AN ANALYSIS OF CULTURAL COMPETENCE, CULTURAL

DIFFERENCE, AND COMMUNICATION STRATEGIES

IN MEDICAL CARE

by

MARISA KRISTINE ABBE

Submitted in partial fulfillment of the requirements

For the degree of Doctor of Philosophy

Dissertation Adviser: Dr. Atwood Gaines

Department of Anthropology

CASE WESTERN RESERVE UNIVERSITY

January, 2011
 CASE WESTERN RESERVE UNIVERSITY

SCHOOL OF GRADUATE STUDIES

We hereby approve the thesis/dissertation of

Marisa Kristine Abbe

_____________________________________________________

Ph.D.
candidate for the ______________________degree *.

Atwood Gaines
(signed)_______________________________________________
(chair of the committee)

Charlotte Ikels
________________________________________________

Eileen Anderson-Fye
________________________________________________

Joseph Sudano
________________________________________________

________________________________________________

________________________________________________

July 8, 2010
(date) _______________________

*We also certify that written approval has been obtained for any
proprietary material contained therein.
 Table of Contents

List of Figures ...................................................................................................................... 3

Acknowledgments............................................................................................................... 4
Abstract ............................................................................................................................... 5
Chapter One: Introduction.................................................................................................. 7
Chapter Two: The Setting and Methodology.................................................................... 63
Chapter Three: Do Cultural Competence Communication Strategies Alleviate
Cultural “Barriers?” ........................................................................................................... 96
Chapter Four: Case Studies in Cross-Cultural Medical Communication......................... 132
Chapter Five: The Lifeworld and Explanatory Models .................................................... 177
Chapter Six: Medical Interpreting ................................................................................... 224
Chapter Seven: Conclusion ............................................................................................. 257
Appendix I: Patient and Clinician Interviews and Patient Survey ................................... 274
Appendix II: Transcription Notations .............................................................................. 282
Bibliography .................................................................................................................... 284
 List of Figures

1.1 Misher’s Model of the Lifeworld 29

2.1 Clinic 2006 Annual Report Data 68
2.2 Clinic Organizational Structure 70
2.3 Methods Used 72
2.4 Patient Age 83
2.5 Patient Sex 83
2.6 Patient Country of Origin 84
2.7 Patient Primary Language 84
2.8 Patient Biomedical Diagnosis 85
2.9 Clinician Sample (n=90) 86
2.10 Patient Age 88
2.11 Patient Sex 88
2.12 Patient Country of Origin 89
2.13 Patient Primary Language 89
2.14 Patient Biomedical Diagnosis 90
2.15 Clinician Sample (n=30) 91
3.1 The Purnell Model of Cultural Competence 103
3.2 Slide from Cultural Competence Workshop 109
5.1 Lifeworld Talk in Relation to Present Complaint/biomedical Diagnosis 179

3
 Acknowledgments

This dissertation research spans multiple phases of my life and I would like to
express gratitude to specific individuals and groups in helping me through this process. I
am forever thankful to the People’s Clinic and the clinicians, volunteers, and patients
who allowed me access to their personal lives. I am continuously inspired by the
dedicated people who sacrifice so much to help people in need. I will always be guided
by their beliefs and actions.
The Case Western Reserve University anthropology faculty provided me with
tremendous knowledge and understanding of the cultural, political, and historical
influences on health and illness. They taught me how to think critically and holistically
about societal problems and how to contribute to finding solutions. I would like to
thank Atwood Gaines for his guidance over the years, listening to my fledgling research
ideas, and helping me flesh out a project I was passionate about. Thanks to Charlotte
Ikels and Eileen Anderson-Fye for their time, comments, and contributions to this
research. And though she is not part of my dissertation committee, Rachel Chapman
taught me the importance of witnessing, listening, and using myself not only as a
research tool but as an instrument for change.
I would also like to thank the University of North Texas anthropology
department members for their encouragement, mentorship, and camaraderie. Being
part of their anthropology community has helped me grow as a professional, academic
scholar, and applied anthropologist. In particular, Alicia Re Cruz, Shimaa Dessouky,
Grace Bascopé, Lisa Henry, and Mariela Nuñez-Janes lit a fire which sustained my
passion for research and the sometimes not so passionate writing process.
Finally, I would like to thank my family, Ann Abbe, David Abbe, Bill Harris, Donna
Abbe, and my wonderful husband, Jarrod Berger. For without their help this would have
never been possible. At an early age I learned the meaning of kindness, selflessness,
and advocacy. With these life lessons and their constant love and support, I have
completed this rite of passage. I can never thank you enough.

4
 An Analysis of Cultural Competence, Cultural Difference, and
Communication Strategies in Medical Care

Abstract

By

MARISA KRISTINE ABBE

This research is directed at the repeated findings that minority populations

suffer disproportionately from the burden of disease in our society, specifically in the

development of disease, health outcomes, and access to care. Even as quality improves

on specific measures, disparities often persist. A common reason cited for health

inequalities is that the U.S. health care system, in its “one-size-fits-all” approach, is

inadequate to meet the needs of minority patients. A proposed solution in biomedicine

is cultural competence.

This dissertation investigates how Anglo-American clinicians and Mexican

immigrant patients communicate in a medical setting. Because of the popularity of

cultural competence as a panacea to health inequalities, my research focused on the

following questions: If the medical encounter provides the space for the intersection of

cultural differences, how might patients and clinicians locate such differences, how are

they talked about or negotiated between participants, and does there exist a set of

strategies that clinicians can adopt to be “culturally competent?” Do cultural differences

between patients and clinicians cause barriers to treatment? What other factors create

5
barriers? How do patients communicate their treatment preferences, medical beliefs,

and personal information? What is the role of medical interpreters?

This research is based on 24 months of ethnographic research at the People’s

Clinic, a free clinic in a metropolitan area in Texas. I utilized participant observation and

interviews as my primary methods for data collection; I observed 120 medical

encounters and interviewed 30 patients after their encounter.

This research expands the knowledge of the role of culture and cultural

difference in medical encounters. I examined how patients communicated information

from their lifeworld, and whether “cultural” narratives provided by patients would

cause barriers to treatment, as assumed by cultural competence models. In light of this

research, I propose measures to redefine cultural competence.

Keywords: medical anthropology, medical communication, cultural competence,

explanatory models, narrative, Mexican immigrants, nurse practitioners

6
 Chapter One: Introduction

This dissertation investigates how clinicians and patients from different linguistic

and cultural backgrounds communicate in a medical setting. The research was

conducted at the People’s Clinic, a free clinic in a Texas metropolitan city, from July

2006 to July 2008. The research project is situated within larger discourses from

medical and social science research fields on health disparities in the US (e.g., medical

anthropology, medical sociology, bioethics, epidemiology, medicine, etc.). As varying

theoretical models from medical anthropology and linguistic anthropology are used in

this project, this introductory chapter is broken into four parts. First, I provide a brief

overview of the issue studied, that is, health inequalities and cultural competence. Next

I provide the medical anthropological context of this issue and review pertinent theories

about the role of culture in health, migrant and refugee health issues, the study of

biomedicine, the notions of explanatory models, illness narratives, and the views of

critical medical anthropology. Third, I examine the importance of linguistic

anthropology to this research, including an examination of relevant theories and

methodological debates. In the fourth section I narrow the focus to the medical setting

and review the literature on medical communication including the role of language in

health and the role of medical interpreters. Finally, I discuss the dissertation project and

situate the research questions among the discourses of medical and linguistic

anthropology. I conclude this chapter with an outline of the entire dissertation.

7
I. Health Disparities and Cultural Competence

Immigrant, refugee, and minority populations in the US are often described as

being “at risk” for illness and disease because of their cultural differences (Brach and

Fraserirector 2000; OMH 2001; Hirsch 2003). Further, recent studies conclude there are

widespread and systematic problems in our healthcare system causing health disparities

between minority and Anglo groups. ‘Health disparities’ is a phrase used by health

professions to refer to differences in morbidity, mortality, and access to health care that

appear along social, cultural, economic, gender, and especially “racial” and “ethnic”

lines (Dressler, et al. 2005).

In the U.S., health disparities are well documented in minority populations such

as African Americans, Native Americans, Asian Americans, and Latinos. When compared

to Anglo Americans, these minority groups have higher incidence of chronic diseases,

higher mortality, and poorer health outcomes. Among the disease-specific examples of

racial and ethnic disparities is the cancer incidence rate among African Americans, which

is 10% higher than among Anglo Americans (Goldberg, et al. 2004). In addition, adult

African Americans and Latinos have approximately twice the risk as developing diabetes.

According to a national survey, Mexican Americans have higher rates of end-stage renal

disease, caused by diabetes, and they are 50% more likely to die from type II diabetes

than Anglo Americans. 1 Minority groups also have higher rates of heart disease,

HIV/AIDS, and infant mortality than Anglo Americans (Goldberg, et al. 2004).

1
http://minorityhealth.hhs.gov/templates/content.aspx?ID=3324 accessed 3/2010

8
 The socio-economic status model, or the idea that wealth equals health,

influences most minority health research (Hayes-Bautista 2002). This theory contends

that the greater likelihood of living in poverty places groups like Latinos at increased risk

of disease and disability because poverty is highly linked with residing in resource-poor

neighborhoods, a greater likelihood of being exposed to environmental hazards, and a

greater likelihood of intentional and unintentional injury (Carter-Pokras and Zambrana

2001). According to the 2000 U.S. census, 24% of Mexican Americans live below poverty

compared to 7.7% of Anglo Americans.

Latino populations are placed at even greater risk compared to other immigrant

groups because of the high percentage who work in hazardous jobs, are undocumented,

and lack health insurance (Chavez, et al. 1992; Carrillo, et al.2001). However, some

studies have shown that even with insurance and access to health services, both

immigrant and non-immigrant Latinos underutilize health and mental health care (Vega,

et al. 2001).

Aside from the moral argument for ending health inequalities, a recent study

concluded that between 2003 and 2006, the combined costs of health inequalities and

premature death in the United States were $1.24 trillion and that eliminating health

disparities for minorities would have reduced direct medical care expenditures by

$229.4 billion (The Joint Center 2009). 2

A common reason cited for underutilization is that the U.S. health care system,

in its “one-size-fits-all” approach, is inadequate to meet the needs of Latinos (Vega and

2
http://www.jointcenter.org/hpi/sites/all/files/Burden_Of_Health_FINAL_0.pdf

9
Alegría 2001; Putsch 2002). The proposed solution in current medical discourse is

culturally aware and competent medicine. Anthropologists have advocated for a more

culturally aware biomedicine since the 1950’s (Foster 1953). However, as cultural

competence models become more and more focused on cultural difference,

anthropologists must ask how we might contribute to a more holistic understanding of

the issue.

A Critical Review of Cultural Competence

A review of the recent medical literature shows that the concern with delivery

and accessibility of treatment to immigrants and minorities in medicine is largely limited

to a concern for providing culturally sensitive services. Advocates for cultural

competence believe that introducing culturally sensitive practices decreases cultural

and linguistic barriers and increases certain patient outcomes, such as patient

understanding, satisfaction, follow-up, and treatment compliance (OMH 2001).

Culture competence models incorporate actions to manage both linguistic and

cultural differences between patients and the health care system. Linguistic

competence is described as an essential component of cultural competence and is

concurrently described as being the bare minimum of culturally competent strategies

(Brach and Fraserirector 2000). Linguistic competence occurs at two levels, the

institutional and individual. Institutions can provide language specific written materials

such as patient sign-in and billing documents, posted signs, and education pamphlets;

clinicians can ensure competence if they are bilingual or use medically trained

interpreters to overcome language barriers.

10
 The consequences of linguistic barriers have been well documented in the

literature. There are examples of medical encounters where interpreters and clinicians

worked together to ensure an accurate linguistic translation of the information provided

to both the patient and clinician. Likewise, the literature contains examples of patient

visits where interpreters were not accurate, or did not fully translate the information

provided to both the patient and clinician; in some cases serious medical errors

resulted. These errors were more likely to occur when the interpreter was a friend or

family member and was not medically trained as an interpreter (Elderkin-Thompson, et

al. 2001; Flores, et al. 2003). Studies that link language barriers with repeat

appointments, extra time spent rectifying misdiagnoses, unnecessary emergency room

visits, longer hospital stays, and patient misunderstanding and dissatisfaction help to

highlight the importance of linguistic competence (Baker, et al. 1998; OMH 2001; Putsch

2002).

Cultural barriers, on the other hand, while infrequently documented in health

care encounters have been presumed to include the following (Chavez, et al. 1995;

Browner, et al. 2003):

(1) differences concerning how patients and clinicians act in a biomedical setting
(including both verbal and non-verbal behaviors, gestures, and procedures) and
differences regarding how clinicians and patients are expected to perform their
respective duties/roles;
(2) differences in certain cultural assumptions of respect, trust, patient autonomy, and
informed consent; and
(3) differences with respect to the patient’s and clinician’s explanatory models (the
etiology, treatment, and outcome) of the illness.

11
 There is an inherent problematic notion of culture in cultural competence

models for anthropologists and others who do not hold a reductionist or static view of

culture. While cultural sensitivity and awareness are not new ideas in medicine, they

have previously been discussed in terms of “cultural bias,” “cultural differences,” or

“cultural misunderstandings” (e.g., Malgady, et al. 1987). It seems to be a recent

phenomenon to frame cultural and linguistic differences in terms of how they constitute

“barriers” to the delivery of health care. 3 Hence cultural and linguistic differences of the

patient, and not necessarily the culture of the medical provider and institution, become

incorporated into the medical model as negatively impacting health care, i.e., posing a

“barrier” (Santiago-Irizarry 2001). With the uncritical and increasing use of the term

“barrier” we are led to believe that the patient’s culture is so problematically different

that treatment may be impeded or come to a standstill.

Despite the increased attention to the need for cultural competence, several

components block the complete acceptance of cultural competence in medical practice

as well as in the social sciences. To begin, there is a failure to provide a consistent and

comprehensive definition of cultural competence. The question or evaluation of which

competencies lead to proficient practices by clinicians and institutions has not been

answered by cultural competence advocates (Brach and Fraserirector 2000).

Second, without the operationalization of such a vague and complex concept,

practitioners are unsure about how to apply written policies to service delivery. Third,
3
For example, the Office of Minority Health’s (OMH) main website states that they were mandated by the
US. Congress in 1994 to, “develop the capacity of health care professionals to address the cultural and
linguistic barriers to health care delivery.” Barrier is also the designated term in the OMH’s National
Standards on Culturally and Linguistically Appropriate Services (better known as the CLAS Standards), the
standard most often used in research and in medical school training.

12
there is a lack of critical questioning of basic assumptions about the role and effect of

cultural differences; for example, statements such as, “all professionals who interact

with minority clients need to possess cultural competence to provide appropriate

services” (Arellano 2004: 10) assumes that only minority clients possess a type of culture

that is problematic or needs a special set of behaviors to accompany appropriate

treatment.

A fourth critique is that few studies exist which explicitly investigate how

utilization of culturally competent services impacts the acceptance or perceived

effectiveness of services by the target populations (Beach, et al. 2005). In fact, one

review article highlights a lack of research on the techniques and behaviors of cultural

competence, whether culturally component actions affect patient outcomes, and

whether or not cultural and linguistic competence in medicine could reduce racial and

ethnic health disparities (Brach and Fraserirector 2000).

Lastly, cultural competence models do little for the structural, political, or

economic causes of limited access and ill health. In fact, accompanying the cultural

competence movement is an explicit shift away from a focus on the role of poverty,

health insurance and access, discrimination, and hazardous jobs in the development of

ill health and disease to an analysis of the role of cultural difference (Hirsch 2003; Shaw

2005).

Actual examples from medical encounters of how culture and cultural

differences may negatively impact the diagnosis or treatment of an illness are very

scarce, and are even more so in the mental health field. When might a cultural issue

13
become a “barrier” and do cultural differences exist which do not evolve into barriers

(e.g., Jenkins, et al. 1996)? Are cultural barriers fundamentally different from other

types of barriers from non-immigrant or non-minority (i.e., “non-cultural”) patients?

And to question the model further, does the narrow focus on cultural difference result

in the “racialization” of health beliefs if the patient’s practices are reduced to an

understanding of illness and disease in terms of their culture and ethnic identity? If the

medical encounter provides the space for the intersection of cultural differences in

health care, how might patients and clinicians locate them, how are they talked about

or negotiated between participants, and does there exist a set of strategies that

clinicians can adopt to be “culturally competent?”

Without clear answers to these questions, many argue that there is little

agreement as to what constitutes cultural competence in medicine and why it is needed

(Brach and Fraserirector 2000; Hirsch 2003). As extensive efforts are underway to

create enforceable national standards for cultural competence, I believe we must take a

step back to identify both how culture plays a role in health care treatment and delivery

and how other issues such as poverty and class fit into a cultural competence model.

Cultural competence definitions and theoretical models will be more explicitly discussed

in Chapter three.

II. Medical Anthropology

The research discussed in this work is drawn largely from Medical Anthropology.

From this field I utilize theories on Mexican ethnomedical systems, the role of culture in

14
health, conceptualizations of migrant and refugee health, explanatory models, illness

narratives, the study of biomedicine, and critical medical anthropology.

Mexican Ethnomedical Systems

Anthropologists have written extensively about Latin American cultures,

customs, healing beliefs and practices, and ethnomedicines (for example, Rubel 1960;

Kiev 1968; Ingham 1970; Clark 1970; Garro 1986; Foster 1994; Finkler 2004). The early

work of George Foster (1953), Rubel (1960), Clark (1970) and others moved

ethnomedical research in anthropology away from studying the exotic practices of

immigrants to a richer understanding of health and illness in the broader sociocultural

arena. They also foreshadowed the problem of culturally appropriate practices in

medicine and low health care utilization rates among immigrants and minorities (Paul

1963; Browner 1994). These studies are particularly pertinent today because

immigrants bring with them culturally-specific beliefs, assumptions, and values which

may not correspond with biomedicine, including procedural differences of accessing and

navigating the health care system and the cultural/social knowledge of how to act like a

“patient,” as well as larger differences in the actual illness.

For example, Finkler (2004) described the Mexican medical system as a mix of

biomedicine and alternative healing systems, including professional and folk (e.g.,

homeopathy, acupuncture, and curanderos). Finkler found that clinicians at one urban

hospital in Mexico held etiological explanations for illness that corresponded to

traditional folk concepts such as nervios, anger, and susto as well as environmental and

social causes. However, their medical training required them to reduce the folk

15
concepts to a diagnosis of disease categories. So while the common folk category of

nerves was widely accepted by clinicians, “they reduced “nerves” to an organic disorder

of the nervous system” (Finkler 2004: 2046).

A second Mexican classification system of health and illness is humoral or hot-

cold dichotomous system. Foster (1994) traced the roots of Latin American humoral

medicine back to three ethnomedicines that rely on basic binary oppositions: Greek

humoral medicine from approximately the sixth century BC to 400 BC, Indian Ayurvedic

medicine dating from the first, forth, and seventh century AD (from classic Ayurvedic

humoral medicine as surviving in Sanskrit documents, the Caraka Samhita, the Susruta

Samhita and the Vagbhata), and Chinese humoral medicine dating from the fifth

century BC. Humoral principles work to maintain the body’s equilibrium based on

metaphorical and thermal hot and cold qualities within food, outside and inside

temperature, and a balance of emotions. Foster (1994) contended that in the Mexican

system, all foods, herbs, and some other substances (such as iron) have a temperate as

well as metaphoric value of “hot” and “cold.” An upset to the body’s equilibrium can

cause, or make a person more susceptible, to illness. Therapies for the most part tend

to conform to the “principle of opposites” so that a cold remedy works best for a hot

illness and vice versa (Foster 1994).

Although all ethnomedical systems are dynamic and changing, it is clear that

Latino immigrants still believe in the importance of this classificatory system to provide

a basis for the explanation of illness. Throughout his decades of research in Mexico,

Foster (1994) demonstrated that despite the dominance of Western medicine, millions

16
of people at some level continue to subscribe to a humoral belief system and engage in

practices based upon it. Clark (1970) also explained that her second generation

Mexican-American research participants were familiar with the hot-cold system of

disease and one-third were able to classify hot and cold foods, dispelling the myth that

ethnomedical knowledge is inversely correlated with acculturation. Humoral medicine

is discussed further in Chapter five, in the context of an examination of patients’ health

beliefs about chronic diseases such as diabetes and heart disease.

Anthropologists have also written about the “new immigration” patterns and

how processes like globalization have destabilized local economies and altered

migration patterns. Scholars have argued that Latinos, for example, are entering the

U.S. because American culture has permeated their own: “With TV shows, soldiers, and

political ideals, the United States has reached out and touched people across an entire

hemisphere. It has gotten back immigrants in return” (Suro 1998: 20).

According to the 2000 census, there were roughly 281 million people living in the

U.S. with 31 million people born outside the country. The sheer size of the immigrant

population and the radical shift in the sources of immigration have led some scholars to

claim that this current wave of migration is unlike any we have seen before in this

country, it truly constitutes a “new” immigration (Suárez-Orozco 2003; Reimers 2005).

What is new about this wave is not only is the volume, but also the geographical make

up of immigrants. Until the middle of the 20th century, immigrants were mostly

European whereas today, more than 50% of immigrants are from Latin America and 25%

from Asia (Reimers 2005).

17
 New immigration scholars recognize that the portrayal of “Latinos” as a unified

group in some research, policy publications, and discussions is misleading; using a pan-

ethnic label such as “Latino” glosses over the contradictions and tensions around class,

race, and color that separate the individuals which are included en mass in the label.

Why certain populations migrated to the U.S., when they migrated, and what they are

migrating to cannot be captured in the “Latino” label. For example, the first migratory

wave of Cubans fleeing from Communism to the U.S. in the 1950’s were welcomed and

benefited tremendously from substantial governmental aid, whereas today, Cubans are

turned away and deported (Suro 1998). To treat all Cuban immigrants alike, much less

all Latinos, simply ignores these historical differences. 4

Scholars studying the new immigration focus on economic aspects of migration

such as unemployment, under-employment, lack of access to credit, and wage

differentials. For example, the majority of uneducated immigrants find work in the low-

wage, low-skilled, secondary sector, which limits access to health care, upward mobility,

and financial stability (Suárez-Orozco 2003). There is evidence that the “economic step-

ladder” of the 1950’s, where subsequent generations of migrants steadily gain higher

paying jobs and education levels, is not available today (Suro 1998; Magaña and Hovey

2003). Additionally, while the children and grandchildren of the 19th century European

immigrants benefited from an expansion of the public education system, Latino

immigrants have arrived only to find the U.S. education system dangerously in disrepair

(Suárez-Orozco 2001).

4
I will use the term “Latino” when discussing other research that is not specific about which cultural or
ethnic groups were surveyed. The research participants in this study were primarily Mexican immigrants.

18
 Medical anthropology research indicates that new immigrants, in particular

Latino immigrants, have high rates of depression, anxiety, occupational diseases, and

chronic diseases such as diabetes and heart disease linked to acculturative and

environmental stressors (Padilla, et al. 1998; Carter-Pokras and Zambrana 2001; Portes

and Rumbaut 2001; Chavez 2003).

Meaning-Centered and Interpretive Theories

Beginning in the 1960’s, medical anthropology began to develop and emerged as

a sub-discipline of cultural anthropology in the 1970’s. Medical anthropology largely

focused on ethnomedicines and a comparative, cross-cultural study of health and illness

with some interest in reducing disease, disability, and human suffering, and

international health and public health measures (Paul 1955, 1963; Browner, et al. 1988;

Sobo 2009). Benjamin Paul, an early founder of medical anthropology, specified two

kinds of medical anthropologists in the 1950’s and 60’s: “those who investigate cultural

components in the etiology and incidence of illness and those who analyze popular

reactions to programs of health maintenance and health improvement” (1963: 35).

A contribution of medical anthropologists to cross-cultural health research was

their definition of health as a broad construct, encompassing physical, psychological,

and community/social wellbeing (Sobo 2009). This concept worked better than the

biomedical concept of “disease,” which referred to more biological or physiological

processes. Medical anthropologists further argued for an understanding of the “illness,”

a culturally-constructed experience of being unwell, rather than the disease process

(Kleinman 1980).

19
 With a new climate and radical cultural changes in the U.S. during the 1960’s and

70’s, anthropology and medicine changed as well and the research that ensued

strengthened the interdisciplinary bonds between them. The very concept of “culture”

and what was considered “objective” and “scientific” in anthropology was changing (see

Geertz 1973; Clifford and Marcus 1986). A growing number of symbolic anthropologists

adopted new methods suited to the study of meaning and began to advocate for

interpretive and meaning-centered approaches in the anthropology of religion and,

later, in medical anthropology.

These new approaches were an outgrowth of two influential anthropologists,

Victor Turner (1967, 1969) and Clifford Geertz (1984, 1973) who incorporated

hermeneutics, psychological anthropology, and psychoanalysis (Gaines n.d.).

Phenomenology and social interactionism played an important role in anthropology at

this time. Borrowing from sociological theories like Garfinkel’s Studies in

Ethnomethodology (1967), Berger and Luckmann’s Social Construction of Reality (1966),

and Schutz’s papers on social reality (1962), anthropologists formulated theories about

the importance of phenomenology in social science research and the selection of

everyday activities and experiences for examining organized, reflexive, accountable, and

observable practices (e.g., Goffman 1959).

Early interpretive anthropologists mainly studied traditional therapies and

culture-bound syndromes and with these, new methods merged interpretive and

symbolic analysis for cross-cultural research in religion and psychology (Good and Good

1982). When the American Psychiatric Association published the first Diagnostic and

20
Statistical Manual of Mental Disorders (DSM) in 1952, ethnopsychiatrists began a

serious comparison of Western diagnostic classifications to other cultural settings.

Studies used Western standards of comparison that explicitly stated that “we have

‘psychiatry’, they have ‘ethnopsychiatry;’ our diagnostic categories are ‘real’, theirs are

‘folk’ or ‘culture-bound’” (Gaines n.d.: 15; e.g., Yap 1951; Devereux 1961; Kiev 1964;

Murphy 1971). The comparative studies highlighted the role of culture and cultural

difference in the form and content of illnesses.

Anthropologists, and especially cultural relativists, reproved the role that culture

played in the epidemiological studies on the course and outcome of illnesses, in

particularly, mental illness. Often treated as superficial background information, cross-

cultural psychiatrists tended to see the essential biological elements surrounded by a

confusing series of cultural and idiosyncratic layers which had to be picked away in

diagnosis to reveal the “real” disease. As Geertz facetiously stated, “culture is icing,

biology cake…difference is shallow, likeness deep” (1986: 269). Psychological

anthropologists recognized the local nature and meaning of illness and pushed forward

the agenda that culture matters at every level of the illness experience: in the processes

of recognizing abnormal symptoms, seeking treatment, labeling and diagnosis, and in

therapeutic actions taken to remedy the illness.

One theoretical outgrowth of this push was the Explanatory Model (EM). EMs

are cognitive models about a specific illness and include ideas about how illness is

defined, what personal and community meaning it has, patterns of treatment resort,

and how treatment is evaluated (Kleinman 1978; Katon and Kleinman 1980). Medical

21
anthropologist Arthur Kleinman formulated an experience-near theory about EMs from

his struggle to explain how differing concepts of disease and illness held by patients and

practitioners could be taken into consideration in the medical encounter. Kleinman

(1978) suggested that these models be elicited from individual patients, families, and

practitioners in order to incorporate all participants’ experiences and beliefs in the

process of negotiation and treatment. Implicit within this model was a deep concern for

understanding the experience and social world that lies within an illnesses as well as

acknowledging the biological processes.

Study of Biomedicine

Despite some anthropologists who felt that medical critiques were generally not

appropriate for the field, medical anthropologists enlarged their scope away from their

strict focus on psychiatry to study Western medicine writ large (Gaines 1992b; see

Kleinman 1978; Gaines 1982a; Engel 1984). Medical anthropologists emphasized that

Western pathology was no less culturally-constructed than others (Gaines n.d.;

Littlewood 1990; Stigler, et al. 1990). Medical anthropologists like Byron Good, Elliot

Mishler, Atwood Gaines, and Arthur Kleinman came to view biomedicine, like all

professional medical systems, as culturally constructed.

For example, Good and Good (1993) critically examined the way in which

medical schools transform students into doctors vis-à-vis a reconstruction of the

medical gaze (see also Good 1994). Social psychiatrist Elliot Mishler (1981)

deconstructed the main assumptions of Western and biomedicine. Ultimately, Mishler

felt that as biomedicine adhered to the doctrine of specific etiology that was derived

22
from L. Pasteur’s germ theory, each disease is expected to have a specific genesis or

cause. But underlying the cause and effect model is a process by which disease is

constructed rather than found. The confusion around diagnosis is that too often

clinicians and researchers have confused the concept of disease (an explanatory model)

with a rigid notion of what reality is, thereby reifying the notion of diseases as real

things (Mishler 1981). Building on Mishler’s assumptions of biomedicine with a specific

gaze on medical systems, Gaines (1992a) offered a cultural constructivism model that

outlined the manner in which biomedicine and all professional medical systems become

culturally constructed. The field of medicine itself is a culturally constructed entity with

its own distinct rituals and ways of seeing the world (Hahn and Gaines 1985; Gaines

1992a; Good 1994).

However, what was so clear to medical anthropologists, namely that the

patient’s experience and explanatory models were just as important as the physical

symptoms of the illness, was not seen as particularly important in biomedicine because

of the way that discipline was constructed and taught. As mentioned earlier, central to

biomedicine is the idea of a single causal agent of illness that is “discovered” through

biological, empirical, and reductionist means.

The recognition that many infectious diseases were caused by microorganisms

was a large impetus in the development of certain pharmaceutical drugs in the 1930’s

and 40’s, namely synthetic sulfa antibiotics and penicillin. These discoveries

transformed medicine as drugs increasingly became “the center of medical practice”

23
(Finkelstein and Temin 2008:22). This pharmaceutical revolution led medicine to the

sciences of biochemistry, microbiology, pharmacology, genetics and others.

The birth of the biomedical model of disease as such left out the patient’s

experience of illness as it sharpened the medical gaze (Foucault 1973). The medical

gaze effectively reifies what is subjective to the patient into something objective for the

doctor (Taussig 1980). Not only does the person transform more and more into the

disease he or she is diagnosed with (e.g., “a schizophrenic” and not a person suffering

from schizophrenia), but the person takes on the “sick role” and becomes a “patient,”

with specific patient duties and linguistic roles to perform (Parsons 1951; Foucault 1973;

Mauss 1996). No longer a whole person, the patient and his or her role becomes that of

information bearer and obedient follower rather than a partner in the medical process.

Thus, because biomedicine constructs disease as a bio-chemical entity, which puts the

central focus of treatment on the body, a patient’s subjective experience of suffering

and malady is often ignored or discounted by the clinician (Taussig 1980; Mishler 1984;

Kleinman 1995).

Throughout the social sciences, these powerful critiques of biomedicine mirrored

the general inadequacies felt by the lay U.S. population. Consistent with the

counterculture movement of the 1960’s and 70’s, there was a general dissatisfaction

amongst the general public with professional medical knowledge – it was often

paternalistic and dualistic and physicians focused heavily on the biological mechanisms

of illness and less on the social aspects (West and Frankel 1991). When medical and

linguistic anthropologists began to write about the culture of medicine in the early

24
1980’s, we received experience-near and rich productions of patient’s accounts of

health, their explanatory models of disease expressed in illness narratives, how they

interacted with the formal and informal medical systems, as well as the rites and

initiations of medical students and other clinicians (Kleinman 1980, 1988; Mishler

1984;Good 1994).

Several medical anthropologists created methods for eliciting narratives and

explaining their informant’s point of view. For example, Byron Good (1977) developed

the Semantic Illness Network theory which stated that illness realities were biologically

constrained as well as culturally constructed. As he compared “fright” and “heart

distress” in Iran, Good illustrated that meaning was constituted as coherent networks of

symbols through which experienced realities were constructed. “A meaning centered

approach to medical anthropology provides a framework for the study of illness

categories that is alternative to both biomedical approaches and cultural relativist

analyses” (Good and Good 1982: 147).

Illness Narratives and Storytelling

One way patients and clinicians provide information to one another in the

medical encounter is through storytelling and narratives (Fisher and Groce 1990). One

of the most powerful forms for expressing the patient’s explanatory model and/or life

experiences with the illness is through narratives. Narratives often give voice to

experiences that lie outside the biomedical space and are a fundamental way we create

and give meaning to our social reality (Mattingly 2000, 2008). The illness narrative or

25
story is saturated with moral, social, and cultural meaning from the patient’s lifeworld.5

“Acting like a sponge, illness soaks up personal and social significance from the world of

the sick person” – meanings from life experiences become interwoven with the long-

term experience of illness, especially chronic illness (Kleinman 1988: 31). Thus,

explanatory models are not just cognitive representations of an illness; the

psychological and social aspects of the illness shape explanatory models and the

meanings they produce.

Especially for people suffering from chronic illness, stories and narratives may be

an attempt to make an unpredictable, chaotic, “natural” disease occurrence into an

ordered, controlled, everyday life event. This excerpt from Kleinman’s Illness Narratives

reminds us how a chronic illness permeates our everyday experiences:

“The undercurrent of chronic illness is like the volcano: it does not go away. It
menaces. It erupts. It is out of control. One damned thing follows another.
Confronting crisis is only one part of the total picture. The rest is coming to grips
with the mundaneness of worries over whether one can negotiate a curb,
tolerate flowers without wheezing, eat breakfast without vomiting,…or just plain
face up to the myriad of difficulties that make life feel burdened, uncomfortable,
and all too often desperate” (Kleinman 1988: 44).

For people with chronic illnesses, narratives and the telling of narratives may also help

shape a person’s identity, making it possible to give coherence and meaning to events

that have disrupted and changed one’s life.

Explanatory models, as deeply rooted in emotions and cultural values, are often

difficult for patients to express, especially when they differ from others’ models, such as

5
Mishler (1984) developed the concept of the “voice of the lifeworld” as “the patient’s contextually-
grounded experiences of problems and events in her life” (104). The lifeworld contrasts with the “voice
of biomedicine” which is technical, scientific, and decontextualized.

26
the clinicians (Kleinman 1988). Not only is the illness experience culturally mediated,

but stories about illness are also told in a culturally specific and appropriate way (Garro

and Mattingly 2000). As such, social scientists are interested in not only what is said

during a narrative but the way in which it is told – the form of the narrative also conveys

information about the narrator (Hyden 1997). In medicine, narratives are seen as

something that is a distinct form of speaking, much different than what occurs during

other portions of the medical encounter.

Narratives and EMs in the Medical Encounter

In a health setting, this web of meanings has great significance for the health

provider and treatment of the illness. Kleinman (1988) and other medical

anthropologists encourage clinicians to elicit illness narratives from their patients in

order to assist people in coming to terms with the personal significances of the illness

that are operating in their lives. Besides getting at the meanings of the illness,

explanatory models also allow patients and clinicians to communicate and talk about

their illness. By talking about these issues all participants can better negotiate a

treatment plan that is mutually acceptable. The medical encounter is a prime place for

such a dialogue as it sits between the patient’s lifeworld and the voice of biomedicine

(Mishler 1984; Sarangi 2004). As such, patient-centered clinicians have begun to call for

a “narrative-based medicine” versus an empirically-based medicine (Sarangi 2004).

Narrative is important because lack of patient participation may cause

misunderstandings about diagnosis, prevention, and treatment. Research from outside

the social sciences also furthers the idea that there is a correlation between patients

27
talking about their explanatory models and patients’ satisfaction, understanding,

“compliance,” and health care utilization (Rao, et al., 2000). In fact, one study found

that in 28 out of 35 medical encounters there was a misunderstanding between patient

and clinician. Causes for the misunderstandings were that most patients had an agenda

item that they did not voice or there were inaccurate assumptions or guesses from the

participants (Britten, et al. 2000).

Mishler’s (1984) articulation of the importance of the patient lifeworld in

medical encounters brings together the explanatory model theory, patient-centered

care, and narrative medicine. Figure 1.1 represents Mishler’s model of the patient

lifeworld. In this model, Mishler proposed that the voice of biomedicine, which focuses

on technical concerns such as the disease process, is at odds with the voice of the

lifeworld, which focuses on patient’s experiences and feelings. Mishler (1984) argued

that the majority of medical encounters take place solely in the voice of biomedicine.

28
Figure 1.1 Misher’s Model of the Lifeworld (from Barry, et al. 2001)

Despite the benefits of having the patient tell his or her illness narrative,

researchers studying the medical encounter found that clinicians frequently opt to take

up the physical discourse of disease but do not interact with the social and cultural

meanings of the disease for the patient (Mishler 1984; Kleinman 1988; Waitzkin 1991;

Britten, et al. 2000). Symptoms are similar to other social and cultural symbols; they are

provided, read, analyzed, and interpreted both by the sufferer and their social network,

by the interpreter speaking for the patient, and by the clinician treating them. At each

29
phase and at different levels, illnesses, and talk about illnesses, are saturated with

moral, social, economic, racial, sexual or disabling meanings. Many times these

meanings, however, are not as important as the “scientific” meaning of the disease to

the physician (Kleinman 1988).

Consider, for example, the main format of a medical encounter. Waitzkin (1991),

a sociologist and physician, highlighted the structure of the typical visit as the elicitation

of a chief complaint by the doctor, followed by a discussion of the present malady, past

history, family history, and social history. Next, the doctor performs a physical exam

and any other necessary investigations or tests and then presents a diagnosis and

treatment plan. Medical residents are taught in medical school that eliciting the chief

complaint and present illness from the patient are considered the most important skills

a doctor may possess.

But telling an illness narrative or story is not so easy for the typical patient.

Interruptions by the clinician frequently occur during the discussion of the present

illness, the phase precisely where contextual information enters the dialogue, in order

to curtail “unnecessary” information in a patient’s story (Waitzkin 1991). The drive to a

correct diagnosis is very strong in every encounter and segments of the patient story

that the doctor perceives as excessive or pointless (i.e., those that are perceived as

having nothing to do with arriving at a correct diagnosis) are ignored and more

frequently impatiently cut off (Waitzkin 1991). Mishler (1997) hypothesized that the

shape of the patient’s story, its thematic coherence, structure, and grounded ending, is

directly related to the interactive roles that the patient and doctor play out. Thus, while

30
patients may be narrating their experience from the perspective of their lifeworld,

doctors are interpreting symptoms from their technological perspective (Mishler 1984).

In a cross-cultural medical encounter, the patient story may hold important clues. How

do Mexican immigrant patients tell their story of the present illness? Are there

culturally-specific ways of communicating that clinicians need to be in tune with?

If the information provided by the patient is so important to arrive at the correct

diagnosis, why is the information provided by the patient sometimes seen as

superfluous? As the physician’s authority over the disease increases, doctors become

the knowledge-controllers of patient health, and the transfer and loss of power over our

own bodies becomes more and more transparent (Foucault 1973). Our health and

health care have additionally become commodities in the biomedical system; doctors

are the providers, we are the consumers, and large profits are made by health insurance

and pharmaceutical companies. Biomedicine is not just any bureaucracy and

profession; “…it is a leading institution of industrialized society’s management of social

reality” (Kleinman 1995: 38). Thus, because of the pressure of time, the sheer numbers

of patients doctors are expected to treat due to managed care which gives incentives for

clinicians to treat more patients with less resources, the gate-keeping function doctors

hold, and the relegation of patient experience with their illness to “soft” science,

doctors are necessarily in a position of more power over health (Dugdale, et al. 1999).

Despite the advancement of meaning-centered research, some in the medical

anthropology discipline believed the focus on meaning led the primary goals of the sub-

discipline astray. Browner, et al. (1988) admonished interpretive anthropologists for

31
being so against the universalist paradigms that dominated in the early century that

they completely refused to explore the intersection between biology and culture.

“While this orientation has enriched ethnology, it has impoverished efforts to build

comparative frameworks with which to verify propositions, determine the validity of

findings in more than one society, or test hypotheses that predict generalized

relationships between social, cultural, and/or ecological variables” (Browner, et al.,

1988: 689). Hahn (1985: 570) also critiqued culturally relative interpretivists for being

“overly xenocentric” to the degree that researchers would no longer account for the

mistaken beliefs of their participants.

These assessments direct attention to one of the greatest theoretical problems

that faced medical anthropology: that meaning-centered anthropology tended to be too

culturally relative. “…the relativist [person] views the understandings of others as self-

contained, incommensurate, ideational universes: across these universes there is no

comparability, no common standard for rational criticism…” (Shweder and Bourne 1982:

104). Inherent tension lies within the need to establish genuine communication

between social science and biomedicine, to collect data that is truly comparable and

useful for applied work in settings like clinics, and the need to search for the specific

cultural influences created within communities and the social systems that play a

profound role in making the meaning behind the symptoms (White 1982). The goal of

medical anthropology should never be to simply discover links between culture and

biology as Browner, et al. (1988) advocated; nor should it be a pure relativistic reading

32
of health and illness. Rather, medical anthropologists should strive for a balance

between the two extremes with a focus on making our research clinically relevant.

Critical Medical Anthropology

Finally, my research is influenced by theories from critical medical anthropology

(CMA). As a reaction against a more meaning-centered approach in medical

anthropology, critical theories developed to include the examination of social structures

that influence health and disease. While such structures as social class, gender, or

ethnicity are culturally-constructed, they nonetheless impact determinants of health

and disease. A CMA approach emphasizes the role of power, poverty, discrimination,

violence, and inequality in health care systems (Singer and Baer 2007).

Early theories of both interpretive and CMA approaches in medical anthropology

were at odds with one another; however, the approaches are not mutually exclusive

and both inform this body of research. I see an individual patient at the clinic situated in

their specific cultures, drawing upon various ethnomedical models, and having agency in

their decision making and actions of obtaining health care. This same individual,

though, also lives within a society with highly unequal access to health care where

health care is not a right for all members. If the individual is a minority or immigrant

they are more likely to face poverty, discrimination, and disparities in health outcomes

(Singer and Baer 2007).

The causes and effects of “structural violence” are often a topic of CMA

research, such as the explicit connections between history, power, poverty, inequality,

economic and social rights, and human rights abuses (Farmer 2003, 2004). “In short, the

33
concept of structural violence is intended to inform the study of the social machinery of

oppression” (Farmer 2004: 307). Structural violence is often embedded in the adverse

events of our research, events such as diseases or violations of human rights. Because

of this focus, critical medical anthropologists often call for anthropologists to clearly

show these linkages in our research and writing (Farmer 2004).

Specifically in the study of clinical interactions, CMA views biomedicine as a

“dynamic, contradictory expressions of overt and covert struggle between dominant

groups who promote a system that enhances control on the one hand and subordinate

groups who demand care on the other” (Singer 1995: 86). While this system of

biomedicine may not be the precise reality at the People’s Clinic, where this research

takes place, because the clinicians at the free clinic were volunteers who verbalized the

effects of structural barriers on health, the clinicians there were necessarily working

within the biomedical model.

Medical anthropologists also examine the way clinicians and patients, using

different sources of knowledge, produce medical knowledge. The concept of

authoritative knowledge grew out of studies of power in medical settings (e.g., Jordan

1978, 1997; Hahn 1985). Studies suggest that patients exclude their own knowledge in

deference to biomedical authority, sometimes to the detriment of patient health

(Kingfisher and Millard 1998). Other research finds that patient knowledge is devalued

or ignored in favor of biomedical knowledge (Jordan 1878, 1997). While certain

characteristics (such as patient or clinician) affects which knowledge dominates in the

34
medical encounter, authoritative knowledge is not “true” or “correct” in any “objective”

sense, but rather is created amongst participants.

Thus, these theories contribute to an overall analysis of biomedical control

(Foucault 1975). Clinician-patient encounters are micro-level situations between

individuals. But as a social and cultural institution, biomedicine and medical encounters

are influenced by and reflect broader macro-level social ideologies, including dominant

ideologies about social class, education, and political-economic power (for examples see

Taussig 1980; Todd 1983;West 1984; Waitzkin 1991; Singer 1995).

Researchers find that many doctors, partly due to the “medical gaze” and

managed care constraints, are reluctant to discuss and even recognize circumstances in

the patient’s lifeworld (Foucault 1975; Waitzkin 1991). However, when clinicians do

converse with their patients about social problems, they tend to reinforce dominant

ideologies of work and disability, sexuality and gender roles, and the “rights” of health

(Waitzkin 1991). Many areas have historically fallen under medical control and with the

addition of cultural competence models, culture may be seen as the latest subject to be

added to this list. Unfortunately, as medical management of culture and language

expand, the socio-political and economic roots underlying many patient problems

become less evident (Hirsch 2003).

Finally, critical medical anthropology also forms a basis from which to critique

cultural competence models for their incomplete views of the role of structural barriers.

As cultural competence theories gained popularity, analysis shifted away from the role

of macro-structural phenomena in health, such as living in poverty, poor working

35
conditions, environmental hazards, institutionalized racism, and an immigrant or

refugee’s migratory and pre-migratory experiences (Hirsch 2003). A CMA approach

allows for a local, contextual understanding of the experience of Mexican patients at a

U.S. health clinic as well as their relationship to broader national and international

systems (biomedicine, immigration politics, political, and economic systems) (Chavez

2003; Hirsch 2003; Sobo 2009).

