October 2002 Bulletin

Culturally competent patient encounter tips Enhance communications with your Hispanic and Latino patients

By Ramon Jimenez, MD

P. Tumulty 

This outline was prepared based on my 30 years of patient encounters (over 100,000) while in practice in Northern California, where Latinos make up one-third of the population. I also have done research and presented several papers on culturally competent care. Bayer Institute’s "Clinician-Patient Communication Course" was also at the basis of this work.

The Hispanic/Latino population is significant and growing in the United States. It now represents 12 percent or 34 million people—it is the largest minority and in a few decades, 25 percent of the US population will be Latino. Presently, only 2.4% of orthopaedists are Latino. Consequently, the non-Latino orthopaedist has to be prepared to effectively evaluate and treat the Latino patients he or she will increasingly encounter.  

Culturally competent care is defined as a complex integration of knowledge, skills and attitudes that allow health care providers to understand and take care of people who are from cultures that are not their own. In this document you will find several patient encounter tips to help you improve your communication with Latino patients. Compassion and communication are essential ingredients for success. 

At a typical patient encounter, you are likely to find one to three family members with the patient in the examining room, especially if the patient is a woman. Don’t walk into the room looking at the patient’s chart, even if you are trying to figure out how to pronounce the name. Practice name pronunciation and review the patient information before you enter the room.

Latino patients hold physicians in great respect—the doctors in their home country practice paternalistic medicine.

Although not entirely necessary, "Buenos días" (Good morning) or "Buenas tardes" (good afternoon) is simple enough and effective. 

Greet the patient with "Senor" or "Senora" Rodriguez; "Yo soy, Doctor Watson." (Senorita for single females. However, if you are not sure, it is better to say "Buenos dias, yo soy el doctor….)

Make sure to greet and acknowledge everyone in the room, even the children. They will immediately accept you as warm and compassionate. Do not act rushed during the appointment.

Try to establish who is going to be the interpreter before you enter the room (sometimes this is not possible) or immediately after introductions. If it is one of your staff, introduce him or her to the patient and/or family. In all of your communication with the patient, do not relate with the interpreter, relate to the patient—the interpreter is purely an instrument or communication tool. It is preferable not to use a family member, but sometimes there may be no choice.

Speak to your patient as if he/she understands your message. The interpreter should translate your messages in the first person. Make sure the patient responds to your questions through the interpreter. Do not allow the interpreter to respond to your questions without the patient answering your questions or replying to your comments. 

Any efforts you make to speak Spanish is admired and appreciated by your Spanish-speaking patients.

Latinos/Hispanics prefer to be addressed by their country of origin: they are "Cubans," "Salvadorans," "Mexicans," and so forth. It is culturally courteous to address your patients by their country of origin. Therefore a good introductory statement is to ask them their country of origin. 

Take some interest in their culture and after a few repeat patients from the same country, you will have a common point of familiarity. Do some light research on that country—you may be surprised and, maybe, discover a new world. In any case, your patients will admire and appreciate your sincere efforts. Latinos and Hispanics are happy when called "Americanos" since their country of origin is, in fact, in the "Americas."

Pitfalls and practical tips

1. Do not ask your patient—"How are you?"—"Como está usted?" For a Latino or Hispanic person these phrases are greetings, and not questions. They may answer, "Fine… how are you?" It is better to ask them—"How can I serve (help) you today?" "Como te puedo sevirle?"
2. Hispanics and Latinos frown upon instant familiarity, especially when meeting a new person (e.g. at the time of the initial office visit). Formality is a sign of respect and deference when you do not know someone well. The Spanish language differentiates between the formal and the familiar forms of salutations—"usted" (more formal) versus "tu" (more familiar).
3. Latino family names and surnames can be confusing. To correctly address your Hispanic or Latino patients, keep the following example in mind. The patient’s name is Maria Guadalupe Rodriguez Santos. Her first name is Maria; middle name is Guadalupe; surname (last name) is Rodriguez; and she is from the family of "Santos." Rodriguez is her married name, so she is Senora Rodriguez.
4. After you have explained something to your patient, do not simply ask the question—"Do you understand?" Your Latino or Hispanic patients are too proud to show that they do not understand, and will just nod affirmatively. Use comprehension checks such as, "In your own words, tell me what I said or what I am proposing to do."
5. Do not stereotype. Stereotyping uses the racial or ethnic background of an individual as simplistic, straightforward predictors of beliefs or behaviors. This leads to culturally insensitive care and is harmful to patients, and, in particular, to the physician–patient partnership.
6. Be knowledgeable of the fact that Latinos embrace alternative therapies, such as massage therapists (sobadores) and healers (curanderos). Herbal remedies are second nature to Latinos and these alternative medicines are typically found in neighborhood stores (botanicas). 
7. The Latino family unit has well-defined gender roles. The man is the provider, protector and the authority figure. The woman is the homemaker, child raiser and subservient supporter. Although the Latino male aims to be macho (stoic and courageous), this is counterbalanced by his innate fear of physical incapacitation and death. You must be extra careful to educate Latino males regarding any proposed surgery. On the other hand, be aware that a Latino woman will not consent to any significant treatment without the specific permission of her husband.

Imagine yourself in a foreign country surrounded by people speaking a foreign language that you do not understand. Imagine further that you need medical services. Sounds like a pretty scary thought. For you, your Latino/Hispanic patient, or any patient for that matter, a warm smile and an attitude of compassion and concern will go a long way toward creating a sense of trust.

Try to be aware of the fears and attitudes your Latino patients may have in regard to:

• Injury—Loss of body image 
• Disability—Loss of livelihood 
• Death—No provider or matriarch
• Laboratory tests—Skeptical unless informed
• MRI and CT scans—Claustrophobia 
• Medications—Traditional belief in and usage of herbal therapy 
• Surgery—Fear release of evil humors and drastic poor outcome 

All of these can be alleviated by communication with the patient, utilizing the technique of education.

Use simple drawings or anatomical pictures, or better yet, models to explain your diagnosis and/or proposed treatment. Most of the information you impart will not be retained, so enhance it with "take home" information, such as a Spanish written patient education brochure or fact sheet.

For your Internet savvy patients, provide information on what is available through the AAOS patient education Web site—Your Orthopaedic Connection. The address is http://orthoinfo. aaos.org. There are approximately 20 topics en español and more are being developed. If your patient does not have Internet access, print out a copy from your office computer.

I have tried to give you some background and practical tips to lead you to a more successful and satisfying encounter with your Hispanic/Latino patients. If you would like to learn more about this topic, visit the Communications Skills Mentoring Program section of the Academy’s Web site at: http://www.aaos.org. Just click on "Medical Education" then "Communications Skills Mentoring Program."

There you will also learn about a unique educational effort being offered by the Academy in partnership with the Bayer Institute for Health Care Communications. The Institute’s mission is to enhance the dialogue between clinicians and patients through education, research and advocacy. The Institute and the Academy have co-developed a number of educational workshops that focus on increasing skills in doctor-patient communication.

These interactive, experiential and skill-based workshops are based on scientific evidence regarding the efficacy of educational interventions. They are taught by orthopaedic surgeons, for orthopaedic surgeons. The program is organized under the Council on Education under the direction of chair John R. Tongue, MD. I encourage you to consider attending one of the workshops.