Health Care: Learning from Latinos

In the US, it seems as if the dominant perception of medicine is that the best is provided by high-technology equipment and pharmaceuticals exclusively. Fears of reforming health care by limiting access to these technological marvels, at least some of them, center around whether or not people will be deprived of the treatment they need to get better.  I don't quite know where to draw the line at what high-tech treatment is, but most of us don't need it most of the time.

In fact it is often the lowest of the low-tech treatment that helps us to avoid much of that fancy stuff and that can prevent serious problems or keep them in check: a healthy diet, exercise, washing hands, being aware of changes in our bodies, following doctor's orders, taking prescribed medicines as prescribed, not smoking, not drinking excessively, etc.  Compliance with these less invasive and less fancy interventions has a lot to do with the importance of re-establishing significant relationships between doctor and patient.

We have become accustomed, in many cases I think, to depend on machines and tests -- technology-- to replace treatment by huma beings rather than enhance it. If you go to the doctor with a symptom you don't understand and the doctor says, "Let's wait and see for a week..." if we don't see the same doctor very often, and if we see him for five minutes when we do, and if he looks at the records more than at us, it is easy to understand why we might want a test to confirm what he tells us.  

But medicine -- treatment of problems with our bodies and minds -- is not just technology and chemicals. As my dad, a cardiologist, used to say, medicine is as much an art as a science.  By that, he meant, I think, a number of things.  He meant, yes, that sometimes doctors had and have to use their intuition, piece together bits of stuff from their experience because they didn't and don't have the scientific knowledge (it wasn't and isn't always available) to come up with an answer any other way.  But more than that, he meant that there was an art to matching patients with treatments, knowing how to talk to them about their problems, knowing how to teach, how to care so that the patient felt your advice was for her, not just a generic patient. It also meant knowing that sometimes it's not the medicine at all, or not only the medicine, that makes a patient better.  This gets called the placebo effect, a generic term referring to whatever is NOT medicine, not scientically tested, that contributes to improvement, for instance improvement,  literally, in those few cases where terrible diseases remit without medical explanation, or improvement where improvement in outlook, perhaps a growth of hope or faith, leads to physical improvement in other areas as when a patient starts to exercise or follow a diet or improvement whe a patient take medicines his grandmother used or when he prays to a certain saint leads to the strength to overcome a disease. 

Indeed all the glittery modern technology isn't foolproof, and it is a LOT more expensive especially when overused or incorrectly used.  The Harvard physician and surgeon and writer Atul Gawunde wrote an article in the New Yorker showing that the use of tests and technology in Brownsville, Texas far outstripped that used in El Paso, Texas, and yet the outcomes were not better, and in some cases were worse. As Gawunde noted in his commencement speech at the University of Chicago, 

Nothing in medicine is without risks, it turns out. Complications can arise from hospital stays, drugs, procedures, and tests, and when they are of marginal value, the harm can outweigh the benefit. To make matters worse, high-cost communities appear to do the low-cost, low-profit stuff—like providing preventive-care measures, hospice for the dying, and ready access to a primary-care doctor—less consistently for their patients. The patients get more stuff, but not necessarily more of what they need. [Italics are mine]

As Gawande says, low-cost measures may actually provide more of what a patient needs than high-cost measures. An increase in primary care physicians trained to deal with the whole person (and to some extent, his family), and to do it in terms of that person's world: physicians who get to know their patients by touching them, listening to them, knowing the support systems they have, their culture: by caring about them, may save costs AND lives.  I suspect such physicians could contribute substantially to a healthier citizenry at lower cost -- and to healthier citizens at all levels of society.  (I think all physicians benefit from these skills, not just primary care providers, but that well-equipped primary care physicians could become the pilots of the ships of their patients' care).

A year or so ago I created the index for a lovely book called The Art of Healing Latinos, edited by David E. Hayes-Bautista and the late Roberto Chiprut.  It is comprised of accounts written by physicians and other health care advocates, not all Latinos, as a means of explaining to Anglo physicians how they might work effectively with Latino patients. But in fact it has lessons for practitioners, and patients, too, throughout the cultures in the US on how doctors can establish healing relationships with their patients and how patients can help them. I offer below some quotes from the introduction to give you an idea of what they are talking about.

On the contributor Jerome Block, Roberto Chiprut says:

"As one of the most culturally competent no-Latino physicians in this country, Block understood the roles that religion, family, healers, and most important of all, faith have in the healing process.  His perspectives on weaving religion and spirituality into teatment, on the emotional commitment that Latino patients expect of their caregivers, and on the sensitive introdction of pain medications and advanced technologies into treatment were qcquired through trial and error over his years ofpractice.  By seeing Latinos at the moment of death [Block was an oncologist],Block learned much about ho his patients lived their lives.  Block showed us that a practitioner can achieve high levels of cultural competence through sensitivity, respect, and patience."

