Health care en español
By Laura Mize
The country’s Hispanic and Latino population is growing, so why aren’t there are more Hispanic health-care providers? This month, The POST takes a look at this issue and examines why cultural understanding between patients and health professionals is key to care.
Diana Narvaez knows what it’s like to start over in a new country.
Now a third-year medical student at UF, Narvaez moved from Colombia to the United States in 2000. Though her family endured their share of hardships adjusting to their new life, Narvaez says she knows some people have it even tougher. She knew some English, for example, and the family immigrated legally. Narvaez says these experiences and her Hispanic heritage inform her interaction with patients, especially those who are Hispanic or are immigrants themselves.
“Right now I’m in the newborn nursery, and I have people (who), as soon as I come into the room, they say, ‘Oh, thank God you speak Spanish.’”
Una pequeña minoriá
When Narvaez earns her medical degree in 2012, she will join the country’s small minority of Hispanic physicians; About 5 percent of U.S. doctors identify themselves as Hispanic, according to the American Medical Association.
The profession’s workforce does not reflect the diversity of the population it serves. The U.S. Census Bureau estimated that 15 percent of all Americans in 2006-2008 were Hispanic. In Florida, the discrepancy is even greater. The state’s population is about 17 to 18 percent Hispanic, but only about 3 percent of physicians are Hispanic, says Donna M. Parker, M.D., an assistant dean for minority affairs in the UF College of Medicine.
Aside from physicians, only about 4 percent of registered nurses are Latino or Hispanic, according to the Health Resources and Services Administration’s Health Workforce Information Center. Among the ranks of pharmacists, dentists, veterinarians and public health professionals, so few people report their ethnicity that accurate numbers are not available, and some professional organizations do not even attempt to collect it.
“One of the major underrepresented … and underserved groups in medicine is the Hispanic population,” Parker says.
Cultural understanding is key to effective patient care, says Jane L. Delgado, Ph.D., M.S., president and CEO of the National Alliance for Hispanic Health.
“We need people who understand the language and the culture of the patients, because that’s how you get behavioral change,” Delgado says. “(Otherwise), you’re not going to get patients who understand what’s being said and can follow what is recommended.”
La barrera del idioma
The most obvious cultural obstacle to good care is a language barrier.
Health-care facilities use a variety of translation resources, including professional translators or language services accessible through telephone or video lines.
But these methods have their flaws and often are not used in favor of other, less official approaches.
Justin Israelsen, a senior in the UF College of Dentistry, once watched a health-care provider and patient communicate through a translator via telephone.
“The translation actually came back completely different (from what the patient meant),” he says. “They came down to the conclusion that it was a complete body language thing, and the person on the phone, of course, cannot see that.”
Israelsen says he prefers face-to-face translation, provided by someone familiar with health care. In a pinch, he uses patients’ family members as translators, though he says it’s not ideal.
“A lot of times a family member will try to downplay the severity of a case, so as not to offend or startle the (patient),” he says.
Abbe Degroat, who’s in her final year of veterinary school at UF, says language barriers are prevalent in large animal veterinary care, her area of interest.
“Most of the farm workers are Spanish, especially at dairies,” she says. “A veterinarian often does educational programs for the milkers. You either have to be bilingual, or you have to have somebody there to translate for you. “Even with beef cattle and even with horses, all the grooms and everybody speaks Spanish. Most of them don’t speak English.”
Degroat, who is not bilingual, says she wants to enroll in a Spanish class after taking her board examinations.
Cultural differences can present problems even without a language barrier.
Israelsen says he learned in a class on cultural awareness that many Hispanic males won’t admit when they’re in pain, but encountering that behavior in a clinical setting still took him off guard.
“I had dark glasses on (a patient) because of the bright light shining on his face. All of a sudden, I noticed tears dropping down his face. I pulled everything back and said ‘Are you okay?’ He says, ‘Oh, I’m fine. You’re fine.’ I’m like, ‘No. Everything’s not fine. You’re crying.’ He was just trying to be tough.”
Ana Rosa, R.N., a student in UF’s nurse practitioner’s program, is a mental health nurse at Shands Vista. She recalled a situation in which a co-worker thought one patient’s rapid speech and hand gestures were disease symptoms. Rosa recognized them as characteristic of the man’s Cuban culture.
“This might just be normal behavior for him,” she told her colleague.
Allyson Hall, Ph.D., an associate professor in UF’s College of Public Health and Health Professions, says such misunderstandings can lead minority patients to feel they’ve been discriminated against, even if that was never intended.
“There’s no cultural broker between the two groups of people, and so people don’t understand how (others) are communicating messages to them, even if they speak the same language.”
For some, fears arising from cultural issues and financial woes influence whether they seek health care at all. Rosa fled Honduras as a refugee with her mother and siblings when a hurricane struck the country in 1998. They moved in with her grandparents in Miami. Though her mother worked, Rosa says the family wrestled with decisions such as whether her younger brother would receive immunizations.
“It was like, ‘Do we take them? Do we not take them? They’re going to ask questions, and it’s going to be like $80 a shot. We can’t afford that.’”
Similar concerns moved her family to visit a friend, a U.S.-licensed dentist from Nicaragua, for care offered at a discount. Rosa says the workforce of health-care providers should be diverse and experienced in working with various cultures.
“You need to at least have that exposure to say ‘This is what’s expected. This is maybe what their baseline normal is,’” she says. “That’s probably about the best you can do, which, I think, is why it’s important to have people of different cultures in different health professions.”
¿Dónde están los estudiantes hispanos?
The shortage of Hispanic people working in health care is linked to low numbers of Hispanic students applying and being admitted to health education programs.
“We constantly have immigration taking place from Hispanic nations, but the number of people applying and getting into med school (is) definitely not increasing accordingly,” Parker says.
There are many possible explanations for this, including educational costs, a lack of familiarity with the application process, the language barrier, improper legal status, reluctance to leave family to pursue education and lower numbers of Hispanic people completing college compared to other ethnicities. In 2007, just 11 percent of Hispanic 25- to 29- year olds had bachelor’s degrees, according to the American Council on Education. Only American Indians had a lower rate of college graduates.
Rosa said many of her friends simply preferred other careers.
In the fall of 2009, rates of Hispanic students in UF’s colleges of Veterinary Medicine, Pharmacy, Nursing and Dentistry were higher than the rate of Hispanic students in such programs nationwide.
Randell Doty, Pharm.D., says it’s important for UF’s pharmacy students to reflect the state’s diversity but emphasizes that preparing them to work with a wide variety of patients is just as essential.
“I think even if (students) come from another cultural background, by the time they leave us, they’re able to adapt to whatever environment they get into,” says Doty, the college’s associate dean for experiential education. “If they go back and decide to open a pharmacy in their hometown, in their home cultural enclave, dealing with the kind of people they’ve known growing up their entire life and speaking in their native language, that’s cool. But if they decide not to do that, I want them to be just as prepared.”
For Narvaez, serving migrant farm workers through the Hispanic American Medical Student Association has reinforced her desire to serve this population when she becomes a doctor. She’s leaning toward a career in primary care.
She says her own family’s struggles have given her an appreciation for the migrant workers’ more difficult plight.
“It’s just something that’s really dear to my heart,” she says.