Preparing your Students to Work with the Spanish-Speaking Patient

1. Preparing your Students to Work with the Spanish-Speaking Patient Aidé Gomez Medical Spanish and Cultural Competency UCSD School of Medicine Skaggs School of Pharmacy and Pharmaceutical Sciences a3gomez@ucsd.edu

2. Not all Hispanics/Latinos share the same values Subculture within a culture Treat each patient on an individual basis 2 Preparing Students to Work with Spanish-Speaking Patients

3. Cultural Values that Influence Healthcare Behavior

4. Role of Religion - Majority of Latinos are Catholic - Abortion not permitted - Birth control not permitted but….. - Discretion with “Day After” pill 4 Preparing Students to Work with Spanish-Speaking Patients

5. Role of Family - Family comes first…”I” am second - Distorted familism – Women postpone their own healthcare. - “Your family needs you” “You are important to your family”….for non-compliant patients. - Adult children participate in the parents’ healthcare 5 Preparing Students to Work with Spanish-Speaking Patients

6. Level of acculturation The degree to which the dominant culture is adopted Level of assimilation The degree to which individuals integrate into the U.S. society Socioeconomic levels Economic status is closely linked to health status and healthcare access Level of education Generation/Age Rural/Urban upbringing Preparing Students to Work with Spanish-Speaking Patients 6

7. What is Cultural Competency and Why is it Important? Develop cultural awareness and appreciate and accept these differences Develop cultural knowledge by exploring various approaches and explanatory models of disease. Develop skills by learning how to culturally assess a patient (Kleinman Model) Understand how cultural beliefs influence medical care and treatment Personal and professional skills that allow us to increase communication Improve patient compliance and outcome Preparing Students to Work with Spanish-Speaking Patients 7 However, we may discover many similarities between our cultures. How do we measure the effect of cultural competency? What is the desired outcome? Compliance? Improved disease management. Disease prevention, education.However, we may discover many similarities between our cultures. How do we measure the effect of cultural competency? What is the desired outcome? Compliance? Improved disease management. Disease prevention, education.

8. Common Practices

9. Common Practices Home remedies OTC medications Herbal teas Homeopathic meds Curanderos Borrow medication 9 Preparing Students to Work with Spanish-Speaking Patients

10. Common Practices Will consult pharmacist before consulting a physician Opportunity for: Referral to community resources Patient education Preventive medicine 10 Preparing Students to Work with Spanish-Speaking Patients

11. Community Resources Patients may confide in pharmacists about breast lumps, testicular lumps, STD’s Patients might be treating with OTC meds only because they think the “problem” will go away or because they don’t have funds to see a physician or to get a mammogram, Pap smear, etc. Patients unaware of free or low-cost screening Contact SYHC or other community clinics for free screenings/medical care 11 Preparing Students to Work with Spanish-Speaking Patients

12. Common Practices Patients will buy medications in Tijuana but may be reluctant to disclose this information to a pharmacist for fear of reprimand. Toma otras medicinas? Do you take other medicine? Toma medicinas que compró en Tijuana? Do you take medication bought in Tijuana? Es importante saber para ver si no hay interacción con la nueva medicina. It’s important to know this to see if there isn’t any interaction with the new medicine. 12 Preparing Students to Work with Spanish-Speaking Patients

13. Myths and Fears

14. Cortisona - Cortisone Patients may discontinue cortisone because of what friends say about the dangers of cortisone Possible solutions: Explain to patients that blood tests will be taken to monitor the prednisone’s effect. Su doctor ordenará análisis de sangre para monitorear el efecto de la prednisona. Inform patient about the consequences of not taking cortisone. 14 Preparing Students to Work with Spanish-Speaking Patients

15. Antibióticos - Antibiotics Patients may take antibiotics for colds. Explain to patient that: Antibiotics are for bacterial infections and not viral infections. Los antibióticos son para las infecciones virales…no bacterianas Patients could develop resistance to antibiotics if stopped early. Podría desarrolar resistencia al antibiótico si lo deja de tomar antes de tiempo. 15 Preparing Students to Work with Spanish-Speaking Patients

