Doctor May Know Best, But Sometimes Patients Know Better

A community-health center in New Mexico shows how to overcome cultural barriers in providing quality care.

Command and compassion: Clinic director Lidia Regino (left) seeks help in recruiting volunteers from Leah Steimel of a local Latino group.
National Journal
Anne Snyder
See more stories about...
Anne Snyder
March 13, 2014, 5 p.m.

AL­BUQUERQUE, N.M. — Dilap­id­ated bill­boards and empty body shops, bare­foot smokers and cliques of trans­vest­ites. Not a fam­ily in sight. Cent­ral Av­en­ue, known loc­ally as the War Zone, shows all the wear of its of­ten hard­scrabble life. Poverty rates ex­ceed 50 per­cent, pros­ti­tu­tion and do­mest­ic vi­ol­ence abound, and un­doc­u­mented im­mig­rants flock to and from its weathered streets.

Amid dusty Ford pickups drop­ping off Latino work­ers while teen­age Nava­jos linger out­side a Vi­et­namese res­taur­ant, it’s hard to en­vi­sion a hub of a co­hes­ive com­munity. But turn left onto a quieter block of com­mer­cial gar­ages and one-bed­room houses, and a sal­mon-colored store­front guards an­oth­er world. It’s the neigh­bor­hood’s health cen­ter, called One Hope. Span­ish col­lo­qui­al­isms fill the air as the door opens to a som­brero-wear­ing pa­tient ac­cept­ing cof­fee from a re­cep­tion­ist jug­gling clip­boards and a baby. In the wait­ing area, out­fit­ted like a fam­ily room with so­fas and art­work, a cork­board pro­claims the clin­ic’s eth­os: “Love is the key to life.”

Born dir­ectly out of needs that are loc­ally defined, One Hope of­fers an an­swer to a puzzle seen around the na­tion. The United States con­tin­ues to face stark dis­par­it­ies in health out­comes along lines of in­come, race, and eth­ni­city. But these dis­par­it­ies aren’t al­ways driv­en by eco­nom­ics or geo­graphy. Some­times, the obstacle is cul­tur­al. A Somali wo­man in the U.S. can’t keep wait­ing to give birth as her moth­er did if labor that goes on “too long” com­pels a Cesarean sec­tion. When a Hmong fath­er be­lieves the body con­tains a fi­nite amount of blood that won’t re­plen­ish, he in­ter­prets a re­quest for a sample of his sick child’s blood as a grisly joke and is un­likely to re­turn to the hos­pit­al.

As this na­tion of im­mig­rants grows ever more di­verse, these clashes of world­view are bound to be­come in­creas­ingly com­mon. Train­ing ses­sions in so­cial and cul­tur­al idio­syn­crasies may help, es­pe­cially if ap­plied to spe­cif­ic groups. But the les­son of One Hope is that an­thro­po­lo­gic­al pars­ing gets you only so far. Something deep­er is re­quired to bridge these gaps, and it’s anchored in trust.

“We’re ba­sic­ally the med­ic­al home for a lot of people,” says Lidia Re­gino, One Hope’s dir­ect­or. “And I mean home.

The clin­ic’s concept is simple, sus­tained by a simple for­mula: Ask the com­munity what it needs, and work with res­id­ents to cre­ate it. In 2005, a health work­er, tired of get­ting so little ac­com­plished as the neigh­bor­hood de­clined, tapped in­to a com­munity-de­vel­op­ment group called East Cent­ral Min­is­tries. To­geth­er, they in­vited a few dozen res­id­ents to a com­munity-health fair, and 250 people showed up, along with curi­ous rep­res­ent­at­ives from the city’s big hos­pit­als.

As people gathered at the fair, Re­gino re­calls, “all these things star­ted com­ing up: ‘Dia­betes is every­where.’ ‘My fath­er has high blood pres­sure.’ ‘We’re afraid and hope­less.’ ‘Doc­tors turn us away if our hus­bands haven’t got­ten paid.’ ‘Re­cep­tion­ists don’t speak our lan­guage.’ ‘They’re mean and ask for So­cial Se­cur­ity num­bers.’ ‘We don’t have trans­port­a­tion.’ ‘Nurses don’t re­spect us.’ “

“Loc­als,” she con­cludes, “were look­ing for a place to feel iden­ti­fied with.”

