Family physicians who care for underserved patients

One of the ugliest incidents in my career occurred during my faculty development fellowship year, when I spent two days each week seeing patients at several federally qualified community health centers in inner city Washington, DC. Midway through the year, I was transferred from a health center that served an African-American population to one serving a mostly Spanish-speaking clientele.

Nearly all of the permanent primary care clinicians at this health center spoke fluent Spanish, and I saw it as a sign of the center’s desperate need for clinicians that they willingly accepted a family physician who had never managed to learn enough Spanish to ask any questions more complex than “where does it hurt?”

The plan had been for me to be paired with a Spanish-speaking medical assistant who could also function as an interpreter, but due to staffing changes and the reality that medical assistants have many responsibilities, that never worked out. So I found myself spending hours using awkward telephone translation services, pressing patients’ relatives and children into service as translators (a big no-no), or as a last resort, deliberately avoiding picking up the medical charts of patients who knew no English.

None of these actions endeared me to the other clinicians, but one in particular, a short-tempered Latino family doctor who had worked at the health center for many years, seemed offended by my presence from the outset. After weeks of giving me the silent treatment, one day he literally exploded and told me in no uncertain terms that I had absolutely no business seeing patients there (especially “his” patients) when I couldn’t speak the language, and that the constant influx of temporary physicians from academic medical centers like me who moved on to other things was what gave health centers for the underserved a reputation for poor quality.

Several years removed from that professionally and personally distressing incident, I came across a study in the Archives of Internal Medicine that examined the relationship between proportions of minority patients served by 96 U.S. primary care clinics and elements of their workplace and organizational environments. Consistent with my experience, clinics that served at least a 30% minority population reported that their patients often spoke little or no English, had lower health literacy, and had more complex and chronic medical problems such as depression, pain syndromes, and substance abuse. To address these challenges, these clinics had access to fewer resources (medical supplies, referral specialists, pharmacy services, and examination rooms) and were more likely to have “chaotic” work environments and low job satisfaction than clinics serving less than 30% minorities. The authors concluded that primary health care for minority populations in this country is both “separate and unequal,” and suggested that health disparities may be due as much to disadvantages built into the provision of care as to patient-centered factors.

And recently, JAMA published an important analysis of Health Plan Employer and Data Information Set (HEDIS) performance measures of 162 primary care physicians in a practice-based research network in eastern Massachusetts. The authors concluded: “Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary care physicians.”

My hat is off to family physicians and other primary care clinicians who care for underserved patients. Every day, you make do with less, manage more challenging clinical problems, and to add insult to injury, apparently are now getting dinged on the quality of care you provide. There is no excuse for the way I was treated in that clinic many years ago, but I have come to understand my antagonist’s “us versus them” mentality as a coping mechanism. Making a real dent in health disparities will require more than expanding Medicaid coverage and building new community health centers. Creative programs are also needed to attract top-flight family physicians to practices for the underserved and keep them there by providing the necessary support for them to thrive, professionally and emotionally.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • http://favilar.org Fernando

    I do not agree with attitude of the jealous short-tempered Latino physician you describe. It’s always welcome any help with the under-served population, especially when it comes from a fresh-uptodated academical setting.

    But, IMAO it’s irresponsible to practice medicine without a fluent knowledge of the patient’s language. If you don’t know enough Spanish, you must use a medical translator or similar. If you don’t have…you should not see these kind of patients; this is not Africa, and you are not in a humanitarian mission where ANY help will be Ok.

    Isn’t the same reason why ECFMG has the “language” requirement in the licensing for IMGs taking the USMLE Step 2 CS???

    It doesn’t matter the patient speaks Spanish, Hindi, Chinese, etc. We must be able to communicate properly with our patients.

    I have seen how much effort many American medical students, nurses, or young MDs put on learning Spanish for their future/current clinical work. It’s inspiring.
    It’s not that hard/expensive to learn a basic clinical-Spanish. I think it’s an ethical obligation.