16. Some patients may stop taking their medications when a new medication is introduced. They believe the “old” meds should be stopped when a new one is prescribed because it might be “too much” medication or the new medication might interact with the usual meds. Solution: Explain to patients that the new medication will not interfere with the usual meds and that stopping the usual medications will … 16 Preparing Students to Work with Spanish-Speaking Patients

17. Linguistic Barriers

18. Communication Between Pharmacist and Spanish-speaking patient Little emphasis has been placed on the interactions between pharmacists and Spanish-speaking patients. (Res Social Adm Pharm. 2009 Jun;5(2):108-20. Epub 2009 Jan 31.) Pharmacists' communication with Spanish-speaking patients: a review of the literature to establish an agenda for future research. J Am Pharm Assoc (2003). 2005 Jan-Feb;45(1):48-54. Links Adherence less in non-English-Speaking patients. Pharmacy-related health disparities experienced by non-English-speaking patients: impact of pharmaceutical care. Westberg SM, Sorensen TD. 18 Preparing Students to Work with Spanish-Speaking Patients

19. The use of interpreters Bilingual does not equal interpreter State-certified interpreters are trained in: - Simultaneous interpreting mode - Consecutive - Sight translation - Medical terminology (Eng/Sp) - Code of Ethics - Tested on English/Spanish grammar 19 Preparing Students to Work with Spanish-Speaking Patients

20. Errors made by hospital interpreters vs ad hoc interpreters Study by Flores, Laws, et al (Pediatrics. 2003 Jan; 111 (1):6-14) Professional hospital interpreters – training or certification not mentioned. Ad hoc interpreters - social workers, nurses, 11 yr-old sibling Thirteen encounters, 6 by professional hospital interpreters Three-hundred ninety-six errors committed. Mean of 31 errors per encounter Errors committed by ad hoc interpreters significantly greater (77% vs 53%). 20 Preparing Students to Work with Spanish-Speaking Patients

21. Errors made by hospital interpreters vs ad hoc interpreters Common errors: Omissions (52%) Questions about drug allergies Instructions on dose, frequency, duration A child was already swabbed for stool culture False fluency (16%) 21 Preparing Students to Work with Spanish-Speaking Patients

22. Errors made by hospital interpreters vs ad hoc interpreters Substitution (13%) Adding that hydrocortisone cream should be applied to the entire body instead of only facial rash. Instructing a patient to put amoxicillin in both ears for otitis media 22 Preparing Students to Work with Spanish-Speaking Patients

23. Errors made by hospital interpreters vs ad hoc interpreters Editorialization (10%) Instructing a mother not to answer personal questions Addition (8%) Instructing a mother to place amoxicillin in both ears for treatment of otitis media 23 Preparing Students to Work with Spanish-Speaking Patients

24. The illiterate patient Use simple explanations Medical terminology must be accompanied by its definition Ask patient to repeat instructions Sun and moon stickers/International codes Write what medication is for on label 24 Preparing Students to Work with Spanish-Speaking Patients

25. What Should I Remind My Patients?Recommendations Have patients repeat instructions Do not share medications Refill medication 3-5 days before it runs out Inform patients that they are to refill their medication. Some patients think they are only to take what’s in the vial and that’s it….or can stop it if they feel better. It’s ok to eat pork or seafood with their medication. Do not stop taking usual meds while taking a new one. 25 Preparing Students to Work with Spanish-Speaking Patients

26. What Do Patients Want? Someone who speaks Spanish Respeto - Respect Confianza - Trust Write what the medication is for on the label. Is it an anti-inflammatory? Muscle relaxant? 26 Preparing Students to Work with Spanish-Speaking Patients

27. Community Resources Patients may confide in pharmacists about breast lumps, testicular lumps, STD’s Patients might be treating with OTC meds only because of they think the “problem” will go away or because they don’t have $ to see a physician or to get a mammogram, Pap smear, etc. Contact SYHC or other community clinics for free screenings/medical care 27 Preparing Students to Work with Spanish-Speaking Patients

28. Recommended Websites www.medlineplus.gov Manual Merck de información médica para el hogar (Merck Manual in Spanish) http://www.msd.es/publicaciones/mmerck_hogar/ 28 Preparing Students to Work with Spanish-Speaking Patients