III. Linguistic Anthropology

Anthropologists who study language view it as a set of symbols and practices

that represent social and cultural worlds. Linguistic anthropology examines language

through the lenses of anthropological concerns and has at its core such studies as the

transmission of culture, forms of social organization, and how language plays a crucial

role in mediating our ways of being-in-the-world.

Arguably, the linguistic study of doctor-patient encounters and communication

has yielded needed data about a situation that nearly every individual has experienced.

This process of sickness and wellness is rife with emotions, cultural patterns and

expectations, and powerful relationships. The participants involved in this encounter,

be it the clinician, patient, family member or medical interpreter, enact specific

sociolinguistic roles which often point to wider social and institutional actions and rules;

speaking produces social action.

It is these behaviors, rules, and outcomes that this section will address with a

focus on the unique situation of cross-cultural and cross-linguistic medical encounters.

36
The section will provide a brief history of the research and methodologies of

sociolinguistics and linguistic anthropology, I will examine the area of doctor-patient

communication, and the use of interpreters in cross-linguistic encounters.

Sociolinguistics and Linguistic Anthropology

The two academic disciplines that most often study medical discourse are

sociolinguistics and linguistic anthropology. Despite sharing certain ideas, theories, and

methods they constitute two related but separate research disciplines.

Linguistic anthropology, the older of the two sub-disciplines, grew out of early

study and documentation of American Indian languages and cultures by Kroeber, Sapir,

Whorf, and other anthropologists in the late 1800’s and early 1900’s. While these

scholars thought of themselves as linguists primarily and chose the name

“anthropological linguistics,” it was the work of Gumperz and Hymes in the 1960’s which

changed the direction and specificity of the sub-discipline (Duranti 2001). Their resolve

to broaden the interest of language beyond the focus of micro-level grammatical

structure of communication is evident in Hymes’ landmark essay Toward Ethnographies

of Communication (1964). He wrote, “…an ethnography of communication must take as

context a community…it is not linguistics, but ethnography – not language, but

communication – which must provide the frame of reference within which the place of

language in culture and society is to be described” (Hymes 1964: 3). Instead of

describing talk as something that directly reflects the beliefs and values of a community

or speaker, Hymes’ important insights show rather, that we should concentrate on

situations of speaking, such as communication during a medical encounter.

37
 Sociolinguistics emerged in the 1960’s as the study of linguistic forms related to

the social context of their use. Gumperz, also a pioneer in this field, used qualitative

methods to understand language contact (Gumperz 1968). Labov provided an empirical

basis for the study of language change that began in urban centers based on

quantitative analysis of recorded interviews. Labov-style research has been known as

quantitative, macro or urban, whereas Gumperz-style sociolinguistics has been known

as qualitative, micro, and interactional (Duranti 2001).

Despite Hymes’ attempts to keep sociolinguistics and linguistic anthropology

under the same umbrella, they generally form a split around their differences in

methodological choices (e.g., ethnography) and theory (Duranti 2001). First, the

treatment of sociological and cultural concepts such as race, class, gender, and age as

static independent variables by sociolinguists is not accepted by anthropologists who

recognize these concepts as culturally-constructed and fluid. Second, inclusion and

attention to context as a changing frame that affects speech itself is generally absent in

sociolinguistics. Third, sociolinguistics’ reliance on the transcript data alone for analysis

is problematic for anthropologists who use ethnographic methods to capture

conversation as an interactional achievement (Ainsworth-Vaughn 1998).

These differences often align themselves along two separate methodological

paradigms, both of which seek to understand how language creates and recreates

meaning through discourse. Conversation analysis (CA), pioneered by sociolinguists

Sacks (1984) and Schegloff (1991), focuses on sequential organization of talk and how

that organization creates meaning in a conversation (Freeman 1987b). For

38
conversational analysts, the varieties of sequential organization – the turn-taking system

for managing the construction of the interaction, allocation, sequences for entry into

and exit from conversation, the pauses or hesitations, and the intonation of utterances

– make up the structure for encounters and thus comprise the bulk of the data. Any

additional information about the context from which the discourse occurs is seen as

secondary and to the extent context enters into the analysis, it must be proved that

contextual cues are linked to the participant’s recognition of the categories as integral

to the events being studied (Schegloff 1991; Zimmerman and Boden 1991).

Alternatively, linguistic anthropologists frequently use discourse analysis (DA) as

their main methodology. DA does not renounce CA’s micro-level analysis, but suggests

that if researchers want to understand the role of language in people’s lives, they must

go beyond the study of grammar to the world of social action. It is within this cultural

fabric which utterances are shaped and meanings produced. Cicourel (1987) argued

that ethnographic material, participant attitudes, and patterns of social organization are

constitutive of talk and should be included in discourse or conversational analysis.

“Language and other social practices are interdependent. Knowing something about the

ethnographic setting, the perception of and characteristics attributed to others, and

broader and local social organizational conditions becomes imperative for an

understanding of linguistic and nonlinguistic aspects of communicative events” (Cicourel

1987: 218).

Both methodological paradigms strive to maintain balance between macro- and

micro-analyses to discover how the organization of talk enables or constitutes the

39
structures of social action (Zimmerman and Boden 1991). The tension between CA and

DA results from inherent differences concerning what is being studied and what should

be contained in the final analysis. DA takes talk and the texture of talk as significant in

and of itself. Context may not always significantly impact the shape, form, or trajectory

of the conversation, but it is almost impossible to analyze the meaning of the interaction

without invoking contextual details (Cicourel 1987; Ainsworth-Vaughn 1998).

The Search for Meaning and Reality in Language

Thus, linguistic anthropology today is more than a study of grammar; it is the

understanding of the crucial role played by language in the constitution of society and

cultural representations. To pursue this goal, linguistic anthropology adopted tenets

from ethnomethodology and directed their gaze into the discourse of everyday social

life, like language socialization, political events, institutional discourse, and doctor-

patient communication (Zimmerman and Boden 1991; Duranti 1997; Gumperz 2001).

Ethnomethodological theories shape the idea that discourse, whether it is of

conversational or interview type, is created interactionally between or among

participants (Garfinkel 1967). The key then is not to search for the “real” meaning of an

expression or utterance (which would be quite impossible), but rather to try and

determine what a speaker intended to convey in a specific message and how meaning is

created between the speaker and hearer (Gumperz 2001).Together with constructivist

approaches that claim that cultural and social worlds are created and recreated over

time through embodied and disembodied communications (Gaines 1991, 1992), these

theories point to the focus on “communicative practices as the everyday world site

40
where societal and interactive forces merge” (Gumperz 2001: 218). To interact is to

engage in a process of negotiation, both for the speaker to say clearly what they mean

and monitor how they are perceived and for the listener to infer what was intended.

Thus, meaning is created in situ because in general, words can never be precise

and detailed enough to convey a speaker’s true meanings; listeners must make sense of,

or use “practical reasoning” to fill in what is left unsaid (Goffman 1981; Grice 1989).

Individuals frequently base meaning on the “surface form” of a message and rely upon

socially and culturally constructed rules of conversation to interpret the underlying

meaning (Gumperz 2001: 216). These rules comprise extra-linguistic ways of

communicating, such as frames, tone, pitch, rhythm, and so forth (Goffman 1981).

Interpretation of these behaviors is as equally important as interpreting the meaning of

the words correctly. No utterance can be made without these signs and because they

are indirect and often unconscious ways that speakers convey and interpret meaning,

linguistics argue that attention should be paid two-fold to these signs in cross-cultural

communication (Gumperz 2001).

“Mis”-communication and Linguistic Competence

Because there are seemingly multiple ways our talk becomes problematic in

interaction, miscommunication comprises a large topic of research. Yet there is no clear

or uniformly agreed upon definition of what constitutes successful or unsuccessful

communication; miscommunication cannot be automatically equated with failed talk

(Freeman 1987b). Miscommunication, as a slippery term, is applied very loosely to any

sort of problem that arises interactionally (Coupland, et al. 1991). What is different

41
about good communication verses bad? How does a researcher define such subjective

variables like appropriate, efficient, or satisfying communication?

Miscommunication is a frequent topic of research in cross-cultural as well as

medical communication not only because of the difficulties in literal translation across

languages, but also because individuals bring with them unique socio-cultural rules

about interaction, such as who has the right to ask and answer questions, who can

speak for the patient, when is it appropriate to remain silent or joke, participant’s roles

(such as patient or doctor), and cultural patterns for certain discussions (Hymes 1972;

Briggs 1986). However, it is a mistake to assume all conversations between different

language speakers would result in a mismatch of rules and competencies and, hence,

result in miscommunication.

At the heart of miscommunication theories is an awareness that individuals of a

speech community share conversational rules about interaction. Chomsky (1965) and

Hymes (1972) both provided theories about “linguistic competence.” However, Hymes

argued that the early separation between competence, or the knowledge of language,

and performance, or the use of language, was problematic. Starting from a

commonsense notion of competence, Hymes believed that speakers are “competent”

not only when they have the knowledge of the grammatical rules but also when they

have the knowledge of how to use them appropriately. To be a member of a particular

speech community, one must know, for example, when to speak and when not to speak,

how to be polite, how to request or offer collaboration, and how to sound calm,

surprised, interested, and concerned. Hymes’ definition replaced the Chomskian notion

42
of competence with the notion of communicative competence which included the

knowledge of language and the ability to use it (Hymes 1972).

With Hymes’ definition of communicative competence, we can see why cultural

competence in medicine must include not only a translation of the language itself but,

for example, the ability to know how to use appropriate visual cues, slang, or how to

negotiate a treatment plan. I will next examine how linguists study medical discourse

beginning with a historical overview of theories and methodologies and concluding with

specific research data that will ground the findings and significance of this dissertation

research.

IV. Medical Communication

Medical interaction and discourse has steadily gained the attention of social

science researchers in the last 50 years. For medical and linguistic anthropologists the

attention to medical discourse is largely due to three main factors: (1) the ability of

research data to positively influence the medical process/community; (2) the specialized

forms of interaction and unique sociolinguistic roles for categories of doctor, patient,

nurse, and interpreter within the medical encounter; and (3) the prominent role of

culture in health and illness. Research not only advances linguistic knowledge and

methods, but is also beneficial for studies of medical anthropology and bioethics and

can be applied to produce better medical and patient education and treatment

decisions.

43
 Medical interactions in the U.S. often contain asymmetrical power relations,

power struggles, and misunderstandings causing real changes in diagnosis, treatment,

and follow-up care (Ainsworth-Vaughn 1998). What are some of the ways in which

clinicians and patients implicitly and explicitly exercise their control and how can we, as

researchers, witness and operationalize these interactionally created power dynamics?

How might a clinician alter their communication strategies with regards to information

sharing, negotiation, and treatment decisions in an encounter with an immigrant patient

who speaks limited English? How should researchers conceptualize the role of a

medical interpreter?

Doctor-Patient Communication

Early scholars believed that asymmetrical roles were essential to the doctor-

patient relationship. For example, Parsons (1951) advocated normalcy in the

unbalanced relationship because it is the doctor and not the patient who is responsible

for restoring health; patients are in a position of dependency for health care, doctors

possess specialized knowledge and technical qualifications, and doctors’ professional

prestige gives them more social capital and thus control over their patients. However

ardently Parsons supported this role, scholars began to move away from believing

asymmetry in this relationship should be standard practice.

Early research on doctor-patient communication from the 1960’s found that

patients were unhappy with the lack of information from their doctors and, in fact, this

was the least satisfactory aspect of their health care (West and Frankel 1991). One

wave of subsequent research tried to correlate the amount of information patients

44
received to better health outcomes. Studies from the late 1960’s to mid- 1970’s looked

at the amount of information given in a visit and how patients obtained that

information. However, this research assumed that patient’s needs, wants, resources,

and abilities were constant and evenly distributed. Researchers did not take into

consideration that if patients required different amounts of something (e.g.,

information), then it was only logical for them to behave differently. And if doctors

perceived these differences then it was logical for them to respond differently as well.

As expected, correlations between patient satisfaction and the amount of information

given to them in a typical visit did not prove significant. Researchers began to look at

exactly what patients were told (West and Frankel 1991).

These studies revealed one of the most prevalent complaints in doctor-patient

research today, that doctors used a high amount of medical jargon in their

communication that was not understood by their patients. Not only were technical

terms misunderstood by patients, but one study found that even names of common

illnesses (varicose veins, cardiac arrest, and diabetes) were misunderstood (Shuy 1983;

West and Frankel 1991). Korsch, et al. (1968) reported that of 800 patients, more than

half said that their doctor sounded “Greek,” fewer than 5% of patients said their doctor

was friendly or sociable, and more than 25% said their chief concerns were never

mentioned. Non-compliance to the treatment plan was found to be a result when

patients failed to receive explanations as to the cause of their illness.

Early conceptualizations of medical communication used a linear, conduit model

of straightforward transmission of information from sender to receiver (West and

45
Frankel 1991). One assumption of this model was that good communication equals

clear communication. Jargon was seen as negative to the receiver, something that

prevented the patient from understanding the transmission message. A second

assumption of the conduit model was that causes of miscommunication could be

explained as a function of the individuals involved in the interaction. Researchers

looked for characteristics of better senders and receivers. “Problem patients” were

identified as alienated, those whose sense of power was associated with their lack of

knowledge about their illness (West and Frankel 1991).

Gender, age, and socioeconomic factors were also scrutinized as findings

demonstrated that less educated patients and those who had low socioeconomic status

(SES) were less knowledgeable about preventive care, medical terms, and were less

likely to listen to their physicians. Better educated patients were found to be less willing

to yield to the time pressure of the doctor and were more active participants in the

interview process (Hein and Wodak 1987).

But just how these factors played out in real interaction was less obvious.

Results of two important studies undermined the conduit model assumption that

miscommunication could be traced back to characteristics of senders and receivers as

individuals. Instead of previous hypotheses that doctors told the same things to

everyone based on the doctor’s personal characteristics, Davis (1963) observed that

doctor’s perceptions of patient’s SES altered what doctors said to patients and Roth

(1963) found that the way patients presented themselves influenced the kinds of

information they were getting.

46
 Thus, a narrow view of language and communication which stressed generic

strategies failed to take into account individual characteristics or resources that

participants may have (Sarangi 2004). The fact that early studies on medical

communication produced contradictory results highlighted essential questions about

research methodology and measurement (West and Frankel 1991). Fundamentally,

these studies did not capture the context of communication. The CA approach used by

such studies utilized quantitative measures of variables and did not often illuminate

what prompted a phenomenon to happen (e.g., a patient question) and what happened

after it occurred (West and Frankel 1991). Discourse, often complex ambiguous, cannot

be dealt with by quantification alone. “Coding cannot capture the multifunctionality

and ambiguity with which speakers negotiate, leaving open multiple possible

interpretations” (Ainsworth-Vaughn 1998: 8).

A methodological shift occurred in the 1980’s and researchers began to examine

context and include verbatim transcripts of the recorded discourse with their

publications. As researchers reflected on the role of context in determining meaning for

participants, they adopted strategies to allow the examination of communication across

contexts. For example, Shuy (1974) presented an overview of sources of communicative

difficulty at varying levels (social, cultural and linguistic) and West (1984), Todd (1983)

and Fisher (1986) analyzed turn taking and interruptions to examine the negotiation of

power by doctors to patients of different SES. Wodak (1996) documented how

institutional members of an outpatient ward in a large hospital engaged in the

organization of reality through symbolism of myths, stories, legends, jokes, and rites and

47
the consequences of medical myths like having enough time for patient treatment.

Lastly, Cicourel (1983) looked beyond verbal data to written texts in order document

how information and meaning is abstracted from the patient, translated through the

doctor, and recorded in the medical chart.

Power, Negotiation, and Deference

Because discourse, and the rules of discourse, reflects broader social issues and

structures, one research theme in the medical communication literature remains

constant – that is, how power is performed and communicated and how features of

larger social structures can be discovered through analyses of discourse. Typically,

power is indexed by such linguistic phenomenon as types of doctor-patient talk:

questions, interruptions, topic transitions and control, information sharing, jargon, and

frames of speaking. Analysis shows that participants exert power in an interaction

through turn by turn processes, constructed partially through actions that control the

emerging discourse, such as interruptions (Ainsworth-Vaughn 1998).

Doctors, by virtue of their position within the social structure of the medical

institution, hold a position of authority that the patient role does not encompass

(Foucault 1973; Mauss 1996). In doctor-patient discourse, the doctor may exercise

more authority over the encounter and interview due to the expertise a doctor has over

the disease or ailment. Besides the role of “doctor,” other variables that correlate with

power are the gender, age and ethnicity of the doctor, usually a white male, and gender,

age, ethnicity, and education of the patient (Ainsworth-Vaughn 1998; Fisher 1998).

While a definition of power as dominance is applicable to doctor-patient

48
relationships and communication, some researchers have defined power in more

neutral ways. Patients are often described as passive in the medical encounter,6 but a

minority of researchers document the ways in which patients claim power through

verbal and nonverbal communication. For example, Ainsworth-Vaughn (1998) identifies

one form of power as the ability to implement one’s agenda. If a patient is able to bring

up his or her main issues during an encounter yet only asked 10% of the total questions,

it may be mistaken to assume the patient did not have any power over the visit. The

focus on patient power does not deny that physicians largely control the communicative

process during medical encounters, but it does stress that this is not the automatic

effect of institutional forms; asymmetry must be formed interactionally by both parties

(ten Have 1991).

The following overview will briefly highlight the common linguistic phenomenon

that researchers focus on when examining power and (mis)communication. These

communication strategies will be used later in the dissertation to examine power and

negotiation at the People’s Clinic.

Jargon

One way miscommunication can arise is through the use of jargon. Doctors,

because of their specialized knowledge, understand and communicate about health and

disease in scientific medical language. Medical terms also offer a more precise way to

talk about the body and disease processes. However, there is often no attempt on the

6 Findings of patient passivity are partially thought to be due to the situations in which research occurs.
Medical communication research is often completed at a free clinic or university-related research
hospital, with doctors and patients with no prior history, looking at isolated visits rather than sequential
encounters, and without female doctors in the sample (Ainsworth-Vaughn 1998).

49
doctor’s part to translate medical jargon to more easily understood terms for the

patient (Shuy 1974). In fact, some researchers believe that doctors and patients can

engage in a kind of “communication conspiracy” where doctors speak as though their

patients are medical professionals and patients nod their head and act as if they

understand what is being discussed (Roter and Hall 1993: 93). The result of such a

conspiracy is a great deal of miscommunication and misunderstanding for all parties

involved, and, in extreme cases, doctors and patients may miss out on important life-

saving information.

Shuy (1974) studied the discourse between black inner-city patients and white

middle class doctors and specifically wanted to know the degree to which patients felt

like they must communicate with doctors in doctor language. Most of the medical

encounters Shuy observed and recorded were conducted in “doctor talk” and he noted

that most serious breakdowns in communication occur at both ends of the continuum.

The post-visit questionnaire given to 86 patients revealed that 41% said they sometimes

felt the doctor didn’t understand their problem, 38% felt that clinicians used words that

were difficult to understand, and 38% thought it was difficult to explain things to the

doctor. These are not startling findings, especially coupled with more recent findings

that in nearly half of 100 visits observed, doctors used words like tricyclics, stool guiac,

creatinine, and tempromandibular joint without following up with an explanation (Roter

and Hall 1993).

50
Questions

The role of questions is three-fold: (1) questions function as a primary method of

acquiring information; (2) questions claim the right to control the topic and determine

who will be the next speaker; and (3) patient questions often signal to the doctor that

the patient is a competent and active participant in their health and treatment plan.

Particular types of questions, for example open ended or closed, may also transform the

topic of discourse. Medical encounters tend to be highly asymmetrical interviews

consisting primarily of doctors asking questions and patients answering them (Todd

1983). The observation that in general the speaker who has the power asks the most

questions has been found not only in medical encounters, but also in attorney-witness

and teacher-student discourse (Ainsworth-Vaughn 1998).

Rhetorical questions may also be used by both patient and doctor to mitigate

power (Ainsworth-Vaughn 1998). Because rhetorical questions often do not expect an

answer, they may not pose a threat of control over the discourse in the same way a true

question would. For example, in a possibly challenging but face saving rhetorical

question posed in Ainsworth-Vaughn’s (1998) research, a patient asked about side

effects from her medication. When the doctor did not answer, she stated, “Who can

answer that. Apparently nobody.” Consider the implication and direct confrontation

that might have ensued if the patient had asked “Why don’t you know about the side

effects of a medication you are prescribing?”

Context also appears to make a difference in the number and kind of questions

asked by the patient. West (1984) studied 21 encounters in a clinic whose patients were

51
primarily of low SES. All 18 doctors were white and 14 were male. Using the narrow

adjacency pair definition, West found that 91% of questions were asked by the doctor

and only 9% by the patient; in 48% of visits, patients asked fewer than 2 questions.

Conversely, Ainsworth-Vaughn’s (1998) data taken from a private setting in which all

patients were white, with equal numbers of male and female doctors, and from which

patients and doctors that had an ongoing therapeutic relationship, found that patients

can ask up to 39% of all questions. Ainsworth-Vaughn also suggested that this high

number may designate a more “conversational” encounter verses a medical interview.

The gender of both the doctor and patient has a significant effect on question

asking. Patients in Ainsworth-Vaughn’s (1998) study, whether male or female, asked

more questions when the doctor was female (an average of 11 questions per visit).

However when the doctor and patient were both male, patients asked on average only 4

questions per visit. This suggests that female physicians may exhibit a more egalitarian

communicative style that allows patients to clarify, discuss, or ask for more information.

Overlaps and Interruptions

Conversing with another person and relaying information involves taking turns in

speaking. Ideally, the listener will begin his or her turn after the speaker is finished.

However, not all discourse follows this egalitarian model and more often, the listener’s

talk will overlap or interrupt the speaker. Not all overlaps of speech are interruptions;

interruptions are defined as an utterance which disruptively overlaps or cuts off the

other speaker (West 1984; Ainsworth-Vaughn 1998). As interruptions, these utterances

attempt and sometimes succeed to cutoff a speaker’s point thereby violating his or her

52
right to finish a thought when in control of the conversation. Overlaps tend to occur

because of errors in topic transition timing (the listener begins to take his or her turn

because they thought the speaker was finished) or because the listener wants to show

that he or she is following the conversation by listening affirmations (i.e., “mmhmm”)

(West 1984). The latter form of overlap may also be described in the literature as a

“back channel” utterance.

Turn-taking in medical interaction usually involves the doctor taking more turns

in speaking as he or she obtains the information for the correct diagnosis and

treatment. West (1984) examined the frequency and outcome of overlaps and

interruptions in 20 medical encounters. Doctors interrupted patients 126 times or 67%;

patients interrupted 62 times or 33%. Interruptions, however, displayed further

patterned asymmetries in her study according to the patient’s race and gender. White

male patients seeing a white male doctor interrupted each other equally, but white

male doctors interrupted white female patients 1.8 per every 1 patient interruption and

a ratio of 4.4 to 1 with black female patients. “To ask where a patient is feeling pain,

how often, when, or under what conditions is justified by, even required for, precise

diagnosis of a problem. However, when these inquiries cut off what the patient is

saying…then the physician is not only violating the patient’s rights to speak, but he is

also systematically cutting off potentially valuable information on which he must himself

rely to achieve a diagnosis” (West 1984: 61, emphasis in original).

While doctors on average took more speaking turns, West’s (1984) data

concluded that when the doctor was a woman, male patients interrupted far more

53
frequently than when the doctor was male. Additionally, female doctors’ interruptions

only accounted for 32% of all interruptions during the visit relative to the patients who

claimed the other 68%. West contended that when the doctor is female, the

sociolinguistic rules of gendered speaking may be more influential than the role of

doctor.

Medical Interpretation

Language barriers affect the provision of quality health care in many parts of the

world. In the U.S., the number of individuals who speak a language other than English at

home has more than doubled over the last two decades, and over four million

households have been termed “linguistically isolated” (Shin and Bruno 2003). This trend

has coupled with far slower increases in the number of bilingual and multilingual health

care providers (Stoddard, Back, and Brotherton 2000), greatly challenging health care

institutions to accommodate patients and families with limited English proficiency.

Research has associated language barriers with the increased potential for misdiagnoses

and inappropriate treatment, the need for repeat visits, inadequate informed consent,

and dissatisfaction in the quality of communication and care among patients and

providers, among other outcomes (Elderkin-Thompson, et al. 2001; Flores, et al. 2003;

Simon, et al. 2004; Dysart-Gale 2005). These findings intensify the need for

ethnographic study and understanding of language barriers in health care.

In the U.S., policy making efforts to improve access to language services have

been stepped up in recent years. Specifically, the Office of Civil Rights and the Office of

Minority Health, together with President Clinton’s Executive Order 13166 in 2000,

54
added pressure to prior regulations stating that all federally funded health care

programs must produce a clear and written plan of action detailing steps to ensure

access for non-English speaking patients and their families (Perkins 2003). Institutions

have responded to these laws in a less than formal and often unorganized fashion.

Some have developed interpreter programs and supported community-sponsored

interpreter pools while others have no formal training programs for their interpreters

and frequently utilize ad hoc interpreters such as friends and family of the patient as

well as janitors, nurses, or other hospital personnel (Putsch 1985).

A National Public Health and Hospital Institute (NPHHI) survey conducted in the

mid-1990’s from 83 hospitals across the U.S. found that ad hoc interpreters made up the

majority of interpreters at these institutions. Clinic/hospital employees can frequently

interpret for a major portion of their workday and yet receive no additional

compensation for their extra duties. Duel work roles can lead to conflict and stress

(Haffner 1992; Wadensjo 1998). Using untrained interpreters can also result in frequent

errors of interpretation, including omissions, additions, or substitutions (Baker, et al.

1996; Baker, et al. 1998). For example, family members tend to respond to questions

for the patient without interpreting them, they volunteer their own information, and

often do not translate patient comments (Haffner 1992). In a cross-cultural situation as

well as a bilingual one, it is not difficult to imagine that family members may not

correctly interpret information that they deem inappropriate to share with strangers.

However great the need for interpreters, there is often little to no

standardization in training or competence, nor are there instructions to health care

55
providers on how to best use interpreter services. Less than ¼ of the surveyed hospitals

by the NPHHI provided any training for their staff and only 9 hospitals trained their

volunteer interpreters. When clinicians are not trained to use interpreters, they often

make mistakes; for example, they have been found to look at the interpreter and not

the patient, decreasing the sense of connection and rapport between doctor and

patient (Baker, et al. 1998; Abbe, et al. 2006).

One group of physicians looked at how interpreter use correlated with patient

satisfaction. Baker, et al. (1998) used a satisfaction scale to assess language barriers as

well as clinician friendliness, respectfulness, concern for the patient as a person, time

pressure, and comfort at one large California hospital. Patients who did not need

interpreters and spoke Spanish with the doctor (n=237) had the highest satisfaction;

patients who used interpreters (n=120, 88% were ad hoc interpreters) rated their

provider as less friendly, less respectful, less concerned for them as a person, and less

likely to make them feel comfortable; patients who needed an interpreter but did not

have one (n=100) not surprisingly had the lowest satisfaction scores for all items (Baker,

et al. 1998). The authors also found that patients who used an interpreter were less

knowledgeable about their discharge diagnosis than patients who communicated

directly with their doctor and that only 38% of patients who did not have an interpreter

when they needed one stated that their understanding of their diagnosis or illness was

good to excellent.

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Errors in Interpreting

Many variables can affect the standards of accuracy and completeness:

interpreter and clinician level of training and competence, nature of the environment,

duration of the encounter, and the speaker’s communication behavior and preferences.

The last point is especially important in influencing accuracy and completeness;

clinicians often use medical jargon or speak in lengthy dialogue making it difficult to

translate.

Clinicians are most concerned with the accuracy of interpretations above other

issues (Abbe, et al. 2006). Because of this importance, the majority of research on

medical interpreting reports the kinds of errors interpreters makes. For example,

Flores, et al. (2003) examined the frequency, categories, and potential clinical

consequences of errors committed by interpreters and compared the quality of

interpretation by professional hospital interpreters versus ad hoc interpreters. Thirteen

patient visits were audiotaped in a pediatric clinic; medical interpreters were present in

6 of the 13 encounters and ad hoc interpreters were used in 7. Errors were classified

errors into 5 categories: omission, addition, substitution, editorializaiton, and false

fluency (i.e., used an incorrect word or phrase). Interpretive deviations from medical

jargon, contextual clarifications or cultural negotiations were assumed to be part of the

interpreter role and were not counted as errors.

Surprisingly the authors found that there were no statistically significant

differences between hospital and ad hoc interpreters with regards to the number of

errors made, an average of 31 errors occurred per visit. Omission of information

57
counted for 52% of all errors and was the most common error followed by false fluency

(16%), substitution (13%), editorialization (10%) and addition (8%). The authors

reported a significant correlation between the type of interpreter and errors that had

potential clinical consequences. Errors made by ad hoc interpreters were significantly

more likely to have potential clinical consequences than those made by hospital

interpreters (77% versus 53%). For example, when an 11 year old sibling was used, 84%

of the 58 errors she made had potential clinical consequences (Flores, et al. 2003):

Pediatrician: So he vomited five times between 1:00 and 3:00? And after that
he hasn’t thrown up?
Interpreter: That since that time he has not vomited?
Mother: No. Now he has like pain in the ear and so on.
Interpreter: Yes, he havin’ pain.
Mother: Tell her [the pediatrician] that he has something on his mouth.
Tell her.
[Silence]
Pediatrician: How old is he now?
Interpreter: Three.

Most research on child interpreters cites numerous errors in translation. Using child

interpreters in a medical setting may additionally place them in a higher power role and

give them access to more information than the child would otherwise have in that

culture or family (Haffner 1992).

Elderkin-Thompson, et al. (2001) focused specifically on the accuracy of nurse-

interpreters, the nature of the inaccuracies, and the behavioral process that promoted

the occurrence of the errors. Language errors were operationalized as a lack of mention

of cultural practices like dietary habits, ethnic beliefs, use of native healers and semantic

problems like medical jargon, paraphrasing, or editing mistakes; interpersonal conflicts

were defined as a lack of trust toward the patient by the doctor or interpreter and

58
conflicts over control of the discussion direction. Of the 21 visits they recorded, 11

contained major interpreter errors.

The authors focused on the processes that foster error development and

prohibit their correction (Elderkin-Thompson, et al. 2001). They found that significant

errors mainly developed due to 4 specific processes. First, when new information

appeared contradictory in the patient’s history and story, these nurse/interpreter-

doctor teams dismissed the contradictory information without verifying its accuracy.

Second, nurses sometimes misinterpreted comments to provide clinically relevant

information they thought the doctor wanted to hear (see also Davidson 2000, 2001).

Third, when Spanish speaking patients differed substantially with the interpreter on

social prestige and power, the patient’s comments sometimes were ignored, the patient

was not asked for clarification, or the nurse spoke for the patient. And lastly, the nurse

interpreter sometimes avoided cultural idioms from the patient and literally interpreted

cultural beliefs as symptoms thereby making the patient sound nonsensical.

V. Introduction to Dissertation

Because of the popularity of cultural competence as a panacea to health

inequalities, my dissertation research is grounded in the position that we must take a

moment to identify, rather than assume, how cultural differences may become

problematic in the delivery of services by examining interactions in the medical

encounter itself. Medical anthropologists have documented and researched cultural

health beliefs and explanatory models about illness (e.g., high blood, nervios, falling out)

59
and have indicated that cultural differences between doctors and patients have the

potential to adversely affect the delivery of health care (Clark 1970; Jenkins 1988;

Chavez, et al. 1995; Browner, et al. 2003). Scholars also highlight related obstacles such

as low patient health literacy, low education levels, low socio-economic status, poverty,

and job-related hazards. Less is known however about whether and in what manner

cultural differences are recognized in clinical encounters, how they may be dealt with,

and which clinical strategies may mitigate the impact of cultural or linguistic barriers

(Brach and Fraserirector 2000).

Further, if illness narratives and information from the patient’s lifeworld

represent a primary way contextual, emotional, personal, and cultural health

information is provided to the clinician, and we hypothesize that this information may

be more important in cross-cultural and cross-linguistic medical encounters (Gumperz

2001; Kleinman and Benson 2006), how then do patients and clinicians take up this

discourse? Do clinicians, who frequently utilize strategies such as interruptions to

mitigate or cut-off patient stories, make efforts to seek out explanatory models and

other health information from patients in a cross-cultural setting? What kinds of

information do immigrant and minority patients deem important enough to provide to

clinicians when given the linguistic space to do so?

In order to understand how clinicians and patients from different linguistic and

cultural background communicate in a medical encounter, I conducted 24 months of

fieldwork at the People’s Clinic, a free clinic in a large metropolitan city in Texas.

Chapter two provides details of the ethnographic setting, the organizational structure of

60
the clinic, as well as the study design, methods, and analysis. The chapter additionally

describes characteristics of the clinician and patient population, recruitment strategies,

and my roles at the clinic.

Chapter three begins the exploration of cultural competence definitions,

theoretical models, and how culture was understood at the People’s Clinic. Observation

of the clinic’s day-to-day practices, including participant observation of the nursing

student clinical program and clinician interviews, provided ethnographic data about how

clinicians and other staff performed cultural competence at the micro, encounter level

and at a macro, community level. The nursing student clinical program provided a

means with which to understand how new clinicians were taught to be aware of the role

of culture and macro-structural barriers in this patient population.

The two case studies in Chapter four supply a “thick description” of the way

patients, interpreters, and clinicians interact in a medical encounter (Geertz 1973).

Specifically, the case studies illustrate the dynamics of a cross-cultural and linguistic

clinical encounter, how treatment decisions were made from the information shared

within the encounter, and the methods used to exercise power and control to either

prevent or encourage information sharing. The case studies articulate how major

communication strategies, such as questions, interruptions, or illness narratives, work

simultaneously with one another in order for participants to fulfill their sociolinguistic

roles of getting and providing health care.

Chapter five uses the concepts from chapter four and applies them across the 30

recorded medical encounters to examine the content of patient narratives or

61
explanatory models. In a cross-cultural encounter, are patients more likely to discuss

“cultural” health beliefs? If cultural health beliefs are discussed, how do clinicians

interact with them and how does the information shape the medical encounter?

Chapter six brings to light the role of the medical interpreter. As interpreters are

seen to bridge linguistic and cultural barriers to health care for immigrant and minority

patients, their role and contribution as a major participant cannot be disregarded. This

chapter highlights the various roles that the interpreters held at the clinic, the

communication processes that fostered accurate interpretations, and how interpreters

shaped the course of the medical encounter.

Finally, Chapter seven concludes the dissertation, where I reflect upon the

scholarly as well as applied contributions of this research.

62
 Chapter Two: The Setting and Methodology

This study is based on 24 months (July 2006-July 2008) of linguistic and

ethnographic field research at the People’s Clinic, 7 a free clinic in a major metropolitan

area in Texas. I chose to conduct my dissertation research at the People’s Clinic because

early communications with the clinic medical director indicated that the clinic was

particularly focused on culturally aware practices with their largely Mexican immigrant

patient population. The medical communication literature is rife with hypothetical

examples of what not to do in a medical encounter but rarely are there real examples of

exemplary practices, especially in a cross-cultural setting. Additionally, the clinic

medical director was also a professor of nursing, and recognized the value of research

on medical communication.

Because of a desire to explain the relationship between micro-level

communication processes and macro-level cultural, social, and political processes, this

research situates the medical encounter within a broader context of the clinic and

community practices. Specifically, this project provides an ethnographic description of a

clinic that is focused on cross-cultural and cross-linguistic health care with minority

patients and their surrounding community. It adds a triangulated layer on top of most

cross-cultural communication projects because, rather than taking one level or group of

participants as my sample, I included all players in the medical encounter – patient,

clinician, interpreter, and clinic volunteer staff.

7
All names in this publication are pseudonyms.

63
I. Research at Home

There is often an unspoken boundary in anthropology between conducting field

research at home and abroad. From one critical perspective, the anthropologist who

conducts research “at home” is a “native,” at risk for losing scientific objectivity and

methodological rigor. Anthropologists firmly rooted in the belief of the necessity of

external fieldwork experience see anthropology at home as a “soft” research experience

(Peirano 1998). However, in deconstructing this perspective, the concept of

“nativeness” is largely attached to one’s cultural or ethnic belonging. Being an insider

involves two processes, identifying and knowing oneself, and the perception and

acknowledgement of others as an insider (Greverus and Römhild 1999).

As an Anglo-American, I was not a native or insider of the main cultural or ethnic

groups I studied, namely, clinicians and Mexican immigrants. While I had previous

experience as a mental health clinician, I entered the field as an anthropologist, carrying

with me notions of the emic and etic perspectives, subjectivity and objectivity, and the

important of reflexivity. The approach, and not the subject matter or location, is what

defines the anthropological endeavor (Sobo 2009). Far from only a discipline of the

“exotic,” anthropology is conceived of as a certain relationship between observer and

observed (Lévi-Strauss 1961, quoted in Peirano 1998).

In this research, a process of continual reflexivity and militant field note writing

aided a constant dance between subjectivity and objectivity. While I did not have to

navigate new rituals of an exotic tribe or sleep in a grass hut, I did undergo my own rites

of passage and felt the need to examine my research community with new eyes. I spent

64
considerable time learning the languages of biomedicine and medical Spanish of the

clinicians and Mexican participants respectively. Even though I grew up less than 40

miles from the People’s Clinic, both of these groups were as foreign to me as the

refugees from Burma I met during the latter part of the project.

Native anthropology additionally represents a decolonizing pedagogy in a

discipline whose early academic strength was devoted to description and analyses

“carried out by Europeans, for a European audience – of non-European societies

dominated by European power” (Asad 1973:15, see also Said 1978, Stocking 1983). De-

colonizing and post-modern pedagogies also blurred the notions “home” and “abroad,”

“inside” and “outside.” They asserted that field sites must be negotiated, and research

and writing given reflection (Clifford 1997). In these frameworks, the fieldworker

herself may be the anthropological subject (Behar and Gordon 1995).

As more anthropologists conduct research “at home,” rather than in a more

traditional foreign field setting, additional issues will surface and should be discussed.

The close proximity of the research community to my home produced new

responsibilities. In conjunction with my research role, and because I believe deeply in

social justice and health care as a right, I volunteered to assist patients when I was not

actively collecting data when my research participants asked for my help. Not showing

up for a research day meant more than data lost; it sometimes meant that a patient did

not get assistance in enrolling in a free prescription plan or did not get help in finding a

free program for diagnostic mammography. The clinic volunteers and medical staff

were not negligent, but rather there were too few clinic staff, too many problems. I was

65
additionally called upon to present preliminary findings to the clinical volunteers

throughout my research, provide training to nursing students on how to use

interpreters, and asked to present a paper at a national YMCA conference in place of the

clinic’s medical director. 8

Research in our own backyard may challenge anthropologists to extend our

involvement beyond the interview in new situations. Instead of this being a burden, my

experience taught me that anthropologists can creatively find ways to be both

researcher and advocate. Any additional responsibilities I carried while at the clinic fed

directly into my data and analysis and shaped my experience with the community.

II. The People’s Clinic

The People’s Clinic was founded in1981 in a low income area of a major city in

Texas. The idea for a formal clinic began with a nursing professor from a nearby School

of Nursing and students from his “community clinical” rotation. 9 At this time, the

neighborhood experienced a rise in the number of refugees from Cambodia and Mr.

Kendall, the professor, wanted to help. Mr. Kendall explained these humble beginnings

during an interview with me. He said, “There were a lot of people with a lot of needs.

We knocked on doors with students…we would find problems and wanted to fix the

problems right there. We began to hold onto some data and made a community

assessment tool.” They took the assessment tool to various community agencies and

8
I happily made these presentations and training sessions once the data collection period was over in
order not to unduly influence the very behaviors I was examining.
9
A clinical class is one in which students practice medicine under supervision of a preceptor in real world
settings, such as nursing homes, schools, clinics, and hospitals.

66
used that data to get grants and additional health care volunteers. They started the first

community health care center in Texas, housed in the local police station; the clinic was

later taken over by the large county hospital.

Mr. Kendall further explained that the philosophy of the clinic came originally

from the nursing model of district health, “We wanted to take responsibility for this

area. We knew what to do, we didn’t need anyone’s permission.” They operated a

mobile clinic for the next few years and finally, in 2000, rented the basement of a local

church. In the initial months they only saw patients on Saturday but gradually, with

more volunteers and funding, they slowly added clinic days, until in 2006 they were

open Wednesday through Saturday.

The People’s Clinic is a not-for-profit agency with 501(c)(3) status. Federal law

allows religious, educational, charitable, scientific, or literary organizations to be exempt

from paying some federal taxes under this status. During 2006-2008 the clinic had

approximately 5,500-6,000 patient visits a year. One quarterly report stated that

because of clinical volunteers and a large pool of donated prescription medicine (mostly

pharmaceutical samples), they treated each patient for less than $25, including all

necessary medicines. The 2006 annual report provided the following information on

how many patients were seen in 2006, how many patients received medication, other

services the clinic provided, and their estimated monetary value.

67
Figure 2.1 Clinic 2006 Annual Report Data

Clinic Organizational Structure

Since the clinic medical director was a professor of nursing, the majority of

clinicians were family nurse practitioners10 (FNP), pediatric nurse practitioners, and

bachelor’s level nursing students. On an average day, three FNP’s were present: a

pediatric nurse practitioner and one or two family nurse practitioners. Additionally, the

clinic was able to offer some specialty services on a consistent basis: every third Friday a

psychiatrist volunteered her morning, and every other Saturday, a dermatology clinic

was held comprised of a dermatology professor and a few residents from a nearby

teaching hospital. During the academic school year a nurse-midwife performed

women’s health exams one afternoon a week. All of the nurse practitioners and

physicians, except the dermatology professor, were Anglo-American. Most clinicians

were affiliated with the Methodist or Presbyterian Church with the exception of two

who self-identified as agnostic.

All clinicians were unpaid volunteers. Those with whom I spoke vocalized a

strong sense of social justice and held the belief that health care was a right to all

10
A nurse practitioner is someone with a master’s degree in nursing and is able to prescribe medicine.

68
people living in the community. During my interview with Mr. Mills, one of the core

family nurse practitioner volunteers, he commented on his motivation to return to the

clinic every week; he said, “The clinic helps me to live my values in a meaningful way,

that’s what motivates me.” Another female nurse practitioner stated that her reason for

volunteering was that the People’s Clinic was not a bureaucracy like the county hospital

for indigent patients, with “intentions and entanglements and limited access to care.”

She strongly aligned herself with the People’s Clinic’s philosophy of “not turning anyone

away…so if [the patient] can give [a cash donation], you give. If you can’t give you don’t

have to worry about giving.” These beliefs inspired volunteers and played an extremely

important role in the sustained success of the clinic.

A social worker, Ms. Kendall, was the nonprofit clinic’s Executive Director. She

was also the wife of the clinic’s medical director, Mr. Kendall. Ms. Kendall worked two

days a week and was in charge of the “front of the house” things, such as the intake

process and administrative duties. In her role as Director of the clinic, she acted both as

gate keeper and advocate. She met with every patient before they saw a clinician to

determine if they were eligible to be seen at the clinic (i.e., no insurance or access to the

county hospital). She additionally helped patients who needed to seek treatment

elsewhere, usually because the clinic did not have the resources to treat more

complicated diseases that required x-rays or specialized tests, insulin, minor surgery,

etc.

Three to five promotoras, or female lay community health care workers, also

worked at the clinic part-time as interpreters and cultural liaisons. Promotoras were the

69
only people employed (paid) by the clinic besides the social worker/clinic director. The

promotoras were from the local neighborhood, all but one was a first generation

Mexican immigrant, and most of them were patients of the clinic prior to becoming

employees.

Figure 2.2 Clinic Organizational Structure

The Patient Population

Individuals who were eligible to utilize the clinic could not have access to the

county hospital, to private health insurance, or to governmental assistance such as

Medicaid, Medicare, or the State Children’s Health Insurance Program (S-CHIP). The

large county hospital in the area did not provide health care other than emergency

treatment to people who were not residents of the county and people who were

offered insurance at their place of employment. This meant if a person worked for a

company that offered insurance, even if the cost per month was too high for them to

afford, they could not see a doctor at the county hospital, other than at the ER. Unlike

other clinics and hospitals in the area, the People’s Clinic did not ask for an identification

card, proof of residency, or proof of legal immigration status. The clinic asked for a

70
donation in an amount that the patient could afford that would cover the visit and any

medication. Most patients gave $5-$20, but patients were not turned away if they

could not make a contribution. Clinic volunteers strongly preferred to keep the clinic

open to anyone who needed health care and had no other place to go.

The constraints at the People’s Clinic were similar to a managed care clinic.

While there was not a policy about the length of patient visits and clinicians knew they

could spend as much time with a patient as needed, they were also aware that most

days, some people were turned away unseen. Other practice constraints included a lack

of sophisticated equipment or lab technology; a lack of continuity of care for patients

due to the voluntary nature of the clinician; and an inconsistent availability of

promotoras.