East Cent­ral Min­is­tries helped find a space for the clin­ic and hired Re­gino, now 41, and three oth­er trained com­munity-health work­ers nat­ive to the area. Re­gino is as com­mand­ing as she is com­pas­sion­ate. She’s the only staff mem­ber with a bach­el­or’s de­gree, but all of them speak Span­ish and need no text­book to “get” the neigh­bor­hood’s cul­tur­al rhythms. Nu­tri­tion­al habits don’t faze them — they share their pa­tients’ love for plantains and carb-heavy fies­tas — and they un­der­stand what it’s like be­ing strapped for money. In­stead of ask­ing new pa­tients scary ques­tions, the re­cep­tion­ist of­fers an apple.

“I tell pa­tients every day, ‘I’m just like you,’ ” Re­gino says. ” ‘I’m strug­gling not to drink that Coke, too.’ “

OVER­COM­ING MIS­TRUST

Big hos­pit­als of­ten aren’t nimble enough to ad­dress the fuz­zi­er dy­nam­ics of pa­tient cul­ture, and ac­cred­ited med­ic­al schools re­quire noth­ing more than a gen­er­ic “cul­tur­al com­pet­ency” course fo­cused on mul­ti­cul­tur­al sens­it­iv­ity. That’s left much of the most in­nov­at­ive bridge-build­ing to smal­ler, usu­ally non­profit, or­gan­iz­a­tions that are agile and cul­tur­ally at­tuned.

The bar­ri­ers are evid­ent coast to coast. In and around De­troit, Ar­ab-Amer­ic­an wo­men were dia­gnosed with ad­vanced breast can­cer at far high­er rates than oth­er Michigan wo­men be­cause they wer­en’t get­ting mam­mo­grams, re­search­ers found in 2010. Why? The pro­ced­ure em­bar­rassed them, and many be­lieved that di­vine will or trapped nerves caused can­cer. More and more Nat­ive Amer­ic­ans, an­oth­er study found, ig­nore their phys­i­cians’ in­struc­tions after tak­ing of­fense at how they’re viewed. “I went to see a doc­tor for a back prob­lem,” a study par­ti­cipant said, “and he ste­reo­typed me as an In­di­an who was over­weight and likely to get dia­betes.”

These aren’t prob­lems that more money or ex­pan­ded in­sur­ance cov­er­age will ne­ces­sar­ily re­solve. Five miles from One Hope, at the Uni­versity of New Mex­ico’s Health Sci­ences Cen­ter, Jes­sica Good­kind is a com­munity psy­cho­lo­gist and the colead­er of a ground­break­ing 2008 re­search pro­ject called Pro­ject TRUST. The pro­ject began as a re­sponse to rising be­ha­vi­or­al health prob­lems among Nat­ive Amer­ic­an youth, but its find­ings have ex­ten­ded to eth­nic and ra­cial minor­it­ies of all de­scrip­tions.

“We be­gin from the premise that every pro­vider-pa­tient in­ter­ac­tion is a cross-cul­tur­al in­ter­ac­tion,” Good­kind says. “But it’s not, ‘Here’s what you should know about this group.’ ” In­stead, she says, the key is re­cog­niz­ing that trust is at the heart of every suc­cess­ful in­ter­ac­tion, and mis­trust is at the cen­ter of every bar­ri­er.

For Amer­ic­an In­di­ans, the cul­tur­al bar­ri­ers are of­ten pro­found. In a coun­try where West­ern medi­cine pre­vails, tra­di­tion­al Nat­ive Amer­ic­an prac­tices and ce­re­mon­ies are treated as sup­ple­ment­al — or su­per­flu­ous.

“For ex­ample, in men­tal health now, the as­sump­tion is that self-ref­er­en­tial talk is help­ful,” says Joseph Gone, an as­so­ci­ate pro­fess­or of psy­cho­logy and Amer­ic­an cul­ture at the Uni­versity of Michigan. “But for many Nat­ive Amer­ic­ans, talk is a form of ex­pres­sion that can al­ter real­ity. There’s a mor­al do­main of who you share what with.” Reti­cence can frus­trate the main­stream treat­ments for men­tal ill­ness and sub­stance ab­use.