    IMAO: Isn’t supposed we have to adapt to our patients’ needs, and not in the other way?. Latino population in the US will soon start to be a majority, and not a minority. The market will tell us soon. A fluent Spanish is and will be a PLUS. This will be true not just for Family Medicine.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      “this is not Africa, and you are not in a humanitarian mission where ANY help will be Ok”

      There aren’t enough primary care physicians, particularly in underserved areas, and there isn’t enough money to employ translators in small facilities.
      This is not Africa, but in some places and for some people, it is fast approaching…

      • ninguem

        The stereotype of an American going to another country expecting everyone to speak English led to the term “ugly American”.

        Yet somehow others can come to the USA expecting us to provide them with services……..FREE services…….in their native language.

        • stitch

          Number one, the vast majority of these clinics are not “free.” There is almost always some fee associated with the visit, even if it is nominal.

          Number two, yes, there are many people who come to these clinics who do not speak fluent English, but many do speak enough to get by in their regular lives. Many do not, however, regularly use English words to describe specific symptoms they may have when they come seeking care. Even when we Americans study other languages, we rarely learn anything approaching medical terminology unless we need it – and often, if we go to another country, it’s also ex post facto.

        • gzuckier

          Next thing you know, they’ll start renaming places like Los Angeles and San Francisco and Arizona with Hispanic names.

          • pj

            LOL!

            GZ, I like your humor. Wish I sould read all your comments. :)

    • Family Doctor

      “Latino population in the US will soon start to be a majority, and not a minority. The market will tell us soon. A fluent Spanish is and will be a PLUS. This will be true not just for Family Medicine.”

      I professionally disagree. Yes, at this moment population demographic projections see an increasing Latino population. Yet, most of those increases will be children born in the US to Latino parents. Meaning, these children will speak English. Spanish will not be necessary with them.

      In addition, I have seen first hand that the low income clinics that serve a predominately mono-lingual Spanish speaking patient population pay their docs lower salaries compared to other clinics that serve other populations. I’m not saying this is fair, just what I have personally observed.

      • stitch

        Many community health centers provide loan payback programs (although not all.) Frequently physicians who take these jobs do so for that payback, and accept the lower pay for that reason. I am also not saying it is fair, but it does not necessarily reflect on the doc or on the clinic itself.

    • Primary Care Internist

      the ECFMG “language” requirement is really an ENGLISH requirement, to ensure basic communication skills in ENGLISH.

      If a patient lives and sees a doctor in America, and doesn’t speak English they are doing themselves a disservice and risking their own health by not bringing a trustworthy relative or friend to translate for them and relay their health needs.

      I, as a physician, do speak some Spanish. Having a Mexican nanny when my kids were small, this was a bonus. And I use it almost daily in patient care, and my patients who speak little/no English are very appreciative. But the entitlement mentality that your doctor has a moral or ethical duty to know your language? simply absurd. And as the poster points out, using telephonic translation services are inefficient and risky.

  • Mark

    MyFernando,

    When I lived in China I didn’t begrudge my doctors a few awkward visits and think they had an ethical obligation to learn English, even in a city like Shanghai with a large foreign population.

    You’re correct that it is a plus when I am able to converse with a Chinese pt in the ED, but we can’t all learn every language. I don’t feel an ethical obligation to learn Spanish.

    • Marcela

      I don’t think Fernando means all health providers should learn Spanish, at least that’s not the way I read his comment. The way I see it, he is highlighting the importance of understanding the patients, and their needs, when providing medical care. If you are unable to communicate with your patient, you can’t provide proper care, that’s it.
      The issue of dealing with non-English speakers patients in health (as in other areas) is a major challenge and has no straight answer. It’s certainly not the responsibility of the physician to learn several languages to solve it. However, I do agree with Fernando that, unless there is no other option available, you shouldn’t treat a patient if you can’t communicate with him/her.

      • Mark

        He said, “It’s not that hard/expensive to learn a basic clinical-Spanish. I think it’s an ethical obligation”. I took that to mean that all heathcare providers should learn Spanish, but my apologies if that was incorrect.

        In any case, I agree with you that it is complicated. In a place where you might see a dozen different languages in a week the phone system works, though it is clunky.

        I also agree with you that in the best of all possible worlds a PMD should speak the language of the patient, but even that is complicated. You cannot deny to take someone on as a patient because of a language barrier, no? You’ll get sued for that.