Over time, the population in the community surrounding the clinic changed from

Cambodian refugees to Mexican and Central American immigrants. Because the

People’s Clinic was the only health care facility in the area that treated people

regardless of where they lived, their citizenship status, and whether they could donate,

patients came from all over, some up to three hours away. The majority of patients at

the clinic were first generation Mexican immigrants (50%). These were followed by

Mexican-Americans (20%), Central American immigrants (10%), refugees from Burma,

Cambodia, Sudan (10%), African-Americans (5%), and Anglo-Americans (5%). Most

patients had chronic illnesses such as diabetes, high blood pressure, depression, and

asthma, but the clinic also treated acute conditions such as colds and the flu.

71
 Census data from America Community Survey 2005-2007 further tells us that

39.4% of the population in this county, or 837,852 people, spoke a language other than

English at home. Thirty-seven percent, or approximately 866,887 county residents,

described themselves as Latino/a. The county ranked 34th in the nation for the

percentage of people living below the poverty line (17%).

III. Participant Observation

This project utilized a mixed method approach to research including participant

observation of the clinic setting, medical encounters, and outreach activities;

unstructured and semi-structured interviews with patients, clinicians, and promotoras;

and patient surveys. All research protocol were reviewed and approved by the

Institutional Review Board of the Case Western Reserve University.

Figure 2.3 Methods Used

Summer Fall/Winter Summer Fall/Winter Summer
2006 2006 2007 2007 2008
Participant
X X X X X
observation
Observation of 90
X X
encounters
Observation of
X X
nursing clinical
Observation of 30
encounters with
X X
patient
interviews/survey
Clinician
X X
interviews

Participant observation and unstructured interviews with clinicians, promotoras,

clinic volunteers, and patients formed a contextual knowledge base from which to

72
understand subsequent data. For linguistic anthropologists, ethnographic analysis and

participant observation is critical for an in-depth understanding of the role of language

in social situations (Hymes 1964). “Language and other social practices are

interdependent. Knowing…the ethnographic setting, the perception of and

characteristics attributed to others, and broader and local social organizational

conditions becomes imperative for an understanding of linguistic and nonlinguistic

aspects of communicative events” (Cicourel 1987: 218, see also Lazarus 1988).

Understanding the cultural fabric and broader environment of the clinic helped me to

understand the situations in which good communication practices and therapeutic

relationships were formed.

Byron Good (1994) suggested that medicine can be examined as a “symbolic

form through which reality is formulated and organized in a distinctive manner” (68).

Foucault (1972) additionally theorized that medical discourse consists of “practices

which systematically form the objects of which they speak” (49). Thus, my participant

observation was informed by an interest to understand this process by which clinicians

“see” and inhabit a culturally-informed medical paradigm. This research was interested

in questions such as, with such a supreme focus on the biological basis of health and

disease in biomedicine, how might clinicians engage with culture in a medical way, both

inside and outside the medical encounter? How does the belief of culture, cultural

differences, and a culturally informed model of health care become created as a distinct

form of reality?

73
 Participant observation also allowed me to triangulate with other methods to

determine differences between what people said to me and what was actually done.

Field notes and notes on methodology benefited the internal and external validity of my

study, facilitated and enhanced the quality of my interpretations, and helped me

formulate clinician and patient interview questions (Bernard 2002; DeWalt and DeWalt

2002).

Throughout the duration of the study (July 2006-July 2008) my observations

included:

1. The general day-to-day routine of the clinic, for example:

o The “front of the house” including the waiting room and triage area – Sitting at

the front desk with the lead promotora and social worker, I observed the

different types of patient problems, heard stories about other clinics in the

neighborhood, observed the social worker refer more complicated patients to

another clinic or hospital with better resources (x-rays, labs, or cultural

resources), observed the social worker help patients with applications or

problems with Medicaid, food stamps, insurance, etc. From the front desk area

I could also observe interactions between the promotoras themselves, the

social worker and the promotoras, and the patients in the waiting room.

o The “back of the house” including pharmacy and exam rooms – Clinicians and

other volunteers (such as students) gathered in the pharmacy. The pharmacy

also represented a division of social status among volunteers because it is not a

place where the promotoras or social worker gathered. In the pharmacy, I

74
 heard clinicians’ reactions to patients they had just seen, general talk about

diseases, general talk about patients, and general talk about nursing.

2. More than 120 family nurse practitioner (FNP) and patient medical encounters; 30 of

these were audio recorded and I administered either a post-visit interview (21) or

survey (9) to these patients.

3. The nursing student community health clinical program – During the study, there

were two clinical rotations per semester of eight nursing students. I collected data

from three groups of students, including their weekly journals.

o I observed three clinic orientations, held on the student’s first day. These

orientations were meant to show students the proper clinic procedures and

how to care for this patient population.

o I observed how students behaved in a medical encounter, how this was

different (or not so different) than seasoned clinicians, and how students

learned to take care of indigent patients.

o I observed how students were sensitized to the clinic philosophy of cultural

competence and holistic care, namely the transfer of cultural knowledge and

information from the nurse practitioners and promotoras to the nursing

students about immigrant health and culture. This unique opportunity allowed

me to explore how such issues as culture, ethnic identity, cultural differences,

education, and socio-economic status were rendered as objects of medical

attention in education and in clinical interaction (Santiago-Irizarry 2001).

75
 Analysis of this process can serve as an entree to an analysis of the way in which

a culturally competent medicine is constructed and taught.

4. I accompanied FNP’s and nursing students on “outreach” activities including visiting

immigrants and refugees who could not make it to the clinic. Outreach remains an

important function of the clinic since the People’s Clinic was started from outreach

efforts to Cambodian refugees.

In short, the hours I spent as an observer helped me become familiar with the

day-to-day routine of the clinic, establish trust and rapport with clinic staff, and

generally observe the rewards and challenges the clinic faced in caring for immigrant

and non-English speaking patients. I also saw how the clinic operated on a daily basis,

including how the clinic was organized, clinic philosophy, and patterns of interactions

and relationships among clinicians, nursing students, staff, and patients.

Ethics and My Role as Participant Observer

Participant observation is a basic tool of ethnographic research. I saw patient

education programs begin and fail; I overheard numerous conversations about diseases

and immigrant patients in the pharmacy; I observed the primary nurse practitioner, Mr.

Kendall, in his training of nursing students – he discussed diseases but also how one

should treat patients, especially poor patients; I saw disenfranchised patients in their

home environment receive medical care they would not otherwise receive. These

observations are priceless.

Participant observation has as its core a tension between participation and

observation. During data collection, I spent the majority of time as a participant-

76
observer versus a more detached observer-researcher. For example, as a participant-

observer I helped with filing patient charts during clinic down time; I greeted patients

and eventually helped with the checking in process when no one was available; I

sometimes acted as a medical interpreter when a promotora wasn’t available; I

volunteered in the pharmacy (under supervision) while “hanging out,” as I helped stock

and organize medicines; I helped patients enroll with various pharmaceutical programs

and helped them with paperwork when they were referred elsewhere for treatment (for

example, getting a diagnostic mammogram). I also participated in outreach activities

such as going door to door in refugee communities to administer flu shots with another

medical anthropologist and nurses from the health department; I made home visits with

nursing students to Mexican immigrant patients who had trouble getting to the clinic; I

participated in and eventually took over refugee outreach (after data collection was

over in July 2008) to refugees from Bhutan, Burundi, and Karen refugees from Burma.

During my fieldwork, I struggled with the ethics of being a participant-observer,

namely conflicts around my role as a researcher and the situations that arise when

conducting research with poor and powerless people. Rather than an objective

execution of the method, which is simply unrealistic, I grappled with my roles as

researcher, volunteer, and at times, paid clinic staff worker. My pendulum of

participant observation was not always balanced over the 2 years of fieldwork. During

the exact mid-point of the research (summer 2007), I became overly involved with

participating when the executive director and medical director (wife and husband team)

left the country for three months and asked me to be one of the people in charge of the

77
day-to-day operations of the clinic. I was also briefly (two months) the volunteer

coordinator, a paid position that created stress while staff tried to understand my

multiple roles of researcher, volunteer, and paid staff. The situation was luckily resolved

when another volunteer offered to take over this job for free. These experiences taught

me the importance of “critical distance” and the ability to question categories and

findings from an outsider or detached perspective (Sobo 2009: 72).

I also found it difficult to obtain informed consent during outreach efforts.

When visiting people in the community with clinic representatives (like a promotora,

family nurse practitioner, or nursing student) I found it awkward to bring out a consent

form, explain anthropology and my project, and continue to observe. Likewise, refugees

simply had a difficult time understanding my project and anthropology itself. While

they gave verbal consent for me to observe their medical visits or home visits I wasn’t

sure they totally understood. Situations in which there was a problem with the consent

process are not included in this dissertation.

Most of all, I found it difficult to face the extreme situations in which my

participants lived. I was not prepared for what was expected of me in the field. While

helping people in their homes, I listened to situations and memories of trauma that left

me with many sleepless nights. I learned that a researcher must draw a line for him or

herself about which ethical actions to take. The anthropologist who believes she should

give back to the community she is studying carries with her an additional burden of

responsibility, especially when the “field” is a car-ride away.

78
 For example, when a research participant tells the anthropologist immediately

after she has observed his medical visit that he needs help applying for food stamps

because he has no food at home, there is no question about the right course of action.

Many times, the patient I had just observed needed additional medical care, such as a

referral for further testing. Other times, while making home visits to immigrants and

refugees, I found additional need for basic living items, such as food. I always tried to

help because I knew I had the skills and resources, whether the assistance was a phone

call to inquire about a hospital bill or whether I needed to help a refugee, who had been

in the U.S. only one month, make arrangements for her husband who had just

committed suicide. To me these are some of the ways I could give back to the specific

participants and communities who so graciously let me observe and ask details about

their health and their private lives.

My roles shifted throughout the research process, from researcher to advocate

to clinic volunteer; these roles allowed me to better understand all sides of the

observed situation. Throughout this dissertation, my goal was to understand why the

research participants acted in the manner they did, to see the medical encounter from

the patient and clinician perspectives. My desire to provide the People’s Clinic with

honest feedback and clear recommendations on patient care ensured an objective

analysis of the data and reporting process.

79
IV. Clinician-Patient Observations & Interviews

A key feature of this project is the observation of patient-clinician-interpreter

interactions in the medical setting in order to identify communication strategies that

patients, clinicians, and interpreters use when they have dissimilar language and cultural

backgrounds. I observed a total of 120 medical encounters; 30 of these were recorded

for more specific analysis. Data collected from each encounter allowed me to examine:

• General communication styles including the ways clinicians elicited patient

symptoms, illness history, and negotiated a treatment plan and follow-up visits,

as well as how patients shaped the encounter to accomplish their goals and

expectations for the visit

• How participants shared their health beliefs and other information including the

manner in which these beliefs were shared

• How clinicians delivered patient education

• How participants used interpreters and the role of interpreters themselves

• How communication styles may have affected patient outcomes such as

satisfaction and understanding

Some medical encounters included student nurses. These encounters consisted

of student nurses collecting the disease history and chief complaint and conducting a

physical exam. Then a family nurse practitioner (FNP) would enter the room, review the

student’s work, and finish the medical encounter. Fifty-four observed (but not

recorded) medical visits and eleven observed and recorded medical visits included a

student nurse.

80
Sampling and Patient Selection

After patients were signed in by the social worker, they sat in the waiting room

until called by a promotora or student nurse to get their vital signs taken. After this

process, they returned to their seats in the waiting room until they were called to an

exam room. I approached patients at random in the waiting room after their vital signs

were taken. I tried to observe a mix of new and returning patients and I oversampled

male patients when they came into the clinic because women and children made up the

predominant patient population.

My selection process involved the following: I looked at the charts of patients

waiting to be called to an exam room. I randomly picked a patient’s name from his or

her chart and approached the person in the waiting room. I explained the study in

Spanish or English, 11 reviewed the consent form, and got his or her permission to

observe the medical visit and conduct a post-encounter interview. At the end of our

conversation, I reiterated I would observe their medical visit, including everything they

discussed with the doctor, and would be in the exam room. The refusal rate was less

than 2% for new patients, and no returning patients refused to participate. 12

Once the patient was placed in an exam room, I watched from the back of the

clinic to observe which clinician would see the patient. With no policy in place regarding

continuity of care, clinicians saw patients based on which patient was next in line. All

11
In the beginning of the study, I used an interpreter for the consent process and for patient interviews.
As the study progressed, my Spanish skills, and particularly my medical Spanish knowledge, greatly
improved. If I used an interpreter during the patient interview, I used an interpreter different than the
one used in the medical encounter.
12
I observed but never recorded three medical encounters with the volunteer psychiatrist. Due to the
sensitive nature of the encounter, the psychiatrist believed it would hinder her rapport with the patient to
audio record the encounter.

81
clinicians signed general consent forms for me to observe them with patients. After

determining which clinician was going to see which patient, I asked the clinician if I

could observe the specific interaction, noting that the patient had already consented.

The clinician and I usually entered the exam room together.

When possible, I chose to follow the same few clinicians. Multiple observations

and unstructured conversations after the encounter with the same clinicians enhanced

the reliability of my analysis and allowed me to distinguish between behaviors that were

routine, accidental, and exceptional for each clinician-patient encounter. For instance,

after hearing clinician A talk with someone who had high blood pressure several times,

it became apparent that this style was different than clinician B’s style.

Unrecorded Medical Encounters

The first 90 medical encounters I observed were not recorded and no patient

interviews occurred. I observed and took notes during these encounters in order to

better understand the normal routine of a medical visit: what happens when, what sort

of questions are asked during the history taking, when the physical exam happens, how

patient’s ask questions, how things are explained, and so forth.

Observing 90 visits provided a foundation for the actions during the next phase,

a detailed linguistic examination of 30 recorded patient encounters. For example, if a

patient had diabetes, I knew what questions would be asked by the clinician, what

should be examined, the type of education the patient would receive. I became familiar

with how some clinicians explained the disease, treatment, and follow up, and noticed

when other clinicians did not; I came to know when promotoras were used and when

82
they were not. In short, the initial 90 observations provided a roughly standard

template of the typical medical encounter.

The following graphs show demographic information of the 90 patients and

clinicians I observed. Figure 2.4 shows the breakdown of patient age. Most patients fell

in the 25-34 and 35-44 age ranges. The mean patient age was 40.6 years, with the

range of 2 to 66 years.

Figure 2.4 Patient Age

Patient Age (n=90)

65+ 5
55-64 16
45-54 12
35-44 25
n=90
25-34 21
18-24 9
1-17 2

0 5 10 15 20 25

Figure 2.5 shows patient sex. The majority of patients at the People’s Clinic were

female (71%).

Figure 2.5 Patient Sex

Patient Sex (n=90)

male (26)
female (64)

83
 Figure 2.6 shows patient country of origin. Forty-five percent of patients were

born in Mexico. The next category, “unknown Latino/a” (37%) represents patients who

were not born in the United States but did not discuss their country of origin.

Figure 2.6 Patient Country of Origin

Patient Country of Origin (n=90)

Mexico 41

Unknown Latino/a 34

Other 6

El Salvador 3

Honduras 2

Guatemala 2

US, non-Hispanic 2

0 10 20 30 40 50

Figure 2.7 shows that 88% of patients spoke Spanish as their primary language.

Figure 2.7 Patient Primary Language

Patient Primary Language

(n=90)

Spanish (80)
English (10)

84
 And lastly, figure 2.8 shows that over half of patients, 55%, were treated for type

II diabetes, hypertension, depression, or another chronic illness; 45% of patients were

treated for an acute problem, such as cold, infection, or some form of body pain.

Figure 2.8 Patient Biomedical Diagnosis

Patient Biomedical Diagnosis (n=90)

Type II Diabetes 9
Hypertension 14
Cholesterol and DM 2
DM and HTN 3
Depression + DM or HTN 10
Depression 1
Other MH 5
Infection (cold, flu, sinus, tooth) 14
Body Pain 8
3 n=90
Asthma
Thyroid 2
Allergies 2
Stomach Pain 2
Headache 2
UTI 2
STD 3
Other 8

0 2 4 6 8 10 12 14

DM=type II diabetes, HTN=hypertension, MH=mental health, UTI=urinary tract infection

Figure 2.9 shows the clinician demographics for the 90 observed encounters.

Over the 90 patient encounters, I observed 12 clinicians. Most of the clinicians I

observed were family nurse practitioners or nurse practitioner students. The majority

of clinicians were female. Four medical doctors volunteered once a month and saw

eight patients in my sample.

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Figure 2.9 Clinician Sample (n=90)

Times Volunteer
Clinician Sex Age Ethnicity Training
observed Frequency
Mr. Kendall 33 male 65 Anglo-American FNP/professor weekly
Ms. Engle 13 female 36 Anglo-American FNP weekly
Mr. Mills 6 male 33 Anglo-American FNP/professor weekly
Ms. Smith 3 female 30 Anglo-American FNP/professor monthly
Ms. Peterson 1 female 49 Anglo-American Pediatric NP weekly
Mr. Jim 12 male 24 Anglo-American FNP student weekly
Ms. African-
3 female 30 FNP student weekly
Davenport American
Ms. Kross 2 female 23 Anglo-American FNP student weekly
Unknown
9
FNP Student
Dr. K 4 female 41 Anglo-American MD/psychiatrist monthly
Dr. Kay 2 female 39 Anglo-American MD monthly
Dr. B 1 female 52 Anglo-American MD/immunology monthly
Dr. McG 1 female 46 Anglo-American MD/internist monthly

Recorded Medical Encounters& Patient Interviews/Surveys

Thirty of the 120 medical encounters were audio recorded and I conducted semi-

structured interviews with patients or administered a survey after the visit. I personally

conducted some of the interviews in Spanish, especially if the patient knew some

English. Some patients spoke no English and an interpreter was needed. I used an

interpreter different than the one present for the medical visit so as not to influence the

patient’s answers about communication. All encounters and interviews were recorded

for later transcription and analysis.

The initial interview and survey questions were designed to collect data on

patient satisfaction and expectations of this particular medical encounter as well as

demographic information. After the first four interviews, I added specific questions

86
about patient illnesses and treatments to get at their explanatory models. I also added

questions to the interview to elicit the patient’s belief about the illness, etiology, course

and outcome, as well as their thoughts about the treatments they were currently

undergoing.

While less than 2% of the people I approached in the waiting room declined to

participate, I noted that some interviews were shortened because of time. Thus, I

created a survey for the patients who had already waited two to five hours at the clinic

and did not have the time necessary for an interview. I designed this survey directly

based on the interview, which was then translated into Spanish by a native Spanish

speaker from Mexico. A total of nine patients indicated they did not have time for an

interview and instead filled out a survey. Patients could choose between an English or

Spanish version of the survey. Both the survey and interview can be found in Appendix

I.

Recorded medical encounters (n=30) lasted on average 26 minutes with the

range being 5 minutes 30 seconds to 71 minutes. The following graphs provide

demographic information for these 30 patients.. A comparison of the 90 observed visits

with the 30 observed and recorded visits indicate that the 30 recorded patient

encounters are similar to the regular clinic patient population and thus could be

generalized to the entire clinic population.

Figure 2.10 shows the breakdown of patient age (n=30). Most patients fell in the

35-44 and 55-64 age ranges. The mean patient age was 43.3 years, with the range of 17

to 63 years.

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Figure 2.10 Patient Age

Patient Age

65+ 0
55-64 8
45-54 6
35-44 9
n=30
25-34 3
18-24 3
1-17 1

0 2 4 6 8 10

Figure 2.11 shows patient sex. The majority of patients I observed and interviewed at

the People’s Clinic were female (76%).

Figure 2.11 Patient Sex

Patient Sex (n=30)

male (7)
female (23)

Figure 2.12 shows patient country of origin. Seventy percent of patients were

born in Mexico. Thirteen percent of patients were U.S. born Latino/a.

88
Figure 2.12 Patient Country of Origin

Patient Country of Origin

(n=30)

Mexico 21
US born Latino/a 4
El Salvador 2
Unknown Latino 2
Columbia 1

0 5 10 15 20 25

Figure 2.13 shows that 76% of patients spoke Spanish as their primary language.

Figure 2.13 Patient Primary Language

Patient Primary Language

(n=30)

English
Spanish

And lastly, figure 2.14 shows that over half of patients, 63% were treated for

type II diabetes, hypertension, depression, or another chronic illness; 37% of patients

had an acute problem, such as cold, infection, body pain.

89
Figure 2.14 Patient Biomedical Diagnosis

DM=type II diabetes, HTN=hypertension, MH=mental health, UTI=urinary tract infection

Figure 2.15 shows the clinician demographics for the 30 observed encounters.

Over the 30 patient encounters, I observed 10 clinicians. Most of the clinicians I

observed were family nurse practitioners or nurse practitioner students. The majority

of clinicians were female, although the majority of the 30 patients saw a male family

nurse practitioner (73%). Three medical doctors volunteered once a month and saw

three patients in my sample.

90
Figure 2.15 Clinician Sample (n=30)

Times Volunteer
Clinician Sex Age Ethnicity Training
observed Frequency
Mr. Mills 13 male 33 Anglo-American FNP/professor weekly
Mr. Kendall 9 male 65 Anglo-American FNP/professor weekly
Ms. Childs 1 Female 37 Anglo-American Pediatric NP monthly
Ms. Engle 1 female 36 Anglo-American FNP weekly
Unknown
3
FNP Student
Dr. Kay 1 female 41 Anglo-American MD/psychiatrist monthly
Dr. Henry 1 female 39 Anglo-American MD monthly
Dr. McG 1 female 46 Anglo-American MD/internist monthly

Clinician Interviews

Four clinicians participated in a semi-structured interview. Questions covered

the following topics: feelings about this patient population (Mexican, Central, and South

American immigrants), stories of successful and unsuccessful patient encounters,

cultural barriers, their experiences using interpreters, communication strategies, and

their explanatory models about the top five diseases seen at the clinic. The interviews

ranged from to one hour and 24 minutes to two hours and 15 minutes. The clinician

interview can be found in Appendix I.

V. Data Analysis

Participant Observation and Interviews

Both observational field notes and patient and clinician interview transcripts

were imported into QSR NVIVO text management software. I used grounded theory to

identify themes and concepts across notes and interviews; this method provides a

91
rigorous procedure for developing theoretical models from the relationships among

themes (Bernard 2002).

Lyn Richards(2005)explained a step by step progression of looking past

descriptive codes in order to formulate analytical themes. Through an iterative process

I continually reviewed field notes and transcripts in order to pose new questions and

reformulate old ones. At the end of each passage I asked myself, “Why is this

interesting? What is the significance of this?” This process generated the first wave of

open codes, the descriptive codes. I saved these “first-hunch” notes in the software

itself as memos so that I could keep a log of early reflections.

Once the descriptive codes were created, I needed to bring passages together to

look for higher level codes. Richards (2005: 88) described this as analytical coding which

leads to “theory ‘emergence’ and theory affirmation.” Once observations and interview

text were coded by theme I began to consider the meaning of these themes in context

(Strauss and Corbin 1990; Bernard 2002). Through developing and applying categories

and codes, I built and generated theories about the ways in which culturally- and

linguistically-different clinicians and patients interact and relate with one another.

Transcribing and Coding the Medical Encounter

Transcription of the medical visit was a detailed and involved process of

listening, playing back, and listening again and again to make certain of the pauses,

overlaps, and intonations of speech. I initially transcribed the medical visits. For each

recording I first completed a rough transcription to outline the initial shell of the

interactions. I then returned to the raw data for a more detailed transcription. All

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medical encounters in which the patient spoke Spanish were then sent to a bilingual

research assistant who completed a detailed transcription, and then translated the

transcription from Spanish to English. In the final step of the transcribing process I

listened again to the recording to finalize the text and add transcription notations for

discourse analysis (such as pauses, overlaps, interruptions, etc). A full description of

linguistic transcription notations can be found in Appendix II. Below is a sample of a

final transcript:

FNP = family nurse practitioner P/I = promotora/interpreter P = patient

FNP: No mucho ingles, ah español.
Not very much English, ah Spanish.
[door opens and closes and interpreter comes in]
Um, so how have you been?
P/I: Como se ha siento.
How have you felt?
P: Oh, bien.
Oh, good.
FNP: No problems or concerns?
P/I: No problemas?
Any problems?
P: No, todo esta bien.
No everything is good.
P/I: No, everything is fine.

Two separate analytical phases occurred for each medical visit, discourse

analysis and qualitative analysis. Discourse analysis allowed me to demonstrate how

information is passed back and forth between the two subjects, how the patient and

doctor fulfill their sociolinguistic roles, and the methods used to exercise power and

control.

For example, each transcript of the medical visit was coded by hand for clinician

and patient questions, interruptions, overlaps, misunderstandings, and education

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strategies. The importance of each of these areas is well documented in linguistic

anthropology and was reviewed in Chapter 1. Because the transcript depicts oral

language, analysis consisted of not only reading the transcript, but also listening

simultaneously to the audiotape to capture the full meaning of what was said.

The medical visit transcript was also imported into QSR NVIVO 2.0 text

management software for qualitative analysis of explanatory models (EM) and illness

narratives, such as:

• What kind of information do patients share with their clinicians?

• Is the sharing of EMs encouraged?

• How do patients share their EM?

• How to clinicians share their EM?

• What is the role, if any, of “cultural” information in the encounter?

• How do participants react to cultural or lifeworld information?

Finally, as a tool for coding passages about the role of the

promotora/interpreter, I used NVIVO 2.0, which also allowed me to code how

promotoras and clinicians worked together.

To summarize, this research utilized a multi-method ethnographic research

approach at a free clinic that treated primarily Mexican immigrants. Central to my

research aims was an awareness to document how clinicians and clinic staff were

“culturally competent” both at a micro-encounter level and macro-organizational level.

The next chapter reviews current definitions and theoretical models of cultural

94
competence in medicine and how clinicians understood and made use of notions of

culture, cultural difference, and structural barriers such as poverty and hazardous

working conditions.

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 Chapter Three: Do Cultural Competence Communication Strategies
Alleviate Cultural “Barriers?”

Cultural competence theories assert that cultural differences between patients

and clinicians create barriers to treatment in health care settings. This chapter explores

current guidelines for culturally competent communication strategies and shows how

clinicians at the People’s Clinic applied such strategies. Because the clinic was the site of

a community clinical for nursing students from a local research university, 13 data were

also collected about how nursing students learned the socio-cultural milieu and cultural

characteristics of this patient population during their clinical rotation. That is, how they

were taught to be “culturally competent nurses.” Additionally, this chapter focuses on

how clinicians at the People’s Clinic widened their gaze regarding patients’ cultural

health beliefs and incorporated macro-structural barriers and the health of the larger

community.

I. Cultural Competence

A review of the recent literature shows that the concern with social service

delivery and accessibility of treatment to immigrant and minority patients in medicine is

largely limited to a concern for providing what is termed “culturally sensitive” services.

The notion that medical institutions and its practitioners should be culturally competent

emerged in the late-1980s and accompanied a shift away from the analysis of poverty

and adverse living and working conditions to the analysis of cultural and linguistic

13
A “clinical” is a set of classes in which students practice clinical nursing under supervision of a preceptor
in real world settings, such as nursing homes, schools, and hospitals.

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difference as an answer to poor health care outcomes among immigrants and minorities

(Shaw, 2005). Advocates for cultural competence believe that introducing culturally

sensitive practices decreases cultural and linguistic barriers and increases certain patient

outcomes, such as patient understanding, satisfaction, follow-up, and treatment

compliance (Brach and Fraserirector 2000; OMH 2001).

Over the past 15 years, many health care institutions, and almost every health

profession, have made cultural competency a priority (Hunt and de Voogd 2005). In

2002, the Liaison Committee on Medical Education required that all medical schools

integrate cultural competence into their curricula (Benacourt, et al. 2005). The

American Medical Association also endorses cultural competence and has developed

several curricula for medical students as well as continuing medical education (CME)

programs.14 Currently there are two states, California and New Jersey, which require

physicians to take cultural competence training as part of their annual CME hours

(Landers 2009). The wide spread impetus for the adoption of culturally sensitive

practices has primarily come from health disparity research finding health inequalities

among minority groups and from governmental agencies such as the U.S. Office of

Minority Health, a division of the Department of Health and Human Services (Chavez, et

al. 1992; Brach and Fraserirector 2000; Carrillo, et al. 2001; OMH 2001; Vega and Alegría

2001; Vega, et al. 2001; Putsch 2002; Hirsch 2003).

14
http://www.ama-assn.org/ama/pub/physician-resources/public-health/general-resources-health-care-
professionals/educating-physicians-controversies-challenges-health/vulnerable-populations.shtml,
accessed 3/10

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 Most cultural competence models build upon medical and linguistic

anthropological research that highlights differing explanatory models (EM) of illness

among cultural groups. Explanatory models are simply concepts about a specific illness

or disease that the sufferer holds and includes ideas about the diagnosis, etiology, and

treatment preferences. EMs are fluid and culturally-constructed, rooted in culturally

symbolic and tacit health belief systems about a particular illness episode (Kleinman

1980; Gaines 1992a). Despite the fact that current research and education on cultural

competence is increasing, anthropologists have not thoroughly engaged the recent

institutional applications promoted by cultural competence models (Shaw 2005). 15

Based on my analysis, I contend that the current debates surrounding cultural

competence provide several areas ripe for anthropological study. Not only are

anthropologists interested in the myriad of ways “culture” is used in our society, but

medical anthropologists have a historical legacy of studying the construction of medical

knowledge(for example, Kleinman 1978; Mishler 1981; Gaines 1982a, 1992; Engel 1984;

Good and Good 1993; Good 1994). Qualitative and ethnographic methods are vital in

highlighting the articulation between the patient and the clinical explanatory model; the

latter model is often treated as uncontroversial and legitimate in cultural competence

research. Anthropologists, whose focus is holistic, can also incorporate political and

economic determinants of society into studies of health and medicine (Lazarus 1988;

Santiago-Irizzary 1996;Hirsch 2003; Hunt 2005; Shaw 2005). Perhaps the most
15
There has been some scholarship in the areas of psychiatric anthropology and international health.
However, with such a central focus on the role of culture and language in cultural competence theories,
anthropologists have been surprisingly silent on this specific framework. Some exceptions include Fortin
2008, Kleinman and Benson 2006, Shaw 2005, Hirsch 2003, Taylor 2003, Santiago-Irizarry 1996, 2001, and
Lazarus 1988.

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important reason to probe this topic further is the potential for designing interventions

that would improve health care services, making them more accessible to a diverse

range of people.

What is Cultural Competence?

All cultural competence models incorporate actions to manage both linguistic

and cultural differences at the health care organization as well as in the medical

encounter (OMH 2001). Based on a literature review of 40 research articles on cultural

competence from various disciplines (medical anthropology, medicine, nursing,

psychology, and social work), a number of definitions and theoretical models emerged.

The following overview includes an exploration of the main cultural competence

models. They are arranged from general definitions of cultural competence to more

comprehensive theoretical models. My goal in reviewing models is not to enter into a

debate over which theoretical model is more correct, but rather to constructively

challenge the assumption that including “culture” as a “barrier” to health is a

worthwhile endeavor (Sobo 2009).

Definitions

Most authors define cultural competence using a variation of a definition

developed by mental health researchers two decades ago. Cross and colleagues (1989)

defined cultural competence as “a set of congruent behaviors, attitudes, and policies

that come together in a system, agency or amongst professionals and enables that

system, agency or those professionals to work effectively in cross-cultural situations”

(2). The U.S. Office of Minority Health also adapted their definition from Cross and

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colleagues. Several research articles used this broad definition as the basis for their

research of clinician behaviors, patient attitudes, and evaluation of cultural competence

training programs (Dolhun, et al. 2003; Johnson, et al. 2004; Beach, et al. 2005;

Betancourt 2005; Park, et al. 2005; Price, et al. 2005). These articles simply defined

cultural competence without elaborating on a theoretical model or framework.

The National Center for Cultural Competence at George Washington University

also defines cultural competence very broadly at both a macro-organizational level and

micro-encounter level and requires organizations to: 16

• Have a defined set of values and principles, and demonstrate behaviors,

attitudes, policies and structures that enable the organization and those who are
employed there to work effectively cross-culturally.
• Have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage
the dynamics of difference, (4) acquire and institutionalize cultural knowledge,
and (5) adapt to diversity and the cultural contexts of the communities they
serve.
• Incorporate the above in all aspects of policy making, administration, practice,
service delivery and involve systematically consumers, key stakeholders and
communities.

Theoretical Models

Theoretical models move from a definition of cultural competence to hypotheses

about specific actions clinicians and organizations should utilize in their efforts to

become culturally competent. Some models incorporate meaning-centered methods to

illuminate the role of culture and others are more comprehensive in scope to include

factors other than culture and culture difference.

16
http://nccc.georgetown.edu/foundations/frameworks.html, accessed 3/2010

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 Meaning-centered and cognitive theoretical models utilize explanatory models

or patient-centered models of care. These models believe that focusing on 1) the

patient’s experience, meaning, and understanding of the illness, and 2) the way of

communicating the illness and treatment are instrumental to achieving cultural

competence. Researchers advocate using these interpretive and cognitive theories as

methodological tools which can help the clinician understand their patient’s culturally

different health beliefs (Chavez, et al. 1995; Korbin and Spilsbury 1999; Browner, et al.

2003; Betancourt 2004; Fitzgerald, et al. 2008; Rosenberg, et al. 2005; Hasnain-Wynia

2006; Haidet, et al. 2008).

In the discussion section of these articles, authors typically suggested that

certain strategies be employed by clinicians to overcome these obstacles. What

constitutes a culturally competent communication strategy, though, is debated in

current literature. Many organizations and researchers use some variation of the

“LEARN” model from physicians Berlin and Fowkes (1983)17 to illustrate a step-by-step

approach of how to be culturally competent when treating immigrant or minority

patients:

• Listen with sympathy and understanding to the patient's perception of the

problem
• Explain your perceptions of the problem
• Acknowledge and discuss the differences and similarities
• Recommend treatment
• Negotiate agreement

17
See for example, http://www.diversityrx.org

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 Berlin and Fowkes (1983) adopted the LEARN model, in part, from medical

anthropologist Arthur Kleinman’s explanatory model approach. In this approach,

Kleinman (1980) recommended that clinicians use a series of questions to elicit the

patient’s model of the illness in order to engage in a process of treatment negotiation:

• What do you call the problem?

• What do you think the illness does?
• What do you think the natural course of the illness is?
• What do you fear?
• Why do you think this illness or problem has occurred?
• How do you think the sickness should be treated?
• How do want us to help you?
• Who should be involved in decision making?

Some researchers have developed original theoretical models, which are partly

based on the above meaning-centered theories, but add communication theories about

the process by which clinicians move towards cultural competency. These models only

focus on the role of cultural difference (Berlin and Fowkes 1983; Rogler, et al. 1987;

Brach and Fraserirector 2000; Wells 2000; Crandall, et al. 2003; Ferguson, et al. 2003;

Kagawa-Singer and Kassim-Lakha 2003; Eunice 2004; Reimann, et al. 2004).

Finally, a small number of theoretical models were more expansive in scope.

They suggested that clinicians and organizations be attuned to cultural difference as

well as macro-structural factors such as poverty, racism and discrimination, hazardous

work sites, and nutrition (Carrillo, et al. 1999; Hansen, et al. 2000; Purnell 2000; Stewart

2004). The notions of “culture” in these models were also more nuanced and complex

as models assessed the degree to which patients were influenced by culture,

acculturation, and ethnic identity. Figure 3.1, the Purnell Model for Cultural

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Competence, is representative of models in this category; it is non-linear and

incorporates certain variables as impacting health and health care: communication,

family, work, nutrition, biology, risk behaviors, health care practices, religion, death

rituals, pregnancy/childbirth, and biomedical and folk practitioners (Purnell 2000).

Figure 3.1 The Purnell Model

Thus, because disciplines, researchers, and organizations define and conceive

cultural competency somewhat differently, practitioners find competing models. Not

only does this make implementation difficult but it also stymies careful comparative

103
research (Brach and Fraserirector 2000). Further, most research articles do not provide

examples for clinicians on how to be culturally competent or how to apply theoretical

models in their everyday practice; out of 30 reviewed articles, only four included actual

case examples.

Cultural competence theories argue for practices implemented at the micro, or

medical encounter level, and at the macro, or organizational level (OMH 2001). Most

research conducted in the area of cultural competence, however, is at the micro-level of

the medical encounter and examines interpreter use, interpreter roles, patient

satisfaction, patient compliance, patient understanding, clinician satisfaction, and

cultural differences (for example, Baker, et al. 1998; Brach and Fraserirector 2000;

Elderkin-Thompson, et al. 2001; OMH 2001; Putsch 2002; Flores, et al. 2003). This body

of research comes from university medical schools and other allied health departments

and tends to be quantitatively driven and focused on one participant (patient, clinician,

or interpreter). Such studies do not inform the qualitative dynamics of the

communicative process, nor are they able to comment on the wider health setting

organization or state and federal practices and policies.

Nursing Models of Cultural Competence

Because the majority of clinicians in this sample were nurse practitioners, it is

important to highlight nursing models of cultural competence. My review of 40

research articles on cultural competence in this chapter included research from

medicine, anthropology, psychology, social work, and nursing. For example, the Purnell

Model of Cultural Competence (figure 3.1) comes from nursing scholarship.

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 Without a large meta-review of the many hundreds of nursing articles written

about cultural competence (the journal Transcultural Nursing alone listed 718 articles

about cultural competence) it would be difficult to definitively describe qualitative

differences, if any, among models of cultural competence in medicine versus nursing.

It is clear, however, that the nursing discipline has been involved with studying

anthropological theories with regard to patient health since the 1960’s. Early milestones

in the literature, such as Leininger’s Nursing and Anthropology: Two Worlds to Blend in

1970 and Brink’s Transcultural Nursing in 1976, not only disseminated early

perspectives, but also demonstrated the influence of anthropology. Nursing scholars

also highlight that in general, nursing curricula focuses more on the holistic elements

that affect patient care than medical curricula (Chrisman 2007).What remains similar

across medical professions is the agreement that more research is needed for the

implementation and evaluation of cultural competence (Shen 2004).

Findings of Cultural Competence Research

A recent meta-review of cultural competence research findings concluded

(Schouten and Meeuwesen 2006):

• Minority patients do not receive as much medical information or explanation

from clinicians as compared to Caucasian patients,
• Minority patients do not understand their diagnosis or treatment plan as well as
Caucasian patients,
• Minority patients rate clinicians as less friendly and less concerned,
• Minority patients think their comments are ignored by their clinician,
• Results regarding encounter length with minority patients are inconsistent; some
research finds encounters are longer while some are shorter,

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 • Minority patients are less adherent to their treatment plans than Caucasian
patients.

Research also associates language barriers with the increased potential for

misdiagnoses and inappropriate treatment, the need for repeat visits, inadequate

informed consent, and dissatisfaction in the quality of communication and care among

patients and providers, among other outcomes (Elderkin-Thompson, et al. 2001; Flores,

et al. 2003; Simon, et al. 2004; Dysart-Gale 2005). These findings intensify the need for

ethnographic study and understanding of language barriers in health care.

The Role of Culture and Language

To re-iterate, as cultural competence theories gained popularity, analysis shifted

away from the role of macro-structural phenomena in health, such as living in poverty,

poor working conditions, environmental hazards, institutionalized racism, and an

immigrant or refugee’s migratory and pre-migratory experiences (Hirsch 2003). Instead,

cultural competence theories in medicine became increasingly based on the assumption

that differences in our respective cultures affect health status, treatment, and

outcomes. “According to advocates for culturally appropriate care, traditional

biomedicine addressed individual, physical bodies apart from their cultural contexts,

wherein lies the “differences” (Shaw 2005: 292). Thus, while culture was neglected in

traditional biomedicine, it is now invoked as a scapegoat in conflictual medical

situations, especially those involving ethnic minorities (Fortin 2008, Sobo 2009).

The concept of culture in culture competence is similar to early anthropological

notions, that culture, as divorced from civilization, is something that others had,

106
something that could be counted and catalogued (Sobo 2009). Seen in this way, culture

is reified and considered as a concrete, bounded entity that exists in and of itself.

Current anthropology whole-heartedly rejects this understanding of culture as

representations show cultural boundaries as evolving, porous, and flexible.

Immigrant and minority patients are seen to be particularly “culture-driven.” In

fact, the literature overwhelmingly discusses cultural competence as a unique set of

actions necessary for minority patients only. For example, one nursing article explicitly

stated that cultural competence was something that physicians or organizations needed

to master for “appropriate relationships with ethnically diverse patients” (Eunice 2004:

94).

Some research focuses on the differences between cultural and biomedical

models with the view that patients’ cultural health beliefs are problematic and should

be changed to incorporate the biomedical model. For example, one medical researcher

stated, “Much of the challenges in blood pressure control in blacks have been ascribed

to poor patterns of medication adherence and dietary indiscretion. Improving

knowledge about hypertension, its treatment and complications has important

implications for medication adherence and blood pressure control. Therefore, culturally

relevant patient education materials are needed” (Boutin-Foster, et al. 2009: 144).

Cultural and linguistic differences of the patient, then, and not necessarily the culture of

the medical provider and institution, or other macro-structural barriers, became

incorporated into the medical model as an external influence that negatively affects

health care (Hunt and Arar 2001; Santiago-Irizarry 2001).

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 Further, a recent meta-review of cultural competence research found that most

studies do not incorporate independent variables other than patient race, ethnicity, or

language preference, making it difficult to understand how other variables beyond these

may factor into medical communication and health inequalities (Brach and Fraserirector

2000; Schouten and Meeuwesen 2006). Quantification of multifaceted variables such as

race, ethnicity, and language use, coupled with a lack of inclusion of other variables such

as health beliefs, structural and social inequality, and a method of direct observation,

has resulted in “an atheoretical, purely descriptive research field” that cannot inform

“any possible explanatory mechanisms for communication problems” (Schouten and

Meeuwesen 2006: 29).

Because variables such as culture, race, ethnicity, language and health beliefs are

often treated as straightforward and one-dimensional by researchers, some

misconceptions can be imparted to clinicians about these phenomena. For example,

cultural competence models define culture as something that minority or immigrant

patients’ posses; Caucasian middle-class patients, on the other hand, are treated as

acultural and represent the standard of “normalcy” (Santiago-Irizarry 2001; Hunt 2005;

Hunt and de Voogd 2005). Since culture is often portrayed as a foreign, static entity,

nursing students at the People’s Clinic often assumed they must use a different set of

communication strategies for immigrant or minority patient in the clinic.

A slide from a cultural competence presentation at a UCLA medical school

workshop illustrates some of these stereotypes (figure 3.2), in this case, how cultural or

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traditional frameworks compare with medical frameworks. 18 The “Other” patient’s

culture is portrayed as timeless, homogenous, closer to nature, and slow, while the

biomedical culture is active, helpful, and treats everyone the same.

Figure 3.2 Slide from Cultural Competence Workshop

Consequently, while cultural competence research may be useful in identifying

and pointing out problematic areas, three major critiques prevent this model from

widespread acceptance across disciplines. First, it is too focused on the micro-level of

patient encounters and patient cultural difference and does not investigate the wider

health care environment and macro-structural barriers. Fortin’s ethnographic study of a

hospital pediatric ward showed that, “conceptualizing the Other as an individual,

outside his or her social environment, isolates the latter from the conditions that

produce inequalities in healthcare” (2008: 183).

18
http://hr.healthcare.ucla.edu/Download/Cultural%20Diversity%20and%20Health%20Care.ppt

109
 Second, the quantitative scope too often ignores the ethnographic context;

studies do not incorporate multiple methods such as interviews or observational data of

the medical encounter. Quantitative data gathering techniques can only succeed if they

are carefully attuned to specific cultural and environmental conditions, local languages,

and other features (i.e., the emic perspective) that are discovered primarily through

ethnographic research. Numeric data additionally needs descriptive, qualitative data to

aid in analysis and hypothesis-generation (Pelto, Bentley, and Pelto 1990).

Third, research and subsequent applications of findings treat multifaceted

variables such as culture, race, ethnicity, or health beliefs as one-dimensional. Since

culture is always evolving, culture must be contextualized as a phenomenon that covers

a wide set of values, beliefs, and ways of being that are meaningful within a particular

relational and historical context. Like ethnicity, culture is not inherent but constructed

in a particular environment and may be enacted differently according to the context

(Gaines 1992). Medical anthropologist Linda Hunt studied how the concept of culture

was used in health research and wrote in the Lancet that “these studies almost never

include indicators of the specific cultural traits in question, but instead assume that by

knowing someone’s ethnic identity or national origin, their beliefs and behaviours [sic]

can reliably be inferred…Attributing variable health-outcomes to unexamined cultural

differences requires several major leaps of faith” (Hunt 2005). This lack of attention to

culture as a multifaceted variable in cultural competence models is mirrored in the data

collected at the People’s Clinic that shows that clinicians have a difficult time dealing

with differences in cultural health beliefs.

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 The remainder of this chapter examines the cultural competence model in

comparison to the People’s Clinic practices. While the clinicians did not verbally define

their actions in relation to a specific model, their views were in line with a more holistic

understanding of the factors affecting patients’ health, rather than a model that solely

focuses on cultural health beliefs.

