Doctor May Know Best, But Sometimes Patients Know Better

March 13, 2014

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

This feature was originally published in March of 2014 in National Journal.

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.’ “


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.


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.”

You Might Also Like