        • ninguem

          They come in my office speaking Arabic, Hindi, Chinese, Korean, Russian, Vietnamese, Ukranian…….and Spanish. I’ve got two Bhutanese. I don’t even know what language they speak. Fortunately, one spouse speaks English and translates for the other. They come in a pair. And when the Samoans and the Marshall Islanders show up, it seems to be five of them for the one patient who doesn’t speak English. Someone in the group speaks English.

          I just agreed to be a “go-to” doc for an Asian-American support group. The patients need medical help for various problems, a lot of which is substance abuse in this particular case. They will supply translators, as the center offers service to the entire Asian/Pacific Island group communities.

          Excuse me for not speaking every language on the planet.

          I’m glad to work with them. That would change instantly if they start to consider it a civil right to free and instant translation for all the languages on the planet.

          • Family Doctor

            Dear Esteemed colleague ,

            You wrote:
            “Yet somehow others can come to the USA expecting us to provide them with services……..FREE services…….in their native language.”
            “I’m glad to work with them. That would change instantly if they start to consider it a civil right to free and instant translation for all the languages on the planet.”

            As a (dark-skinned) Latino doctor (with a Hispanic last name) who was born here in the US but by circumstance doesn’t speak Spanish, I have been shocked & repeatedly insulted over the years by the Latino population who are mono-lingual Spanish speaking. I have worked in my fair share of low income clinics & when they meet me, they not only anticipate, but EXPECT that I speak Spanish. When they discover I do not, I have often been the recipient of rudeness & inappropriate behavior from them. And interesting how it has ALWAYS been from low-income patients who are receiving their care at free/low cost clinics.

            I no longer work, nor do I have any desire to work with this population.

          • pcp

            Be careful.

            You can be sued big time for failing to provide a satisfactory translator (as determined by the patient). Family members are a no-no.

            Under Bush era regulations, a doctor is required to provide at his/her own expense a translator for any laguage that a patient may speak.

          • stitch

            In my experience in an FQHC, I also had many patients from a variety of backgrounds and it was like a Tower of Babel. Many of them would come in with family members as well, but often the family members had a hard time translating med speak, from both ends. I also found that there were times when some family members were clearly not translating all that I was saying to the patient.

            During the less than 6 months I worked there, there were 4 Spanish medical translators sequentially; the last one would get into side conversations with the patients which frustrated me no end. I had picked up enough Spanish at that point to recognize that the translator was giving their own medical advice.

            The regulations pointed out by pcp are true (and onerous.) We had a telephone service – I had patients who spoke Tibetan and Amharic. Both of those patients (among others) could carry on basic conversations in English but needed the telephone service for more detailed information. Very frustrating.

            We live in a polyglot culture and even when people are making attempts to assimilate culturally and lingually, it takes time.

  • Sharon Dietrich

    and, so, have your learned Spanish in the meantime?? I work in a Migrant and community Health clinic in WA state, and many of my patients don’t speak much English–my ability to speak Spanish has been crucial to my work. The abuse you received was not warranted, but hopefully inspired you to learn a modicum of medical Spanish.

  • Sarahw

    Why isn’t it crucial for anyone who want to come to the US to learn basic English? There shouldn’t BE any signifigant resident portion of the population here who can’t.

    • Dave Miller

      SarahW makes a great point!

    • stitch

      As I said above, describing symptoms generally goes beyond basic English. There are also cultural issues involved in perception of illness that go beyond language.

      • gzuckier

        Makes you respect veterinarians.

  • http://www.smartmothersguide.com Dr. L. Burke-Galloway

    I just resigned from a FQHC/Health Dept. after working almost 15 years. I’m board certified in ob-gyn and wanted to help medically underserved women. It was a thankless job run by administrators who I swear were committing fraud regarding pt billing. My patients were appreciative and many were Latinas. I learned enough Spanish while I was there to communicate basic information but you should have insisted upon having a translator. The phone translating service is both awkward and inefficient. Thanks for sharing your story.

    • ninguem

      I’ve lost count how many times I’ve heard that story from docs at FQHC’s. All too many of them are little more than jobs programs and sources of graft. Their business model is to find ways to extract higher payment from the government payers.

      I’ve seen FQHC’s get paid more than I get from Blue Shield for the same service. If Medicaid paid me what they pay those places, I’d dump Blue Shield and run a 100% Medicaid practice.