Chiprut says of Dr. America Bracho:

"Nobody uses cultural symbols to achieve patiet compliance like Dr. America Bracho."  Bracho has a program for teaching patient compliance in the treatment of chronic diabetes which has had "remarkable success."  Bracho's commitment is as important as her patients'.  "She is not afraid to sing alog with patiets in her weekly two-hour educational sessions or to teach them how to read numbers so they can read their glucose meter, or to spend a Sunday cooking and selling tamales to raise money for more otreach efforts....She stresses...the power that comes from understanding--of cultre, of illness, of self.

Chiprut continues:

"Offenses that occur between a physician and a patient frequently are the result of poor communication.  But this may be a matter not so much of lanuage as it is of cultural-psychological knowledge.  In spite of what is commonly taught about modern medical diagnostic and therapeutic methods, ultimately what patients want is a doctor who is available, who treats them with compassion, and who tries to open a path through the thicket of modern medical care. That is precisely what Dr. Camilo Jorge has done for his patients for over fifty years of medical practice....One quality that stands ot...is his understanding of Latino patients.  This is nor more than the difficult task of perceiving what the patient truly wants from a doctor.  [He obtains compliance by never offending.] What this meas in practice is that Jore listens carefully and respectfully, treats even the humblest of his patients without arrogance, and acknowledges the patient's fears and apprehensions, no matter how rooted in superstition.  Thus, like other Latinno physicians, he frequently shares with a healer or curandero in the treatment of folk ailments.

Discussing Dr. Margarita Keusayan, he says,

"Dr. Margarita Keusayan agrees with Dr. Jorge that all caregivers should include prudence and respect in their daily practice.  Physicians with a abrupt manner who only spend a short time with each patient, frequently find themselves faced with the 'unhappy patient.'  Keusayan went so far as to say 'I become part of my patient; I feel the patient's anguish and share in his suffering."

In The Art of Healing Latinos, we see vividly how healing is much more than pharmacology and machinery.  But we need doctors who understand this: who can build trust with their patients so that the human connection has strength.

I think people are afraid of not having access to the latest technology for a number of reasons (fear of death often being mentioned) including the lack of reliable human connections. In the US, it seems as if the dominant perception of medicine is that the best is provided by high-technology equipment and pharmaceuticals exclusively. Fears of reforming health care by limiting access to these technological marvels, at least some of them, center around whether or not people will be deprived of the treatment they need to get better.  I don't quite know where to draw the line at what high-tech treatment is, but most of us don't need it most of the time.

In fact it is often the lowest of the low-tech treatment that helps us to avoid much of that fancy stuff and that can prevent serious problems or keep them in check: a healthy diet, exercise, washing hands, being aware of changes in our bodies, following doctor's orders, taking prescribed medicines as prescribed, not smoking, not drinking excessively, etc.  Compliance with these less invasive and less fancy interventions has a lot to do with the importance of re-establishing significant relationships between doctor and patient.

We have become accustomed, in many cases I think, to depend on machines and tests -- technology-- to replace treatment by huma beings rather than enhance it. If you go to the doctor with a symptom you don't understand and the doctor says, "Let's wait and see for a week..." if we don't see the same doctor very often, and if we see him for five minutes when we do, and if he looks at the records more than at us, it is easy to understand why we might want a test to confirm what he tells us.  

But medicine -- treatment of problems with our bodies and minds -- is not just technology and chemicals. As my dad, a cardiologist, used to say, medicine is as much an art as a science.  By that, he meant, I think, a number of things.  He meant, yes, that sometimes doctors had and have to use their intuition, piece together bits of stuff from their experience because they didn't and don't have the scientific knowledge (it wasn't and isn't always available) to come up with an answer any other way.  But more than that, he meant that there was an art to matching patients with treatments, knowing how to talk to them about their problems, knowing how to teach, how to care so that the patient felt your advice was for her, not just a generic patient. It also meant knowing that sometimes it's not the medicine at all, or not only the medicine, that makes a patient better.  This gets called the placebo effect, a generic term referring to whatever is NOT medicine, not scientically tested, that contributes to improvement, for instance improvement,  literally, in those few cases where terrible diseases remit without medical explanation, or improvement where improvement in outlook, perhaps a growth of hope or faith, leads to physical improvement in other areas as when a patient starts to exercise or follow a diet or improvement whe a patient take medicines his grandmother used or when he prays to a certain saint leads to the strength to overcome a disease. 