II. Micro-level Cultural Competence in the Encounter

Step 1: Clinicians’ Understanding of Culture

Cultural competence focuses specifically on clinicians’ knowledge of the values

and belief systems of diverse cultural groups and their impact on health care access and

utilization. The first step in cultural competency asks clinicians to be self-reflexive of

their own culture and cultural biases in order to understand how the culture of their

patient may bring a different set of beliefs and experiences to the encounter.

Based on my observations and interviews, nursing students tended to hold

stereotypical or superficial understandings of the concept and role of culture in health

and illness. For example, one young female nursing student gave the following answer

when I asked her what she learned about the role of patients’ cultures on health from

her time at the clinic.

“For instance, if you have blonde hair and green eyes or blue eyes and touch a
baby of Hispanic culture you can give them mal de ojo(the evil eye). So when I
went up to a kid and told the parent, “You have a cute kid,” they said, “Ugh.”
Now I won’t say how cute they are. Or if I was assessing the baby, after a while,
when I built a rapport, I would complement maybe the smarts of the baby and
not that they were cute.” [interview with female nursing student]

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In a second example, a nursing student talked about gendered cultural

stereotypes.

At the end of the day, during the debriefing session, Mr. Kendall (the preceptor)
asked the nursing students, “Did anyone see cultural differences today?” One
student answered that there were more females than males at the clinic, but
then said, “I didn’t see a male make a decision for a woman.” [field notes 10-18-
06]

Thus, I observed nursing students project timeless cultural stereotypes upon

patients without really asking the patients whether they believed, for example, if

strangers could give their children mal de ojo (the evil eye) just by complimenting them.

To many nursing students I observed, culture beliefs often represented a set of

stereotypes about what a certain group thinks, “or a bunch of rules about how to deal

with “them,” like so many specialized tools to be stashed in a briefcase and trotted out

each time one of “them” shows up…” (Taylor 2003: 179).

During afternoon debriefing sessions, but especially at the orientation session on

the first day of the clinical rotation, Mr. Kendall, the clinical preceptor and clinic medical

director, oriented the nursing students towards an awareness of cultural difference

between the patients and themselves. Concurrently Mr. Kendall pointed out that all

patients, American and Mexican, come with a cultural background.

At orientation Mr. Kendall asked the students, “What is different and the same
with Mexican and American patients?” One student said, “They rely more on
family and on traditional methods of treatment.” One student stumbled over
the word curanderos (traditional healers). Mr. Kendall said, “But that’s no
different than anyone. There are differences of opinion regarding traditional
healers. But who is the definer? What is a culture bound syndrome?” He said
that anorexia nervosa was an American culture bound syndrome and from the
students’ expressions, it seemed that some of them were surprised that
Americans can have culture bound syndromes too. [field notes 8-23-06]

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 Compared to the nursing students, family nurse practitioners (FNP) verbalized

the importance of culture on health care at a more holistic level. My observational data

show that most of the FNPs at the People’s Clinic talked about the general role of

culture in health care with one another during the course of a clinic day and during

interviews with me. For example:

“Culture is like my glasses, my first view is my own culture and then I have to see
the patient and their glasses, their culture. We’re like looking at each other
through these glasses and it’s worth recognizing that hey, we have these glasses
on.” [interview with Mr. Mills, FNP]

Mr. Mills’ quote was representative of the family nurse practitioners’ awareness

that patients’ cultures represent a lens from which health and illness experiences are

mediated; few relied on cultural stereotypes as a guiding framework. However, having

this view of culture did not necessarily facilitate clinicians to incorporate culture in the

medical encounter. How might clinicians move from awareness of the importance of

culture to specifically asking about it and utilizing it in the medical encounter?

Step 2: Eliciting Patient Agendas and Health Beliefs

Whereas traditional approaches to cultural competence relied on the clinician

memorizing lists of stereotypical beliefs and practices of a particular group, more recent

approaches use patient-centered strategies as a model. This model of care is explicitly

used, for example, in the American Medical Association’s Cultural Competence

Compendium (Hedrick 1999). Patient-centered care is often defined as the degree to

which clinicians ask detailed and open ended questions, elicit patient questions, educate

patients, test for patient understanding, elicit the patient’s explanatory model(s) of his

or her illness, build partnerships by asking for patient’s opinions and expectations, and

113
negotiate treatment plans (Rivadeneyra, et al. 2000; Roter and Hall 2004). Patient-

centered styles are particularly advocated in situations in which the patient has a

chronic illness and in situations in which ethnocultural beliefs about illness may play an

influential role (Harwood 1981; Kleinman 1988). 19

Generally, family nurse practitioners asked many open ended questions, elicited

patient questions, and provided educational information to patients. They were much

less likely to test for patient understanding (which is especially important when using an

interpreter), elicit explanatory models, discuss cultural differences, and negotiate

treatment plans.20 Many clinicians asked for patient agenda items and began the

encounter with open ended questions such as “How can I help you today?” or “What

brings you here?” Fewer clinicians also elicited agenda items throughout the encounter

although Mr. Mills (FNP) would routinely ask, “Anything else I can get you?” at the end

of the encounter. Moreover, explanatory models were rarely discussed by patients or

clinicians. The patient’s explanatory model was verbalized in four of the thirty recorded

encounters, or in 13% of encounters. Two of these encounters involved differences in

the patient’s and clinician’s health beliefs. In these cases, the clinician’s inability to fully

incorporate the health belief resulted in an encounter in which participants were

unsatisfied and patient agenda items were not met.

19
Some patients in this study did not respond to a patient-centered style of communication and did not
participate in informal conversations and treatment plan negotiations with the clinician (see chapter 5). A
patient-centered approach is arguably rooted in Western notions of patienthood and may not be the
desired style by all patients.
20
Patients at the clinic for a routine medication refill arguably may not need to negotiate their treatment
plan at each visit.

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 The following excerpt with Mr. Mills and a Spanish-speaking female patient

illustrates how patients discussed their agenda items and explanatory models and how

clinicians negotiated a treatment plan. This patient had been to the clinic before

although this was the first time that she and Mr. Mills had met. This medical encounter

was observed but not recorded and the data for this excerpt is from field notes.

M=Mr. Mills, FNP P=patient

M: “How have you been?”

P: I have allergies.
M looks through the chart and then said, “Tell me about, you’re sneezing?”
P: Yes, I have to sleep sitting up my allergies are so bad.
M: “And you have headaches too?”
P: Yes and throat pain. Sometimes I get dizzy because of the headaches.

The patient took an empty bottle of medicine from her purse and told Mr. Mills
that two years ago she got this prescription at the clinic and it really helped. But
she was out and she would like them again. She gave the bottle to Mr. Mills.
They talked more about her symptoms.

M: “It sounds like you have allergies.” This is said in a joking manner because
it is obvious that this was what she had.
P: “Yes, I know.”

Mr. Mills talked about nasal sprays and then asked, “How do you feel about
them?” He used the Nasanox 21 education poster on the wall to tell her about
allergies, the inflammation process, and how the new sprays worked to decrease
the inflammation. Mr. Mills asked, “So would you be interested in trying this?”
The patient said that she used one before and it didn’t work. Mr. Mills asked if
she would like to try another one. Patient said yes, she would try a different
kind, but she also asked if she could have pills too. She then said, “What you just
explained, I feel it” referring to the inflammation of her entire face.

In this encounter, the patient immediately told Mr. Mills her explanatory model,

that she had allergies based on the fact that she had these symptoms before. She

directly asked for a specific allergy medicine and even brought the pill bottle from a

21
Nasonex is a nasal spray for indoor and outdoor allergies.

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previous visit at the clinic. Using these direct statements is a rare strategy for a patient

because it places the diagnosis and prescribing power in the hands of the patient

instead of the medical professional (Ainsworth-Vaughn 1998). Mr. Mills picked up on

this and commented on the strategy by making a joke when he said, “It sounds like you

have allergies” to which the patient replied, “Yes, I know.” Mr. Mills recommended a

nasal spray to decrease inflammation and headache and he negotiated this with the

patient. The patient responded that she did not want a nasal spray but when Mr. Mills

recommended it a second time, her answer was deferent. She answered respectfully

that she would try a nasal spray again but she also asked for the pills as well.

This encounter represented one in which the patient voiced her agenda,

explanatory model, and treatment preferences. The clinician acknowledged these

items, provided educational information about allergies, and negotiated a treatment

plan. In an encounter where clinician and patient verbally shared their explanatory

model and ideas about treatment and agreed upon them, the communication styles

were participatory and tended to include joking or other ways of making the discourse

more relaxed, and participant’s agendas were met. However, when explanatory models

and ideas are verbalized by patient and clinician, but differ, communication may break

down.

Step 3: Engaging Cultural Health Beliefs

I observed that cultural differences were less tangible, or real, for clinicians to

understand and manage than linguistic differences. For example, a few times Mr. Mills

(FNP) asked his patient what he or she thought was wrong in an attempt to elicit

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information from the patient’s point of view. Most of the time the patient would

respond with, “No se” (I don’t know), but on one occasion the patient offered his

explanatory model that included a hot-cold imbalance. Mr. Mills listened attentively,

did not correct the patient, but then reported to me after the visit that he did not know

how to apply the information he had elicited. Other clinicians also reported that they

did not know how to “use” the cultural health information they received from patients.

This is most evident by a patient I observed with Mr. Kendall (FNP):

One of the patient’s reasons for coming to the clinic is his nervios. Mr. Kendall
asked him how he came to have nervios. Sr. Lopez said that on a really hot day
in August he was pushing his ice cream cart down the street (his job). He drank a
cold coke and got the illness. Mr. Kendall prescribed an anti-depressant and told
me after the encounter that nervios was a cultural idiom and probably translated
into anxiety. The student-pharmacist asked what to put on the medication label
in the place indicated for diagnosis; she asked, “Should I put depression?” Mr.
Kendall said, “No, put ansiedad (anxiety). Better yet, don’t put anything.”
[fieldnotes 9-29-06]

In this encounter, Mr. Kendall elicited the patient’s own definition and etiology

of the illness; the patient said he had nervios from drinking a cold coke on a hot August

day. However, as he was constrained to prescribe medication, Mr. Kendall mapped the

patient’s cultural idiom of distress, nervios, onto a Western diagnosis of anxiety.

Mr. Kendall’s beliefs and actions represent a key debate amongst clinicians and

anthropologists, whether illnesses are universal with only the content (symptoms)

affected by culture or whether illnesses are culturally relative. Universalist theories,

especially as espoused in biomedicine, distinguish between the form

(pathogenic/biological processes of cause) and content (pathoplastic/cultural or

personal variation of symptoms) of an illness (e.g., schizophrenia is a universal disease,

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but the content or symptoms are culture specific). However problematic it is to

distinguish form from content in illnesses with no clear biological basis, this dichotomy

continues in medicine, and especially psychiatry (Littlewood and Dein 2000). Thus,

clinicians and researchers assume a priori that illnesses around the world fit into

Western nosologies and diagnoses, in this case, that the patient’s nervios can clearly be

diagnosed and treated as anxiety.

Other occurrences of cultural differences were observed within the 30 recorded

medical encounters. Two encounters contained differences in ethnomedical beliefs

between the clinician and patient and the result of these encounters was unsatisfactory

for all participants according to their comments in the post-encounter interview. Also,

in the post-encounter interview with this researcher, four patients described

explanatory models that contained cultural etiologies of their illness and four patients

described models that contained a mix of cultural and biomedical etiologies. This

information will be discussed in detail in Chapter five.

A recent study illuminates the impact of explanatory models on treatment

decisions in medical encounters. Browner, et al. (2003) determined that the decision by

Mexican women in the U.S. to decline genetic testing during pregnancy often resulted

from a lack of trust between provider and patient. There was a statistically significant

correlation between the decision to decline amniocentesis and the women’s

understanding of what the test meant. Additionally, the clinicians in the study exhibited

a reluctance to directly address “mistaken” cultural beliefs of the patients. While these

clinicians elicited the patient’s views and explanatory models regarding the testing, they

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failed to engage in an information sharing dialogue that may have resulted in both

parties gaining a better understanding of the others’ views.

Explanatory models have also been shown to correlate with patient medication

adherence. In a study about hypertension with African-American female patients from

New Orleans, researchers found that there were two distinct illness models for patients

with hypertension, “high blood” and “high-pertension.” The women with “high blood”

felt their blood was thick due to frequently eating fatty foods; these women took their

medicine regularly. On the other hand, women with “high-pertension” did not believe

their illness was chronic and only took their medicine when they felt a “pertension”

attack caused by sudden emotion such as anger or anxiety (Heurtin-Roberts and Reisin

1990). Though the researchers did not collect data from the medical encounter, and

thus cannot speak to how participants communicated their health beliefs to one

another, we can appreciate how a conversation between these patients and their

clinicians may have enlightened and supported participants’ health care decisions.

At the People’s Clinic, cultural health beliefs also posed difficulties for clinicians

outside the medical encounter. During 2007, two nurse practitioners wrote a type 2

diabetes training manual and intervention program for clinic patients. The manual

contained four stages of information for patients and included a pre- and post-test at

each stage. For example, one lesson was created for patients who had just learned their

diabetes diagnosis; the lesson contained information about the disease and a suggested

diet and exercise program.

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 Several “information sessions” were then held for promotoras and nursing

students as the primary implementers, however the intervention never succeeded. One

of the main reasons for the failure stemmed from a lack of relevant information for this

patient population. When promotoras read the lessons to the patients, I observed a

noticeable lack of interest on the part of patients. The diabetes manual appeared to be

written for health professionals rather than patients and did not include cultural health

information that the patients spoke about during their interview with me, such as the

role of bitter cactus tea or other herbs. Nor did it contain information about what

seemed to concern patients most about having diabetes, a deep concern about death,

hospitalization, diet, and a lack of money to purchase testing materials.

Thus, despite the importance and role of explanatory models, I found that when

clinicians elicited them, they did not know how to use the cultural information they

obtained. They did not know how to move beyond this phase to a meaningful dialogue

and negotiation process. Since there is not a “correct” or one-size-fits-all response in

these encounters that clinician can memorize and utilize, they must be self-reflective

about their own cultural biases and understand that biomedicine is one of many

culturally-constructed ethnomedicines. They should be aware of cultural differences,

non-verbal communication, the role of interpreters, and other factors at the macro-

structural level that may affect health. And lastly, they should understand that some

patient-centered strategies such as negotiating a treatment plan may not be how all

patients see their role in a health care setting.

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III. Macro-level Cultural Competence

While cultural competence models advocate for clinicians to understand cultural

attitudes, beliefs, and practices of their patients, the People’s Clinic focused equally if

not more so on macro-level concerns in their patient’s lives. For example poverty, low

educational levels, low health literacy, lack of understanding the U.S. medical system,

and work related issues were seen as influencing patient health. Cultural factors were

not ignored, but perhaps mirroring the patient’s primary concerns of money and

joblessness as evident from their narratives in the medical encounter, other factors

were believed to be interrelated and as important, if not more important, than culture

to health.

An example of attention to socioeconomic issues transpired when Mr. Kendall,

the medical director and clinical preceptor, taught nursing students about the clinic’s

patient population. Because the typical nursing student did not have similar religious,

economic, or racial backgrounds as the patients, Mr. Kendall consistently tried to orient

them to the lifeworlds of the patient. In doing so, he emphasized poverty and the type

of job one holds as being related to health.

During Mr. Kendall’s debriefing at the end of the day he said how important it is
to teach mothers how to help their child succeed in school. “The fact is that rich
people get sick, but it’s unhealthy to be poor.” He then linked the type of work
the typical patient does with difficulty accessing services. Mr. Kendall told the
group for example that the People’s Clinic is the only clinic in the city open on
Saturdays for immunizations. “Texas has the worst problem with access…if you
have to work every day and will get fired for taking time off, wouldn’t you need
to get your child immunized on the weekend?” [field notes 8-23-06]

The clinic’s pediatric nurse practitioner also advised the nursing students to be

aware of the role of poverty in the lives of patients. One afternoon a nursing student

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came into the pharmacy where other students and I were sitting. She complained about

a frustrating encounter in which the patient did not appear to be taking his medicine.

The pediatric nurse practitioner provided advice to everyone in the room.

“I occasionally know that people don’t adhere to my recommendation or I get

annoyed that they don’t come back for follow up, but I understand from having
worked for so many years with people who are impoverished that their priorities
and mine are very, very different. They aren’t gonna match up no matter what.
I don’t go home to no A/C, or plumbing that may be bad, or inadequate food,
nasty land lords. I don’t go home to that.” [field notes 9-26-07]

Mr. Kendall also explained to the students that many patients had difficulty in

understanding the U.S. health care system. Often, the social worker helped clinic

patients make an appointment for a special test or access a better-equipped clinic. She

did not do this because patients literally could not call themselves, but because the

bureaucracy at many of these clinics made it almost impossible for patients to navigate

their systems. Mr. Kendall said:

“The world is full of people who don’t know how to use their insurance. It’s
tragic that people pay for it but they don’t know how to use it. This insurance
system is all set up by white upper-class people and other people don’t resonate
with it or don’t understand it. We find with our patients, they may have access
to the county hospital, but they can’t call to make an appointment.” [field notes
11-2-06]

Nursing students were challenged to think about the choices that many migrants

face, often leaving loved ones behind to make better lives in the long run for their

families. For example, Mr. Kendall, the preceptor, also stressed good communication to

the students, not by using interpreters or speaking Spanish, but treating people with

respect.

“Interactions are characterized with warmth but also with respect. This is Mrs. X
or Mr. X. This is a 40 year old woman who has made it across the desert walking,

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 not Maria, but Mrs. Garcia…The unpardonable sin here is disrespect for patients.
We see different people with all kinds of strengths and backgrounds. Who was
with me with that woman who left her two-year-old baby in Mexico to come
here and make a better life for them? You have to respect that.” [field notes 8-
23-06]

Thus, while cultural issues were discussed, Mr. Kendall and other clinicians

stressed that other forces, such as poverty, can also be barriers to health care.

Interpreters should be used to facilitate communication, but it is just as important for

students to convey respect for patients through their communication style.

In fact, the understanding of macro-level barriers faced by patients spurred the

family nurse practitioners to volunteer week after week, treating patients and teaching

the next generation of nurses:

“The clinic helps me to live my values in a meaningful way, that’s what motivates
me” said Mr. Mills (FNP). When asked, what values, Mr. Mills said, “I value social
justice, I feel everyone deserves basic rights, like a healthy life, and I can help in
that way….Like for the students, the Mexican immigrants can easily become a
nameless entity you read about but volunteering at the clinic makes it personal.”
He said there was a common theme in vulnerable populations and while he
couldn’t erase the disparity, he wanted to do what he could to give them the
best chance to succeed. “I feel that with immigrant populations, they have so
many barriers: access, taking off work, paying for health care, that I spend
probably more time than I should with them. I want to give as much as I can.”
[interview with Mr. Mills, family nurse practitioner]

A similar sentiment was provided by a second nurse practitioner:

“So I actually, as I came of age and I was in my last year of college and my first
job, I just developed a philosophy of health care as a right and so everyone
deserves it and there should be no strings attached. And so I always had a
problem with the bureaucracies who have these intentions and entanglements
and limited access to care, blocks, obstacles and everything else.”[interview with
female pediatric nurse practitioner]

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Community Participation

In Mr. Kendall’s belief, an extension of being a competent community health

practitioner included participation in the local community and seeing patients in their

home environments. The student clinical activities reflected this belief through

involvement in weekly education classes for new immigrants at two local elementary

schools [photo 1], bi-annual health fairs [photo 2], and home visits to “needy” patients

including visits to Mexican immigrants and recent refugees from Burma and Sudan

[photos 3 and 4].

Photo 1: A promotora and nursing student lead a health class at the local elementary
school

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Photo 2: A health fair booth

Photos 3 and 4: Clinic outreach to refugees

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 Nursing students were significant partners in these community participation

programs. Afternoon debriefing sessions were used as a way to discuss and digest what

they learned from observing and treating people in their own community setting. In

short, community participation was the best method, in the opinion of this researcher,

for training students about the role of cultural differences and macro-structural forces

on health. Students often told me they had learned about these issues in their classes,

but to observe, first-hand, the complex relationships between culture, poverty, poor

working conditions, environmental hazards, institutionalized racism, and migratory and

pre-migratory experiences in an individual or family was a very powerful learning

method for them. In support of my findings, one recent study of 134 clinicians found

that hands-on participation in educational experiences correlated with an increase of

cultural knowledge and awareness (Reinmann, et al. 2004).

Case Study of Community Participation

The following case study is an exceptional example of how the clinic’s outreach

activities provided culturally sensitive health-related assistance to a refugee family. The

data was drawn from observation notes over several months in the summer and fall of

2007, as clinicians, nursing students, and the clinic social worker aided a specific refugee

family from Sudan.

Salma and her brother Ahmed, both refugees from Sudan in their late 20’s, first
came to the clinic in August 2007. They each had a medical problem and heard
from other refugees that the People’s Clinic was a trusted place to get care in the
community. Both spoke English fairly well which was good because the clinic did
not have an Arabic translator. Salma had a swollen arm which was too severe

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 for the clinic to treat and the clinician referred her to the ER for an x-ray; Ahmed
told the social worker that he was having trouble sleeping and that he could not
concentrate well enough to read a page in a book and understand what it said.
He said, “This is America, don’t you have pills to make me smarter?” Ms.
Kendall, the social worker, laughed and said if they did, she’d be taking them. He
said that he was on Seroquel 22 and Ms. Kendall asked who prescribed them. He
said the name and Ms. Kendall recognized the person as a psychiatrist at a local
center for torture survivors. Since none of the family nurse practitioners at the
People’s Clinic felt comfortable prescribing antipsychotic medications, Ms.
Kendall called the center and made him an appointment to see the psychiatrist
who prescribed the medication.

Two weeks later Ahmed came back to the clinic and gave the same symptoms.
He had missed the appointment at the other center and the social worker asked
Ahmed if he felt comfortable with the other psychiatrist or if he wanted to be
seen next week by the People’s Clinic’s psychiatrist. He said he wanted to come
to the People’s Clinic and she made him an appointment.

Mid-morning on November 21, 2007, Ahmed walked to the clinic to talk with Mr.
Kendall (FNP and clinic medical director). He said that his sister was in terrible
pain, that she could not move and he asked if someone could come to their
apartment. Mr. Kendall asked me and two nursing students to go. They lived in
the same apartment complex a few blocks away where a lot of refugees lived. It
was an old complex, the swimming pool was “open” but the water was low and
dirty and there were many large cracks in the concrete around the pool. Their
apartment was on the first floor by the pool; it was small and the only furniture
in the living room and dining room were two old couches. There were no lights
in the room except for a hanging light in the small kitchen area.

Salma was sitting on one of the couches, the nursing students and I sat on the
other couch. Ahmed paced around and eventually stood in the doorway
between the living room and bedroom. Salma looked like she was in a lot of
pain, her body rigid. She explained that she moved a heavy couch at work two
months ago and hurt her back and it had been steadily worse for the last three
weeks. The nursing students gave her the naproxen 23they brought with them
and said to take it with food. Salma said she had not eaten recently because she
had no appetite and she hadn’t slept in two weeks. The nursing students asked
about Salma’s job and she said she worked at the large local research hospital on
the cleaning crew, the very hospital where their School of Nursing was located,

22
Seroquel is a “second generation” antipsychotic medication and treats bipolar disorder and
schizophrenia.
23
Naproxen is an over the counter anti-inflammatory medication.
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but Salma said they did not offer health insurance to their maintenance or
cleaning people.

I asked Salma what she did in Sudan and she said that she had a bachelor’s
degree in medical equipment and technology and had worked at a large clinic.
When I asked why she was working on the cleaning crew she said that was the
only local job she could find. We talked to her about workers compensation and
she said that she was denied workers comp and even got a letter, but then
yesterday someone called and said that she had an appointment next week with
a worker’s compensation doctor. Salma did not know where or what time. She
asked if someone could take her because she physically could not get on the bus.

Eventually the students examined Salma’s back and they found a large knot next
to her spine. It looked extremely painful. We left after about 20 minutes to
consult with Mr. Kendall and Ms. Kendall about what to do. As we left, a man
and woman knocked on the door; they were cousins, also refugees from Sudan,
who lived in Colorado. They were worried and came to help. They said they
wanted to take Salma to the ER and the male cousin and Salma’s brother
followed us to the clinic to speak to Mr. Kendall directly. Mr. Kendall advised
them to go to the hospital where Salma worked and ask for at least an x-ray.

A few days later I got an email from Ms. Kendall, the clinic social worker and
executive director, which said Salma had breast cancer and that the cancer had
metastasized to her back. I went to visit her in the hospital two days later.
Salma was really angry because the oncology doctor told her the diagnosis in
front of her brother. She said her brother was very fragile, had PTSD and
psychosis, and she didn’t want him to know because he would be really upset.
Later that week Ms. Kendall called me and said that the cancer had spread to
Salma’s brain and she only had a short time to live. This was very upsetting news
to me and all the clinicians who knew the brother and sister. Immediately, Ms.
Kendall worked to get her hospital bill waived and to set up hospice care so
Salma could go back to her apartment.

Two nursing students and I visited Salma weekly for the next three months. The
students helped Salma’s brother and female cousin who had temporarily moved
in, and worked with the hospice nurses. Whenever I visited, Salma’s cousin did
not want me to talk about the cancer in front of Salma nor did she want the
hospice nurses to talk to her about what she should expect to happen as she
died (in terms of pain management and expected course of death). In the last
few weeks, members of the local mosque contributed enough money for a plane
ticket and VISA so that Salma’s mother could come from Egypt. A Muslim social
worker from the mosque helped the family with funeral arrangements at a local

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 Muslim cemetery. After Salma died, her mother returned to Egypt and Ahmed
moved to Colorado to live with his cousins.

Salma and Ahmed’s circumstances were incredibly sad and challenging to

absorb. Looking back on my field notes with temporal distance, I can see how the

situation exemplified the caring, respect, and hard work on the part of volunteers at the

People’s Clinic. The nursing students learned firsthand how biology, culture, poverty,

poor working conditions, and experiences being tortured combined to create Salma and

Ahmed’s circumstances. Salma was a relatively skilled refugee with a university degree

whose lot was to work as a cleaning woman at a major research hospital. She did not

receive health insurance from this hospital because she was considered a contract

laborer. She thought her back pain resulted from an injury on the job, so she was never

examined because of a lack of insurance, and died from breast cancer at 28. I do not

suggest that health insurance could have prevented Salma’s death had she been seen

earlier, but she may have been more likely to take advantage of routine preventative

care such as regular breast exams.

Through cases such as this, nursing students and other volunteers learned first-

hand about cancer and hospice treatment, about religion, cultural rules about who has

the right to know health information in the family, and cultural burial preferences.

Students also learned that working at a hospital did not guarantee access to health care.

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IV. Discussion

While cultural competence and the reduction of linguistic and cultural barriers

have their necessary place in research and advocacy, macro-structural factors can

overwhelm these efforts. For example, Chavez and his research team (2003) attempted

to implement an intervention program for breast and cervical cancer awareness for

Latina women based on their findings about cultural health beliefs. In the end, Chavez

expressed doubt about how much his knowledge of cultural differences could really help

the women:

“Although it may have effectively changed beliefs and behaviors of individuals, it

did nothing to alter the structural obstacles encountered by Mexican immigrant
women, and other low-income people, when seeking medical services…we could
do nothing about the cost of medical care, financial screening, lack of medical
insurance, English language skills, and immigration status…we realized, with
frustration, that only fundamental changes in embedded societal inequalities
would have a real and lasting impact on immigrant’s lives and well-being”
(Chavez 2003: 225).

Therefore while most researchers and health advocates tout cultural

competence in medicine as a major step in the right direction for immigrant and

minority health, anthropologists who study this movement believe that cultural

competency discourse can result in blaming “culture” for ill health (Lazarus 1988;

Santiago-Irizarry 2001; Hirsch 2003; Taylor 2003; Hunt 2005; Shaw 2005). Hirsch (2003)

wrote that both our theoretical and applied work has been stymied by an over-

investment of the importance of cultural differences in medical anthropology and she

argued that more attention be paid to the broader structures of knowledge that serves

some and silences others.

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 At the People’s Clinic, practices reflected a certain understanding of linguistic

barriers, cultural differences, and the role of macro-structural barriers. While family

nurse practitioners did not verbalize a specific theoretical model related to cultural

competence, they had a general awareness of the role of culture on health care and

illness. Their views on medicine as a right for all people motivated them to volunteer

week after week and to teach the next generation of nurses. Cultural competency and

attention to the role of macro-structural barriers could therefore be a mechanism to

ensure the observance of patient rights, such as the right to respect and

nondiscrimination. Nursing students, on the other hand, often spoke about how much

they learned from a hands-on application both in the clinic and with community

outreach activities.

Although nurse practitioners understood the role of culture, they were less

proficient at incorporating cultural health beliefs into their practice. Chapter five

provides an in-depth examination of these types of encounters. But first, Chapter four

introduces the dynamics of a cross-linguistic and cross-cultural medical encounter, with

specific attention paid to the way participants provide medical and lifeworld

information.

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 Chapter Four: Case Studies in Cross-Cultural Medical Communication

This chapter is an ethnographic analysis of communication, a detailed look at

how information is shared within the encounter. Chapter five will provide an analysis of

the content and type of information shared across the 30 encounters.

Utilizing two representative case studies from the 30 recorded medical

encounters, this chapter illustrates how participants of these encounters provide

information to one another and how that information is used in subsequent treatment

actions. Because the medical encounter and the wider clinic environment are

negotiated spaces where social, cultural, and structural relations are played out, case

studies provide detailed snapshots of the ways patients, clinicians, and interpreters

fulfill their sociolinguistic roles of securing and providing health care. Specifically, the

case studies indicate the dynamics of a cross-cultural and linguistic clinical encounter,

how treatment decisions are made from the information shared within the encounter,

and the methods used to exercise power and control to either prevent or encourage

information sharing.

An examination of encounters as linguistic case studies articulates how major

communication strategies work simultaneously with one another. Linguistic studies that

only examine the space of the medical encounter and not the clinic environment, or

that only analyze one type of speech activity in order to understand communication

strategies and power, such as questions, interruptions, or topic transitions, are

incomplete because they ignore not only the ethnographic context but how each
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strategy works in tandem with others.

I. Patient-Centered Encounter/Mutual Lifeworld (encounter 30)

The first case study took place between a 65 year old man from Mexico, Señor

Hernandez, and Mr. Mills, an Anglo family nurse practitioner who was 36 years old.

Luisa was the promotora; she was in her early 30’s, was a first generation Mexican-

American, and lived close to the People’s Clinic. Luisa took the patient’s vital signs

before his visit (i.e., took his blood pressure, blood glucose level, weight, and chief

complaint). This was the first time Señor Hernandez and Mr. Mills had met. Señor

Hernandez had type II diabetes, high cholesterol, and high blood pressure and he had

been a patient at the clinic for almost 4 years. This encounter was exemplary of a

cooperative venture with participants working together to have good and clear

communication. Señor Hernandez provided a substantial amount of health and

personal information, Mr. Mills used numerous open-ended questions to encourage

participation, and Luisa worked as a team member with Mr. Mills to ensure accurate

interpretations and further, served as an advocate for Señor Hernandez.

Prior to this visit, I observed Mr. Mills 19 times and Luisa 27 times, and thus was

familiar with their styles, both individually and how they usually worked together. Mr.

Mills was typical of a clinician with a “patient-centered” style of treatment, meaning he

asked many open-ended questions, tended not to interrupt patients, provided verbal

cues to show he is listening (“mhmm” or “yeah”), and invited patients to participate in

their treatment plans through a process of negotiation (Rivadeneyra et al. 2000; Roter

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and Hall 2004). He also spent time providing educational information to patients and

frequently drew diagrams on the exam table paper to show various disease

complications or treatments (e.g., drawing the concept of blocked arteries or showing

how a nasal spray works).

Señor Hernandez was unlike the typical male patient at the clinic as he provided

a great deal of information to Mr. Mills and Luisa about his medical and personal issues.

Several times he demonstrated his knowledge and competence as a patient,

understanding that he had three major chronic diseases. As a patient of the People’s

Clinic for a number of years, he was familiar with the routine of the clinic, including

being familiar with the lack of continuity between clinicians and patients. The fact that

he was a regular patient may have contributed to his active participation in the medical

encounter (Ainsworth-Vaughn 1998). Señor Hernandez’s participation was also unusual

in relation to the literature on minority patients; Roter, Hall, and Katz (1988) show that

minority patients receive less information, ask fewer questions of the clinician, and

receive fewer positive comments than Caucasian patients (see also West 1984).

The ethnographic context of this case study informs the qualitative data that

contextualizes the subsequent discussion of cross-cultural and cross-linguistic

communication. Transcription notation can be found in Appendix II.

Total time: 41:41 med encounter: 30:30 my interview: 11:11

Excerpt 1(beginning of encounter)

M=Mr. Mills, FNP L=Luisa, promotora P=Señor Hernandez, patient

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 M: Señor Hernandez.
P: A-huh.
M: ¿Hablas inglés?
Do you speak English?
P: No.
M: No, no hablo mucho. Un momento. Ay. (….)
No, no I don’t speak much. Wait a second. Ay.
M: Sabes Luisa y Marisa?Okay. Alright.
You know Luisa and Marisa?
¿Cómo está usted?
How are you?
P: Bien.
Good.
M: Ah, so what can I do for you today?
L: ¿Que qué puede hacer por usted ahora?
What is it that he can do for you today?
P: Pues que me de la medicina.
Well he can give me the medicine.
L: Just give him the medicine.
M: Okay. How has everything been?
L: Dice que cómo ha estado todo?
He says how has everything been?
P: Bien.
Good.
L: Well.
M: Any problems with the medicines?
L: ¿Algún problema con la medicina?
Any problem with the medicine?
P: No, no, ninguno.
No, no, none.
[
L: No.

This encounter began with Mr. Mills immediately speaking to Señor Hernandez

in his native language. Mr. Mills used Spanish to find out whether Señor Hernandez

spoke English and to ask for a moment so he could bring in an interpreter. Mr. Mills

then used Spanish to introduce Luisa and me. Even after the interpreter was present,

Mr. Mills used Spanish to ask Señor Hernandez how he was doing (“Como esta usted?”)

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and used the respectful form of the verb (usted), rather than the more familiar, intimate

form of the verb (tú).

As is common in biomedical encounters, the clinician initiated the medical

inquiry (Mishler 1984; Fisher and Groce 1990; Wodak 1997). The initial question by Mr.

Mills is significant because it sets the tone of the encounter. In this case, an open-ended

question, asked in the patient’s native language (“How are you doing?”), indicated a

respectful invitation for the patient to provide information about how he was doing.

When Señor Hernandez gave a one word answer “good,” Mr. Mills asked another open-

ended question, “What can I do for you today?” Señor Hernandez’s answer provided a

very direct reason as to why he was at the clinic, “Well he can give me the medicine.”

None of Señor Hernandez’s answers to Mr. Mills’ questions added valuable information

(okay, good). This lack of information may be the reason Mr. Mills asked four open-

ended questions in a row at the beginning (as noted in bold type). This type of opening,

which includes introductions and four open-ended questions, is different from other

encounters that are less open and participatory.

Patient Competence

Communicative competence, as discussed in Chapter one, is not only the manner

in which individuals show they understand and perform the rules of communication, but

competence is also fundamentally co-constructed in the process of interaction (Hymes

1972). Both patient and clinician occupy specific sociolinguistic roles in the medical

interaction, and each participant’s role contains fairly rigid rules about his or her

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expected behavior. For example, the sociolinguistic role of clinician, as someone with

more knowledge capital, is more powerful than the role of patient. Hence, clinicians

tend to control the subject of conversation and the time in which patients speak. A

patient, however, may control the medical visit, while staying within the “patient role,”

by demonstrating that he or she is a competent participant in his or her health care

(Fisher 1998).

The next excerpt from this encounter demonstrates that Señor Hernandez is

competent as a patient with diabetes, high blood pressure, and high cholesterol.

Excerpt 2 (1:49 minute)

M=Mr. Mills, FNP L=Luisa, promotora P=Señor Hernandez, patient

M: Cause your sugar this morning is still (..) pretty

[
L: Dice que la azúcar todavía
He says your sugar is still
M: It’s still on the high side.
[
L: Está alta.
Is high.
P: Es que casi recién me comí unos panes dulces con un refresco.
It’s that I just ate some sweet bread and a soda.
L: He had some ah, I guess pan dulce, a lemonade which had sugar, a soft
drink.
[
M: Okay, mhmm
Okay, okay so you’re thinkin’ that maybe that that was the reason
L: Usted piensa que esa es la razón por la que.
You think that is the reason why.
M: That sugar was high.
[
P: x [unintelligible]
L: Yes that’s the reason.
P: Porque yo tengo un librito en el que he contado todos los días desde la

137
 mañana a la tarde.
Because I have a notebook in which I have counted every day from the
morning to the afternoon.
L: He has ah a book where he’s point, ah writing down how much is the DFS
and what is he eating.
M: Okay so-
[
P: Y a lo más me ha llegado a 200, no más.
And it hasn’t gone beyond 200, not more.
L: And the highest has been 200.
M: Okay, and you’ve been doing that at home?
L: ¿Y lo está haciendo en la casa?
Are you doing that at home?
P: Sí.
Yes.
L: Yes.
M: Do you have the (..)? Did you bring the?
[
L: ¿Trae el librito con usted?
Did you bring the notebook?
P: No, no lo traje.
No, I did not bring it.

At the beginning of the excerpt, Mr. Mills told Señor Hernandez that his “sugar”

was high this morning and in response, Señor Hernandez offered his explanation, that

he had a sugary drink and pan dulce, or sweet bread, that morning. Mr. Mills rephrased

what he just heard, either to show he was listening or to double check the information:

“So you’re thinkin’ that maybe that that was the reason.” And Luisa translated back to

the patient who confirmed, yes, that was the reason.

Mr. Mills’ rephrasing of this question is significant because it kept the topic

focused on what Señor Hernandez just said. During his “turn” to speak, Mr. Mills did

not change the topic to move on to another medical question. He confirmed what he

heard which allowed Señor Hernandez to have the floor, or control of the topic. Thus,

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Señor Hernandez offered even more information; that he regularly checked his sugar at

home and kept a notebook of the results. The highest blood sugar number he had

recorded was 200. Mr. Mills asked if he brought the notebook to the clinic, and Señor

Hernandez responded that he did not.

Interestingly, Luisa added medical jargon, which the patient had not used, when

she interpreted Señor Hernandez’s statement for Mr. Mills. Her insertion of the medical

term “DFS” (the blood glucose number) and re-phrasing of the statement from “Because

I have a notebook in which I have counted every day from the morning to the

afternoon,” to “He has ah a book where he’s point, ah writing down how much is the

DFS and what is he eating,” changed what Señor Hernandez said and made it more

congruent with “medicalese.”

The information provided by the patient, information that he kept a daily food

journal and tested his blood sugar at home, carried certain implications for future

expectations and treatment based on the amount of cultural capitol Señor Hernandez

demonstrated in his patient role. For example, in a study comparing linguistic

interactions and treatments for cancer in two women’s clinics, Fisher (1998) found

direct correlations between a woman’s competence in her role as a patient and the

physician’s treatment decisions between a hysterectomy and other less invasive

options, such as cryotherapy. Notions of competency in Fisher’s study were often

indexed by patient questions and knowledge about the illness, both of which “…have

the potential to change the direction of the treatment decision” (Fisher 1998: 110).

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 In this case example, the fact that Señor Hernandez provided information

showed more than his patient competence. Because he told Mr. Mills that 200 was the

highest blood sugar count, and that the lowest was 80, Mr. Mills did not increase his

diabetes medicine despite the fact that the blood glucose level was high the day of this

medical encounter. 24

Another outcome that resulted from Señor Hernandez’s ability to demonstrate

high patent competence is that the clinician, Mr. Mills, verbalized his trust in the

patient. This excerpt is from the end of the medical visit.

Excerpt 3 (26:08 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P=Señor Hernandez, patient

M: Anything else I can get for you?

L: ¿Algo más que pueda (.) darle?
Anything else he can (.) give you?
P: Pues con esto estamos.
We’re set with this.
L: Just whatever is there.
M: Okay, alright. Like I said, we’ll go up a little bit on your blood pressure
medicine.
L: Le va subir un poquito la presión, la medicina.
He will increase a little the blood pressure, the medicine.
P: mhmm
L: En lugar de la mitad va a tener una entera.
Instead of having half you’ll take it all.
M: And then I’ll get all the stuff we talked about.
L: Y todo lo demás le van a dar todas las medicinas.
And everything else, they will give you all the medicine.
P: Si, si. Yo lo tomo luego como dice ahí en el frasquito.
Yes, yes. I then take it like it says on the box.
L: Yeah, he takes them just exactly how it says.
M: Absolutely, absolutely and I, I, I can’t, I’m not at your house, I don’t know,

24
The normal reading for a person’s blood glucose level is 80-125.
140
 but I get that feeling from you that you’re at the point.
L: Dice que él no sabe porque estás en tu casa pero el siente que sí te has
tomado la medicina.
He says he doesn’t know because you’re at home, but he feels you have
been taking the medicine.
M: That you’re doing those things to
[
L: Y lo estás haciendo bien
And you’re doing it well
P: Sí entiendo
Yes, I understand
L: Yes he is doing it.
M: I get that feeling from you for sure.

Wrapping up the medical encounter, Mr. Mills asked his usual open-ended

question, “Anything else I can get for you?” and Señor Hernandez said “no.” Mr. Mills

repeated the treatment plan a final time; he reminded Señor Hernandez which medicine

was changing, “We’ll go up a little bit on your blood pressure medicine,” to which Luisa

translated and then added “instead of having half you’ll take it all.” Señor Hernandez

offered that he takes the medicine as directed on the box and Mr. Mills replied that he

knew Señor Hernandez was taking his medication as directed, that he was doing the

right thing.

Providing Information through Narrative

The medical encounter primarily is an opportunity for clinicians and patients to

provide information to one another, sometimes verbally communicated and sometimes

nonverbally communicated though a physical exam or through nonverbal

communication such as gestures, nods, or silence. Most of the literature finds that the

information discussed during the encounter stays in the biomedical realm and that

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participants have difficulty discussing issues in the social, emotional, or personal realm,

also known as the patient’s lifeworld (Mishler 1984; Waitzkin 1991; Barry, et al. 2000;

Barry 2002).

Chapter one discussed the beneficial reasons why clinicians are encouraged to

talk with patients about the way in which their illness affects them in medical,

emotional, and social ways. However, an inherent tension exists between the kind of

information the clinician wants, needs, and tends to elicit. Scholars argue that clinicians

need to hear information about the patient’s lifeworld to arrive at a correct diagnosis

and treatment plan. Encouraging the patient to share this information may also

increase patient trust, satisfaction, and create a sense of compassionate understanding.

Yet the majority of research shows that clinicians utilize communication strategies to

prevent this from happening. Calls for a narrative-based medicine from within the

medical profession further the argument that a scientific-based medicine alone cannot

help patients cope with the meaning of their illness or loss of health (Brody 1987;

Kleinman 1988; Charon 2001). As one physician noted, “if physicians cannot practice

with empathy, reflection, and trustworthiness… the patient might not tell the whole

story, might not ask the most frightening questions, and might not feel heard” (Charon

2001: 1897).

The example below shows communication in a medical visit with three

participants. After briefly talking about diabetes, blood pressure, and cholesterol, Mr.

Mills turned to the new medical complaint presented by Señor Hernandez: his painful

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knee. The following excerpts provide three points of interest: 1) Señor Hernandez

offered many illness stories and personal information, 2) Mr. Mills spent time talking

with Señor Hernandez about arthritis and treatment options, including drawing a

diagram of the problem on the exam table paper, and 3) Luisa provided information to

Mr. Mills, without prompting, in addition to what Señor Hernandez said. These excerpts

represent short stories which can be woven together into a meta-narrative about Señor

Hernandez’s current knee pain and the course of treatment he preferred.

Excerpt 4 (12:04 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P=Señor Hernandez, patient

M: Okay and then you’re having, your knee’s hurting huh?

L: También la rodilla le sigue doliendo ¿verdad?
And your knee’s been hurting, right?
P: Sí:
Yes.
L: Yes.
M: What’s been going on there?
L: Y ahí ¿qué paso? Me dijo que se le hinchaba ¿verdad?
And there, what happened? You told me it swelled up, right?
P: Sí, se hinchó, me quedó como ruma, se hinchó el otro día.
Yes, it got swollen, it was like, this was the other day.
[
L: It got swollen.
In one occasion it got swollen.
M: Okay.
L: And it was just pain there. And it passed to the other and it came back to
this one.
M: Okay.
L: And that’s gone away [the pain in the other knee].
M: So it’s just this knee that’s hurting.
L: Yes.
M: Okay. For how long?
L: ¿Cuánto tiempo tiene con eso?
How long has it been with that?

143
 P: Ya tengo años ya, como unos dos, tres años.
It’s been some years now, like two or three years.
L: Two or three years.