“WE SET THE RULES”

A typ­ic­al ap­proach to sur­mount­ing cul­tur­al bar­ri­ers is on dis­play in Al­buquerque’s South Val­ley, at a clin­ic called Casa de Sa­lud. It boasts shiny new fa­cil­it­ies and a pas­sel of med­ic­al-stu­dent in­terns. The dir­ect­or brags about the clin­ic’s polit­ic­al ad­vocacy work and the “su­per­i­or work­force de­vel­op­ment” of its in­terns. But its ser­vices seem geared more to­ward push­ing pa­tients in and out rather than en­ter­ing their lives and delving in­to the roots of their health woes.

At One Hope, people are made to feel com­fort­able as soon as they walk in the door. A boom box plays Lat­in rhythms, and a cof­fee­pot brews next to bowls of grapes and straw­ber­ries. Pa­tients are asked to pay $20 and, if they can’t, the fee is waived. Most people have been here be­fore, and the staff ad­dresses them by name. A re­cep­tion­ist asks a young moth­er if her Uncle Ant­o­nio has found that job at Carl’s Jr., the fast-food chain. To oth­ers: “How is your com­mit­ment to eat break­fast go­ing?” “What col­or is Rosa’s quinceañera dress?” At night, the clin­ic holds classes on dia­betes and dent­al hy­giene, where health care pro­viders join the pa­tients in eat­ing wrap sand­wiches provided by One Hope. Doc­tors and nurses come to the clin­ic in the even­ing; for day­time emer­gen­cies, pa­tients are re­ferred to pro­viders out­side.

“It’s a power shift,” Re­gino says. “We set the rules in the clin­ic. We have the au­thor­ity to dir­ect a pro­vider to do three [lab tests] on a pa­tient, not 20. The pro­viders are our col­lab­or­at­ors. If they have a ques­tion about a pa­tient, they come and con­sult with us. If a pa­tient comes in with an is­sue, we typ­ic­ally already know the health back­ground be­hind that is­sue. We also know about a pa­tient’s em­ploy­ment situ­ation, about his wor­ries, and his niece’s quinceañera” — a Lat­ina’s com­ing-of-age cel­eb­ra­tion. The clin­ic staff briefs the doc­tor or nurse, so that the pa­tient’s cir­cum­stances are taken in­to ac­count.

A dis­tinct­ive as­pect of One Hope’s care is called Sali­das — the exit in­ter­view. After see­ing a pro­vider and get­ting treat­ment, pa­tients will enter the Sali­das room with Re­gino and tell her how they’re feel­ing, as­sess their pro­vider’s care, and maybe con­fide what’s go­ing on in their lives that could hinder fol­low-up treat­ments. Re­gino shapes the in­ter­view to fit the pa­tient, and she has gained the cred­ib­il­ity to chide them if ne­ces­sary — to en­cour­age or cor­rect them. This takes trust.

“The Sali­das is all about the per­son, not just their health,” she says. “It’s a very vul­ner­able space — a lot of people cry. They may be em­bar­rassed that they don’t have the money to pay the $20, not want­ing to say so. I just tell them they don’t have to be em­bar­rassed with me, that I’m part of this com­munity, that I know what’s go­ing on, and I un­der­stand. It’s like we’re two friends talk­ing.”

This per­son­al touch is hard to scale up, however. Nor is it easy to rep­lic­ate Re­gino, with her edu­ca­tion and her will­ing­ness to re­main near home. The clin­ic also has the ad­vant­age of be­ing fun­ded and born out of a com­munity or­gan­iz­a­tion that already main­tained loc­al re­la­tion­ships and pur­sues a mis­sion that tran­scends med­ic­al care.