      • Primary Care Internist

        i’ve heard the same thing, something like $135 for 99213 from MEDICAID! i think in NY the regular private office fee from medicaid to a solo doc is around $35.

        what a ripoff of taxpayers!

        • stitch

          Community health centers are allowed to charge facility fees rather than professional fees, which is what makes up for the discrepancy. Not defending it. Those fee rates are also set by the states for Medicaid, so what is paid will vary from state to state.

          • pj

            Good point. Thanx for clarifying! I also worked at a CHC where the CEO was engaging in borderline fraudulent practices (didnt provide a translator, billing for provider’s services under the facility ID to avoid having to credential the provider)…

        • ninguem

          It was some time ago, but it was a front-page Wall Street Journal article. The story had to do with the Floating Hospital system in NYC. There was some sort of scandal, some money in the organization went astray, investigation into the system’s administration, blah, blah…….

          By itself, the story did not hold that much interest to me. Another scandal, we have plenty in my town, too.

          What caught my interest was a couple of paragraphs describing the background of the Floating Hospital system. Where it came from historically, and it’s current place in the healthcare big picture.

          They continue to exist because private doctors did not want to see Medicaid. The article mentioned NY Medicaid paid private doctors……..about the number you described. That same Medicaid recipient walks into one of their clinics, gets seen by a Nurse Practitioner instead of a real doctor, and NY Medicaid paid………about the number you described.

          That back story caught my attention. Since then, I’ve seen the same thing, time and again. One time at a medical meeting, someone running an outreach clinic described their work and how wonderful they are, what humanitarians and great businesspeople. They mentioned their finances, the annual revenue and the number of patient visits. Simple math was $165 a visit. I told the director if I got paid that, I’d dump Blue Shield to be paid more to treat the poor.

          The director mumbled something about offering all the ancillary services. I’d offer them too, I’d subcontract out all that work if I were paid so richly.

          Time and again, when I hear about these places, what I see is their secret is simply the ability to extract higher payment from the entitlement payers for the same service.

          Pay me, in my private clinic, what you pay them, and I’ll see Medicaid too.

  • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

    “Creative programs are also needed to attract top-flight family physicians to practices for the underserved and keep them there by providing the necessary support for them to thrive, professionally and emotionally.”

    Actually, if the creative programs for the ‘underserved’ (that is, relatively poor) were focused on making these folks richer – you wouldn’t need such creativity to attract top-flight family physicians. The real problem is the relative wealth of the population.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      Well said, Dr. Allen.
      Health care and its myriad of problems is nothing more than one of the many symptoms of Poverty and poverty is what we need to “fix”.

    • http://Www.twitter.com/alicearobertson Alice

      What country has distributing the wealth helped healthcare of the population? Cuba?

      • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

        What?

        Somewhere in there is redistribution of wealth. How about helping people to help themselves (start businesses, use your mind, create a better system w more opportunity). Cuba doesn’t create much of that!

      • gzuckier

        Doesn’t “distributing the wealth” also include the top few percent of the economy “earning” all the wealth in the country over the past few decades? Or is it that their labor has been so remarkably fruitful over that period that it’s only natural?

        • http://Www.twitter.com/alicearobertson Alice

          No…forced distribution of the wealth is not the same as equal opportunity for others to make wealth…it actually removes the very catalyst.

          Of course, the new compromise will be the “means test” so the rich cannot get unemployment, Medicaid, Medicare, and SS….but that is problematic…sounds completely logical to most…..but there is no means test if you buy insurance and place a claim.

  • soloFP

    I have a midwest practice with about 5-10% Spanish speaking patients. I know a few phrases from college Spanish, but most of them bring their children who are bilingual for any translation for Adults and Seniors. I find all of them in my practice are hard working and 90% of them have private insurance. Most of the children are first generation college students or plan to go to college. The patients are very respectful and thankful for their care. My Spanish-speaking patients add to my joy of treating patients.

    • ninguem

      Some of my best friends are………

      Fine. I’m Hispanic too. Yes, they’re hardworking and all that, and yes I like to treat them as well. The overwhelming majority of the time, it’s great. Their limited English, my less-than-prefect Spanish, we can communicate OK. A family member helps. Yes, I’m fully aware of the problem with using family members.