After tackling Señor Hernandez’s chronic diseases (diabetes, hypertension, and

cholesterol), Mr. Mills asked about his knee pain, “Okay and then you’re having, your

knee’s hurting huh?”to which Señor Hernandez responded “Si.” Instead of launching

into a series of closed questions (how long does it hurt, when does it hurt) which

constrains the patient’s response and decontextualizes his experience, Mr. Mills

followed up with an open-ended question, “What’s been going on there?”

Open-ended questions are meant to invite the speaker to give an answer that is

more than a few words. However, Luisa had prior knowledge about the knee, so when

she translated Mr. Mills’ open-ended question, she turned it into a closed question and

prompted the “correct” answer from the patient: “What happened? You told me it

swelled up right?” Señor Hernandez answered, “Yes, it got swollen the other day.” Luisa

interpreted this but also added information for Mr. Mills: “On one occasion it got

swollen…and it was pain here. And it passed to the other and it came back to this

one…and that’s gone away.”

Storytelling is a relational act that involves the audience in the process of

creating meaning (Garro and Mattingly 2000). Señor Hernandez’s symptoms were co-

created by Luisa, showing that illness narratives, as “lived” and unfolding interactions,

cannot be separated from their narrators or the space in which they are told. Luisa’s

involvement could be a form of patient advocacy, helping Señor Hernandez tell the

144
“correct” story to Mr. Mills. Or it could be a way of speaking, providing an illustration of

illness narratives that are created interactionally and contain multiple voices, both

Luisa’s and Señor Hernandez’s.

Luisa’s participation raises important questions about the role of medical

interpreters. What is the role of the interpreter when she knows additional information

about the patient? Why did she tell the clinician, in this case, in a way manner that

made the clinician think she was quoting the patient verbatim, rather than stating, “He

told me earlier that his knee was swollen.”? These issues, and the interpreter-clinician

relationship, will be further discussed in Chapter six.

Once Mr. Mills examined Señor Hernandez’s knee and explained that he was

suffering from arthritis, Mr. Mills began to talk about treatment options. Señor

Hernandez, who had a friend with a knee replacement, interrupted Mr. Mills to tell a

story.

Excerpt 5 (17:47 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P=Señor Hernandez, patient

M: So, so, how do we fix this?

L: ¿Cómo arreglamos eso dice él? ¿verdad?
He says how do we fix this, right?
M: Right, there’s not a great way to fix this? Except,
L: Dice que no hay ningún modo bueno para arreglarlo.
He says there is no good way to fix it.
M: Except surgery and
L: Solamente hay cirugías ¿verdad?
Only surgery, right?
M: Putting in a new
[
P: Sí hay-

145
 There is-
Si hay porque allá en mi rancho se dio un hombre que pronto estaba
chueco de los dos pies.
There is because over there in my town there was a man that all of a
sudden was stiff on both feet.
L: He says there is a cure for that.
P: Y aquí está trabajando ya con fuerza.
And now he is working strong.
[
L: In his town, he had a friend who had kind of the same and
now he, I guess he couldn’t walk over there and now here is he working
now already.
M: A-huh, a-huh and so-
[
P: Está listo y hasta corre.
He’s all set, he even runs.
L: Now that person can run, he doesn’t know what operation it is.
P: Si, si.
M: A-huh, so what they probably did is they probably did a knee
replacement.
L: Lo que pasa es que a lo mejor le hicieron le reemplazaron la rodilla.
May be what happened is that they replaced his knee.
P: Algo hubo pero no supe qué, el ya está listo.
There was something, but I didn’t know, he’s set.
L: He doesn’t know.

Señor Hernandez interrupted Mr. Mills twice in this excerpt (bolded), a very

unusual communication strategy for minority patients to use with a Caucasian clinician

because of the power differentials between patients and clinicians (West 1984). He

interrupted the clinician to tell a story about his friend who had severe knee pain. While

the type of treatment prescribed for his friend is unknown, Señor Hernandez indicated

the knee is now “working strong.” Interestingly, Señor Hernandez described this

friend’s recovery in terms of work. He could have said that his friend was pain free.

Instead he positioned the benefits of the surgery in terms of being able to go back to

146
work. Later Mr. Mills returned to the relationship between the potentially disabling

knee pain and work and talked with Señor Hernandez about his job.

At the end of the excerpt, Mr. Mills moved the story into the medical realm and

explained that the patient’s friend probably had a knee replacement. Mr. Mills talked

about knee replacements and the components of the surgery [omitted from excerpt].

He also said that the typical process is to wait until the pain is extremely intense before

surgery is prescribed. Finally, Mr. Mills described a new anti-inflammatory drug that

Señor Hernandez could try.

In the next excerpt Señor Hernandez again took control of the conversation to

tell two treatment stories. He did not interrupt Mr. Mills, but rather spoke in Mr. Mills’

position, or turn, in the pattern (bolded).

Excerpt 6 (21:51 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P=Señor Hernandez, patient

M: So we’ll see if we can, if the medicine is gonna do the trick.

L: Y a ver si esa medicina le funciona bien.
Let’s see if this medicine works well.
M: And we’ll see over time, over probably-
L: Y en el paso del tiempo-
And with time
M: Probably several years if it starts hurting with that medicine then that’s
when we’ll-
L: A ver que sigue pasando con eso.
We’ll see if it you still have that pain.
M: Do we need you to see a surgeon to get it fixed?
[
L: Si le duele con esa medicina ya tiene que irse a un
cirujano.
If it still hurts with the medicine you will have to go to a
surgeon.

147
P: Tengo un primo mío en México y va y le inyectan este líquido.
I have a cousin in Mexico and he goes and he gets a liquid injected.
L: He had a cousin, in Mexico they inject him (.) with a kind of liquid.
P: Y le ponen líquido y anda un tiempo bien pero se le acaba y otra vez anda
ahí.
And they put liquid and he’s fine for a while but when it’s over he’s again
like.
[
L: So they inject him
M: mhmm
L: And sometimes he’s well with that liquid and then he’s back with pain.
M: We do, that is something that (.) how do I say this. It’s something that is
done here in the US too.
L: Dice que eso también es algo que lo hacen aquí.
He says that they do that here too.

[Mr. Mills describes a Cortisone injection]

P: Sí. Una vez allá en Durango llevé a mi esposa al doctor y mi esposa x-

Yes. Once in Durango I took my wife to the doctor and my wife
[
L: They went one time
into Durango, where he’s from.
P: y le dije de mi no le digas nada te tiene que mejorar a ti y dijo dile a tu
esposo que yo le pongo una inyección y se le va a mejorar el dolor y dije-
And I told her don’t tell him anything about me, he has to cure you, and
he said tell your husband that I will put him an injection and he will feel
better about the pain and I said-
L: The doctor told him he could get an injection into his leg and the pain
would go away.
M: A-huh, a-huh
P: Pero yo le dije que vengo a curarla a ella no yo.
But I told him that I came for her, not me.
L: But he was taking his wife to the doctor
[
P: dijo-
Me dijo no te voy a cobrar por ponertela y no te va a doler, no yo no
quiero que me pongan nada.
I tell you-
He said I won’t charge you for putting it, and I won’t hurt, but I don’t
want anything to be injected.
L: But he didn’t want to because the doctor wasn’t going to charge him to

148
 put the injection in but he didn’t want to, he just stayed with the pain.
M: Gotcha.
P: Dijo y si te sientes bien después vienes y yo te pongo una cada vez que te
duela el pie.
He said and if you feel better later, you come and I will put it in every time
your leg hurts.
L: So that doctor wanted him to try that injection and the next time he
would just come and get it and he would pay for it.
M: Oh gotcha.
L: But he didn’t want to.
M: I understand.
P: Sí, pero mejor me voy a tomar las pastillas que me dieron
Yes, but I better take the pills you gave me.
L: So he’s gonna take the pills.

By offering information through stories and narratives, patients have the

opportunity to share their knowledge and feelings about the illness. However, it is

sometimes difficult for patients to feel comfortable sharing such information, much less

gain control of the conversation long enough to tell a story. Tuckett, et al. (1985) found

that during most observed surgery consultations (n=405) in the UK, doctors made an

effort to state their views on the medical topic and to provide a rationale for them.

However, doctors rarely initiated discussions of the social or psychological implications

of the patient’s condition or asked patient to share their illness stories. When patients

spontaneously volunteered personal information, doctors did not ask the patient to

elaborate and, in fact, they often evaded or inhibited these expressions from the patient

by interrupting and changing the topic.

These last two excerpts of the case study demonstrate that Señor Hernandez

successfully told several illness narratives. Most of the narratives were about treatment

options for his knee pain. In excerpt five, Señor Hernandez gained control of the

149
conversation by interrupting Mr. Mills twice. He told a story about a cousin in Mexico

who had found relief from a liquid injection but the injection was a temporary solution.

Mr. Mills responded to this illness narrative and explained that the injection was most

likely cortisone and then explained how it was used [this part omitted from excerpt]. In

excerpt six, Señor Hernandez responded to Mr. Mills’ explanation by saying, “Yes.” He

then kept control of the conversation to tell another illness narrative, this time one

concerning going to the doctor with his wife.

Señor Hernandez initiated the story by describing himself as self-sacrificing,

despite his pain. At the appointment with his wife, he did not want his wife to tell the

doctor about his knee pain. He explained, “I told her [his wife] don’t tell him anything

about me, he has to cure you.” The doctor offered to inject the knee at no cost but

Señor Hernandez did not want anything injected, regardless of the cost. Mr. Mills did

not attempt to interrupt the story or regain control of the exchange; he provided

several utterances to show he was listening, “a-huh,” “gotcha,” and “I understand.”

Señor Hernandez ended the lifeworld narrative by bringing the topic back to the medical

realm by saying he would take the pills that were given to him for his knee pain.

The subjects of Señor Hernandez’s narratives included his friend, his cousin, his

wife, and his own story. By telling other people’s stories in relation to his own, Señor

Hernandez demonstrated his wide authoritative knowledge about the subject and

positioned himself as a patient who talked to friends and had seen other doctors for his

medical problem. Clearly, Señor Hernandez told narratives about treatments such as

150
Cortisone injections or surgery to indicate that he preferred not to undergo these

treatments at this point because they were too invasive. Stories, because they display

and define the self, are one way that patients can exert power over the medical

encounter (Ainsworth-Vaughn 1998). Thus, stories can be told to persuade the

audience one way or another, even to teach the audience. By telling Mr. Mills stories

about treatment options, Señor Hernandez tried to convey his authoritative knowledge

and treatment preferences in a deferential and respectful way, possibly instead of

engaging in a direct treatment negotiation process.

Cultural Competence

One goal of studying medical communication at this free clinic was to observe

communication strategies of participants in cross-cultural and linguistic encounters. As

mentioned in chapter three, cultural competence models advocate for clinicians to

understand the cultural attitudes, beliefs, and practices of their patients. While

clinicians at the free clinic talked about the importance of cultural differences with one

another and the nursing students, in the medical encounter, when they were one-on-

one with the patients, they more often focused on poverty, low education levels, low

health literacy, and work related issues.

Researchers have found that doctors are reluctant to discuss or even recognize

circumstances in the patient’s lifeworld (Taussig 1980; Mishler 1984; Waitzkin 1991;

Ainsworth-Vaughn 1998). However, when clinicians do converse with their patients

about social problems, they tend to reinforce dominant social ideologies in areas such as

151
work and disability, sexuality and gender roles, the “rights” of healthcare, and other

issues (Waitzkin 1991). Instead of avoiding macro-level issues, many clinicians at the

free clinic talked regularly to patients about their lifeworld including poverty, education,

class, and the U.S. health care system. For example, in this excerpt below, while

discussing Señor Hernandez’s knee pain, Mr. Mills asked what he did for a living.

Excerpt 7 (27:37 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P=Señor Hernandez, patient

M: What do you do for a living?

L: ¿Qué hace para trabajar?
What do you do for work?
P: Yo trabajo en la construcción.
I work in construction.
L: Works construction.
M: Oh okay. So you, what kind of construction?
L: ¿Qué clase de construcción?
What kind of construction?
P: Soy eh, tiro cement.
I’m the, I finish with cement.
L: Finish.
M: Finish cement, yeah. So you’re up and on your feet all the time=
L: Está todo el día parado ¿verdad?
You are on your feet all day, right?
M: =walking, ladders. Uh-huh and working construction,
my father worked construction all his life.
[
L: La construcción es un trabajo pesado, su papá también trabajó en
construcción.
Construction is a tough job, his father also worked in construction.
P: mhmm, mhmm. Oh.
M: So, so I know that it’s hard work and it’s
L: Es algo pesado.
It’s hard work.
M: Lots heavy lifting, moving and
[
L: Mucho levantamiento y todo eso

152
 A lot of lifting and all
P: Sí.
Yes.
M: I know that um, things like that affect what you do and how you make a
living so.
L: Se sabe que cosas así como esas pues afectan las cosas que hace, como el
sobrevivir.
He knows how these things can affect the things you do every day.

Throughout the encounter Mr. Mills did not seek out or begin a discourse about

cultural differences with Señor Hernandez; rather the life circumstances he discussed

were those surrounding the patient’s job. In excerpt five, Señor Hernandez told a story

about his friend in Mexico who had knee pain, underwent a procedure, and then was

“working strong.” This story may indicate that Señor Hernandez worried about his own

knee pain, but a worry that he did not directly want to talk about. The fact that Señor

Hernandez had osteoarthritis, was older than 65, and worked on his feet in a

construction job was significant. Rather than ignore these difficult life circumstances

and what they may have meant in relation to his role supporting his family (Waitzkin

1991), Mr. Mills shared with Señor Hernandez that his father was also a construction

worker. Mr. Mills showed empathy by saying he knew how difficult it was to work a

manual labor job with “lots of heavy lifting, moving…” and that knee pain could affect

how someone makes a living. By these actions, Mr. Mills may have reduced the social

distance between the two, rather than emphasizing their differences.

Obviously, all participants in this encounter, the nurse practitioner, patient, and

promotora, felt comfortable sharing general information, medical information and

lifeworld information. As discussed previously, the literature indicates that patients

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rarely have the opportunity to share personal information with clinicians, given the

power differentials amongst participants and communication strategies that diminish

the patient’s abilities to share stories (Mishler 1984; Ainsworth-Vaughn 1998).

When attending to this patient’s lifeworld, Mr. Mills used different techniques.

First, he used statements and questions to produce structural cohesion. Rather than

using the classic strategy of clinician question - patient response - clinician

acknowledgement and assessment/next question, which often restricts patient

involvement (Mishler 1984), Mr. Mills’ responses often supported Señor Hernandez’s

statements and kept the topic of conversation open until they were both ready to move

on. In this manner, Mr. Mills clearly demonstrated that he heard and understood what

was said and further, that Señor Hernandez should continue talking. For example, in

excerpt six, Señor Hernandez held the floor to tell his story while Mr. Mills’ statements

worked to support the story until it came to a conclusion.

P: Dijo y si te sientes bien después vienes y yo te pongo una cada vez que te
duela el pie.
He said and if you feel better later, you come and I will put it in every time
your leg hurts.
L: So that doctor wanted him to try that injection and the next time he
would just come and get it and he would pay for it.
M: Oh gotcha
L: But he didn’t want to.
M: I understand.
P: Sí, pero mejor me voy a tomar las pastillas que me dieron
Yes, but I better take the pills you gave me.
L: So he’s gonna take the pills.

In the post-encounter interview, Señor Hernandez said that at other clinics it was

difficult to communicate because they lack trained interpreters. He specifically

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mentioned that he liked coming to the People’s Clinic because the clinicians explained

things in a way that he could understand. The next section proceeds to the second case

study, a different kind of medical visit in which the patient’s lifeworld issues were not

attend to.

II. Patient-Centered Encounter/Lifeworld Ignored (encounter 4)

The second case study describes an encounter with a 36 year old woman, Señora

Lopez, born in a rural part of Mexico. As I entered the exam room with an interpreter

before the encounter to ask consent to observe the medical encounter, I noted that she

had a worn and tattered-looking spiral notebook on her lap. I asked Señora Lopez if she

was writing down medical information and she said she was writing a letter to her

husband who was in jail. Talking about her family, Señora Lopez told me her husband

was caught a few months ago while crossing the border near Laredo, from Mexico into

Texas. She had seven children, three of whom were small. She started crying as she told

me about her children, saying that her blood sugar that morning tested over 500 and

that she was afraid of dying. 25 She knew friends and family who died from diabetes.

She also said someone broke into her apartment three months ago, which added to her

worry. It was evident that Señora Lopez felt unsafe at home, was very worried about

her husband in jail, which increased her strain as a single parent, and her uncontrolled

diabetes exacerbated her already stressful situation.

25
Fasting (not eating in last 8 hours) normal blood glucose levels are between 80-125; over 500 is
considered an emergency and many people are hospitalized when their sugar level gets this high. National
Diabetes Information Clearinghouse, www.niddk.nih.gov
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 After Señora Lopez and I talked about the research project, Mr. Mills, the family

nurse practitioner from the first case study entered the room with Luisa, the same

promotora and interpreter. This was the first time Señora Lopez and Mr. Mills had met.

Total time: 49:37 med encounter: 29:21 my interview: 20:16

Excerpt 1(beginning of encounter)

M=Mr. Mills, FNP L=Luisa, promotora P= Señora Lopez, patient

M: Me llamo Mr. Mills. So how are you doing today?

My name is Mr. Mills.
L: ¿Cómo esta oraste?
How are you today?
P: Me siento mal [short laugh]=
I feel bad
[=
L: She’s feels bad
P: =me duele mucho [unintelligible].
[unintelligible] hurts a lot.
L: She has pain in her back and her head.
M: Okay.
[7 sec]
Alright, so let’s see. The last time you came in
L: La última vez que vino aquí
The last time you came
P: mhm
M: WM:s a week ago
L: Hace una semana
A week ago
P: [soft] una semana
One week
M: How have things been going since then?
L: Que de una semana para acá cómo ha estado todo.
That how has it been from a week until now.
P: Me, me siento, hay días que me siento bien, hay días que me siento mal.
I, I feel, there are days in which I feel fine, others I feel bad.
[=
L: Sometimes she feels good, sometimes
she feels bad.

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 M: Okay, alright. Have you, how have you been feeling with the medicine?
L: ¿Y cómo se estado sintiendo con la medicina?
And how have you been feeling with the medicine?
P: Con es, es como te digo hay días que me siento bien y hay días que me
siento mal.
It’s, like I tell you, some days I feel fine, others I feel bad.
L: Sometimes well, sometimes bad.

As with the first case study, this one also began with an introduction by Mr. Mills

in Spanish followed by an open-ended question, “So how are you doing today?” Señora

Lopez answered with a feeling, “Me siento mal” (I feel bad) and then redirected this

feeling to physical symptoms, that she had pain in her back and head. Mr. Mills

responded, “Okay,” and then paused for 7 seconds, possibly encouraging the patient to

continue to talk about her pain. When she did not, Mr. Mills spoke again and said the

last time she was in the clinic was a week ago. He then asked another open-ended

question, “So how have things been going since then?” Señora Lopez again said some

days she feels good, some bad.

Mr. Mills briefly mentioned her medicine and then asked the third open-ended

question, “How have you been feeling with the medicine?” Señora Lopez again simply

repeated that some days are good and some bad. Possibly trying to understand more

specific feelings and symptoms from the patient, Mr. Mills next explained how people

feel when their blood sugar is low. This prompted Señora Lopez to say that she had

been feeling that her sugar level was high, that she eats and eats and is always hungry

with a pain in her stomach.

In the next few minutes Mr. Mills asked about her diabetes symptoms and

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discussed the lab results from the last visit. In addition to her blood sugar levels being

dangerously high, Señora Lopez had high cholesterol levels. Because of these two

issues, Mr. Mills recommended that Señora Lopez make an appointment with the out

patient clinic of the county hospital, which had a greater ability than the People’s Clinic

to help her with lab testing and insulin, if needed. Señora Lopez explained that she did

not know how to access the hospital and Luisa asked her several questions to see if she

qualified for the hospital “insurance” card for indigent people. If so, Señora Lopez could

access services on a sliding scale fee. After determining that she did qualify because she

lived within the city limits, it came to light that the patient was not working and was not

in the country legally. Señora Lopez quickly changed topics to one of her concerns

about going to the hospital.

Excerpt 2 (14:38 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P= Señora Lopez, patient

L: Yeah. So este lo que puede hacer es ir a la clínica de [name]. ¿Conoce esa

clínica de [hospital]?Es lo mismo.
So what you can do is go to the [hospital] clinic. Do you know that
[hospital] clinic? It’s the same.
P: ¿La [clinica]? No la he mirado…¿será que está por el lado de H[street]?
The [clinic]? I haven’t seen it… is it the one that is by H[street]?
L: Sí, por la H[street].
Yes, by H[street].
Usually we just refer them to the [clinic] and from there they get their
papers transferred to any other clinic.
M: Oh, okay, gothcha. Um,
P: ¿Pero esto es de que no me van a dejar internada verdad?
But this doesn’t mean that I will have to spend the night right?
L: No.
No.
P: No.

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 No.
L: No. She’s not going to be staying there over night.
M: No, no, no.
P: ¿No?
L: They
P: Me tengo…mi chamaca le da miedo quedarse con [unintelligible].
I have… mi little girl is afraid to stay with [unintelligible].
L: No, cierran a las seis esa clínica.
No, they close that clinic at six.
P: ¿Oh sí? Y tengo dos chiquillos.
Really? And I have two small boys.
L: Because she has small babies.
M: No, I-I, you, with your sugar at 500,
L: Con la azúcar a quinientos,
With your sugar at five hundred,
M: we get concerned,
L: Lo que es preocupa
What worries him
M: but there’s not, (..) it can get so high that you would have to spend the
night.
[
L: Puede llegar más alto a modo que tiene que quedarse allí.
It can go higher and then you might have to stay there.
M: But where we are right now, it, it wouldn’t be a time to spend the night.
[
L: Pero orita, esta en un nivel donde puede llegar a
controlar.
But now, they are at a level where you can control.
P: Sí, mhm.
Yes, mhm.
M: What are we going to do in the meantime?

Señora Lopez interrupted Mr. Mills to voice concerns from the space of her

everyday life (bolded); she asked if she would have to spend the night at the hospital.

She went on to say that she had small children and they did not like staying there alone.

Mr. Mills reassured her that she would not need to stay the night this time, although her

sugar levels were extremely high. Mr. Mills did not take up discourse around Señora

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Lopez’s contextual fears about her diabetes, that very high sugar levels could

necessitate an overnight stay at the hospital. She also did not have the opportunity to

clearly explain that she had no childcare assistance, that her husband had been in jail for

some time, and that she felt the neighborhood was unsafe. Mr. Mills did not recognize

her lifeworld and thus did not ask Señora Lopez if she had a husband, partner, or any

other social support. His discourse with the patient stayed strictly within the medical

format. After he reassured Señora Lopez that she would not have to spend the night he

changed the topic and asked, “What are we going to do in the meantime?”

The consultation continued in the voice of medicine as Mr. Mills explained the

treatment plan to Señora Lopez: that he would increase her diabetes medicine and add

a medication for cholesterol. Almost 19 minutes into the encounter, he asked Señora

Lopez if she had any questions.

Excerpt 3 (18:48 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P= Señora Lopez, patient

M: I think that’s kind of where we’re going to be for now.

L: Dice que eso es donde van a llegar ahorita.
He says that’s where you will be going for now.
M: And then, calling, um we’re gonna get you on the phone
to call over to [hospital], to-
[=
L: Y este también van a hablar con [hospital].
And um they will also talk to [hospital].
M: to see what, when they can see you, to make sure you qualify and
everything.
[
L: para ver cómo y ver si califica y
todo.

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 to see how and if you qualify and
everything.
P: Okay.
M: Alright. [said in a concerned /caring tone:] Do you have any questions or
anything?
L: ¿Una pregunta?
A question?
P: Eh, no.
Eh, no.
L: She said no.
M: I know it’s kind of scary too.
L: Dice que sabe que está un poco, le puede dar miedo.
He says he knows you are a bit, that it can be scary.
M: But-
[=
P: Porque tengo, no le digo que dos chiquitas [short laugh]
Because I have, I’ve told you I have two girls
[
L: She has small kids, children
P: y que no me quiero morir todavía.
and I don’t want to die yet.
L: and she doesn’t want to die yet.
M: No, understand, understand. And you’re. We’re the same age so I
understand, I understand. We’re close to the same age.
L: Dice que…si entiende.
He says that... he understands.
M: The good news is that you’re here, you’re-
[
L: La buena noticia es que está aquí
usted.
The good news is that you are here.
M: You’re working hard, you know you’ve been
[
L: Está trabajando duro
You are working hard
M: coming the last you know, you came in June, a week ago=
[
L: Vino en junio, vino hace una
semana
You came in June, you came
a week ago
M: =You’re right back here again, you’re taking your medications.

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 [=
L: Ya está aquí usted, se está tomando la
medicina.
You are here now, you are taking your
medicine.

Mr. Mills now seemed to open the floor for an emotional discussion about

Señora Lopez’s illnesses asked how Señora Lopez felt about her diabetes; he related that

it was scary. For the second time, Señora Lopez voiced concern about her high blood

glucose levels from her diabetes, the fact that she had small children, and that she was

afraid of dying. However, Mr. Mills did not talk with Señora Lopez about these issues, or

probe into the fears of her illness and what it meant in her life. Rather, he tried to make

her feel better by talking about what she was doing medically right: coming to the clinic,

keeping appointments, and taking medicine. His response, meant to be empathetic,

seems disjointed in relation to the patient’s repeated voicing of lifeworld concerns.

Twenty minutes into the encounter Señora Lopez brought the conversation back to her

lifeworld.

Excerpt 4 (20:18 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P= Señora Lopez, patient

P: Iba a entrar a trabajar en la lavandería donde yo trabajaba antes pero no

fui porque como
I was going to start working at a laundry where I used to work, but I
didn’t go because since
L: She says that she stopped working at a laundry where she used to work
before.
P: Está bien caliente, caliente este xx por esta on la G[street]
It’s really hot, hot um xx around G[street]
L: It was too hot for her…..it’s on G[street]
M: Mhmm, mhmm.

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 P: Y no fue.
And I didn’t go.
L: And she can’t…ahora fue?
You now went?
P: No, está bien caliente.
No, it’s too hot
[
L: It’s too hot for her to work.
M: mhmm-mhmm
[
P: Y cual tengo azucar alta no puedo
And since my sugar is high I can’t
[=
L: When her sugar is really high and she feels she can’t-
M: Mhmm-mhmm
P: Tengo, vivo en apartamento que tiene aire acondicionado pero
[unintelligible]
I have, I live in an apartment that has A/C, but [unintelligible]
L: She says that she lives in apartments and there’s central AC but she still
needs to have another fan.
M: Mhmm-mhmm, absolutely.
[to himself:] Where was I going with that. And then the other thing is,
you know, what we’re going to be worried about is:

In the middle of Mr. Mills’ discussion of diabetes medication, Señora Lopez

interjected and said that she previously had a job at a laundry mat but had to quit

because it was too hot. She went on to say that when her sugar was high, she felt too

hot to work. She may have wanted Mr. Mills to legitimate this claim that her diabetes

made her unable to work. But by not commenting or engaging in this topic, Mr. Mills

subtly reinforced the idea that Señora Lopez’s diabetes should not be a medical excuse

to quit work (Waitzkin 1991).

As excerpt four illustrates, patients present a variety of social and personal

troubles in tandem with their medical discourse, many of which have roots in socio-

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political issues beyond the individual level. When such personal, economic, and social

concerns arise in the medical encounter, the language of medicine leaves few options

for action. Generally, clinicians respond with technical solutions and counsel patients

toward dominant status-quo behaviors; i.e., that healthy people work. “The language of

medical science can convey ideologic content, especially when it converts social

problems into technical ones…that is, by a lack of criticism directed against sources of

distress in the social context, medical discourse ideologically reinforces the status quo”

(Waitzkin 1991: 47). Many times, clinicians are not prepared to discuss basic social

change as a meaningful alternative.

Not only did Mr. Mills remain silent when his patient stated that she could not

work because of her high sugar level, he changed the topic and brought the discourse

back to the medical realm by saying that with the increase in diabetes medicine she

needed to be aware that her sugar level could get too low. He explained that one of the

symptoms of hypoglycemia, or low blood sugar, is tiredness. This prompted Señora

Lopez to interject that she was so tired on some days that she did not want to get out of

bed to feed her children.

Excerpt 5 (21:41 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P= Señora Lopez, patient

M: Um, always (.) know that if you

L: Dice que todo el tiempo sepa que
He says that you should always know that
M: Feel really, really tired
[

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L: Si se siente muy cansada
If you feel really tired
M: You feel like you can’t even hardly get out of bed
L: Y que no se pueda parar de la cama
And you can’t get out of bed
M: Um-
[
P: Hay días que me pasa eso
There are days I feel that
[
L: There are some days like that
M: mhmm, but-
[
P: Hay dias que me pasa eso que no me dan ganas ni de salir de la cama a
darle de comer[unintelligible].
There are days I feel like I don’t want to even get out of bed and feed the
[unintelligible].
L: She, she feels that sometimes like that, that she doesn’t even want to
feel like feeding her children.
M: Mhmm-mhmm
P: Y no me quiero parar de la cama porque me siento cansada
And I don’t want to get out of bed because I feel tired
[
L: She doesn’t want to get out of bed, she’s
tired.
M: Mhmm, the um, sometimes what that is is-
[
L: Dice que lo que pasa a veces lo
que es
He says what’s happening is
M: When your sugar is high
[
L: Cuando tiene la azucar muy alta
When your blood sugar is too high
P: mhmm
M: Your body
[
L: Su cuerpo
Your body
M: is trying to adjust and so,
[

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 L: esta ajustantdo, verdad.
is adjusting, right.
M: That’s why you’re hungry all the time.
[=
L: Y por eso tiene usted mucha hambre todo
el tiempo.
And that’s why you are very hungry all the time.

Señora Lopez interrupted Mr. Mills two times and told him how terribly tired she

felt (bolded). Mr. Mills again did not respond to Señora Lopez’s concerns that there

were days she could not even get out of bed to feed her children. He returned to a

medical explanation. Instead of probing for other possible signs of depression, or asking

about her feelings and support systems that she might access, Mr. Mills switched the

topic to the voice of medicine and explained that the reason she was tired was because

her sugar levels were so high and that the sugar was not getting into the muscles where

it needed to be. He unilaterally shut down the topic of her tiredness by saying that they

would continue to work together at the clinic in the future, although the hospital was

the best place for her to receive treatment currently. Mr. Mills asked Señora Lopez to

return next week, and then asked if there was anything else he could get her. She

responded, “no.”

Excerpt 6 (24:13 minutes)

M=Mr. Mills, FNP L=Luisa, promotora P= Señora Lopez, patient

M: Alright, can I get anything else for you?

L: ¿Algo más para usted?
Anything else for you?
P: No.
L: She says no.

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 M: Alright. Hang in there, everything’s going to be good. I promise.
L: Dice que aguante y que todo va a estar bien.
He says hang in there and that everything will be fine.
P: [short laugh] Okay.
M: I can tell she’s (..) scared.
L: Que sabe que tiene miedo.
He knows you are scared.
P: [short laugh]
[22 sec while A listens to heart and lungs]
M: Good, let me check. [8 sec]
Alright, alright let me go and get some medicine and I’ll be right back.
L: Va por la medicina y ya viene para acá.
He will go for the medicine and he’ll come back.
P: Okay.

At the very end, in this last excerpt, Mr. Mills actively brought up Señora Lopez’s

feelings. After asking a highly open-ended question (“Can I get anything else for you?”),

he said, “Hang in there, everything’s going to be good. I promise.” After Señora Lopez

laughed nervously, Mr. Mills again tried to connect with his patient’s feelings by saying,

“I can tell she’s scared.” And again Señora Lopez laughed. It could be that at this point,

Señora Lopez had given up on discussing her worries and concerns with Mr. Mills and

simply retreated into the voice of medicine.

In summary, excerpts from this case study show instances in which the clinician

spoke in the voice of medicine against the patient’s lifeworld concerns. Mr. Mills’

strategies produced a scattered affect from the point of view of the patient’s lifeworld.

Many times his statements or questions lacked cohesiveness and did not refer back to

Señora Lopez’s prior response. Instead, he introduced medical information into the

conversation to which the patient was expected to reply (Mishler 1984). This pattern

167
occurred five times throughout the entirety of the encounter. The patient’s story, told

in fragmented pieces throughout the encounter, can be summarized as follows:

My sugar level is very high, in fact so high that I am afraid of dying and leaving
my small children alone. I am also the sole family caretaker and am afraid of
seeking additional treatment for my diabetes at the county hospital because I
don’t want to be admitted overnight. If I stay overnight, there will be no one to
look after my children. While I am the sole caretaker, I can’t keep the job I had
because my sugar level is so high that it makes me very hot and the job at the
laundry was so hot it was unbearable. All of this leaves me very tired, so tired
that sometimes I do not want to get out of bed, even to feed my children.

Barry, et al. (2001) described patients such as Señora Lopez as notable in their

repetition of their lifeworld in the face of the structure of the medical encounter. Most

patients who repeatedly brought up personal situations did so because they had strong

feelings about their situations, often situations that included chronic diseases like

diabetes. In their study, Barry, et al. (2001) described this kind of encounter as

“lifeworld ignored.” As patients spoke in the voice of their lifeworld, clinicians ignored

their comments and communicated in the voice of medicine. Patients in this category

often left the office visit feeling unheard; patients in this category also had the poorest

medical outcomes of any group in their study.

IV. Discussion

Patient-Centered Style

Overall, Mr. Mills’ style of treating patients fell squarely within a “patient-

centered” style rather than a “disease-centered” one. Patient-centered care

incorporates a bio-psycho-social perspective of illness and recognizes the “patient-as-

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person.”Clinicians with this style believe that “knowing what kind of person has a

disease is as essential as knowing what kind of a disease a person has” (Platt, et al.

2001). These clinicians are more likely to use language as a diagnostic tool in

conjunction with physical exams and tests. Additionally this style focuses on creating a

partnership between the clinician and patient both by considering the patient’s point of

view and negotiating aspects of the treatment. Unfortunately, while medical students

as well as seasoned clinicians want to focus on the patient, studies by Platt, et al.(2001)

indicate they often lack the tools to do so.

Patient-centered care is often operationalized in the literature as the degree to

which clinicians ask detailed and open-ended questions, elicit patient questions,

educate patients, test for patient understanding, elicit the patient’s explanatory

model(s) of his or her illness, build partnerships by asking for patient’s opinions and

expectations, and negotiate treatment plans (Rivadeneyra, et al. 2000; Roter and Hall

2004). Patient-centered styles are particularly advocated in situations in which the

patient has a chronic illness and in situations in which ethnocultural beliefs about illness

may play an influential role (Harwood 1981; Kleinman 1988).

Over-laying these patient-centered strategies with the 19 encounters I observed

between Mr. Mills, his patients, and the interpreters resulted in the following

observations: Mr. Mills was mindful of the positioning of his body as he tried to sit at

eye level or below the patient; he maintained very good eye contact with patients and

did not always focus on the interpreter; he provided backchannel cues of listening (e.g.,

169
“mhmm” or “yeah”) and nodded his head; he introduced himself to the patient at the

beginning of the encounter and sometimes introduced the interpreter; he asked open-

ended questions about the illness and the patient; he sometimes talked about his

personal life to make connections with the patient; he used humor; he did not use a

large amount of jargon when discussing complicated medical terms such as the analysis

of a blood test; and he frequently drew diagrams to educate patients. During my

interview with Mr. Mills he explained his communication strategies:

“I try to make a personal connection because I feel, to establish a

partnership that I’m not the expert. We’re in this together. I try to make
it informal. I try to jot something fun or what they are into down into the
chart so that next time I will hopefully find it and read it and remember
that connection, that person. I purposely try to limit them getting up on
the exam table or me being above them looming over. I want to keep an
even eye level, keep them comfortable.”

Unfolding the Lifeworld

Because the first case study was in essence a first-encounter visit between Señor

Hernandez and Mr. Mills, the encounter included many of the history-taking questions

in which the patient’s participation was limited. Nevertheless, Mr. Mills’ repeated

invitations for the patient to be an active participant allowed Señor Hernandez to

discuss his lifeworld and opinions about treatment. In fact, Mr. Mills asked 13 open-

ended questions and Señor Hernandez volunteered personal information eight separate

times. Mr. Mills did not interrupt Señor Hernandez during the encounter; however,

Señor Hernandez interrupted Mr. Mills twice (excerpt 5) to tell his treatment narratives.

This is a very unusual pattern for patients to use as clinicians are consistently found to

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interrupt patients at a rate of four-to-one (West 1984).

In the second encounter, Mr. Mills asked a total of six open-ended questions,

about half the number as in the first case example. Interestingly, Señora Lopez

volunteered information about her lifeworld several times, but she did not do so in

response to one of Mr. Mills’ open-ended questions. She interjected lifeworld

information during a different topic of conversation or at the end of a topic. As with the

first encounter, Mr. Mills did not interrupt Señora Lopez during the encounter but he

used two distinct patterns to diminish her lifeworld comments: 1) he engaged with the

patient’s topic but changed the topic out of the lifeworld into the medical realm, or 2)

he took control of the floor and abruptly changed the topic. For example, in excerpt four

when Señora Lopez spoke about not having a job because of her diabetes symptoms,

Mr. Mills’ next utterance was not a comment about joblessness. Instead, he provided

listening cues (mhmm, absolutely) and then changed the topic of conversation.

M: Mhmm-mhmm, absolutely. [to himself:] Where was I going with that.

And then the other thing is, you know, what we’re going to be worried
about is:

When the patient’s lifeworld is repeatedly blocked by clinicians, the patient can

be de-contextualized from his or her illness. However, Señora Lopez’s dangerously high

diabetes levels, over 500, may have been such a concern to Mr. Mills that he was not

focused on her personal and emotional narratives. The American Diabetes Association

identifies hypoglycemia as a prolonged glucose level greater than 130 (fasting) or 180

(non-fasting). Chronic hyperglycemia at levels more than slightly above normal can

171
produce a very wide variety of serious complications over a period of years, including

kidney damage, neurological damage, cardiovascular damage, damage to the retina, and

so forth. Glucose levels as high as 600 may trigger a diabetic coma.26 It is possible,

then, that Mr. Mills unconsciously focused on this high risk danger as the more pressing

and immediate problem in the patient’s case.

As a clinician who frequently verbalized his intense feelings about social justice

and “health care for all,” Mr. Mills knew that the People’s Clinic was the only medical

organization that could provide healthcare to this population. He also understood that

most patients who were referred to the county hospital (observed during my research),

such as Señora Lopez, did not follow up and make appointments. The financial cost of

receiving treatment and numerous bureaucratic barriers at the hospital were too

difficult for most immigrants to manage. Mr. Mills, perhaps, wanted to focus on Señora

Lopez’s critical medical concerns to emphasize that she really must get help outside the

free clinic. Seen in this way, Mr. Mills’ typical meaning-centered role diminished as he

adhered to biomedical authoritative knowledge about the risks of diabetes.

These two case studies, focusing on Señor Hernandez and Señora Lopez,

illustrate that having a patient-centered clinical communication style does not

necessarily mean that clinicians are always open and responsive to the patient’s

personal and emotional issues. Rather, clinicians are challenged to make a concerted

effort to notice and be attentive when the patient overcomes discourse obstacles and

26
WebMDhttp://diabetes.webmd.com/hyperglycemic-hyperosmolar-nonketonic-syndrome accessed
3/10
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presents information from their lifeworld. Obstacles which make it difficult for patients

to bring up personal and emotional information include the normative format of the

medical encounter which gives clinicians more power over discourse, sociolinguistic

roles such as the authoritative role of clinicians in comparison to patients, and clinician

strategies: to speak and remain in the voice of medicine, such as interruptions,

controlling the topic of discourse, and asking closed questions (those that elicit a yes or

no response).

While individual communication styles were very different in these two cases,

each case example was comprised of the same clinician and interpreter. Both case

studies were representative of encounters in the “mutual lifeworld” and “lifeworld

ignored” categories. Deeper analysis of each encounter, however, illustrates that

communication behaviors are situation specific and constructed in the interaction rather

than a fixed quality by each individual. Medical communication studies emphasize that

patients and clinicians are not all alike. Each brings different expectations and desires to

the medical visit, including how they communicate their expectations and desires. Thus,

all patients do not want to talk with their clinician about how their illness influences

their personal lives; nor do clinicians, even those who purport patient-centeredness,

what to hear and respond to lifeworld experiences.

Suggestions for Incorporating the Lifeworld

Taking a broader look, numerous clinical studies show that medical outcomes

are improved when patients are treated as interactive partners during medical

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encounters (Roter and Hall 1992; Koehn 2004). However, while medical anthropologists

and other social scientists have emphasized the importance of the patient’s lifeworld in

medical encounters, few studies have assessed specifically the benefits of

acknowledging lifeworld experiences or the consequences of ignoring them. Barry, et

al. (2001) stands out as the experts in this minority group. She and other authors asked

“whether ignoring the lifeworld leads to medicine which is less effective and which fails

to be attentive and responsive to the patient’s needs as a unique human being” (491).

Their study found that patients who attempted to discuss their lifeworlds, but had

clinicians block or ignore these attempts, had the worst medical outcomes of any group.

The challenge faced by clinicians and patients alike is that they must establish a

space of shared meanings, to the patient and clinician, in order to communicate and

understand one another. At the People’s Clinic, clinicians faced a double burden; not

only did words need to be translated into Spanish or English, but languages and beliefs

from patients’ lifeworlds had to be analyzed in relation to biomedical understanding and

treatment. As Mishler, author of the seminal work on lifeworld narratives, noted, “The

special asymmetry of the medical interview is that the physicians are communicatively

competent in both codes. They can speak in either the voice of the lifeworld or of

medicine, but patients are competent in only one” (1984: 172). Thus, the burden falls

on the clinician to translate the patient’s experiential statements into medicine and

medicine into lifeworld experiences.

Recognizing and engaging the patients’ lifeworld, perhaps by conducting a “mini-

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ethnography,” has the possibility to greatly reduce mistakes due to misunderstanding

and misinformation. It can reveal unmet patient needs and minimize unrealistic

expectations, and it can provide a vehicle for the patient’s voice to be heard (Roter and

Hall 1992; AMA 1999; Barry, et al. 2001; Koehn 2004; Kleinman and Benson 2006).

Kleinman provides a clear methodology for this in his writings on the explanatory model.

In reality, at a free clinic such as the one studied, conducting a mini-ethnography may be

highly challenging. In most cases, the clinician is forced to make rapid assessments

about the patient’s lifeworld while simultaneously treating the physical or medical

condition. Developing an understanding of one another’s expectations of the medical

process and life-shaping experiences can be time-consuming; however, this information

can be gathered over the course of several medical encounters, thus enhancing the final

outcome of the medical problem.

This chapter presented ethnographic case study data about how medical and

personal information is shared within a cross-cultural and linguistic medical encounter.

A careful analysis of communication strategies showed that patients and clinicians can

create a space for patient’s authoritative knowledge and lifeworld information, which

can be incorporated into the medical treatment. On the other hand, lifeworld

information can be blocked by clinicians, which may lead to the patient feeling unheard

and dissatisfied.

Chapter five discusses the content of lifeworld narratives across the 30 medical

encounters at the People’s Clinic. In these encounters, primarily with Mexican

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immigrants, the analysis shows that differences in cultural health beliefs were not found

to be included in patient’s primary lifeworld narratives as frequently as conversations

about poverty and joblessness.

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 Chapter Five: The Lifeworld and Explanatory Models

The case studies from the previous chapter provided a detailed view of

communication strategies and the ways information is invited and passed from one

participant to another. This chapter shifts emphasis to examine the content of patient

information across 30 medical encounters. When patients discuss their lifeworld, what

do their narratives contain? What is the clinician response? Because of the explicit

research focus on cross-cultural and linguistic medical encounters, it is fruitful to

examine the kinds of messages and information that are discussed by the participants,

whether cultural differences may affect health care decision making and treatment, and

how participants make sense of issues that are communicated during the encounter.

A common theme expressed throughout the medical anthropology literature is

the notion that patients and clinicians have different perspectives about diseases,

illnesses, and the illness experience (Kleinman 1980). A medical encounter often

represents a plurality of voices and systems of knowledge; the “voice of biomedicine,”

the “voice of the lifeworld,” and voices from other ethnomedical systems (Mishler 1984,

Gaines 1992a; Kingfisher and Millard 1998). In this chapter, the fluidity of these voices,

as dynamic conceptual systems, are present in the way participants communicate and

act during the medical encounters.

Unfortunately though the concepts are well articulated, relatively little linguistic

data exists from cross-cultural medical encounters about the nature or consequences of

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possible discordance in these voices.27 Do patients share cultural or ethnomedical

issues with the clinician? If so, how does this information shape the medical encounter?

The concluding section of this chapter discusses participant communication strategies

that may more fully incorporate mutual agreement and acceptance in a medical

encounter.

I. Lifeworld Narratives in the Medical Encounter

This section examines lifeworld narratives in the medical encounter. Lifeworld

narratives are simply stories that patients tell about their life experiences, including

illness experiences and problems. The lifeworld often contrasts with the “voice of

biomedicine,” which is described as technical, scientific, and decontextualized (Mishler

1984).