Still, the clin­ic’s suc­cess sug­gests that, for cul­tur­ally di­verse pa­tients, truly ef­fect­ive health care re­quires an un­der­stand­ing of their per­son­al lives. It also shows that the sort of com­munity health work­ers One Hope em­ploys — lack­ing a bach­el­or’s de­gree and eas­ily avail­able loc­ally — provides an af­ford­able and work­able means to ac­com­plish this. These em­ploy­ees ex­tend the reach of doc­tors and nurses, and even en­hance col­lab­or­a­tion between them; nor are they ter­rit­ori­al about med­ic­al spe­cial­ties in a way that all too of­ten hinders the flow of care.

In Den­ver, at an out­reach pro­gram run by com­munity-health work­ers for men in need of med­ic­al care, a study found a re­turn on in­vest­ment of more than $2 for each dol­lar in­ves­ted. In Min­neapol­is, com­munity-health work­ers have per­formed 18,000 home vis­its since 2004, reached 135,000 in­di­vidu­als with in­form­a­tion and edu­ca­tion, and re­ferred more than 2,100 smokers to to­bacco-ces­sa­tion pro­grams.

At the heart of ef­fect­ive com­munity health is the step-by-step pro­cess of build­ing a re­la­tion­ship between work­er and pa­tient. One re­cent even­ing, after a dia­betes clin­ic at One Hope, a man named Eduardo asked to have his sug­ar levels checked, and a nurse took him to a private room. Thirty minutes later, he re­turned and high-fived the re­cep­tion­ist who was clear­ing the re­mains of the even­ing’s wheat wraps.

“Six A1c’s!” he de­clared in Span­ish, grin­ning at his en­vi­able blood gluc­ose levels.

The re­cep­tion­ist stopped what she was do­ing and re­turned his smile. “Fe­li­cid­ades, Eduardo!” she replied.

Which meant that Eduardo would prob­ably come back to One Hope, for it is a place where — as Re­gino sug­gests — the pa­tients wind up “feel­ing em­braced, feel­ing like some­body cares.” 

——————————-

The au­thor is a freel­ance writer liv­ing in Hou­s­ton.

What We're Following See More »
“PROFOUNDLY DANGEROUS”
Clinton Rips Into Trump
3 hours ago
THE DETAILS

Just a day after Donald Trump called her a bigot, Hillary Clinton delivered a scathing speech tying Trump to the KKK and so-called “alt-right.” This new frontier of debate between the two candidates has emerged at a time when Trump has been seeking to appeal to minority voters, among whom he has struggled to garner support. Calling him “profoundly dangerous,” Clinton didn’t hold back on her criticisms of Trump. “He is taking hate groups mainstream and helping a radical fringe take over the Republican Party,” Clinton said.

SEVEN-POINT LEAD IN A FOUR-WAY
Quinnipiac Has Clinton Over 50%
6 hours ago
THE LATEST

Hillary Clinton leads Donald Trump 51%-41% in a new Quinnipiac poll released today. Her lead shrinks to seven points when the third-party candidates are included. In that scenario, she leads 45%-38%, with Gary Johnson pulling 10% and Jill Stein at 4%.

Source:
PROCEDURES NOT FOLLOWED
Trump Not on Ballot in Minnesota
8 hours ago
THE LATEST
MIGHT STILL ACCEPT FOREIGN AND CORPORATE MONEY
Chelsea to Stay on Board of Clinton Foundation
8 hours ago
THE LATEST

Is the Clinton family backtracking on some of its promises to insulate the White House from the Clinton Foundation? Opposition researchers will certainly try to portray it that way. A foundation spokesman said yesterday that Chelsea Clinton will stay on its board, and that the "foundation’s largest project, the Clinton Health Access Initiative, might continue to accept foreign government and corporate funding."

Source:
INTERCEPT IN MIDDLE EAST
Navy Calls Iranian Ships’ Actions Dangerous, Unprofessional
9 hours ago
THE LATEST

"Four Iranian ships made reckless maneuvers close to a U.S. warship this week, the Pentagon said Thursday, in an incident that officials said could have led to dangerous escalation." The four Iranian vessels engaged in a "high-speed intercept" of a U.S. destroyer in the Strait of Hormuz. A Navy spokesman said the Iranina actions "created a dangerous, harassing situation that could have led to further escalation including additional defensive measures" by the destroyer.

Source:
×