Indeed all the glittery modern technology isn't foolproof, and it is a LOT more expensive especially when overused or incorrectly used.  The Harvard physician and surgeon and writer Atul Gawunde wrote an article in the New Yorker showing that the use of tests and technology in Brownsville, Texas far outstripped that used in El Paso, Texas, and yet the outcomes were not better, and in some cases were worse. As Gawunde noted in his commencement speech at the University of Chicago, 

Nothing in medicine is without risks, it turns out. Complications can arise from hospital stays, drugs, procedures, and tests, and when they are of marginal value, the harm can outweigh the benefit. To make matters worse, high-cost communities appear to do the low-cost, low-profit stuff—like providing preventive-care measures, hospice for the dying, and ready access to a primary-care doctor—less consistently for their patients. The patients get more stuff, but not necessarily more of what they need. [Italics are mine]

As Gawande says, low-cost measures may actually provide more of what a patient needs than high-cost measures. An increase in primary care physicians trained to deal with the whole person (and to some extent, his family), and to do it in terms of that person's world: physicians who get to know their patients by touching them, listening to them, knowing the support systems they have, their culture: by caring about them, may save costs AND lives.  I suspect such physicians could contribute substantially to a healthier citizenry at lower cost -- and to healthier citizens at all levels of society.  (I think all physicians benefit from these skills, not just primary care providers, but that well-equipped primary care physicians could become the pilots of the ships of their patients' care).

A year or so ago I created the index for a lovely book called The Art of Healing Latinos, edited by David E. Hayes-Bautista and the late Roberto Chiprut.  It is comprised of accounts written by physicians and other health care advocates, not all Latinos, as a means of explaining to Anglo physicians how they might work effectively with Latino patients. But in fact it has lessons for practitioners, and patients, too, throughout the cultures in the US on how doctors can establish healing relationships with their patients and how patients can help them. I offer below some quotes from the introduction to give you an idea of what they are talking about.

On the contributor Jerome Block, Roberto Chiprut says:

"As one of the most culturally competent no-Latino physicians in this country, Block understood the roles that religion, family, healers, and most important of all, faith have in the healing process.  His perspectives on weaving religion and spirituality into teatment, on the emotional commitment that Latino patients expect of their caregivers, and on the sensitive introdction of pain medications and advanced technologies into treatment were qcquired through trial and error over his years ofpractice.  By seeing Latinos at the moment of death [Block was an oncologist],Block learned much about ho his patients lived their lives.  Block showed us that a practitioner can achieve high levels of cultural competence through sensitivity, respect, and patience."

Chiprut says of Dr. America Bracho:

"Nobody uses cultural symbols to achieve patiet compliance like Dr. America Bracho."  Bracho has a program for teaching patient compliance in the treatment of chronic diabetes which has had "remarkable success."  Bracho's commitment is as important as her patients'.  "She is not afraid to sing alog with patiets in her weekly two-hour educational sessions or to teach them how to read numbers so they can read their glucose meter, or to spend a Sunday cooking and selling tamales to raise money for more otreach efforts....She stresses...the power that comes from understanding--of cultre, of illness, of self.

Chiprut continues:

"Offenses that occur between a physician and a patient frequently are the result of poor communication.  But this may be a matter not so much of lanuage as it is of cultural-psychological knowledge.  In spite of what is commonly taught about modern medical diagnostic and therapeutic methods, ultimately what patients want is a doctor who is available, who treats them with compassion, and who tries to open a path through the thicket of modern medical care. That is precisely what Dr. Camilo Jorge has done for his patients for over fifty years of medical practice....One quality that stands ot...is his understanding of Latino patients.  This is nor more than the difficult task of perceiving what the patient truly wants from a doctor.  [He obtains compliance by never offending.] What this meas in practice is that Jore listens carefully and respectfully, treats even the humblest of his patients without arrogance, and acknowledges the patient's fears and apprehensions, no matter how rooted in superstition.  Thus, like other Latinno physicians, he frequently shares with a healer or curandero in the treatment of folk ailments.

Discussing Dr. Margarita Keusayan, he says,

"Dr. Margarita Keusayan agrees with Dr. Jorge that all caregivers should include prudence and respect in their daily practice.  Physicians with a abrupt manner who only spend a short time with each patient, frequently find themselves faced with the 'unhappy patient.'  Keusayan went so far as to say 'I become part of my patient; I feel the patient's anguish and share in his suffering."

In The Art of Healing Latinos, we see vividly how healing is much more than pharmacology and machinery.  But we need doctors who understand this: who can build trust with their patients so that the human connection has strength.

I think people are afraid of not having access to the latest technology for a number of reasons (fear of death often being mentioned) including the lack of reliable human connections.  How many of us really have been able to choose a physician and spend enough time with her to think she really knows who we are?   Lowering the costs of providing treatment by reining in costs of unnecessary tests and treatments makes huge sense, not simply in terms of the money saved, but in terms of eliminating harm and improving outsomes.  But only if we invest (much less money) in the development of physicians who can look more into the world of their patients and learn to incorporate it in their treatment.

  How many of us really have been able to choose a physician and spend enough time with her to think she really knows who we are?   Lowering the costs of providing treatment by reining in costs of unnecessary tests and treatments makes huge sense, not simply in terms of the money saved, but in terms of eliminating harm and improving outsomes.  But only if we invest in the development of physicians who can look more into the world of their patients and learn to incorporate it in their treatment.