Patient narratives were analyzed by listening to the encounter recording in

tandem with reviewing the encounter transcript to see if lifeworld narratives were

present in the encounter and the content of those narratives. Explanatory models are

ideas and preferences about the diagnosis, etiology, and treatment that people believe

about a specific illness or disease. Because models are partly rooted in symbolic and

tacit health belief systems, models are not static and can lack coherence (Kleinman

27
In fact, of the 26 research articles about cultural competence written by medical professionals
discussed in Chapter 3, only four contained real examples of medical communication in a cross-cultural
encounter (Hansen, et al. 2000; Eunice 2004; Fitzgerald, et al. 2005; Rosenberg, et al. 2005).
Anthropologists writing about cultural competence nearly always include examples from their research
data (e.g., Chrisman and Maretzki 1982; Lazarus 1988; Santiago-Irizzary 1996; Hunt 2005; Shaw 2005;
Kleinman and Benson 2006).

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1980). Specific attention was paid to whether explanatory models were discussed, and

if so, which primary model they were most closely aligned, biomedical or cultural. Of

the 30 observed and recorded medical encounters, nine encounters stayed entirely in

the voice of biomedicine; fifteen patients brought up explanatory models, disease

etiologies, or issues from their lifeworld. And in six encounters, the clinician tried to

engage the patient in casual conversation.

Table 5.1 presents this information along with the patient’s biomedical

diagnosis. The last column, “post-interview with researcher,” shows the patient’s

etiological beliefs and whether he or she utilized treatments other than the medication

provided by the People’s Clinic. In some instances the patient did not discuss their

explanatory model during the interview; this is designated by “--” in the cell. Nine

patients completed a survey instead of an interview; the survey medium was not

reliable in eliciting an explanatory model.

Table 5.1: Lifeworld talk in relation to present complaint/biomedical diagnosis

Present
Encounte Post-Interview
Complaint/Biomed Encounter
r# w/ researcher
Diagnosis
No Lifeworld (n=9)
7
ACUTE: Ear infection No lifeworld Survey
9 CHRONIC: Type II
No lifeworld Survey
Diabetes
10
CHRONIC: Allergies No lifeworld Survey
Mixed etiology: “tensions” and the
12 CHRONIC: pancreas not working well
No lifeworld
Type II Diabetes
Was taking cactus for diabetes
CHRONIC: Type II Cultural etiology: drinking certain
19
Diabetes, leg cramps, No lifeworld liquids, such as grape juice, on the
shoulder pain full moon

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24
CHRONIC: Allergies No lifeworld Biomed etiology: dust
25 ACUTE: Stomach Biomed etiology: overeating,
No lifeworld
pain/gall bladder “bad” foods
26
ACUTE: Stomach pain No lifeworld Survey
Mixed etiology: a sudden event
that caused the sugar/pancreas to
CHRONIC: Type II
28 be high
Diabetes, toe/foot No lifeworld
infection
Spoke a lot about fears of
infection
Clinician Initiated Lifeworld (n=6)
6 CHRONIC: Hypertension,
Clinician initiated lifeworld --
High cholesterol
8
CHRONIC: Hypertension Clinician initiated lifeworld Survey
11 ACUTE:
Clinician initiated lifeworld Survey
Ear infection
16
ACUTE: Infection Clinician initiated lifeworld Survey
17 CHRONIC: Type II
Clinician initiated lifeworld Survey
Diabetes
CHRONIC:
18 Cultural etiology: a
Hypertension, Clinician initiated lifeworld
traumatic/emotional event
Depression
Lifeworld and Explanatory Model Discussions (n=15)
CHRONIC:
1 Biomed etiology: eating “bad,”
Hypertension, Type II Lifeworld talk engaged: general
being fat, smoking
Diabetes
CHRONIC:
2 Lifeworld talk engaged: worries about
Hyperthyroidism, --
possibility of cancer
Depression
3 Lifeworld talk engaged: high expense of
CHRONIC: Hypertension --
medicines
CHRONIC: Type II
Lifeworld talk ignored (case study #2 in
4 Diabetes, High Biomed etiology: genetic,
ch 4): how diabetes impacts life, weak
cholesterol, overeating/eating “bad”
support network, joblessness
Hypertension
Mixed etiology
5 CHRONIC: Type II Lifeworld talk ignored: high expense of
Diabetes diabetes testing materials, joblessness Takes herbs and cactus for
diabetes
Mixed etiology: not following a
13 CHRONIC: Lifeworld talk engaged: life stresses,
clear schedule or order to life, not
Hyperthyroidism joblessness, impact of disease on life
eating
14 ACUTE:
Pt provides biomedical EM of rash Survey
Rash
15 Lifeworld talk engaged: life stresses, Mixed etiology: animals, dust,
CHRONIC: Asthma
money plants and hot/cold imbalance
20 ACUTE: La Gripa vs. Cultural etiology: hot/cold
Cultural lifeworld in encounter – EM
Allergies imbalance
21 CHRONIC: Infection vs. Cultural lifeworld in encounter – HIV Cultural etiology: hot/cold
HIV EM: cold  infection,  bone/bone imbalance

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 pain, then major distrust in biomedicine

Biomedical etiology: poor diet,

Lifeworld talk engaged: financial, job,
22 CHRONIC: Type II alcohol, being alone
life issues, how diabetes affects his life,
Diabetes
his diet, his libido
Was taking cactus for diabetes
23 Lifeworld talk ignored: past personal
CHRONIC: Hypertension --
issues, illiterate, fear of doctors
27 CHRONIC: Depression/ Lifeworld talk engaged: how depression Biomed etiology: worries,
anxiety impacts life problems
29
ACUTE: Rash Pt provides biomedical EM about rash Biomedical etiology: unclean razor
Lifeworld talk engaged: life issues,
30 CHRONIC: Type II Biomed etiology: too much sugar
treatment preferences (case study #1 in
Diabetes in pancreas
ch 4)

Voice of Biomedicine

Nine medical encounters followed the structure outlined by Mishler (1984) of an

“unremarkable interview.” That is, these encounters took place entirely in the voice of

biomedicine and neither patient nor clinician ventured into the lifeworld. Most of these

encounters adhered to the typical pattern of the unremarkable interview, a sequential

set of three turns: the clinician asked a question, the patient responded, and the

clinician acknowledged/assessed the response and asked the next question. This format

allows the clinician to retain control of the topic of conversation. Patients in these

encounters communicated in ways congruent with this format. For example,

S=student nurse P/I=promotora/interpreter P=patient

S: Do you ever have any headaches or anything like that?

P/I: ¿No tiene dolores de cabeza?
Do you have headaches?
P: mhmm [yes]
S: Yeah? How often do you have headaches? When you feel nauseous?
P/I: ¿Qué tan seguido tiene?
How often do you have them?
P: Pues ahorita ya los traigo ya.
Well I bring them in right now.
P/I: He has it right now.
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 S: You have a headache right now?
P/I: Yes.
S: Do you feel nauseous right now?
P/I: ¿Siente nausea ahorita?
Do you feel nausea right now?
[2 sec]
S: Is there anything that makes this feel better? Is this during the day as
well?
P/I: The nausea?
S: Yeah.
P/I: También en el día le da las nauseas o nada más en la noche?
Do you also get nausea during the day or only at night?
[
S: Or is just at night?
P: También en el día.
Also during the day.
P/I: During the day also.
S: During the day too? Can I look in your nose?

As with this example (encounter 26) and the other “unremarkable” encounters,

the clinician controlled the topic of conversation and freely changed topics when she

saw fit, even if the next topic lacked subject cohesion. In the example above, the

clinician asked numerous closed ended questions and then jumped from asking about

the patient’s nausea to asking if she could look up his nose in one turn. The nine

patients in this category did not attempt to bring up their lifeworld and also stayed in

the voice of biomedicine.

Barry, et al. (2001) also studied the presence or absence of lifeworld talk and

found that almost one-third of patients and clinicians in their sample of 35 participated

in encounters that stayed strictly in the medical realm (i.e., no mention of the lifeworld).

These visits tended to be patients with acute problems and the patients or clinicians

perhaps wanted the medical visit to be as quick and efficient as possible. Interestingly,

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patients who had this type of encounter gave the doctor the highest satisfaction rating

(Barry, et al. 2001).

Congruent with these findings, all but one of the patients at the People’s Clinic

who participated in this type of encounter expressed satisfaction during the interview or

survey with the medical encounter.28 Most (6 of 9) were at the clinic for a chronic

problem, for example, type II diabetes or allergies.

Lifeworld Discussion Initiated by the Clinician

An interesting pattern emerged when examining lifeworld narratives and how

they were introduced within the encounter discourse. Fifteen patients brought up

lifeworld issues in dialogue with the clinician. However, in six other encounters in which

the clinician tried to engage the patient in a lifeworld conversation, the patient did not

reciprocate or gave minimal responses. This pattern of clinician initiated lifeworld

discussion is not addressed in the medical communication literature as clinicians are

often portrayed as people who use strategies such as interruptions and closed-

questions to disengage from the patient’s lifeworld narratives (Mishler 1984; Waitzkin

1991;Ainsworth-Vaughn 1998; Fisher 1998).

Two male family nurse practitioners, Mr. Mills and Mr. Kendall, often asked

about the patients’ home lives, their families, and their jobs, as evidenced in the next

two examples. It frequently seemed they initiated these discussions to establish rapport

28
One patient expressed dissatisfaction for having to wait 2 hours to see the family nurse practitioner.
183
and to get a sense of their patients’ lives in general. Encounter eight shows that

patients often answered the questions, but gave minimal answers.

M=Mr. Mills, FNP P/I=promotora/interpreter P=patient

M: Um, are you working?

P/I: Esta trabajando?
Are you working?
P: Yeah, yeah
M: What do you do?
P/I: Que lo que usted hace?
What do you do?
P: Delivery, pizzeria.
M: Ah, very good. Have you been doing that a long time?
P/I: Esta haciendo lo mismo mucho tiempo?
Have you been doing the same thing for a long time?
P: Ah, como dos anos.
Ah, about two years.
P/I: Two years.
M: Okay, good, good. And you have family around?
P: mhmm
M: Who do you live with?
P/I: Con quien vive usted?
Who do you live with?
P: Ah, con mis fam- [ahm, clears throat], mi esposa y dos hijos.
Ah, with my fam-, my wife and two kids.
P/I: His wife and two sons.
M: Okay, how old?
P: Eleven y cuatro.
Eleven and four.
M: Four and eleven. It’s a big house. They’re out of school for the summer?
P: Yes.
M: Good, so you’re spending some time?
P/I: Esta pasando mucho tiempo con ellos?
Are you spending a lot of time with them?
P: Si, si.
M: Good, good.

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 For Mr. Mills, his lack of direct connection with patients because of the language

barrier led him to instigate informal conversations. He spoke about this connection

during his interview.

“I miss the connection. Because I have to go through the promotoras, I do that

informal chit-chat and personal connection. On a practical side, like that patient
today, is he at a job that is physically demanding? Part of our job is to help him
keep working as long as he wants to because he is probably the only support for
his family” [interview with Mr. Mills, FNP].

In a second example of clinician initiated lifeworld conversations, Mr. Kendall

(FNP) saw a young female patient for an ear infection (encounter 11). 29 The girl’s

mother was also in the exam room; however, she did not speak English and the patient

acted as an interpreter for her mother. After Mr. Kendall examined and discussed

treatment for the ear infection, the patient’s mother prompted her daughter to inquire

about her wrist that had been hurting. Mr. Kendall asked what the mother did for a

living and she answered that she made tortillas at a local restaurant. Mr. Kendall asked

whether she could go to the local county hospital but the mother was undocumented,

was not a county resident, and thus did not qualify. He suggested several treatment

options and recommended that the mom speak with the clinic social worker to

determine if the mother could visit other clinics that had more advanced equipment

than the People’s Clinic. At the end of the encounter, Mr. Kendall talked to the young

patient about the importance of education and how education is linked to a better life,

including a life that is healthy.

29
Informed consent was received from both the 17 year old patient and her mother.
185
K=Mr. Kendall, FNP P=patient

K: Now listen. The reason everybody wants you to stay in school? And do
well in school? Is so you won’t end up making tortillas for a living.
P: [short laugh] ah-huh
K: Okay? Your mom doesn’t want you to do that.=
P: A-huh
K: =She wants you to go to college. She wants you to go to college, and buy
a house, and get insurance and so you don’t, you know. (.) So you’ll have
an easier life. [whispers] Okay?=
P: =Yeah=
K: =Really important.
P: Yeah
K: And all it takes is getting pregnant and then, you know, you’re going
down a different road.
[
P: Yeah [short laugh]
K: And so if you can avoid that, you’ll have an easier life. Okay, see ya, bye.
P: Bye

After Mr. Kendall left, the patient’s mother asked two times, “Que dice?” or

“What did he say?” The young patient did not translate the advice Mr. Kendall gave.

We might hypothesize that she was embarrassed at Mr. Kendall’s statements or felt he

had over stepped a boundary with his comments. Indeed, from this passage, Mr.

Kendall’s words may seem condescending and paternalistic. In context, however, he

routinely talked to young people about studying hard, he spoke to parents at the local

elementary school about helping their children succeed in school, and he mentored one

local Mexican immigrant girl who volunteered at the clinic to help her graduate from

high school and get into community college.

Clinicians have numerous reasons to engage patients outside of the voice of

medicine: to establish rapport, to better understand the lives of their patients, and to

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help them become successful individuals. Not all patients in this sample appeared to

want to talk with the clinician about their personal lives and perhaps felt as if he was

intruding in their personal space. For many encounters, it was the first time the patient

and clinician had met, and it is possible that the patients did not believe the clinician

was authentically interested. A third hypothesis may be that a patient-centered style of

care, a view that the patient is a partner in his or her treatment, may not be the desired

approach by all patients. This is certainly an area for further research.

Lifeworld Discussions

Fifteen patients talked about their lifeworld or explanatory model with the

clinician; of these, six patients brought up lifeworld issues that included finances or

joblessness (encounters 3, 4, 5, 13, 15, 22). That is to say, the predominant themes in

their narratives were centered on their current financial or work situation and how

those circumstances affected their lives, families, and illnesses. For example, in the

following encounter (encounter 3) Mr. Mills (FNP) saw a patient from Columbia who had

hypertension. Mr. Mills told the patient he wanted to increase the dosage of the blood

pressure medicine. The patient then spoke to the promotora and she interpreted to Mr.

Mills:

M=Mr. Mills, FNP P/I=promotora/interpreter

P/I: He just wanted to let you know that a couple years ago he was taking
some kind of medicine from, he is from Columbia? And this medicine, it
was very expensive and he couldn’t afford it.
M: Okay. Mhmm, and so if you can’t afford it, what good is it, right? And, we
could find the best medicines, but if they are too expensive for people to

187
 buy, then people aren’t going to buy them, so why, so we’re going to try
to find medicine that works for you.

Despite the fact that patients received medicine at the clinic pharmacy for free, Mr.

Mills discussed the high cost of pharmaceuticals in today’s health care climate and

reassured the patient that he would receive medicine that worked and was affordable.

In two other encounters, the clinician made no response to their patients’

lifeworld issues concerning finances and joblessness. For example, one female doctor

from a nearby hospital, Dr. Henry, who was not a regular volunteer at the clinic,

repeatedly mentioned throughout the encounter that the patient, Señora Vazquez,

should check her blood sugar at home. While this was not an abnormal request, most of

the patients at the People’s Clinic could not afford the necessary diabetes testing

materials, such as a glucometer and test strips. In this case (encounter 5), Señora

Vazquez told Dr. Henry that she and her husband lost their jobs recently and could not

afford to purchase a glucometer to monitor her blood sugar at home.

Dr=Dr. Henry P/I=promotora/interpreter P=patient

Dr H: Mh. Does she, ah, does she check her blood sugar at home?
P/I: Se checkar su azucar en casa?
Do you check your sugar at home?
P: No, ya no tengo una machina.
No, I don’t have a machine.
P/I: No, she doesn’t have a machine.
[86 seconds later]
Dr H: And she can’t get a machine to check her (..) blood sugar?
P/I: Her husband recently lost his job and she is not working right now either.
Dr H: Well, it sounds like her blood sugar is getting low.
[100 seconds later]
Dr H: Okay, ideally she could check it every day for…[not translated]
[83 seconds later]

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 Dr H: M-kay. That’s why it’d be nice if we could get her to check her blood
sugar…[not translated]

Alternatively, the following example shows how Mr. Mills (FNP) responded to his

patient’s inability to afford diabetes test strips. The patient, Señor Garcia (encounter

22), was a second generation Mexican immigrant and this was his third visit to the clinic.

M=Mr. Mills, FNP P=patient

M: Good, good. Are you checking your sugar at home? I know in the past
you’ve had kind of a little bit of a chance to check your sugar at home.
P: I didn’t have a meter and ah, and the one that I had I never did use again
because I ran out of strips and-
[
M: Okay, yeah. Yeah, the strips are the
expensive part. You can always come here to get your sugar checked.

Later in the same visit, Sr. Garcia said that he lost his reading glasses and could

not replace them because of the cost. Mr. Mills recommended he see an eye doctor

and gave him information about a low cost doctor in the community, while also verbally

recognizing that the patient might not be able to afford it.

M=Mr. Mills, FNP P=patient

M: It’s a hundred dollars for the exam and glasses. So for everything and
um.
P: Okay.
M: With diabetes we want to make sure those blood vessels in your eye look
okay and so, you know. I’m not saying you need to do it, I know a
hundred bucks, I would have to go and look in my wallet to see if I could
spend that hundred right now. But you know, it can help, you might give
‘em a call anyway.

The differences between the responses from Dr. Henry and Mr. Mills are

apparent. Despite the fact that Sra. Vazquez lost her job and could not afford diabetes

189
testing materials, Dr. Henry seemingly did not consider her responses and repeatedly

mentioned that she should check her sugar every day. Interestingly, the last two times

the clinician repeated this, the promotora did not translate the doctor’s comments to

the patient, perhaps because she felt the doctor was not listening to the patient’s

circumstances.

Mr. Mills, on the other hand, asked about his patient’s job at the beginning of

the encounter and later, when Sr. Garcia said he could not afford the diabetes test

strips, Mr. Mills agreed that they were expensive and offered that he could come to the

clinic to test his blood. Mr. Mills also recommended that Sr. Garcia make an optometry

appointment because of his diabetes, provided information about a low cost clinic, and

indicated that while he knew it was expensive, it was important. During the post-

encounter interview with me, Sr. Garcia described how he was unable to see his

previous doctor and get medication for his diabetes because he did not have health

insurance.

P=patient R=researcher

P: Right, if your question started as why I came here in the first place, is
because I don’t have insurance. It’s too expensive where I work at and I
just can’t afford it on my pay.
R: I know, I don’t get insurance either at my job, luckily I’m a student and
can get it though the school, but otherwise.
P: Right and I also, I skipped a lot of doctor’s visits and medicine because of
that reason. I started getting real bad so I had to find another option. It
was through word of mouth that I found this clinic which is helping a lot
and I’m very grateful to be coming here.

190
 Researchers hypothesize that clinicians have a difficult time acknowledging

patient’s narratives, especially those about poverty, because of a lack of experience and

training in dealing with certain social and political issues, such as poverty, environmental

pollution, or sexuality (Mishler 1984, Waitkin 1991). However, in two encounters when

the patient brought up these issues, the clinician went further than simply talking about

joblessness or health insurance and actively tried to help the patient.

Señora Ruiz, a Mexican immigrant in her early 40’s, came to the clinic to refill her

thyroid medicine and to ask why her heart was racing (encounter 13). As the nursing

student was asking the patient’s history, she asked how everything was going at home.

The patient responded that her husband had a heart attack one month ago. After the

heart attack and subsequent stay at the hospital, her husband was fired from his job,

lost his health insurance, and had to seek follow up treatment at the county hospital.

When they missed the first appointment, her husband was told he could not make a

follow up appointment for three months. Thirty minutes into the encounter, Mr.

Kendall, the medical director and family nurse practitioner, joined the student nurse to

see Señora Ruiz. After he heard about her husband, he took action.

K=Mr. Kendall, FNP S=nursing student P=patient

K: He is signed up for us to see him today?

P: No. I need to x [unintelligible] him, he’s outside.
K: Okay, does he have, where does he go to the doctor?
P: Ah (..) we make ah appointment for my husband to go see um, therapy?=
K: =Okay
P: Um, but my husband loose the appointment and I call again ah, at the
L[name] clinic? And they told me he, he need to wait three months
because they had ah.

191
 S: They were booked.
K: Yeah, well, whatever. Um, okay. Here’s the plan, okay? First of all, I
want you to come back tomorrow at one o’clock. You have an
appointment with Dr. [name]. Okay? And she’ll be able to, she’s smarter
than I am.
[P and S laugh]
K: And then, ah, um, and then the other thing is, we want to check your
husband today, want to check his blood pressure. But we also want you
to talk with Ms. Kendall[social worker] tomorrow, okay? This is very
important, she will be sure, this three months is not okay.
P: No.
K: So we’ll get Ms. Kendall [social worker] to help you on this, okay? So you
came to the right place today, you’re gonna have to come back
tomorrow, but you came to the right place today.

This excerpt demonstrates the possibilities when the clinician’s communication

style makes it possible for the patient’s lifeworld to emerge. Because the student nurse

asked many open ended questions during the encounter and allowed the patient to

have control of the conversation, the patient told a story about her husband’s heart

attack and subsequent problems getting follow up care. Later, the social worker helped

Señor Ruiz make an earlier appointment with the county hospital out-patient clinic, and

the People’s Clinic provided medications until that appointment.

In summary, a predominant theme in patient narratives was financial situations

or joblessness. In encounters where the clinician spoke with their patient about

finances, or directly tried to help the patient, knowing the local health care system,

other low-cost providers in the area, or having access to knowledgeable staff, such as

the social worker, may have helped clinicians discuss their patient’s financial situation

and offer solutions.

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II. Cultural Worlds in the Medical Encounter

Explanatory Models

Explanatory models are simply ideas and preferences about the diagnosis,

etiology, and treatment that people believe about a specific illness or disease. Because

models are partly rooted in symbolic and tacit health belief systems, models are not

static and can lack coherence (Kleinman 1980). Kleinman described important

applications of this model to clinical medicine. “The study of the interaction between

practitioner explanatory models and patient explanatory models offers a more precise

analysis of problems in clinical communications” (Kleinman 1980: 105). Thus, it is

presumed in cultural competence models that differences in explanatory models are at

the core of a problematic medical encounter. This hypothesis proved to be correct in

two encounters at the People’s Clinic.

Of the encounters observed and recorded for this research, half of the patients

introduced explanatory models, disease etiologies, or issues from their lifeworld during

the medical encounter. While six of these lifeworld discussions centered on poverty or

joblessness, a surprisingly small number of them dealt with culturally different

ethnomedical beliefs (i.e., explanatory models that varied from those of biomedicine).

The use of the word “cultural” does not imply that Western biomedicine is not also a

culturally created ethnomedicine (Gaines 1992a). The term “cultural difference” used in

this analysis represents the difference in health beliefs that are rooted in traditional

Mexican ethnomedicine from those that are rooted in biomedicine.

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 Two medical encounters described below were very different from each other:

one revolved around differences in disease etiology and treatment of la gripa, and the

other dealt with beliefs about the nature of AIDS and distrust of the biomedical system.

First Cultural Example

The first example in which cultural difference influenced the encounter was with

a 33 year old Mexican immigrant woman, Señora Rios (encounter 20). Señora Rios

asked for antibiotics for what she felt was a very strong infection (la gripa, a term which

means a bad cold or the flu); in fact Señora Rios said four times during the encounter

that she had an infection. Her symptoms of sore throat, coughing, and headache had

lasted two weeks. However, the family nurse practitioner, Mr. Mills, believed she had

severe allergies instead. Mr. Mills sensed that Señora Rios wanted antibiotics so he

spoke with her about the differences in allergies, colds, and influenza and the reasons

why clinicians do not want to prescribe antibiotics when there is no bacterial infection.

Mr. Mills offered this information using an illustrated anatomy book, and he drew a

model of how multi-drug resistant bacterial infections occur with unnecessary use of

antibiotics. The medical encounter lasted sixty-eight minutes, one of the longest I

observed.

Señora Rios did not appear to understand Mr. Mills’ explanations, possibly

because this information was relatively new to the interpreter who did a poor job of

interpreting, and partly because it conflicted with Señora Rios’ health belief that she had

an infection that required antibiotics. Señora Rios’ body language and lack of

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communication following the explanation indicated that she was not satisfied with how

the encounter had unfolded. Mr. Mills invited the promotora to talk with him in a side

conversation.

M=Mr. Mills, FNP P/I=promotora/interpreter P=patient, Señora Rios

M: So, and I know. So the more you.(..) She’s [the patient] not buying any of
this. She’s not buying anything I’m telling her is she? Um,
P: La tos?
The cough?
P/I: What about the cough? For the cough? Um, she’s gonna take
something? It looks like she wants medicine.
M: I know, I know, and I.
[8 seconds]
I’m trying to make the case to give her antibiotics but there’s nothing. I
mean, I’m trying. (….) We only have this pain and pressure here, so it
doesn’t sound like there’s a lot of infection here. So, let me ask you
because this is where, this is a great communicate on thing. Are you
getting the feeling, I mean, is she understanding about using antibiotics
or not? And do you get a feeling, my feeling that I’m getting from her is
to give her antibiotics.
P/I: Yeah that’s what I feel too because she’s saying like, she’s been thinking
like if I take antibiotics, you know? I will get better.
M: And then it will get better.
P/I: So she’s saying I don’t want to wait to take something to treat, if not
she’s gonna have to come back and she, she’s saying like I don’t want to
come back.
M: A-huh, a-huh. Okay.
P/I: My feeling.
M: So okay, that’s what I was feeling but I can’t.
P/I: I know.

There are two reasons for highlighting this excerpt. First, it is interesting that

Mr. Mills invited the promotora, as someone who may better understand the patient’s

feelings, to discuss the situation, thus placing her in several roles. Initially, the

promotora acted as an interpreter. Mr. Mills’ side conversation then placed her in the

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role of culture broker rather than a strict interpreter. In a third role, the promotora,

recognizing Señora Rios’ desire for antibiotics, advocated for these twice when she

asked Mr. Mills, “What about the cough?...She’s gonna take something? It looks like she

wants medicine.” And “…she’s been thinking like if I take antibiotics, you know? I will

get better.”

Second, in this excerpt Mr. Mills verbalized his frustration about his inability to

directly and clearly communicate with Señora Rios. He may have realized that the

information he provided was not satisfactory because the patient had different

ethnomedical beliefs about the presence of an infection and the appropriate treatment

to cure the infection. At this point in the encounter, Mr. Mills decided to negotiate a

treatment plan to incorporate both sets of beliefs; he gave Señora Rios allergy medicine

to try for three to four days, but he also provided antibiotics if the allergy medicine did

not work. Mr. Mills obviously felt this encounter was unsatisfactory for Señora Rios and

he apologized to her twice at the conclusion of the encounter.

M=Mr. Mills, FNP P/I=promotora/interpreter P=patient, Señora Rios

M: Okay, sorry I was frustrating.

P: Estas pastillas son para x [unintelligible] como eso?Para todo?
Those pills are for x [unintelligible]? For everything?
P/I: That pill, ah, that’s for like killing the symptoms?
M: Mhmm. Absolutely.
P/I: Claro que si.
Yes, clearly.
M: It looks like you probably have, a lot of this is being caused by allergies.
[P coughs]
P/I: Todo lo que se siento es con alergias. Okay?
Everything you feel is with allergies.

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 M: And that’s why, that’s my, and that’s why I’m feeling a lot of this is
happening and that, and to tell you the truth, just taking antibiotics won’t
do anything for your allergies.
P/I: Obviamente tomando antibioticos no ayuda con la [unintelligible], okay?
Obviously taking antibiotics won’t help with [unintelligible], okay?
[P cough]
P: Ay, xx xx [P cough] xx [P cough]
M: It’s okay, your lungs are clear. So let me go and get that medicine for you.
I’m so sorry. Don’t, I, I hope you won’t ah,
[=
P: It’s okay, it’s okay.
M: I hope you don’t take it personally from me, I was just, you know what
I’m trying to do, but we worked out a way, right?

In my post-encounter interview with Señora Rios, she expressed that she had a

very strong infection that was caused by drinking a cold coke when it was warm outside.

She had been examined by a different clinician at the People’s Clinic on a previous visit

for the same symptoms. He had given her Penicillin. Señora Rios said she wanted to see

the same clinician because she felt he had done a good job and had given her

appropriate medicine. Señora Rios said that she was not satisfied with this clinician,

even though, ultimately, she received antibiotics, because he did not seem to notice

that she had an infection. Likewise, Mr. Mills articulated frustration in the pharmacy.

He was unable to “connect” or communicate with the patient, yet, he gave her

antibiotics against his better judgment.

Second Cultural Example

The second example was with a 54 year old Mexican immigrant woman, Señora

Moreno who disagreed with her positive AIDS test (encounter 21). Señora Moreno had

visited the clinic a year before. She was told at that time that her lab test results were

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positive for HIV. However, at this visit, she used a different name and was seen as a

new patient. Thus, the student nurse did not know that she had AIDS until later in the

encounter.

At this visit, Señora Moreno had several sores on her face, ears, and mouth. She

believed the sores were caused by an exposure to a cold surface and the cold weather,

and not related to the AIDS virus. The excerpt below occurred before the woman’s

positive HIV status was known.

S=student nurse P/I=promotora/interpreter P=patient, Señora Moreno

S: Is there a pattern to when she’s getting these sores? Like um, is there
anything that she’s doing that brings them, any triggers? That she is
aware of?
P/I: No está cuándo le salen, no está haciendo algo que puede ser la causa?
When they come, are you doing anything that you think might be the
cause?
P: Yo pienso que es por el frío porque yo cuando me resfríaba era por las
paredes de la escuela, yo pienso que es por el frío.
I think it might be the cold because when I got cold it was because of the
school’s walls, I think it’s because of the cold.
P/I: ¿Por el frío?
From the cold?
P: Si por el frío.
Yes, from the cold.
P/I: She thinks it’s because of the cold.
S: The cold? Where she works?
P/I: ¿Trabaja?
Do you work?
P: No, sí trabajo pero eso fue aquí en la escuela cuando fui a traer a los
niños a la escuela. Estaba muy frío ahí en la pared y duramos como media
hora en la pared y estaba bien fría.(…) Yo pienso que es por el frío.
No, I do work but it was at school when I went to get the kids from school.
It was very cold on the wall and we were standing like half an hour on the
wall and I was cold.(…) I think it’s because of the cold.
P/I: She thinks it’s because of the cold.
S: Okay.

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During the physical examination, Señora Moreno explained that the sores were an

infection that also caused bone pain.

S=student nurse P/I=promotora/interpreter P=patient, Señora Moreno

S: Just open your mouth I’m gonna look at your teeth.

[7 seconds]
M-kay and can you go like, say ahhh. (…) Can you go ahh like that?
P: Tengo una infección doctora [short laugh]. Ya tengo una semana que me
duelen los huesos y me duele en los huesos y, y, y como que me quiere
dar calentura.
I have an infection doctor [short laugh]. It’s been a week now that my
bones hurt, and it hurts in the bones, and, and, and like I were to have a
fever.
P/I: She will have like bone pain and she will get like fever for a week.
S: Like associated with the pain? I mean her sores and stuff?
P/I: ¿Esto está asociado con lo de estas?
Is this associated with these?
P: Sí es por eso.
Yes, it’s because of them.

In Señora Moreno’s explanatory model, she described that the sores happened

because she was outside in the cold for some time waiting for her children to get out of

school. The cold from the school wall she was leaning on radiated out to her, which

then caused infection, the sores, and bone pain. The student nurse did not respond to

the patient’s explanatory model, indicating that the symptoms started because of the

cold.

While the patient’s history was being taken, the lead promotora came into the

room twice for different tasks. In hindsight, the promotora was checking on the

patient’s identity. Soon thereafter, about 30 minutes into the encounter, the medical

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director, Mr. Kendall, entered the room with the lead promotora and confronted Señora

Moreno with her real name and situation. The clinicians and promotora tried to

persuade her to go to the county hospital AIDS outpatient program. Señora Moreno

repeatedly voiced distrust with the biomedical system and said that doctors were often

wrong; she pointed out cases in which friends or family members were told they had

diabetes but in fact, they did not.

P/I=promotora/interpreter P=patient, Señora Moreno

P: También a mi esposo le decían que tenía diabetes y no tenía.

They also told my husband that he had diabetes and he did not.
P/I: Ah, si. She said that someone told her husband he has diabetes but he
don’t have it.
P: Y el doctor le afirmaba que si tenía y él que no tengo, y fue con los
bomberos y le dijeron que no tenía
And the doctor affirmed that he had it and he didn’t, and he went to the
firemen 30 and they told him he didn’t have it.
P/I: Bueno como aquí el examen que le hicieron le salió que era positivo.
Well since the [HIV] exam that they did here was positive.
P: Si, a veces salen así, como te digo que a mi esposo también le han dicho
eso que sí y no tiene, no tiene diabetes, él no tiene.
Yes, sometimes they come out that way, as I’m telling you they told my
husband the same, that yes, and no, he doesn’t have diabetes, he doesn’t
have it.

Señora Moreno so distrusted blood/lab tests and doctors that, in the next

example, she also said that her husband was diagnosed with AIDS, but he did not have

it. In the next utterance she repeated again that her husband was told he had diabetes

when another test indicated that he did not. It was not clear whether her husband had

two wrong tests, one for AIDS and another for diabetes; whether she was confused

30
Various city agencies hold periodic health fairs where the community can receive free health screenings.
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about the diseases; or whether, in the midst of the charged back and forth exchanges

between clinicians and patient, she misspoke and said “AIDS” when she meant

“diabetes.”

P/I=promotora/interpreter P=patient, Señora Moreno

P: Si, si, si, si. Este a mi esposo no le digo y también a otra señora creían
que eso tenía, tenía SIDA, pero él no tenia SIDA, tenía esto de aquí en la
garganta. Y mi esposo también el doctor le quería dar la medicina. En
esta clínica de aquí, una que está por aquí.
Yes, yes, yes, yes. Well I’m telling you is my husband, and also this other
lady they thought that that was what he had, AIDS, but he did not have
AIDS, he had this thing here in his throat. And the doctor also wanted to
give my husband the medicine. In this clinic here, one that is close
around.
P/I: L[clinic]?
P: A-huh. Dice tú “tiene diabetes” dice mi esposo “pero no tengo
diabetes.”“Y vas a tomar la medicina,” y “no, no me la tomo porque no
tengo diabetes” y fue mi esposo con los bomberos y le dijo chequéeme
mi sangre porque me están afirmando que tengo diabetes y le dicen no
tienes diabetes.
A-huh. They said “you have diabetes” and my husband said “but I don’t
have diabetes.” “And you will take the medicine”, and “No, I will not take
it because I don’t have diabetes” and it was my husband went to the
firemen and told them to check his blood and “they tell me that I have
diabetes” and they tell him that he doesn’t.
P/I: Si usted dice que no lo tiene vaya al P[county hospital] a que le hagan
otros estudios, no pierde nada.
If you say you don’t have it, go to P[county hospital] so that they can do
other analyses, you have nothing to lose.
P: Pues si, porque como ledigo mucha gente ha ido con los doctores y el
doctor le ha dicho a mi esposo tienes que tomarte la medicina.
Well I do, because I have told you a lot of people have gone to the doctors
and they have told my husband that he has to take the medicine.

For 17 minutes Mr. Kendall and the promotora spoke with Señora Moreno about

HIV/AIDS and transmission. They recommended that she talk with her husband and

family about it as well as other medical facilities where she seeks treatment. The

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encounter ended with Señora Moreno twice asking for medicine to help the sores and

Mr. Kendall explaining both times that the sores were from the HIV virus, and that she

needed to get treatment at the county hospital AIDS outpatient program.

Señora Moreno repeatedly denied that she had AIDS, and, based on her

comments and demeanor, it seemed highly unlikely that she was going to follow up with

the outpatient program. While she was obviously motivated to seek treatment for her

sores, she was not going to accept a diagnosis of AIDS. Señora Moreno’s distrust could

have been compounded by not having a sustained relationship with a clinician whom

she trusted and who was familiar with her case. Because of this situation, my interview

was brief and did not follow the interview schedule. However, Señora Moreno again

mentioned her explanatory model during the interview.

R=researcher P/I=promotora/interpreter P=patient, Señora Moreno

R: Do you understand the disease?

P/I: ¿Si entiende la enfermedad esa?
Do you understand that disease?
P: Si pero yo pienso que no la tengo.
Yes but I don’t think I have it.
P/I: She thinks she doesn’t have it.
R: Why?
P/I: Por qué?
Why?
P: Porque yo me siento bien, nada más es por el frío que tengo esto.
Because I feel well, it’s only because of the cold that I have this.
P/I: She understands it but she said she has this for a cold.

Señora Moreno left hurriedly after the nursing student gave her printed

information in Spanish about the skin lesions, the disease in general, and coping

strategies. In the afternoon debriefing meeting, the nursing student verbalized to her

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classmates and Mr. Kendall that she was frustrated about the encounter and wished she

could have helped Señora Moreno better understand her situation.

These two encounters were the only ones of the thirty observed and recorded in

which patients voiced information in the medical encounter that was “cultural” and

fundamentally different from biomedicine; both patients and clinicians had different

beliefs about what was wrong and what the course of treatment should be. Clearly,

when differences appeared in these two examples, all participants were dissatisfied,

and, miscommunication was apparent. Thus, these encounters are classified as negative

medical situations in which agendas and expectations were not met.

However, it would be incorrect to deduce that the other 28 patients did not have

ethnomedical beliefs that were different from those of the clinicians’ simply because

they were not voiced during the encounter. The post-encounter interviews illustrate

that some patients who had satisfactory or “successful” medical encounters also had

cultural differences in the etiology or treatments of their conditions that were not

vocalized in the encounter.

III. Culture Difference in the Post-Encounter Interview

While with clinicians, patients mostly talked about lifeworld issues that focused

on personal problems and money concerns. On the other hand, during the post-

encounter interviews, patients discussed culturally different narratives in response to

specific questions related to their explanatory models. This information can be

categorized into two areas: etiology and treatment preferences.

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Etiology

The decisions people make about their illness largely depend on their

understanding of the etiology, or cause, of the illness (Sobo 2009). Because of this

importance, my interview contained questions to elicit their etiology:

7. What do you think causes [illness]? How did you get [illness]?
8. What other treatments have you tried to help with [illness]?

I did not organize etiologies with regards to previous anthropological classification, such

as Young’s (1986) internalizing versus externalizing systems or Foster’s (1976)

naturalistic verses personalistic models. Rather, I was interested in whether patients’

etiologies were similar or different from a biomedical model.

Seventeen patients discussed the etiology of their illnesses in the post-encounter

interviews (21 patients completed an interview; the other nine completed a survey).

Patients’ models of causation can be categorized as biomedical etiology, mixed etiology,

or cultural etiology.

Biomedical Etiology

Of the 17 patients who spoke with me about the cause of their illnesses, eight

patients (47%) gave a strictly biomedical explanation. Señor Hernandez, from the first

case study in Chapter four, described an etiology of type II diabetes in which the

pancreas supplies too much sugar to the body.

R=researcher P/I=promotora/interpreter P=patient

R: Okay. Um, what do you think caused your diabetes?

P/I: ¿Y que piensa que le causó la diabetes?
And what do you think caused the diabetes?

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 P: No come entonces todos el páncreas le pasa azúcar al cuerpo cuando
pasa hambre. Son muchas las [unintelligible] y el páncreas ya no puede
con toda el azúcar que tiene acaparada aquí. Así me dijo el doctor y yo
creo que sí.
If you don’t eat, then the pancreas provides the body with sugar when
you’re hungry. There are many [unintelligible] and the pancreas can no
longer stand all the sugar it has stored. That’s what the doctor told me
and I think that’s it.

Most patients with diabetes described a disease etiology that included the

pancreas and sugar production although as with Señor Hernandez, the answers were

vague and often incomplete. Other answers included behavioral causes such as

generally eating non-nutritional foods, smoking, and not taking good care of his or her

health. Señora Lopez, on the other hand, discussed how diabetes “runs in her family,” a

genetic explanation:

R=researcher P=patient

R: ¿Cuándo fue la primera vez que se enteró que tenía diabetes?

When did you learn you had diabetes?
P: Oh, hace seis, seis años.
Oh, six, six years ago.
R: ¿Qué pensó cuando oyó que tenía esa noticia?
What did you think when you heard the news?
P: Pues me sentí mal porque como mi hermano la tenía. Y parece que está
en la familia porque la tiene mi mamá, mi hermano mayor, el que sigue el
segundo y luego el más chiquito, y mi hermana la que tengo en México
también tiene diabetes.
Well I felt bad because my brother had it. And it looks like it’s in the family
because my mom, my older brother, the next one and also the smallest,
and my sister that is in Mexico, all have diabetes.
R: So toda su familia ha estado con la diabetes por mucho tiempo.
So your family has been with diabetes for a long time.
P: Sí.
Yes.

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Mixed Etiology

Five people (29%) expressed a mix of biomedical and traditional cultural

etiologies. In this example, a woman from Mexico (encounter 12) described how her

explanatory model of diabetes changed from a traditionally Mexican view to

incorporate a biomedical view.

R=researcher P/I=promotora/interpreter P=patient

R: Um, what do you think causes diabetes?

P/I: ¿Qué es lo que usted cree causa la diabetes?
What do you think causes diabetes?
P: Antes, antes yo creía que era. Según era, antes platicaba la gente que era
este por la tension. Pues después tuve una plática aquí con los de aquí
de la em...clinica me dijeron que es por el la pancreas no está
funcionando bien.
Before, before I thought it was. According to, before people talked that it
was because of tension. Well then I had a talk here with the people here
from the um... clinic told me that it was the pancreas that is not working
correctly.
P/I: Okay, ah. Most of the people know that diabetes come from tensions.
But when she came to the clinic she knows that it wasn’t from tension it
was from people who are sick from (…)
R: Pancreas?
P/I: Pancreas.
R: What tensions? What type of tension?
P/I: Tensiones como, ¿qué clase de tensiones?
Tension like, what kind of tensions?
P: Es, sí por es preocupaciones…yo creo que ambos tienen razón.
It’s, yes because of worries... I think both are right.

This patient recalled that most people feel that diabetes is caused by tensions

and worries, but that once she came to the clinic, she was told that diabetes is caused

by the pancreas not working correctly. She incorporated the clinic’s biomedical

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knowledge into her understanding of diabetes and said she believed that both

explanations are right.

Cultural Etiology

Four people (24%) provided explanations that differed from a biomedical

etiology in their entirety. There was no pattern related to patient diagnosis and a

culturally different disease etiology, though three of the four had a chronic disease (see

table 4.1). Cultural explanations ranged from theories about hot-cold imbalance and

stress to susto.

Two people thought they became ill because of a thermal imbalance. The

following excerpt is from the interview with Señora Rios (encounter 20) discussed above

whose belief about her severe infection (la gripa) was at odds with the clinician’s belief

that she suffered from allergies.

R=researcher P/I=promotora/interpreter P=patient

R: Um, how do you think you got the illness? What caused it?
P/I: Que lo que causo.
What caused it?
P: Um. (5) Pienso, bueno? X xx nada yo le xx [ininteligible]
Um, I think, well? Xxx[ininteligible]
P/I: She thinks that she drank a very cold coke when she was hot. So.
R: mhmm.
P/I: Last week. And that started the cough. And then everything else came
from the cough.

The hot-cold dichotomy, popularized in the anthropology literature by Robert

Redfield (1934) and George Foster (1994) contends that all foods, herbs, and some

other substances (such as iron) have a temperate as well as metaphoric value of “hot”

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and “cold.” As with the etiology example above for la gripa and the woman who was

HIV positive, some patients believed illnesses can be caused by hot or cold insults to the

body that upset the body’s equilibrium. Therapies for the most part tend to conform to

the “principle of opposites” so that a cold remedy works best for a hot illness and vice

versa (Foster 1994).

All instances of illness stemming from a hot-cold imbalance in this research

revolved around thermal imbalances of the body being unusually hot, often from the

Texas heat, and ingesting something cold, therefore putting the body at risk. Foster

(1994) also found from his extensive research in Mexico that the thermal temperature

of food or drink is cited more frequently as a factor leading to illness than the

metaphoric value. In the example above, the patient was hot outside and drank a cold

coke, thereby disturbing her natural balance which put her at risk for illness. The cold

drink caused the cough which led to la gripa (the flu or bad cold), an infection that

required antibiotics.

Some patients believed that a specific instance of strong emotion or anger

caused their illness. One person from the 30 interviews spoke of this etiology

(encounter 18), which was common throughout my two years of research at the clinic.

R=researcher P/I=promotora/interpreter P=patient

R: Okay. What do you think caused your high blood pressure?