      Sometimes I’ve BEEN that family member. Not all my relatives speak English.

      I’ll use whatever tools are available to me. If I began to get a large influx of people demanding paid translators, I’d reconsider my practice to limit exposure to the population. Meaning, drop Medicaid completely.

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        Are they demanding such services now? or is this a hypothetical possibility that you are exploring?

        • ninguem

          Huh? Hypothetical? Are you serious?

          No, most people are reasonable. Sometimes they’re not. A patient who feels denied a translator can file civil rights actions against the doctor.

          Physicians HAVE been fined, tens of thousands of dollars, for failure to provide a translator.

          It’s not just Spanish, it could be for any language, or signers for the deaf. It’s been done, the reports are out. For the successful prosecutions and fines of physicians, I can only speculate how many doctors went through hell defending themselves successfully from similar charges.

          It just takes one activist type to make your life a living hell.

          • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

            I understand, I was just curious if you have encountered anything like that yourself.

  • Muddy Waters

    It’s simple- if you live in America, you should be EXPECTED to learn English. America should not be expected to provide translation services. Nobody forced these immigrants to move here, and they can go home if they want to speak their language. I would expect nothing less if I were to move to a foreign country.

    • ninguem

      Works for me.

      For those types who like to play the race card, I’m Hispanic myself, and I have been that family translator a couple times, with non-English-speaking relatives in the Emergency Room.

      The Tower of Babel patients I describe, and do get in my clinic, daily…….I do take one local-physician-run Medicaid managed care plan that pays almost halfway decent, mainly to be able to see children. Medicaid patients want to see me in my private office for my great quality. (Translate: the telephone is answered and the appointment is longer than five minutes, and with a real doctor no less….as opposed to the typical Medicaid mill FQHC).

      I tell the parents all the time…….teach their children Spanish, Ukranian, Korean, whatever their native language is, at home. Insist on it. They’re not well-to-do by definition if they’re on Medicaid, it’s the most valuable thing they can give their kids for education, as I doubt they can afford to send their kids to a fancy private school. Heck, I can’t afford to send my kids to a fancy private school.

      The kids will learn English just fine. Teach the native language. Even without true fluency, the kids will pick up the phonetics and some basics, so they know what the language is supposed to sound like if they get formal education on the language later, so they’re still advantaged.

      I’ve got a family history of a relative who was your basic high-school-educated kid with mediocre job prospects. He was a general laborer. Turns out the language skill was helpful at that particular job, and at the time and location hard to find. He was noticed by management because of it, and they started promoting him. When his lack of college education became an issue, the business sent him to college and kept promoting him. He retired a well-to-do executive.

      I tell that story every day.

      I’m not opposed to foreign languages, I’m opposed…..and deeply opposed……to the Federal mandate and the penalties that go with it.

    • pj

      Then please write your congressman/woman- cuz, sadly, that’s not how it is here.

    • gzuckier

      And let all the deaf people move back to Deafsylvania where they came from.

      • Apurva Bhatt M.D.

        Cute but dodges the problem. Regardless of why the communication problem exists, it should not, by force of law, fines, loss of licensure or other coersion, be made the problem of the treating doctor. It should be the patient’s responsibility to provide for their own communication needs. If society feels magnanimous enough to do so, society can (through tax-payer funded programs) pay for this cost over and above the medical cost of care.

    • http://twitter.com/AustrianSchool_ Austrian School

      Alternatively, I’d say that if you live in America and do no speak English, you should expect difficulties.

  • gzuckier

    I’ve mentioned this elsewhere; there can be problems when a patient from a small, close-knit (linguistic) community perceives the presence of the translator to be a potential risk to his/her privacy, with the details of the visit soon to spread to all his/her friends and neighbors. In some cases, probably correct.

    • Dave Miller

      GZ,

      You mention this and another poster earlier mentioned a paid translator not providing accurate translation and interjecting their own advice. In both cases, there are violation of the translator’s professional ethical standards. These are professional people with standards of practice the same as us. If these sorts of things are happening then we need to report these incidents and make sure they are held accountable for not doing their jobs properly.

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