassirer 1998). Despite their obvious relevance, these observations are fragmented and lack coherence. We were interested in discovering the more holistic aspect of the clinical experience. What does a Hispanic patient expect from the care giver, based on previous experiences in the country of origin? What can the US doctor do to make the Hispanic patient feel better cared for?.
The method
Emili had contacted the physician earlier by mail and by phone and agreed on a continuous, two-month visit to observe his work and assist in his practice. Her spoken Spanish was at an advanced intermediate level and improving her command of the language with the ultimate career goal of practicing family medicine in North Carolina, was overtly the primary justification for her request to the physician and her interest in his practice 3.
The Census of 1990 reported 58.4% of the families in the town of Toa Alta had incomes below poverty level in 19894. Approximately 50 physicians service this community, and yet it still feels like a small town. The majority of the population commutes to San Juan for work, shopping, recreation, and medical care.
The physician's office, is located in a one story, flat roofed, cement house like most others in the town. The waiting room used to be the living room. It opens onto a front porch that is literally a stone's throw away from the town square, or plaza. None of the furniture matches. A fan stirs the hot, humid air. Many plaques hang on the walls and testify to the experience of the physician: a diploma from the University of Bologna 1953, Charter Fellow, American Academy of Family Physicians 1974, framed letters from patients thanking Dr. Ortiz for
When the door opens in the hallway that extends
from the waiting room, two voices are heard engaged in a dialogue in
Spanish.
Instantly two people emerge: Dr. Ortiz is easy to identify by the
stethoscope
draped around his neck, and by the way all attention focuses on him. He
is not wearing a lab coat, but a white guayabera. This is a
straight,
long-sleeved shirt, worn over the trousers; made of cotton and open at
the neck, with small tucks and embroideries down the front.
Guayaberas
are common formal attire in the Spanish-speaking Caribbean.