P/I: ¿Sabe o qué piensa usted que le ha causado la alta presión?
Do you know, or what do you think caused the high blood pressure?
P: Pues yo pienso que eso me habla a mí que yo tenía la niña de ella y se las
vine a dejar y yo lloraba mucho, yo pienso que por eso me enfermé.

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 Well now I think about this that you talk to me about, I had her child [her
daughter’s child] and I came to leave them and I cried a lot, I think that is
why I fell sick.

In other words, the patient believed that her deeply felt emotion at leaving her

grandchild had caused her illness.

Other people had similar explanations that involved a specific instance of fright

or deeply felt emotion. One afternoon, two nursing students, a promotora and I went

to visit Señora Torres, a 77 year old woman who lived alone in the back of a house with

no running water. She suffered from uncontrolled diabetes with blood sugar over 500.

She explained that her diabetes was caused by a specific life event that was very

upsetting.

I asked Señora Torres if other people in her family have diabetes. She said one
son, who was in jail, and her sisters and brothers all had diabetes. I asked what
she thought caused her diabetes. She said her anger and emotions. She said
that someone killed her husband and son and since then she’s had diabetes.
N[promotora] told me that a lot of people in Mexico believe that emotions or
anger cause disease. [field notes 8-29-07]

Susto is most often described as a sickness that results from fright and is

generally classified as a Latin American culture-bound syndrome (Simons and Hughes

1985). As described in the literature, susto is due to a startling event that may cause

part of the self or soul to separate from the body. Upsetting situations may also cause

susto (Rubel, et al. 1987). Although none of the participants in this study specifically

said that susto caused their illness, they described personal traumatizing events that

they believed triggered their illnesses or made their body more susceptible to illness.

Participants could not explain why or how the event caused the illness; a traumatic

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event was simply a factor in the development of the illness. Several medical

anthropologists and researchers from the medical community report similar findings,

i.e., that Mexican-Americans and Mexican immigrants connect the cause of type II

diabetes to a traumatic event or series of events (e.g., Hunt, et al. 1998; Poss and

Jezewski 2002).

Treatment Preferences

The second area related to patients’ explanatory models discussed during the

interview was their preferences about treatments. I asked four questions specific to

treatment preferences:

8. What other treatments have you tried to help with [illness]?

11. What medicine are you taking?
12. How long have you been taking that medicine?
13. Do you feel it is working for you?

Nineteen of the thirty patients were diagnosed with chronic diseases such as

type II diabetes, high cholesterol, or hypertension. Each of these patients was taking at

least one prescribed oral medication. All patients with a chronic disease reported

during the post-encounter interview that they were satisfied with the prescription

medicine they were taking and they believed the medicine was helping.

Nine patients were diagnosed with type II diabetes; of these, three (33%,

encounters 5, 12, 22) also talked about taking some form of cactus in conjunction with

their medicine. Two of these patients had stopped taking the cactus because they said

it did not help them feel better. One man who was diagnosed with depression said he

took herbal remedies in the past but had stopped them because they did not help his

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feelings of sadness and anxiety (encounter 27). In the encounter below (12), the

patient described the reasons why she took dry cactus to help with her diabetes.

R=researcher P/I=promotora/interpreter P=patient

R: What else have you um, tried to help with the diabetes?
P/I: ¿Qué ha tratado usted de actividades por la diabetes?
What activities have you tried for the diabetes?
P: Ah, un tiempo tome una, es coma una yerba seca que me mandaron de
México.
Ah, for some time I took a, it’s like a dry herb that they sent from Mexico.
P/I: Ah, for a very long time she was taking some kind of um, herb, natural
herb from Mexico.
R: Herb, a-huh. What was it?
P/I: Cómo se llama?
What’s it called?
P: Es como si fuera um, jicama seca, así cortadita en trocitos pero es bien
amarga. Viene seco.
It’s like as if it was um, dry jicama, cut in bits, but it’s very bitter. It comes
dry.
P/I: Viene seco, okay.
It’s dry, okay.
It’s like some kind of I don’t know, jicama. It comes dry, okay.
R: Jicama, a-huh.
P/I: Very dry, so that it looks like,
P: Yo le decía que con lo amargo, eso decian en México que con lo amargo
se bajaba el azúcar y yo me lo tomé mucho tiempo.
I was telling you that with the bitterness, so they said in Mexico that with
the bitterness the sugar would go down and I took it for a long time.
R: Okay, are you still taking the jicama?
P/I: ¿Todavía está tomando la jicama?
Are you still taking the jicama?
P: No. [laughs]
R: No.
P: No, porque no se me quitó nada. [laughs]
No, because nothing happened.

Similar to the illness model for a hot-cold imbalance, this patient described how

a bitter herbal treatment was said to cure her diabetes, an illness that is caused by too

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much sugar. Whereas a relatively small number of participants spoke about using

alternative therapies such as herbs or cactus to treat diabetes, other researchers have

found that the number of Mexican immigrant participants who used “home remedies”

to augment their medial prescriptions was as high as one-third of the participants

(Brown and Hanis 1999).

Course and Outcome

Other aspects of Kleinman’s explanatory model theory, such as course and

outcome of the illness, were not as fully discussed with all patient participants

compared to comments about their illness etiology and treatment preferences. Patients

who had a chronic illness talked about behavior changes that they knew were important

but were difficult to strictly adhere to, such as regular exercise or a special diet. Several

patients brought up that during the course of their work day, they were on their feet

and that should “count” as their exercise, or that they could not fix special meals when

they were the only ones in the family who required a healthy option.

Patients with diabetes, in particular, told stories of friends and family members

who had suffered from diabetes and eventually died from complications associated with

diabetes. These stories made the reality of the disease very stark and scary for them

and served as personal reminders of what might happen. When talking about loved

ones who had died from diabetes, though, patients did not attribute blame. That is,

they refrained from commenting whether death was just an inevitable progression of

the disease, or if these loved ones did not do enough to control their diabetes.

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 Patients who described a “mixed” etiology of cultural and biomedical beliefs, or

those who augmented their biomedical oral medications with herbal treatments,

indicate fluid movements between traditional and Western ethnomedicines. This data

supports the view of pluralistic explanatory models of disease as patients talked about

traditional and mixed etiologies of their illness and four spoke about herbal treatments

(Leslie 1980, Poss and Jezewski 2002). These patients, while having more traditional

beliefs about their illness, also are regular patients in a biomedical clinic and take

prescribed Western medicines.

This research also contradicts prior assumptions that people would not utilize

“modern” health care if they suffered from an illness believed to be caused by “cultural”

agents (Pelto, Bentley, and Pelto 1990). Many participants had multiple etiologies and

ideas in their explanatory model and most were influenced by the biomedical model.

When people move across borders, either within Mexico, or from Mexico to the U.S.,

their traditional illness models may undergo transformations as they encounter new

ideas and experiences. These transformations may be gradual, assisted by repeated

exposure to Western medical concepts and experiences with medications. This is

especially true for patients with chronic illnesses that require periodic medical visits in

which the patients are likely to receive reinforcing information about Western

biomedicine.

Considering the high number of Latin Americans who have diabetes, it is

surprising how little is known about their knowledge, beliefs, practices, preventative

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measures, and treatment preferences towards the disease. According to a national

examination survey, Mexican Americans are almost twice as likely as non-Hispanic

whites to be diagnosed with type II diabetes. They have higher rates of end-stage renal

disease, caused by diabetes, and they are 50% more likely to die from type II diabetes as

non-Hispanic whites. 31 Further research is needed to investigate early prevention

practices for Mexican immigrants who suffer from diabetes, as well as other illnesses.

IV. Discussion

To summarize, patients and clinicians in this sample of 30 encounters exhibited a

range of communication strategies to share medical and lifeworld information:

• Nine followed a pattern outlined by Mishler (1984) of an “unremarkable

interview,” meaning there was no lifeworld talk. All but one patient reported

satisfaction with this type of visit.

• Six followed a pattern not typically found in the medical literature, a pattern I

labeled “clinician initiated lifeworld.” In these encounters the clinician tried to

establish rapport to better understand his patient by making casual conversation

about the patient’s life. In most instances, patients did not engage by talking

about their lifeworld.

• Fifteen patients talked about their lifeworlds; of these, 12 lifeworld

conversations were engaged by the clinician and three were ignored. Six

31
http://minorityhealth.hhs.gov/templates/content.aspx?ID=3324 accessed 3/2010
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 patients focused their lifeworld conversation on finances or joblessness; in two

of the 15 encounters, cultural differences were observed.

Clearly this examination indicates that patients share lifeworld narratives in the

medical encounter to a greater degree than some medical research suggests (Mishler

1984; Tuckett, et al. 1985; Ainsworth-Vaughn 1998). A major theme of lifeworld

narratives in this sample of predominately first-generation Mexican immigrants was

finances and joblessness, socio-economic issues rather than cultural differences. This

data further show that when patients and clinicians have discordant cultural

backgrounds or speak different languages, an automatic “cultural barrier” does not exist

as many cultural competence models assume, even when patient’s health beliefs are

culturally different from biomedicine.

In two encounters, cultural differences were vocalized by the patient. While

anthropologically interesting, the focus on this research is not Mexican ethnomedical

beliefs per se. The focus is centered on the information vocalized in the medical

encounter and how participants grapple with the issues that are communicated during

the encounter.

When differences in ethnomedical beliefs between patients and clinicians

materialized, both encounters were problematic and unsatisfactory for the clinician and

patient. The post-encounter interview data show that other patients had cultural

differences in ethnomedical beliefs, but these patients did not speak about these beliefs

with the clinician. Their encounters were satisfactory and their expectations were met.

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Thus, in these cases it is not cultural differences in isolation that are problematic, but

rather that their presence may cause problems.

The question becomes, whys some patients who had cultural differences related

to disease etiology or treatment preferences vocalized those differences and some did

not. Additionally, how did the clinician respond to the differences in health beliefs and

how might other strategies facilitate a mutually acceptable treatment plan? The next

two sections will discuss these crucial questions.

Which Lifeworld Information is Discussed with Clinicians

Ethnographic research from multiple medical practices in the United Kingdom by

Barry and colleagues (2000, 2001, 2002) help add a new lens from which we can analyze

this data. A relatively new concept in the medical communication literature is that of

patient agendas. An agenda includes the reasons the patient came to the encounter

and it encompasses the patient’s concerns, emotional and social issues, diagnostic

ideas, illness fears, and expectations (Barry, et al. 2000). The concept of patient agenda

is similar to the explanatory model concept but it encompasses the specific goals of

what the patient wants to happen from this specific medical encounter. Barry, et al.

(2000, 2001) research revealed that patients in general practice had several agenda

items (5+), or specific reasons for being at a clinic, but they did not voice their full

agendas in the medical visit. When they did, patients often voiced agenda items that

were in the biomedical realm; social and emotional topics were the most difficult and

least likely items to be discussed (Barry, et al. 2000).

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 This present study also examined patient agendas as a means to triangulate and

compare the patient’s primary goals of coming to the clinic to what was observed during

the encounter. The post-encounter interview focused on three specific questions aimed

at eliciting patient agenda items:

1. Why did you come to the clinic today?

2. What did you want the doctor to do for you today?
3. Did you want a specific medicine or treatment for your illness?

The answers to these questions provided information that was compared to the

patients’ lifeworld narratives during the clinical encounters to determine whether or not

there was a relationship between the two. This comparison finds that all but three

lifeworld narratives were related to the patient’s agenda. The majority of patients

brought up lifeworld issues when 1) their lifeworld intersected with their agenda, and 2)

the communication strategies of both participants enabled lifeworld narratives to

emerge in the encounter.

The telling of a lifeworld narrative, then, does more than bring the human

element to the encounter, a patient’s feelings and experiences. Lifeworld narratives can

function as a communication strategy that allows patients to voice their knowledge and

agenda items in a linguistically appropriate way. Telling a lifeworld narrative can be a

polite and deferent way for patients to exercise power over the encounter (Ainsworth-

Vaughn 1998). For example, in the first case study from chapter four, Señor Hernandez

discussed lifeworld narratives that dealt with treatments he did not want to have for his

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arthritic knee. He told these stories because one of his agenda items, reported to me

during the interview, was to get his knee examined and treated.

Thus, the research points to several hypotheses. First, patients who held

culturally different health beliefs about their illness, but did not talk about them in the

encounters, did not do so because their health beliefs were not associated with their

specific agenda for that visit. In two encounters, for example, the lifeworld issue that

intersected with the patients’ agenda happened to be culturally different ethnomedical

beliefs. In short, the woman with la gripa came to the clinic to secure antibiotics for her

illness, an illness that was caused, she believed, by drinking a cold coke on a hot day.

She did not believe, as Mr. Mills did, that she had allergies. Thus, she vocalized her

health beliefs, that she needed antibiotics, because they intersected with her agenda.

Other hypotheses about why more narratives did not contain culturally different

health beliefs include: 1) financial issues were more pressing than culturally different

health beliefs for patients, 2) most of the patients with cultural health beliefs also had

explanatory models that incorporated biomedical treatment, and 3) patients did not

discuss their health beliefs for fear of being criticized; they have learned what not to say

to clinicians. This last hypothesis may be less valid at the People’s Clinic because

patients said, over and over, that they trusted this clinic and the promotoras who

worked there. In fact, they recommended this clinic to their neighbors and family.

Fundamentally, all communication and dialogue is co-constructed in the

moment, by each participant. Participants may have intended to talk about a particular

218
issue, but decided not to; or there may have been no communicative space to do so.

The concept of patient agendas helps to recognize the function of lifeworld narratives

and improve our understanding of why certain lifeworld narratives may have been

brought up while others were not.

Clinician Response to Cultural Health Beliefs

Culturally competent clinicians and those who utilize patient-centered strategies

are encouraged to elicit and discuss their patients’ health beliefs and explanatory

models (see Chapter three for an overview of these theories). The data from this

research suggests that differences in ethnomedical models between patients and

clinicians pose challenges for both patient and clinician in a medical encounter. Two

encounters in particular contained differing explanatory models which produced

dissatisfaction for clinician and patient alike and hindered the patient’s agenda from

being fully realized and acted upon.

What were the strategies used by participants in these two encounters and

might additional or different strategies have resulted in mutual acceptance or

satisfaction? Both clinicians asked detailed and open ended questions. Both female

patients provided their explanatory models of la gripa (severe infection, like the flu) and

sores/infection, respectively, and believed that a thermal imbalance caused their illness,

although the woman with la gripa did not overtly verbalize this in the medical

encounter. Both clinicians provided their respective explanatory models of allergies and

HIV.

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 However, in both encounters, after patients stated their health beliefs, the

clinicians employed a health education strategy instead of discussion. For instance, in

the first example, Mr. Mills believed the patient to have allergies, but he realized that

the patient believed she had an infection and wanted antibiotics. Mr. Mills engaged in a

side conversation with the promotora to confirm that the patient “wasn’t buying any of

it.” He then attempted to educate the woman by providing information about bacterial

infections, viral infections, and allergies. He talked about the dangers of using

antibiotics when they were not medically necessary and even drew several diagrams

about multidrug resistance. Likewise, with the HIV positive patient, the clinicians

focused their efforts and time on providing education about HIV-AIDS.

In both instances, the patient did not understand the educational information

nor believe what the clinician said to be true. In the first example, after hearing the

information, the patient told the clinician, “Okay I don’t understand everything you have

told. I just want something to make me better, I don’t want to return with a cough.” In

the second example, the woman with HIV denied several times that she had HIV and

repeatedly said she did not trust the U.S. medical system. Thus, an educational

approach on “correct” health beliefs was not a successful strategy in either situation.

The explanatory model was designed to be a tool for negotiation between

clinician and patient to allow clinicians to talk with their patients about health beliefs.

Increasingly, it is only used to elicit the patient’s model without engaging in a dialogue

about both models and how they may overlap (McNees 2001). Clinicians can be

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challenged by their patients’ cultural and health beliefs coupled with the belief that

their own biomedical knowledge is more correct, factual, and rational. “The underlying

goal of such behavior seems to be to render "difference" comprehensible from the

biomedical perspective, in order to promote better control of patient behavior” (Hunt

and Arar 2001: 350).Therefore, even when clinicians ask patients about their knowledge

and health beliefs, these beliefs are often viewed as “misconceptions” with the need on

the part of the clinician to re-educate the patient’s health knowledge.

What was missing from both encounters was a conversation and negotiation

about health beliefs with a view that they could both be valid. Mr. Mills never asked the

female patient with la gripa, “Why do you think you have an infection that needs

antibiotics?” Or, “What caused your infection?” Similarly, the clinicians who saw the

woman with HIV did not get to the root of her beliefs and her distrust with the U.S.

medical system.

As in the first cultural example, even after Mr. Mills negotiated a treatment plan

that included antibiotics which should have been acceptable to the patient, the patient

reported in the interview that she was not satisfied because she felt Mr. Mills should

have seen that she had an infection and trusted her feelings. Instead of “education” in

these situations, this data suggests it may be more effective for clinicians and patients

to discuss a common view of the illness and a treatment plan that is possible and

practical, given the specific circumstances of patients’ environments.

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Summary

Many anthropologists have documented culturally different explanatory models

or health beliefs of specific illnesses such as diabetes, high blood pressure/hypertension,

depression, etc. They have written extensively about Central and South American

cultures, customs, healing beliefs and practices, and their ethnomedicines (for example,

Foster 1953, 1994; Rubel 1960; Kiev 1968; Ingham 1969; Clark 1970; Garro 1986; Finkler

2004). The early work of Foster (1953), Rubel (1960), Clark (1970) and others moved

ethnomedical research in anthropology away from studying the exotic practices of

immigrants to a richer understanding of health and illness in the broader sociocultural

arena. They also foreshadowed the problem of culturally appropriate practices in

medicine and low utilization rates of biomedicine among immigrants and minorities

(Browner 1994).

Building on the information gleaned from previous anthropological research, this

study looked at the next obvious question: what happens when explanatory models of

patients and clinicians conflict in a medical encounter? Are cultural competence

strategies, alone, sufficient to engage both patient and clinician in discussion that results

in a satisfactory medical encounter?

The results documented in this chapter detail the type of information patients

and clinicians share during a medical encounter, as well as the role that lifeworld

narratives can play to introduce patient agenda items. It also demonstrates that cultural

differences in health beliefs, while present between patients and clinicians, only

222
surfaced in two of thirty encounters. Despite the importance and role of health beliefs

or explanatory models in cultural competence, this research showed that when

clinicians elicited these responses, they did not know how to use the cultural

information they obtained. They did not know how to move beyond this phase to a

meaningful dialogue and negotiation process with the patient.

The next chapter will introduce the third primary participant, the interpreter, or

promotora. Chapter six highlights the various roles that the promotoras held at the

clinic, the communication processes that fostered accurate interpretations, and how

promotoras shaped the course of the medical encounter.

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 Chapter Six: Medical Interpreting

“Language is the framework in which the world view of a culture

is molded, and it describes the boundaries and perspectives of a
cultural system. A language barrier disarms a communicant’s
ability to assess meanings, intent, emotions, and reactions and
creates a state of dependency on the individual who holds the
keys to the entire process – the interpreter” (Putsch 1985: 3344).

Research has associated language barriers with the increased potential for

misdiagnoses and inappropriate treatment, the need for repeat visits, inadequate

informed consent, and dissatisfaction in the quality of communication and care among

patients and clinicians, among other outcomes (Elderkin-Thompson, et al. 2001; Flores,

et al. 2003; Simon, et al. 2004; Dysart-Gale 2005). Interpreters are often perceived as

the solution to bridge these barriers.

This chapter brings attention to the clinic promotora and interpreter, her

relationship within the encounter, and her roles at the clinic. Medical interpreters

influence the texture of information in the medical encounter, the amount of

information provided, and what is understood amongst participants. Further, despite

the fact that the uniquely powerful role of an interpreter is situated at the juncture of

negotiation and exchange, little has been said about the linguistic and social role of

interpreters in medical encounters (Davidson 2000; Hsieh 2010).

One objective of this study was to broadly understand how English-speaking

clinicians, interpreters, and Spanish-speaking patients perceived the challenge of

communicating across a language barrier. Most similar studies have surveyed or

interviewed either clinicians, or interpreters, or patients (e.g., Kline, et al. 1980; Baker,
224
et al. 1996; Baker, Hayes, and Fortier 1998; O'Leary, Federico, and Hampers 2003).

Inclusion of all three groups permitted a triangulated view of the issues and concerns

facing the primary participants in bilingual medical encounters. This research was

conducted to answer such questions as, what is the role of medical interpreters and

how are they trained? How do interpreters shape the course and outcome of a medical

visit? What is the relationship between clinicians and interpreters? Responses to these

questions are offered in this chapter.

I. The Complex Dynamics of Medical Interpreting

Accuracy, completeness, and impartiality are among the standards most often

cited as the ethical pillars of professional medical interpreting (Cross Cultural Health

Care Program; National Council on Interpreting in Health Care 2005 32). Generally

speaking, interpreters must overcome several major challenges in their efforts to

respect these three interlocking standards. These challenges include, among others:

1) Dissimilarities between languages, which may prevent certain stock (including

medical) phrases, idioms, metaphors, and other language formations from being

easily and meaningfully converted from one language to another. Languages

that are phonetically and otherwise very dissimilar to one another, such as

Burmese and English, make this process more challenging.

2) Differences between biomedical and everyday discourse, including ‘doctor-talk’

and ‘patient-talk’ (Shuy 1974; Mishler 1984). The former is often arcane and

32
http://www.ncihc.org/mc/page.do?sitePageId=57768andorgId=ncihc, accessed 3/2010
225
 rooted in clinical concerns, while the latter is reflective of the patient’s everyday

language and individual and social concerns.

3) Normative differences between patients and/or families who do not share the

biomedical notions about truth telling and the right to know, the need to treat,

and other moral and ethical assumptions. These and other differences can

strongly affect interpreted informed consent and ethics consultations, among

other health care interactions (Kaufert and O'Neil 1990; Simon, et al. 2003).

Thus, an interpreter who is asked to translate an encounter between an English-

speaking, Caucasian clinician and a Spanish-speaking, Mexican patient will likely need to

bridge: 1) linguistic differences between English and Spanish, 2) discursive differences

between biomedical professionals and laypersons, and 3) normative differences

between European-American and Mexican culture. Furthermore, a triadic medical

encounter will entail different communicative norms than in monolingual talk, for

example specialized speech activities such simultaneous interpreting (Hsieh 2010).

Shifting Conceptions of the Interpreter’s Role

Many professional codes of ethics and medical institutions in the U.S. place

heavy emphasis on the notion that interpreters should function merely as conduits, or

faithful echoers, of the information flowing between clinician and patient. As scholars

have suggested, this view of the interpreter’s role is rooted in a distinctly American, as

well as Western, model of information flow (Kaufert and Koolage 1984; Dysart-Gale

2005). In this view, information travels in a linear fashion, moving between senders and

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receivers, with the interpreter serving as a “conversion point” in the transmission

process. Critics of this model have emphasized that it does not take into account the

fact that mere conversion would leave much information unintelligible given the

discursive, cultural, and other differences evident among health care senders and

receivers (Haffner 1992; Dysart-Gale 2005). The conduit model and its mechanistic

positioning of interpreters is potentially also demeaning and disrespectful of the

interpreter’s capacity for creative, compassionate, problem-solving thought and action

(Kaufert and Putsch 1997).

Accordingly, some researchers have sought to broaden the interpreter’s role and

to conceive of it in less linear and more interactive terms. Anthropological,

communications, and other literature advocates that interpreters be allowed to act as

linguistic as well cultural “consultants,” “mediators,” “advocates,” and “brokers”

(Kaufert and Koolage 1984; Erzinger 1991; Haffner 1992; Dysart-Gale 2005). The

potential merits of broadening the interpreter’s role to include these and other

functions include enhanced understanding on the part of the patient and clinician,

increased patient satisfaction and comfort, and improved self-image among

interpreters. Cultural brokerage on the part of interpreters can also play a key part in

establishing trust between biomedical practitioners and local communities in parts of

the world where biomedicine is not necessarily the first and most trusted health care

option (Kaufert and Koolage 1984).

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II. The Role of Promotoras at the Clinic

Three years prior to my entry, the People’s Clinic hired promotoras, or lay female

health promoters, to provide interpreter services for their increasingly Mexican

immigrant population. During my two years of observation, there were three core

promotoras, including one “lead promotora,” and two to three promotoras who worked

for a few months before quitting or being fired. The promotoras were all single mothers

who had high school educations. All but one was a first generation Mexican immigrant.

Promotoras acted in several roles simultaneously, such as interpreter, advocate,

culture-broker, educator, and at times, even para-clinician (Davison 2000). The

promotoras were often the “face” of the clinic: they were the first ones to greet

patients; they took the patient’s vital signs and then later interpreted for the patient;

and the promotoras, because of clinic outreach activities in the neighborhood and at the

two local elementary schools, were often known within the community as health

workers.

Promotoras as Familiar Agent

The significant and strong connection of promotoras to the clinic became clear at

one of the clinic fundraising luncheons. The lead promotora, Nina, was asked to give

brief remarks about her role at the clinic.

Nina stood up at the front of the room and began to read the prepared
paragraph that she had written. Then, as she was nearing the conclusion of her
remarks, she looked up and folded the paper. She tried to speak, but her voice
shook. She was obviously emotional. She held her hand out to Mr. Kendall
(clinic medical director) who was sitting nearby and motioned for him to stand
next to her. She held his hand for support and said, “When I first came here, it
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 was as a patient. They helped me so much when I had nowhere else to go.
When I see the people coming in here, they see Louisa and I and they know they
have found a place to trust. They don’t have anywhere else to go…” She started
crying. Then Louisa, another promotora started crying; a man at my table began
to tear up, as were some people sitting behind me. It was a powerful moment,
not only for Nina, but for those in the audience, i.e., potential donors to the
clinic. [field notes 1-19-07]

As Nina’s story illustrates, the promotoras, because they were from the local

community and were also first generation Mexican immigrants who faced similar

hardships, represented familiar faces to patients, faces that fostered trust. During an

interview, one family nurse practitioner described this connection as a “comfort” factor:

During the interview Mary told me that many times she tried to communicate in
Spanish but the patient didn’t understand even though she was saying the words
correctly. Then, when the promotora came into the room and said the exact
same thing, the patient understood. I asked Mary what she thought was
happening. She said, “…I think it’s a comfort thing. When you’re sick and you
are vulnerable, you need a connection. Sometimes we can’t be that
connection.” [family nurse practitioner interview]

Thus, promotoras not only interpreted the clinicians’ words, but were viewed as

a connective force or familiar agents for the Mexican immigrant patient population.

Promotoras as Advocate

Promotoras acted as advocates for patients at the clinic as well as for people

who needed help obtaining healthcare outside the clinic. Examples have been shared

throughout this dissertation of advocacy at the medical encounter level, such as a

promotora advocating for antibiotics for a patient. Some instances of advocacy helped

patients receive health care they otherwise would not have received. The following is

229
an example of how promotoras acted as an advocate when helping a patient who did

not know how to navigate the U.S. health care system.

Nina, the lead promotora, told me about a confused elderly woman who came to
the clinic. The woman brought a letter addressed to the county hospital, written
by a ministry clinic a few miles away. The letter provided health information
about the woman and asked for an appointment as soon as possible; she had
cervical cancer with an increase in vaginal bleeding in the last few months.
However, it was evident to Nina that this woman did not know where she was
and what she was doing. Eventually Nina drove the woman to her home so that
she could see if the woman lived with family members. Nina helped the woman
gather required documents to apply for the county hospital “insurance” card.
Ms. Kendall, the clinic social worker, called the hospital and eventually, after
speaking to several people including a doctor about the seriousness of the
situation, made the woman an appointment for the next week. [field notes 9-14-
06]

This woman, who was later confirmed as mentally disabled, was sent from a

local ministry clinic to the large county hospital with only a letter detailing her medical

history. Once Nina realized the woman did not have the mental capacity to secure the

required documents, complete the forms, and make an appointment at the county

hospital, she guided the woman through this process and acted as her interpreter and

advocate by accompanying her to all the appointments for treatment of her cervical

cancer. Nina was not financially reimbursed for this work, but over the course of my

research at the clinic Nina helped several older women in similar situations. She once

told me that she hoped someone would do the same, for example, if her grandmother

were in need.

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Promotoras as Culture-Broker

The culture-broker role was not as obvious and prevalent as the other roles held

by promotoras held, possibly because cultural differences did not surface in the medical

encounter as frequently as other topics, such as finances and joblessness. In the

following example, the family nurse practitioner (FNP)/midwife was seeing a 31 year old

Mexican woman for a follow up visit. The patient’s test results from her prior exam

showed she tested positive for Chlamydia.

The FNP frankly told the patient that she had Chlamydia and explained the
disease, as well as the fact that it was treatable. She asked the patient if she had
any sexual partners other than her husband and the patient replied, “no.” The
patient mentioned that she didn’t know if she could tell her husband because
when she told him she had a pelvic exam he got mad and asked what she did
that she needed that exam. The FNP reinforced that she needed to talk to her
husband because she could be treated, but if they didn’t use a condom [patient
shook her head at this] and he didn’t get treated, then the patient could be re-
infected again, which may cause infertility. The patient asked another question
and the FNP said, “The question she should be asking is if she wants to be
married to someone who is sleeping with other women.” Before the promotora
translated this, the FNP asked her a couple of times, “Is that a culturally
appropriate thing to say?”and the promotora said “yes.”[field notes 11-2-06]

Thus, when promotoras helped clinicians understand a cultural difference, it was

often to explain a traditional herbal remedy such as taking cactus for diabetes or how to

say something in a culturally appropriate way. Noticeably, during the two encounters

that contained differences in cultural health beliefs, discussed in Chapter five, the

promotoras did not step outside their interpreter role to act as a culture-broker.

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Promotoras as Educator

A forth role that promotoras performed was one of educators. Since the

promotoras’ job duties included providing basic health care information to patients,

such as signs of hypo- and hyperglycemia (high and low blood sugar level), they often

spoke with patients informally about their illness and treatment. During one medical

encounter I observed, the clinician stepped out of the room for a few minutes and the

promotora and patient discussed the patient’s life and his diabetes.

After the clinician left, Louisa and the patient started talking about the patient’s
job. He was a painter from El Salvador and worked in Mississippi on new houses
being built. He comes back here to see his family every six weeks. Then the
patient asked a question about his diabetes medication and Louisa told him how
to take his medicine and that it was really important. He said that his mother
died from diabetes and then said that his priest told him he was cured from
diabetes and didn’t have to take medicine anymore. Louisa told him there were
two kinds of help, one from God and one from medicine. Then the clinician came
back in the room and they stopped talking. [field notes 10-12-06]

Although patient education was an important aspect of their job, promotoras

had difficulty providing formal education. Most times clinicians had to prompt

promotoras to speak with the patient on a certain subject. The clinician might say, “Be

sure to go over signs of hyperglycemia.” Additionally, even though promotoras were

one of the responsible team members for implementing a type II diabetes intervention

program, I never observed them reviewing a program lesson with a patient who had

diabetes.

Several times the medical director, Mr. Kendall, asked my advice about how to

encourage promotoras to take more responsibility for patient education and patient

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well-being. He wanted to move their responsibilities from interpreting and taking vital

signs to initiating conversations about diabetes, obesity, or smoking. He said that he

hoped my observations of the clinic could help him find a way to instill a sense of

ownership in the promotoras.

Observations indicated that a primary reason for this lack of ownership was that

no training was provided for promotoras. They were not required to have formal

training in medical interpreting nor did the free clinic offer formal training. This lack of

training seemed to exacerbate their already unclear job roles and responsibilities.

Training could have instilled a sense of ownership and responsibility across their roles

and solidified their accountability in each role. A training program may also have helped

ensure quality and accurate interpreting, and fostered increased clinician trust in the

promotoras, an issue that each clinician spoke about in his or her interview.

Promotora as Para-Clinician

Finally, some promotoras took on the role of para-clinician (Davidson 2000). This

occurred when the promotora gave her own medical advice, added or omitted a

patient’s medical history or symptoms to the clinician, or took over the role of the

clinician. While I never observed an encounter in which the promotora gave her own

advice, two clinicians remarked on the role during their interviews. The pediatric nurse

practitioner (PNP) explained that she did not mind when the promotora gave medially

sound advice, but thought it inappropriate when the advice was incorrect.

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 PNP: …I’ve actually heard the interpreter give misinformation. Ah, just not
saying what I had just said, throwing in a bit of her own advice, which was
inappropriate for the patient.
R: If she had given good advice would that have bothered you?
PNP: No, no good advice does not bother me.
R: So it’s not that she said something different from what you said.
PNP: No, I don’t need to be interpreted literally. But I don’t want to hear, she
was recommending Vicks Vapor Rub, which you do not want to use on
children because it has camphor in it which is a poison. She just threw
that in, her own personal advice. Now it’s fine if it weren’t something I
would never ever advocate or recommend it because toxicities are so
different for children and adults.

The role of para-clinician occurred more frequently when promotoras were in

encounters with nursing students. Because nursing students were still learning the

correct sequence of questions to ask about a particular disease, the promotoras, as

women familiar with the routine nature of questions, sometimes controlled the medical

encounter. The following example occurred in the waiting room; the young patient and

her mother were the first people in line to see the clinician, and a student nurse was

attempting to take a brief history.

The patient was a one year old girl and she had been crying for over 15 minutes
in the waiting room. The nursing student did not know what to do. Finally, after
a couple of minutes, the student asked the mother if she had given the patient
anything for her fever. The mother responded that she had given the child
Motrin two hours ago. Then the promotora started asking her own questions in
Spanish: how was the cough, was it productive, what color was the phlegm, how
long had the patient had the fever. Then the promotora told the student the
answers. When the student finally took over this role, she asked her questions,
but looked at the promotora for guidance. [field notes 11-2-06]

Thus, as some promotoras gained knowledge, they began to “claim” medical

expertise. While this role may be acceptable for some clinicians, as with the pediatric

nurse practitioner above, other clinicians may chafe at this intervention if the

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interpreter’s actions are not transparent. Regardless of the promotora’s medical

knowledge, her usurping of the clinician’s role might lead to clinician distrust.

II. Accuracy in Interpreting

Clinicians have been found to rate “accuracy of interpretations” above other

issues they are concerned about in interpreted encounters (Abbe, et al. 2006). Because

of this importance, the majority of research on medical interpreting reports the

frequency and kinds of errors interpreters make (Davidson 2000, 2001; Elderkin-

Thompson, et al. 2001; Flores, et al. 2003). In fact, many variables can affect the

standards of accuracy and completeness of a translation, such as interpreter and

clinician level of training and competence, nature of the environment, duration of the

encounter, and the speakers’ communication behaviors and preferences. This is

particularly important as clinicians often use medical jargon and/or speak in lengthy

dialogue making it difficult to interpret accurately (Abbe, et al. 2006).

However, the analysis for this research project was not as concerned about the

frequency of translational errors made by participants (since this type of data may only

be helpful for the specific participants involved in that specific encounter) as which

processes or communication strategies facilitated accurate interpreting and which

factors correlated with inaccurate interpreting. This information would be more useful

to a broader audience. The following data represents the major types of translational

errors that participants made and the communicative context surrounding the error.

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Clinicians as Interpreters

Many errors occurred when monolingual clinicians did not use a promotora

during the entirety of the encounter. For example, some nursing students began the

medical encounter without a promotora present or they dismissed the promotora after

the history taking part of the encounter was over, thus having no interpreter during the

time the physical exam was conducted. Regardless of the reason for dismissing the

promotora, when she was not in the room, the encounter suffered from errors or

incomplete patient medical histories and information about the chief-complaint. When

the clinician tried to “make do” with his or her Spanish skills, the patients did not speak

as much during the encounter, or there was a significant amount of misunderstood

dialogue. The following example occurred after the nursing student dismissed the

promotora.

The male patient complained of stomach pain and told the nurse he thought he
had a parasite infection. After the physical exam, the nursing student handed
him a plastic cup with a lid. The patient asked, "Excremento?" (Excrement?) and
the student said, “Si.” (Yes) He repeated "Excremento?" and again the student
said, “Si.” Even though the student might have learned the value of using
interpreters if I had not intervened, I quickly said, "No, orinar, solamente orinar"
(No, urinate, urinate only). [field notes 2-27-07]

During their interviews following the medical encounter, patients spoke about

the lack of interpreters, usually at health facilities other than the People’s Clinic. Some

patients discussed situations in which interpreters were not available and they did not

understand the clinician, or that because there was not an interpreter, they were turned

away from seeing a clinician. In general, patients preferred clinicians who spoke

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Spanish, but all patients said they were satisfied if they had interpreters to help them

communicate.

False Fluency

A second type of situation which led to errors in interpretation was when the

promotora lacked the knowledge necessary to interpret. Two promotoras who were

hired during the period of my research simply did not have the required medical

language fluency in Spanish or English to interpret accurately. Because there was not a

formal training process, these promotoras were hired and began working despite their

lack of knowledge. As there was not a formal review process of promotoras’ abilities,

several months might pass before complaints accumulated by clinicians. The following

example demonstrates the confusion that ensues when the promotora does not know

how to translate simple body parts.

The female patient had a lot of pain in different places and the two nurses were
visibly frustrated with her vague symptoms; they talked to each other, saying
that her pain did not make sense. One reason for their frustration was that
Cindy, the promotora , did not translate words correctly. For example, when the
nurse examined the patient’s lower abdomen, the patient said that it hurt. The
nurse followed up by asking, “Does she still have her uterus?” Cindy hesitated,
and instead of asking about the patient’s uterus, she asked if the patient had
stomach pain. The woman said yes, she did have stomach pains, she had
gastritis. Cindy responded to the clinician, “Yes.” The nurse asked if the patient
had been vomiting or having diarrhea and if so, for how long. Cindy asked the
patient how long had she had gastritis and the patient answered for three years.
Cindy told the nurse “Yes, for 3 years.” [field notes 10-26-06]

In this example, Cindy was clearly not fluent in medical terminology. Her errors

moved the focus from the patient’s uterus to her stomach, and told the nurses that the

patient had been vomiting or having diarrhea for three years. In actuality, the patient

237
really said she had gastritis for three years. However, neither nurse paused to clarify

this contradiction, nor were they listening to what was being translated.

Many clinicians told me that because they were concerned about accuracy, they

monitored and listened closely to what the interpreter said in Spanish even if they were

not familiar with the language. Some Spanish words are similar to their English

counterparts, for example, stomach in Spanish is estómago and vomiting is vómitado, so

clinicians could more readily understand if an interpreter was incorrect. Another

strategy clinicians employed was to listen for congruence in the length of talk between

what they said and what the promotora said. In the following example, the clinician

repeatedly listened to the Spanish translation and frequently questioned and corrected

the promotora (encounter 24).

FNP=family nurse practitioner P/I=promotora P=patient

FNP: Hola. Me llamo C[first name].

Hi. I’m C[first name].
So um, ah, what brings you in?
P/I: ¿Qué es lo que tiene ahora?
What do you have now?
P: Pues que ando con las alergias, tengo tos por las alergias. Ya tengo un
mes así.
Well, I have allergies, I have a cough because of the allergies. It’s been a
month like this.
P/I: Her cold and her um sinus,
FNP: Okay um
P/I: She’s been a month like this.
FNP: Sinus or allergies?
P/I: Allergies.
FNP: Okay.
P/I: I call them both, sinus and allergies. It’s not the same, right?
FNP: No.

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 The promotora translated the patient’s illness as a cold and sinus when the

patient had said allergies. The clinician was familiar enough with the Spanish words and

questioned the promotora. Later in the same encounter, the clinician told the patient

that because she had high blood pressure she needed to be careful when taking over-

the-counter cold or sinus medicine.

FNP=family nurse practitioner P/I=promotora P=patient

FNP: Tell her, because she has high blood pressure, she needs to be careful
and not take decongestants because that can raise her blood pressure.
P/I: Dice que tiene que cuidar ah,
She says you have to be careful ah,
How do you say that?
FNP: Decongestant. Like Sudafed, especially.
P/I: How do you say that in Spanish?
FNP: Or like, ah, like Tylenol cold and allergy.
P/I: No mas como el Tylenol es para la gripa, sí se puede, pero tiene que tener
mucho cuidado con la otra pastilla porque se le puede subir también la
presión.
You know how like Tylenol is for the cold, you can, but you have to be very
careful with the other pill because it can increase your blood pressure.
P: Oh.
P/I: Puede tomar el Tylenol.
You can take the Tylenol.

The patient, who was on medicine for hypertension, was cautioned by the

clinician to avoid over-the-counter decongestants that could raise her blood pressure.

However, the promotora was not familiar with the term “decongestant” and asked the

clinician twice to clarify the word. Instead of defining decongestant, the clinician gave

two popular examples that were known to raise blood pressure, Sudafed or Tylenol Cold

and Allergy. The promotora did not double check her understanding with the clinician

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and made a potentially serious clinical error when she told the patient that Tylenol Cold

was safe and would not raise her blood pressure.

Omissions

Errors of omission occurred when promotoras did not fully translate words,

phrases, or whole sentences that were spoken. Typically, information was omitted by a

promotora for three common reasons. First, promotoras omitted information when

they either did not understand the information or they felt it did not add value to or

detract from the dialogue. In this example the promotora omitted information from the

patient (bolded) about her bunions (encounter 21).

N=student nurse P/I=promotora/interpreter P=patient

N: Okay, can you ask her how long has she had the bunions on her feet.
P/I: ¿Hace cuánto tiempo que tiene lo de los pies?
How long have you had that on your feet?
P: Ya tengo como un año.
It’s been close to a year.
P/I: For a year.
P: Además que me duele mucho estar así.
Also, it hurts a lot to be like this.
N: And are they getting bigger and bigger too?
[
P: Pienso que por los zapatos.
I think it may be the shoes.
P/I: ¿Se están haciendo más grande?
Are they growing bigger?
P: mhmm

In this example, the promotora omitted the patient’s symptoms that her bunions

are painful and that she believed them to be caused by her shoes. In context, the

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interpreter may have felt that the symptoms did not add to or detract from the

dialogue.

Omissions also have the potential to change the quality or texture of talk. The

promotora in the next example excluded the clinician’s apology for the time the patient

had to wait. This patient waited over an hour in the exam room and his responses

throughout the encounter were very curt and abrupt. Had the patient heard the

apology he may have been more participatory and satisfied with his visit (encounter 26).

FNP=family nurse practitioner P/I=promotora/interpreter

FNP: Okay, Mr. [last name]. I’m [name], I’m the nurse practitioner here. I’m
sorry you had to wait so long. Uh, nevertheless. Okay. Can you have a
seat up here?
P/I: Tome asiento.
Have a seat.

Second, promotoras omitted information when clinicians spoke several

sentences at once without pausing for the promotora to interpret. At the end of one

encounter, the nursing student gave the patient new medicine for her diabetes and

dyslipidemia (high cholesterol). However, because she spoke several sentences at once

and used medical jargon, such as dyslipidemia, the promotora omitted the instructions

for how to take both medicines as well as other important information (encounter 19).

S=nursing student P/I=promotora/interpreter

S: And this is Actos, and this is one pill, one time a day. And for these, can
you tell her to look for if she’s having some signs of dizziness or light
headedness, or like her heart starts pounding or something, it’s called
hypoglycemia? It means her blood sugar is getting too low and to drink
some orange juice or have some candy, something like that.
P/I: Si se marea o si le duele la cabeza, dice que tome como jugo de naranja o
un dulce que es lo mismo de las medicinas, porque le está bajando.
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 If you get dizzy or you get a headache, she says that you should take an
orange juice, or a candy, which is the same as the medicine because it’s
going down.
S: Okay, um, this Tricor, where is this one, okay, this one is for her
dyslipidemia. She needs, the important one about this is one pill one
time a day. The important one about the Tricor? This one has side
effects of nausea and vomiting and diarrhea? So can you tell her.
P/I: Esta tiene efectos secundarios de nauseas, diarreas o vómitos.
This one has nausea, diarrhea, and vomit as side effects.

Again, the promotora gave incomplete information and did not explain to the patient

how and when to take her medications, potentially causing a clinical error.

Finally, promotoras omitted information when clinicians spoke in a certain way

that did not signal a “patient communication” code, such as “teaching” codes or “talking

to oneself” codes. These are known as “frames,” which are mental cognitive structures

surrounding a piece of discourse marked by pitch, register, and nonverbal cues which

allow the hearer to make sense of the information (Tannen and Wallat 1986, 1987).

Because many encounters included student nurses and family nurse practitioners, they

frequently spoke with one another about the patient’s symptoms or illness in a

“teaching” code. The manner and style in which they spoke to each other, often facing

or looking at each other, while using medical jargon, signaled to the promotora not to

translate the information to the patient.

However, in some encounters, the clinicians, after discussing the patient

amongst themselves and deciding on a course of action, forgot to then communicate

the information back to the patient. In the following example, a male patient came to

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the clinic for his lab results. A family nurse practitioner (FNP), nursing student,

promotora, and I were in the room.

Both nurses were speaking at once making it difficult for the promotora to
translate. The nurses did not know why the patient was sent for a blood test at
his prior visit, if there was a specific reason. The nursing student asked the
patient if he knew why he was sent for labs and he said no. The FNP and student
reviewed the lab results and the FNP told the student that the results ruled out
anemia and high cholesterol. But this was not translated to the patient because
it was said in “teaching code.” The FNP then dismissed the promotora and
conducted the physical exam. She put the stethoscope up to his chest and said
in English, “breathe deeply.” The patient did not know what to do. She
continued the physical exam in English. The two nurses left the room without
saying anything to the patient. The patient then asked me, “Was there anything
wrong with my labs?” [field notes 10-12-06]

This type of omission, caused by a specific clinician frame, or way of speaking,

became apparent when a professional interpreter volunteered one day at the clinic.

The interpreter, an attorney from Venezuela who worked as a courtroom interpreter

while studying for the U.S. bar exam, brought attention to these kinds of omissions. A

family nurse practitioner (FNP), nursing student, volunteer interpreter, and I were in the

room.

The FNP told the nursing student that the patient’s diabetes was under control.
He opened her chart and talked with the student about the patient’s urine
analysis and said that her weight loss helped her blood sugar level. The new
interpreter asked, “Should I translate that?” and the FNP said “Yes.” At the end
of the encounter, the FNP instructed the student to review the symptoms of
hypoglycemia (low blood sugar) since the patient had lost weight and was doing
really well. Again, the interpreter asked if she should translate that and the FNP
responded positively. [field notes 1-12-07]

Thus, when a trained interpreter was faced with dialogue spoken in a different frame,

she clarified with the clinician whether she was supposed to translate that dialogue

243
rather than omitting it. The trained interpreter likely was introduced to national codes

of professional ethics that stressed that interpreters need to interpret all and only what

was said (Cross Cultural Health Care Program; National Council on Interpreting in Health

Care 2005).

Many errors in interpreting occurred, then, because the relationship between

promotora and clinician was unclear or not defined and defaulted to a hierarchical one

with clinicians having the higher status and authority. Even when promotoras were

uncertain of how to translate jargon or when the clinician spoke several sentences at

once, promotoras did not follow up to clarify or ask the clinician to slow down and

repeat what was said. This could be due to a lack of training about the mechanics of the

interpretive process coupled with the fact that their role was perceived as less powerful

than the role of clinician. The higher status of the clinician, though, tended to place the

entire burden of accuracy with the promotora.

III. Promotora-Clinician Relationship

Trust and Transparency

In their interviews, clinicians reported a concern with the accuracy of

interpretations and level of transparency, above other factors. This finding is

comparable to other research on clinicians’ concerns in interpreted medical encounters

(Abbe, et al. 2006). Trust is the degree to which clinicians, interpreters, and patients

believe in and rely on each other’s actions. Transparency refers to the level of

understanding and awareness participants have of each other’s actions in the

244
interpreting process (Abbe, et al. 2006). Trust, then, is inextricably linked with levels of

transparency.

Nursing students, who were often unfamiliar with using interpreters in general,

and especially these specific promotoras, reported experiencing a greater lack of trust

between themselves and promotoras. Nursing students reported that this lack of trust

was primarily caused because they did not receive training on how to work with

interpreters in school or at other medical facilities where they were employed. One

nursing student said she could tolerate minor inaccuracies as long as the promotora

communicated the “big picture.” In her interview she said, “I have a trust problem with

interpreters. Are they really saying what I am saying? It’s okay as long as the big picture

was conveyed.”

On the other hand, clinicians who had an established working relationship with

the promotoras, such as the family nurse practitioners, had greater trust. For example,

one family nurse practitioner who volunteered weekly mentioned that trust in a

promotora was something that came with time and repeated exposure between the

two.

Mr. Mills mentioned by name the two promotoras he trusted a “great deal.”
When I asked why, he said that since they worked together frequently, these
two promotoras both knew his next question or utterance almost before he
spoke it and he trusted them because he had confidence that they both knew
what they were doing. However, he said that sometimes he wanted to tell the
patient something in a certain way and he was unsure of the manner in which
the promotoras said things on their own. [interview with Mr. Mills, FNP]

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 Mr. Mills’ comments in the interview highlighted two main themes related to

trust and transparency. First, as specific clinicians and promotoras worked together,

they learned and became familiar with the other person’s style and even their routine

dialogue. In the following example, Mr. Mills and Louisa, who worked together often,

exhibit this pattern (encounter 30).

FNP=Mr. Mills P/I=promotora/interpreter P=patient

FNP: Alright, the blood pressure

P/I: La presión
The pressure
FNP: Is 158 over 78
P/I: Son 158 con 78
It’s 158 over 78
FNP: And so (.)
P: ¿Es mucho eso o es poquito?
Is that a lot or a little?
P/I: Es mucho.
It’s a lot.
P: Oh
P/I: Ahí le va a decir.
He’ll tell you.
FNP: So this is what your blood pressure is today.
[
P/I: Eso es lo que tiene ahorita
This is what you have right now
P: mhmm
FNP: What we’d like to see
P/I: Lo que a él le gustaría mirar es eso, 120 sobre 80
What he’d like to see is this, 120 over 80
P: hm
FNP: So this number you’re doing good.
P/I: Este número lo está haciendo bien pero el de arriba
This number means you’re doing good, but the one above
FNP: This number we still have some work to do to bring this down
[
P/I: En este no, tiene que ponerle mucho trabajo
In this one not, you have to put a lot of work onto it
FNP: The closer we can get to this number the better.
246
 [
P/I: Lo más cerca que pueda llegar mejor. A
cien veinte.

The closer you can get to it the better. To 120.

P: A-huh

In this example, the information flow was facilitated by Mr. Mills speaking in

short phrases and partial sentences (“the blood pressure”…“is 158 over 78”…“what

we’d like to see”). Since Mr. Mills and Louisa had frequently worked together, she was

familiar with his educational style and what he tended to say when a patient’s blood

pressure was elevated. In these instances, Louisa began her translation usually after the

first few words of Mr. Mills’ utterance (bolded).

Louisa often used simultaneous interpreting when working with Mr. Mills, and

Mr. Mills complimented this style with his short, jargon-free phrases. Simultaneous

interpreting can provide an illusion of monolingual talk because of the smooth

transitions between speakers. Participants tend to like simultaneous interpreting

because it keeps the focus on the patient and clinician (Hsieh 2010). Mr. Mills did not

interrupt Louisa and he waited until she was finished translating to speak his next

phrase.

A second reason to highlight Mr. Mills’ interview comment is that he touched on

issues of transparency in an interpreted situation. Mr. Mills remarked that he

sometimes wanted to tell a patient something in a particular way and he was unsure of

the degree to which promotoras said things on their own. Some clinicians, when they

247
wanted patients to hear information in a certain way, monitored the promotora’s words

and prompted the correct words. For example (encounter 22):

Dr=Doctor P/I=promotora/interpreter

Dr: Okay, I want to examine her, I want to make sure while I have you and
we’re sort of on a roll, that she understands that we’re probably going to
put her on some medicine to relax the blood pressure.
P/I: Te van a ponerle si la medicina para baja la pression.
She’s going to give you medicine to lower the pressure.
Dr: Okay, and use the words relax the blood pressure.

While clinicians verbalized these uncertain feelings about the process of

interpreting outside the encounter, they rarely engaged in a dialogue with the

promotora about the process of interpreting. I observed only four occasions out of 90 in

which the clinician instructed the promotora, as with the example above, or initiated a

discussion about the interpreting process. For example, prior to the encounter, one

nursing student told a promotora with whom she had not worked with before, “I’m

going to talk and look directly to the patient and you translate what I say.”

Thus, in order to facilitate transparency, the data show that instruction from the

clinicians and promotoras, prior or during the encounter, may result in a more positive

encounter. Accuracy and completeness may be enhanced if a clinician stated, “This next

part may be a little difficult to understand. Let me know if I need to repeat something,”

or if participants requested a back-translation such as, “Could you please repeat what

you just said.” Further, interpreters could be more transparent by explaining to the

clinician or patient when they have altered or culturally brokered messages to promote

sensitivity and understanding.

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 This level of transparency may help alleviate some of the tension around the

contradictory expectations that are placed on interpreters, and may advance better

understanding among clinicians and patients of their respective communication needs,

priorities, and preferences. For patients, a transparency rule or norm could increase

patient involvement and sense of control. In short, clinicians and interpreters could

encourage patients or families to ask clarifying questions or to provide clarification

themselves.

Teamwork

The communication processes that facilitated accuracy and trust occurred when

clinicians and promotoras worked as a team. For example, Louisa (promotora) and Mr.

Mills(FNP) utilized a teamwork strategy that I label “double-checking.” While double-

checking can make the encounter a bit longer, it is a strategy used to verify that the

clinician correctly heard and understood the patient’s comment or answer. For

example:

FNP=family nurse practitioner P/I=promotora/interpreter P=patient

FNP: Okay, okay. When was the last time you took your medicine?
P/I: La última vez que toma medicina.
The last time you took the medicine.
P: Hoy, en la mañana.
Today, in the morning.
[ [
P/I: Today in the morning.
[ [
FNP: Today Okay. (3 seconds)
Okay, um you took ‘em this morning.
P/I: Se la tomó esta mañana, ¿verdad?
You took it this morning, right?

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 P: Sí.
Yes.

Mr. Mills asked the patient when he last took his medicine and the patient

responded that he took them today, in the morning. In his next turn to speak, when Mr.

Mills could have asked another question, instead he used back-channel listening cues of

“today” and “okay,” and double-checked what he heard with a statement, “Okay, um

you took ‘em this morning.”Instead of answering Mr. Mills’ question with, “Yes,” Louisa

translated the question back to the patient who confirmed, yes. This pattern continued

throughout the encounter where Mr. Mills rephrased what he heard and Louisa

translated it back to the patient who then provided confirmation or clarification.

A few times the clinician and promotora engaged in a side conversation to clarify

with each other what was occurring in the encounter. Chapter five provides an

excellent example in which Mr. Mills stopped the encounter to speak with the

promotora about the patient’s desire for antibiotics.

In a second example, Mr. Mills was treating a male patient who was diagnosed

with depression and anxiety. The patient had not taken his antidepressant medication

for five months. This was the first time Mr. Mills, Elena (the promotora), and the patient

had met. My observation notes of the visit commented on their body language: “Mr.

Mills sat about two feet in front of the patient facing him with his hands in his lap,

focused on the patient. Elena also sat close to patient so that she, the patient, and Mr.

Mills made a triangle.” This physical positioning elevated the promotora to a full

member, and equal partner, in the dialogue rather than a less visible member.

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 After talking about the patient’s symptoms of anxiety and depression, Mr. Mills

asked a question with the goal of determining whether or not the patient was

experiencing symptoms of psychosis. This meaning of the standard psychiatric question

did not translate well so Mr. Mills and Elena discussed it.

FNP=family nurse practitioner P/I=promotora/interpreter P=patient

FNP: Let’s see and you’ve never had any, have you had any feelings of ah,
seeing something that you know wasn’t there or hearing something that
nobody else could hear?
P/I: Usted tiende a sentir que alguien le estaba hablando o-
You tend to feel that someone is talking or-
[
P: Sí, a veces si me pasa eso.
Yes, sometimes it happens.
P/I: Sometimes.
FNP: Sometimes. Can you tell me about that a little bit?
P/I: ¿Le puede explicar eso un poquito?
Can you explain that a bit?
P: Como el dice como que no se, como que oigo cosas así nada que ver que
yo no sé no por qué.
Like he says, like I don’t know, like I hear things that have nothing to do
with anything, I don’t know why.
P/I: ¿Cómo qué es lo que oye?
What is it like what you hear?
P: Oh, como no se como.
Oh, like I don’t know.
P/I: ¿Que alguien le está hablando, que alguien le está diciendo algo?
That someone is talking, that someone is telling you something?
P: Sí como que se me viene a la mente como que yo he estado viendo eso
pero no pero no sé por qué.
Yes, it like comes to my mind like I have been seeing this but I don’t know
why.
P/I: ¿Pensamientos, palabras?
Thoughts, words?
P: Algo así.
Something like that.
P/I: Como que alguien le está hablando.
Like someone is talking.
P: mhmm
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 P/I: Like somebody else is telling him something, like thoughts.
FNP: Okay, and do you, do you, does it sound like you’re hearing voices?
P/I: Usted escucha voces?
Do you hear voices?
P: Dentro de la mente, dentro de la mente y se me olvida después.
Inside my head, inside my head and then I forget.
P/I: He thinks he forgets about it.
FNP: Okay, what do, when you hear those things, what are they saying to you?
P/I: Cuando usted escucha esas cosas, ¿qué es lo que le están diciendo?
When you hear these things, what are they saying?
P: Escucho tantas cosas [short laugh]. Como que deberías hacer esto o ya lo
hiciste o cosas así pero no se ni por qué.
I hear so many things. Like you should have done this or you did or things
like that but I don’t even know why.
P/I: Cosas que debiste hacer eso y no lo has hecho, ¿cosas así?
Things that you should have done and you haven’t, things like that?
P: Sí, habla así.
Yes, like that.
P/I: He wants to explain it. He’s like saying that he’s thinking that x. He had to
do it, but he don’t feel like doing it but the voices are telling him he needs
to.
FNP: Okay, okay and so E[promotora], it sounds like it’s hard with the
translation to say, is it like a voice that he hears? Or is it his, him telling
himself. You know what I’m saying?
P/I: Okay, yes, okay.
Es una voz que usted escucha que le está diciendo o usted mismo se lo
está diciendo?
Is it a voice that you hear that is telling you or is it you telling yourself?
P: No, es como yo mismo, que es la gente más bien.
No, it’s like myself, that it’s like people rather.
P/I: It’s like himself.
FNP: It’s himself. Okay, okay, gotcha.

Prior research indicates that interpreted psychiatric visits in particular may prove

the most difficult for all participants due to the sensitive nature of the interview, the

stigmatizing symptoms associated with mental illnesses, the different interpreter

competencies required in psychiatric versus non-psychiatric encounters, and the fact

that a large part of the actual “exam” relies on verbal communication (Klein, et al. 1980,

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Marcos and Trujillo 1981, Putsch 1985, Diaz-Duque 1989). Additionally, there are

serious questions about the applicability of Western mental health diagnoses cross-

culturally (Barrett 2004).

Mr. Mills asked the patient a standard psychiatric question, phrased in a specific

way, but the meaning of the question did not necessarily translate well into Spanish (see

Barrett 2004 for a discussion of the difficulty in translating symptoms of psychosis).

Compounding the situation, the promotora did not provide a translation of the patient’s

comments to the clinician; for the majority of the excerpt, the patient and promotora

spoke together without including the clinician. This lack of transparency, even in an

encounter in which the clinician and interpreter usually worked well together, may be

why Mr. Mills paused and asked the promotora to clarify both his meaning and what

was being said by the patient.

In summary, clinicians reported that accuracy and trust was a main concern

when working with promotoras. Transparent actions, such as back-translations or

having conversations about the interpreting process may help participants with these

concerns. A relationship based on the understanding that clinicians and promotoras

both are responsible for accurate interpretations may also lead to better patient care.

IV. Discussion

Promotoras held numerous roles at the People’s Clinic. By virtue of their

familiarity, their presence portrayed trustworthiness to patients; they also were culture-

brokers, advocates, educators, and at times para-clinicians. However, barriers at the

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organizational level, such as a lack of training for promotoras, meant that these roles

were not always fulfilled in the manner expected and desired. A lack of training also

allowed some promotoras to work as interpreters despite their deficient knowledge of

medical terminology and understanding of the interpretive process. Additionally,

clinicians and patients were not taught how to work in an intercultural space nor were

they experienced in working with interpreters. This lack of training for all participants

was one of the most critical weaknesses in the clinic’s efforts to understand and utilize

theories of cultural competency.

Other key factors that disrupted the seamless provision of language services

within the People’s Clinic are various types of errors that occurred in interpretation, and

the processes that facilitated inaccurate as well as accurate interpretations. When

clinicians were unfamiliar with interpreted encounters, or had not often worked with a

specific promotora, they felt distrustful of the promotora and situation. This distrust

was often compounded by the low level of transparency in participant actions and roles.

However, with repeated exposure to one another, clinicians seemed to gain trust in the

promotora’s ability to provide accurate interpretations. The data also suggests that

when clinicians and promotoras engaged in dialogue aimed at increasing transparency,

and engaged in actions that fostered teamwork, trust deepened and accuracy increased.

Better Practices in Medical Interpretation

Robert Putsch’s quote at the beginning of this chapter is instructive about the

ways in which interpreters are viewed in medicine and research. He ascribed extreme

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power to medical interpreters and described them as those who “hold the keys to the

entire process” (see also Davidson 2000, 2001). New research, however, has emerged

that alters this notion of interpreter as institutional gatekeeper. Despite the smattering

of linguistic errors attributed solely to interpreters in the literature, scholars have begun

to focus on the process of interaction by the interpreter and clinician as co-constructed.

Recent proposals call for a bilingual communication that need not be based on

models that rely on interpreters to be conduits (interpreting all and only what is said) or

culture- brokers. Rather, a dynamic view of language interpretation allows for the

possibility that the models play a complementary role (Dysart-Gale 2005). The working

relationship between clinician and interpreter is ideally a partnership rooted in a mutual

understanding of both the communicative and interpretive dynamics that play out in

bilingual clinical consultations (Elderkin-Thompson, et al. 2001; Jacobs and Goldin 2002;

Dysart-Gale 2005). The final excerpts in this chapter, specifically the ways participants

work as a team, support this argument.

Besides these recommendations, the data imply the need for a “rule of

transparency,” which could be a way of making the interpretive process more visible

and explicit by encouraging participants, for example, to confer about the meaning and

substance of messages either before they are communicated, afterwards, or before and

after (Avery 2001; Elderkin-Thompson, et al. 2001; Abbe, et al. 2006).A short debriefing

session may be particularly useful in institutions where individual clinicians and

interpreters have had little or no prior opportunity to work together and get to know

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one another’s communicative styles, skill levels, and preferences. This interactive

process has several potential benefits, including increasing interpretive accuracy and

completeness, mobilizing patients to ask more questions and engage in discussions

more actively, and bringing to the fore the clinician’s shared responsibility for effective

communication and interpretation.

Lastly, training amongst participants is critically needed. A recent nationwide

study reported that more than 50% of medical residents received no training regarding

how to work with interpreters (Hsieh 2010). This data also suggests that training

programs for promotoras, clinicians, and patients may help participants adapt their

communication strategies and manage situations in which they suspect inaccuracies due

to a lack of transparency.

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 Chapter Seven: Conclusion

I. Summary

This dissertation coalesces several streams of inquiry from medical

anthropology, linguistic anthropology, and medical communications. At a fundamental

level, this research manifests an ethnographic exploration of a free clinic, in which

participants focused on being culturally sensitive to the primary patient population of

Mexican immigrants. The research sought to answer broad questions about how

clinicians, patients, and interpreters communicated within the framework of a linguistic

or cultural difference between clinicians and patients. All interpreters in this study were

of Mexican descent, as were the majority of the patients.

An ethnographic examination of the clinic in Chapter three provided data about

the day-to-day functioning of the clinic, as well as the planned structure of the

environment in order to facilitate the needs of the primary population. For example, a

social worker met with all patients and made appointments for them at other medical

facilities, if needed. Further, she helped patients apply for governmental assistance,

such as S-CHIP (State Children’s Health Insurance Program).

Observation of the nursing community clinical program yielded data about how

nursing students were taught to be aware of the specific socio-cultural, economic, and

health issues of this patient population. A variety of activities, such as direct patient

care, providing health education classes at a local elementary school, community

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outreach activities, and afternoon debriefing meetings with the clinical preceptor,

helped students recognize the various factors that affect health and illness. Nursing

students often spoke about how much they learned from a hands-on pedagogy at the

clinic and during community outreach activities.

The micro-examination of discourse within the medical encounter in Chapter

four illustrated how clinicians, patients, and interpreters fulfilled their sociolinguistic

roles of receiving and providing health care. Specifically, the case studies revealed the

dynamics of a cross-cultural and bilingual clinical encounter; treatment decisions were

made from the information shared within the encounter and negotiated between

patient and clinician, sometimes including the interpreter; methods used to exercise

power and control either prevented or encouraged information sharing.

Two case studies were representative of the fifteen other encounters in which

patients shared information from their lifeworlds. In the first example, the clinician

encouraged the patient’s narrative to unfold during the encounter. In the second, the

patient spoke frequently about her lifeworld concerns, but the clinician primarily

ignored her narratives. By supporting or ignoring the patient’s lifeworld, clinicians

controlled the amount and type of information that patients shared. In cross-cultural

encounters, these narratives, as linguistic forms for expressing experiences that lay

outside of the biomedical space, arguably are especially important. Because illnesses

are saturated with cultural, social, moral, and physical meanings, clinicians must

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understand the nature and impact of the illness on the patient and his or her family in

order to become a partner in successful treatment (Kleinman 1988).

Chapter five was informed by the use of the theoretical tools and concepts from

the case studies in Chapter four and applied them to the 30 encounters that were

observed and recorded. Half of patients (n=15) discussed their lifeworld and/or

explanatory models of illness with clinicians; in three of these encounters, clinicians

utilized communication strategies to diminish patients’ lifeworld narratives. Twelve

patients, then, successfully discussed lifeworld experiences with their clinicians,

suggesting that clinicians, to a greater extent than previously reported, recognized the

importance of including the patients’ experiences, feelings, and beliefs in their medical

treatment (for example, Mishler 1984; Tuckett, et al. 1985; Ainsworth-Vaughn 1998).

As cultural competence is the current dominant model in biomedicine for the

examination of treatment with immigrant and minority groups, this research explored

the role of culture in a medical interaction and the strategies clinicians used to be

culturally competent. Chapter five examined the type of information patients and

clinicians provided to one another, and whether “cultural” narratives provided by

patients would cause barriers to treatment, as assumed by cultural competence models.

In particular, previous anthropological and medical research indicated that

differences between the clinician’s and the patient’s explanatory models could be a

primary locale for such cultural barriers to emerge (Kleinman 1980; Chavez, et al.

1995;Browner, et al. 2003; Betancourt 2004; Fitzgerald, et al. 2005; Rosenberg, et al.

259
2005; Hasnain-Wynia 2006; Haidet, et al. 2008). In analyzing patient narratives in the

medical encounter during this research, two patients out of 30 voiced cultural health

beliefs that differed from the clinician’s biomedical beliefs. In these two cases, cultural

differences may have caused “barriers” to treatment as both patients and clinicians

reported unsatisfactory medical encounters and their expectations of the encounter

were not met.

However, most of the patients spoke with the clinician about joblessness and

financial difficulties rather than stereotypical cultural health beliefs. During the post-

encounter interviews, patients shared information from their explanatory models that

were not shared during the medical encounter. Almost 1/3 of patients (n=9) discussed

traditionally cultural health beliefs regarding causation (such as a hot-cold imbalance)

and treatments of their illnesses (such as the use of cactus for diabetes). Most of these

patients had “successful” medical encounters that were satisfactory and their

expectations were met. Thus, although patients held cultural health beliefs that

differed from biomedicine, they did not discuss these beliefs with the clinician, and the

beliefs did not tend to cause barriers to treatment.

This data holds important information for cultural competence models, training

programs, and practices through an understanding of the role of culture in biomedicine.

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II. Theoretical Contributions

First, it is important to recognize how this methodology differed from other

studies of medical communication. Few studies of medical communication or cultural

competence incorporate an ethnographic understanding of participant actions, as well

as the broader social organization. Both are imperative for an understanding of

linguistic and nonlinguistic aspects of communicative events. Without such knowledge,

researchers run the risk of missing the cultural fabric and broader environment from

which communicative actions are made meaningful. As Hymes eloquently stated, “…it is

not linguistics, but ethnography – not language, but communication – which must

provide the frame of reference within which the place of language in culture and society

is to be described” (1964: 3).

An additional problematic methodology within medical communications

research is that conclusions are drawn from an observation of an encounter at one point

in time, one visit between patient and clinician. Repeated observation of clinicians over

the course of 120 patient encounters in this study served to show how communication

strategies are nuanced, and co-created within the particularities of the medical

encounter. These observations thus provided understanding regarding how clinicians’

communicative actions were routine or unusual, given the specific patient

circumstances.

It seems important, in addition, to understand how this study informs, builds

upon, and extends past scholarship. It is best to begin this summary reflection with Eliot
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Mishler’s articulation of the importance of patient lifeworld narratives in a medical

encounter. Mishler’s linguistic analysis in The Discourse of Medicine (1984), influenced

by the work of Foucault (1973), Kleinman (1978), Habermas (1984) and others,

portrayed biomedicine and its practitioners as agents whose medical gaze fully focuses

on the disease, objectifying and decontextualizing the patient and his or her everyday

experiences. Within this view, actions are driven by success, which is defined by

scientific and technical considerations, not moral ones. Language becomes the primary

mechanism for achieving success and the speaker may use deception or distorted

communication to accomplish it. Mishler (1984), following Habermas’ Theory of

Communicative Action (1984), hypothesized that in order to regain a balance between

the voice of the lifeworld and the voice of biomedicine, actions need to be negotiated

through a communicative process of mutual understanding, without the use of

coercion.

Mishler’s scholarship arguably helped usher in a much needed paradigm shift in

medicine, one more focused on the patient, such as patient-centered care or narrative-

based medicine. However, Mishler’s conclusions were quite judgmental of biomedicine

stating that current biomedical practice was inhumane and inefficient (1984: 192). An

inhumane individual is unfeeling and without compassion for suffering and Mishler

perhaps used such powerful language to make a strong point.

Drawing directly from Kleinman’s explanatory model theory (1978, 1980) and

narrative theory (Kleinman 1988; Fisher and Groce 1990; Hyden 1997; Garro and

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Mattingly 2000; Mattingly 2000), I sought to articulate how immigrant patients might

utilize narratives to convey to the clinician important information from their lifeworld.

My analysis suggests that nurse practitioners, in particular, allowed for such

subjectivities and were aware of the patient-as-person and the factors that influenced

their health and illness, such as work, family, and structural barriers. Furthermore,

clinicians in this sample used communication strategies, such as asking multiple open-

ended questions, to inquire about patients’ lifeworld experiences. The patients in this

sample shared information from their lifeworld to a greater extent than some research

suggests (Mishler 1984; Tuckett, et al. 1985; Ainsworth-Vaughn 1998).

Still, a number of patients did not conform to previous models. They did not

discuss information from their lifeworld with the clinician, even when the clinician

initiated such a discussion. Patients who did not enter into this space with the clinician

may have felt an intrusion into their privacy. Foucauldian notions of power and control

may shed light into these actions; an expansion of biomedicine into the patient’s

everyday world signals further surveillance of biomedicine into the social and cultural

body (Foucault 1973, 1975). As health and health care become commodities in the

biomedical system, doctors serve as the providers and patients are the consumers.

Biomedicine, then, is not just any bureaucracy and profession, “…it is a leading

institution of industrialized society’s management of social reality” (Kleinman 1995: 38).

Thus, the six patients who did not engage with the clinician in lifeworld discourse may

have felt that discussing lifeworld discourse was unnecessary and inappropriate.

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 While I can infer the importance of lifeworld narratives, this research cannot link

the presence or absence of patient lifeworld narratives to patient outcomes, like patient

compliance or satisfaction. The majority of patients reported satisfaction with the clinic

and their treatment, regardless of happened during the encounter. Rao, et al. (2000)

reported that patients were more satisfied when doctors asked about their expectations

for the visit and for treatment and incorporated expectations in their clinical actions. In

a different study, researchers discovered that patient-centered care was associated with

improved health status (less discomfort, less concern, and better mental health) and

increased efficiency of care (fewer diagnostic tests and referrals) (Stewart, et al. 2000).

This research suggests that patients who talked about their lifeworlds used those

narratives as a mechanism to discuss their treatment preferences or an agenda item.

Narratives often functioned as a way to not only bring the human element to the

encounter, a patient’s feelings and experiences, but also as a communication strategy

that allowed patients to voice their concerns or preferences in a linguistically

appropriate way. In some instances, talking about lifeworld concerns helped the patient

get assistance from clinicians for their problem. For example, the female patient who

came in because her heart was racing finally discussed with the nursing student the fact

that her husband lost his job after his heart attack and that they were having trouble

obtaining follow up care and medication. The nursing student and clinic medical

director treated her husband and made him a follow up appointment at the county

hospital.

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 Finally, this research expands our knowledge of the role of culture and cultural

difference in medical encounters. As discussed above, the fact that patients had

different health beliefs from clinicians did not automatically cause barriers to treatment.

Barriers were created when patient agendas (to secure an antibiotic, for example), or

reasons for being at the clinic, were different from the clinician’s treatment decision.

For example, in the two encounters that represented a barrier to healthcare, the

female patients had different health beliefs that directly influenced their treatment

preferences for their respective infections. Interestingly, in these two cases, the

clinicians elicited the patients’ explanatory model, but did not know how to utilize the

cultural health information they received. They inquired about health beliefs, but were

not sure how to incorporate that information into their biomedical beliefs in order to

negotiate a treatment plan. Instead, the clinicians focused on trying to educate the

patients in order to replace the patients’ cultural health beliefs with biomedical ones.

This strategy was not successful in either situation.

What seemed to be missing from both encounters was a true conversation and

balanced negotiation about health beliefs with a view that the patients’ views and the

clinicians’ views could both be valid. Instead of trying to educate in these situations, the

data suggests it may be more effective for clinicians and patients to discuss a common

view of the illness and a treatment plan that is possible and practical, given the specific

circumstances of patients’ environments.

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 Consequently, this research also served to address the understanding of

“culture” in cultural competence. The next section will build upon previous

anthropological critiques to hypothesize a new model.

III. Redefining Cultural Competence

The language barrier is a major obstacle to medical treatment in bilingual

medical encounters (Elderkin-Thompson, et al. 2001; Flores, et al. 2003; Simon, et al.

2004; Dysart-Gale 2005). Attention to the role of language and the provision of quality,

trained medical interpreters must be upheld and maintained. This research found that

without proper training, interpreters may provide significant errors that have the

potential to cause medical harm. Responding to clinician concerns and observational

data, it was suggested that strategies that increased transparency would make the

interpretive process more visible and increase trust amongst participants. Additionally,

trust and accuracy improved when clinicians and interpreters worked as a team, both

bearing responsibility for clear communication.

However important the role of language, the use and role of the patient’s

“culture” in cultural competence, clearly, is where anthropological insight is the most

needed. The notion that it is something inherent within a patient’s culture, and not the

culture of biomedicine or other factors, which creates a barrier to care, is problematic.

As noted in prior anthropological and communications research, miscommunication

exists even in medical encounters where the patient and clinician share the same
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cultural and linguistic background (Korsch, et al. 1968; Shuy 1983; West and Frankel

1991; Good 1994; Hahn 1995). This is because the intensive training clinicians receive

creates a linguistic and cultural gulf between patients and clinicians (Good 1994; Sobo

2009). To quote anthropologist Robert Hahn, “All medicine is cross-cultural” (1995:

265, emphasis in original).

Cultural competence necessitates that a different set of communicative and

behavioral strategies be used when treating minority or immigrant patients. Because of

the difficulties in taking an anthropologically sophisticated view of culture, cultural

competence training often uses a “cookbook” approach of listing stereotypical cultural

beliefs or behaviors for clinicians’ review. Rather than another call for medicine to make

“culture count,” this research points to a wider set of competencies than those that

solely focus on cultural difference. The competence needed is thus one that helps

clinicians translate biomedicine to a host of differing backgrounds, including cultures

that are similar to their own, a kind of communicative competence.

Moreover, expansive or holistic cultural competence models (reviewed in

Chapter three, such as the Purnell model (2000), do not help clinicians understand how

to incorporate factors that may affect patient’s health and illness. Therefore, some

medical anthropologists argue for a model that emphasizes functionality. Elisa Sobo

proposes a “functional biomedical acculturation” model that encourages patients to

possess the skills to be “at least minimally or functionally acculturated to the world of

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their health care system in a way that allows them to function within it and achieve

desired ends” (2009: 119).

This approach moves away from a focus on the shoulders of ethnically diverse

patients whose language and culture causes the barrier, to a focus on the gap between

the two cultures and in “the health care system’s own ethnocentrism” (Sobo 2009: 120).

Such a model would address the challenges that patient participants in this research

possessed, i.e., a lack of skills and knowledge necessary to apply for the county

“insurance” program for indigent patients, or an inability to apply for a pharmaceutical

Patient Assistance Program for free medicine. Shifting the focus away from the patient

and his or her culture also changes the implicit assumption in cultural competence that

biomedicine and American culture are the standard, normal cultures.

Thus, as cultural competence focuses on the patient’s cultural health beliefs that

are different from the clinician’s beliefs, it implicitly blames barriers to treatment on

these cultural differences. A functional model identifies the barrier outside of these

stereotypical cultural differences to the health care system itself, and recommends that

patients have knowledge of how to navigate the system in order to successfully receive

treatment. Many patients in my sample had difficulties in navigating the health care

system.

This kind of model would also directly address the use of stereotypical health

beliefs by clinicians when treating immigrant patients, for example, the nursing student

at the People’s Clinic who reported that she no longer touched or complimented

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Mexican babies for fear of giving them mal de ojo (the evil eye). Sobo’s example is also

informative: “Clinicians treating a girl from Somalia for a toe problem asked about

genital cutting, as if that had anything to do with the problem at hand; they did so

because they had been “educated” about Somali culture” (2009: 121).

This is not to say that culture does not matter. On the contrary, culture is an

intrinsic part of who we are and it cannot be separated out as a set of variables to be

discovered and altered. Instead of searching for cultural differences in patients,

however, clinicians should invite all patients, regardless of background, to discuss their

present understandings of their illness and health concerns.

In this way, clinical encounters could represent a two-fold process of treatment

and learning. I suggest openness on the part of clinicians as well as a readiness to seek

clarification when patients present unfamiliar experiences or symptoms. When

differences in health beliefs arise, clinicians should be extra vigilant to have a true

dialogue with patients versus “educating” them on “proper” health beliefs.

IV. Study Limitations and Directions for Future Research

The research reported in this dissertation provides ethnographic data about how

patients and clinicians communicate in a bilingual, cross-cultural medical encounter. A

limitation of this study is that my observation of one medical encounter represents one

point in time amongst presumably multiple visits between patients and clinicians.

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Therefore, a longitudinal study with the same patient and clinician will yield a more rich

understanding of the role of patient lifeworlds or health beliefs.

Second, my research participants represented several sub-cultures and my

findings may be unique to these groups. For example, the clinicians in my sample were

nurse practitioners, whose training is more holistic than medical doctors. Specifically,

nurse practitioners have been found to spend more time with patients, and spend more

time discussing treatment options, when compared to medical doctors (Seale, et al.

2006). Research is needed to compare my findings amongst other health professionals

such as emergency room doctors or specialists.

Further, the clinicians were volunteers and often stated one reason they

volunteered at the clinic was that they could treat patients how they wanted to. While

supervised, clinicians were not governed by constraints that other clinicians may

experience operating in a managed care environment. The amount of time spent with

patients was not regulated, although it was clear that patients were turned away from

the clinic every day. Thus, clinicians were aware that the more time they spent with

patients meant that other people did not receive the needed treatment.

More broadly, with respect to future theoretical directions, I want to expand

upon this research to examine the extent to which the explanatory model concept is

useful in medical encounters as a device to help clinicians and patients negotiate

treatment. As other researchers point out, explanatory models are fluid, cognitive

constructs influenced by culture, society, and other factors (Lazarus 1998; Larsen 2004).

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Explanatory models are spoken within specific stories or discourses narrated by

individuals in one time and place. Larsen found that “the actual explanatory model used

by an individual is linked to the situatedness of the narrative event” (2004: 450). Thus,

encouraging a clinician to elicit a patient’s explanatory model, which can be a time

consuming process, may become an end in itself if it is not coupled with the knowledge

of how to incorporate fully the information into a meaningful discourse with the patient.

More research is needed about how clinicians may use the explanatory model concept

to locate patients’ changing reflections and experiences throughout the continuous

process of treatment.

A second future strand of research in this immigrant population is to study how

patterns of circular migration affect health care decisions and treatment. Two patients I

interviewed indicated they live both in Texas and in Mexico and El Salvador. Both

patients had primary clinicians in each country and both patients reported consistency

in their pharmaceutical treatment for their chronic diseases.

An additional direction for future research involves how to translate a more

anthropologically-informed conceptualization culture and patient-centered care to

practicing clinicians. As previous medical anthropological research has demonstrated, it

is difficult to build bridges and collaborate with medical disciplines (Kleinman and Good

1985; Hopper 1991). In the last thirty years, funding cuts and managed care restrictions

have had negative consequences on clinical training and have left health, social and

rehabilitation services, and case management in a disconnected and compartmentalized

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system (Lefley 2001). The current failure to apply anthropological knowledge is part of a

more general failure to incorporate information at the time of training from the social

and behavioral sciences to the clinical domain.

In order to continue a dialogue, anthropologists must be overtly visible and clear

about the relevance of their work to other disciplines (Rylko-Bauer 1989; Kleinman

2001). To this end, I anticipate working with the People’s Clinic to create a training

program for the promotoras and nursing students on how to work as a team to ensure

accurate interpretations. In the future, more research is needed about possible

interventions for patients and clinicians alike to help them clearly articulate their goals

in order for agendas and expectations to be met. Training for clinicians on how to

translate biomedicine to the lay individual, regardless of the patient’s cultural

background, also emerged as a necessity for medical success. Modules on

communicative competence or “functional biomedical acculturation” (Sobo 2009) would

be the next logical step.

Research is also needed with other types of populations as points of comparison.

For example, a second research population emerged at the People’s Clinic during the

latter stages of my research, namely Karen refugees from Burma. My preliminary

observations indicated that these refugees had far greater difficulty than the Mexican

immigrants in understanding the entirety of biomedicine, including biomedicine’s

culture, language, etiological models, and structural systems. This was not only because

the cultural differences to American culture were greater than the Mexican immigrant

272
patients, but also because of the political, economic, and personal suffering the Karen

refugees have endured under a military dictatorship since 1984. Research into this

population is clearly needed.

At a national level, the recent change in health care policy by the current federal

government can only create more opportunities for anthropologists to contribute to

policy change. The Joint Commission, the agency that maintains hospital accreditation,

is poised to develop proposed accreditation requirements for hospitals to advance

effective communication, cultural competence, and patient-centered care within the

year. This dissertation research speaks directly to such proposed requirements, making

anthropologists invaluable to hospitals and clinics as they formalize and implement

individual plans. Anthropologists, whose focus is holistic, can also incorporate political

and economic determinants of society into studies of health and medicine (Lazarus

1988; Santiago-Irizzary 1996;Hirsch 2003; Hunt 2005; Shaw 2005). Perhaps the most

important and compelling reason to continue this field of study is the potential it brings

for designing interventions that would reduce health inequality and improve health care

services, making services more accessible to a diverse range of people while providing

care for all people, regardless of status. Research remains crucial to achieve these

changes.

273
 Appendix I: Patient and Clinician Interviews and Patient Survey

Clinician Interview
Volunteering

1. How long have you been a volunteer at the clinic?

2. How did you get into volunteering here?

3. What motivates you to volunteer week after week?

Patient Population

4. How would you define the patient population at the clinic?

a. Is this a different population than you normally treat?

5. What is it like to treat Spanish-speaking patients or patients from other

countries?

6. Do you consider there to be unique aspects of providing care to this population?

What are they?

7. What do you consider to be success with respect to patient care in this

population?

8. From your experience, what makes a patient a “good” patient?

9. Tell me about a time when you were treating a patient at the clinic that was
really rewarding.

10. What about a time that was quite frustrating?

Communication

11. I’m interested in the interpreting process. What do you think of the
promotoras?

12. How did they help your communication?

13. What do you think is the role of the promotoras?

14. What are some differences in an interpreted medical conversation? How is

communication different when using an interpreter?
274
15. What are some strategies you’ve used in these situations?

16. I’d like to talk now about culture. Does understanding the patient’s culture help
you communicate or understand better?

17. Have you ever had training in cultural competence?

18. My final question is whether you have additional overall comments. I would like
my study to help other clinicians learn how to communicate better with patients
from different cultures or language backgrounds.

275
Patient Interview
Explanatory Model

1. Can you tell me why you came to the clinic today? (Also probe for the name of
the illness)

2. When did you first learn you had X?

3. Was that here at the People’s Clinic?

4. What did you think when you heard you had X?

5. What were your symptoms?

6. Are you having symptoms today of X?

7. How did you get X? What do you think causes X?

8. What other treatments have you tried to help with X?

Patient Current Agenda

9. What did you want the doctor or nurse to do for this illness (today)?

10. (Before you came in) Did you want specific medicine or treatments for this
illness?

Current Treatments

11. What medicine are you taking?

12. How long have you been taking that medicine?

13. Do you feel it is working for you?

*If patient has a new diagnosis:

14. Did the nurse/doctor tell you what is wrong with you? What did they say?

276
 15. What do you think about the explanation of the illness?

16. Did the nurse/doctor prescribe any treatment for your illness?

17. What do you think about the treatment?

Communication

18. Do you understand everything the nurse or doctor said today?

19. Are there ever times at this clinic or other places that you don’t understand what
was said? What happened during those times?

20. Did you have any questions or things you wanted to discuss today with the
nurse or doctor but didn’t?

21. What can doctors and nurses do to communicate better with their patients?
Especially patients from different countries?

Patient is from ______________________

Has been a patient since ____________

277
Patient Survey
This survey is to help me understand how patients and doctors from different cultures
communicate, especially when they do not speak the same language. Please answer all
questions. Your answers are confidential and will not be directly shared with the
People’s Clinic. Thank you for participating!

1. Why did you come to the clinic today?

2. Please describe your symptoms or illness/illnesses.

3. What do you think is wrong with you?

4. Before you came in to the clinic today, what other treatments have you used for this
illness?

*Please answer the following questions by checking the right box or boxes.

5. Often people come to the doctor with expectations. What were you wanting or
expecting from the doctor today? Check all that apply.

 Advice about symptoms  Diagnosis

 Information about my illness  Referral to a specialist

 Test (like sugar or blood pressure)  Check-up

 Medicine, pills Other, please explain:

 Medicine, cream _______________________

 Medicine, other _______________________

278
6. Did the doctor or nurse do what you hoped?

 Yes

 No

 If not, what other things did you want them to do?

7. What treatment did the doctor or nurse prescribe today?

 Medicine  Rest

 Exercise  Other, please explain:

 Eating better _______________________

 Loosing weight _______________________

8. Did the nurse or doctor prescribe or refill medicine(s) today?

 Yes

 No

 I don’t know

If yes, what is the name of the medicine? How long have you been taking the
medicine?

1st medicine______________ _____ months _____ years

2nd medicine ______________ _____ months _____ years

3rd medicine ______________ _____ months _____ years

4th medicine ______________ _____ months _____ years

279
9. Please think about your visit to the doctor today.
Did your doctor or nurse fully explain:

Yes No

  your illness or diagnosis

  your treatment options

  how to take your medicine or prescribed therapy

10. Did you have any questions or things you wanted to discuss today with the nurse or
doctor but didn’t?

 Yes

 No

 If yes, what kept you from doing that?

 What did you want to discuss or ask?

11. What could doctors or nurses do to improve their communication with patients?

12. Please answer true or false:

I would recommend the clinic to a friend

or family member………………………………………………….. True  False

The clinic interpreters help me communicate…..……. True  False

I was satisfied with my doctor visit today…….………… True  False

I trust the doctors and volunteers at the clinic……….. True  False

280
13. How long have you been a patient at the People’s clinic?

 1-6 months

 6-12 months

 1 year

 2 years

 3 years

 4 years

 5 or more years

14. Are you:

 Female

 Male

15. Where were you born?

 Mexico  Guatemala  Honduras

 United States  Puerto Rico  South America

 El Salvador  Panama  Other country

281
 Appendix II: Transcription Notations

The transcription notation is based on Gail Jefferson’s “Transcript Notation,” a standard

methodology in conversation analysis (Atkinson and Heritage1984).

Overlapping Utterances
When utterances do not start simultaneously, the point at which a new utterance
overlaps or interrupts an ongoing utterance is marked by a single left bracket.

Joe: It’s freezing in here. Where is your jacket?

[
Sue: It sure is.

Contiguous Utterances
When there is no silence between two speaker’s utterances and the second one is
immediately latched onto the first without overlapping, the utterances are marked with
equal signs:

Joe: Can you please turn the heat on?=

Sue: =Yes that’s just what I was doing.

Equal signs are also used to link different parts of a single speaker’s utterance when that
utterance has been interrupted by another speaker, to accommodate the transcript
design:

Sue: When do you think it’ll warm up around here=

[
Joe: I don’t know
Sue: =because my car doesn’t have heat.

Intervals
When there are intervals between speech either between or within utterances, they are
timed by 1 second and marked (.) within parentheses; pauses more than 5 seconds are
marked by the number of second (6) within parentheses.

Sue: I just can’t imagine (..) I’ve never seen anything like it before.

282
Intonation
Punctuation is used to capture characteristics of speech delivery. A colon indicates an
extension of the sound or syllable it follows:

Joe: Why ca:n’t you do that?

A ?mark indicates a rising inflection.

A .indicates a stopping fall in tone.
CAPITAL letters indicate speech that is louder than the surrounding talk.
Italicized letters indicate speech that is said with emphasis.

283
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