Keep or fire your PCP?
It’s been a long time since doctors made house calls, although an emergent trend of the old-fashioned practice is making some headway in some areas. I can still picture our family doctor Dr. Rosenquist, who would come to our home to check a fever, wrap a sprained ankle, or just to pick up some homemade tamales. He doubled as obstetrician when he delivered me at the Tempe Clinic on Mill Avenue. He was patient and kind, and he spoke Spanish, which seemed so odd to me as a child.
Oh, if it were only that simple anymore. Nowadays it can be challenging to find a regular MD, family doctor, or a primary care physician, much less one that speaks Spanish or any other foreign language, for that matter. A degree in medicine is quite an investment of money and time, so med students are, unfortunately, incentivized to specialize in a higher-paying practice (can you blame them?). A survey by the University of Missouri-Columbia (UMC) and the U.S. Department of Health and Human Services predicts that by 2025, the United States will be short 35,000 to 44,000 adult care primary care physicians. In a 2007 survey of 1,177 graduating U.S. medical students, only 2 percent planned to enter a general internal medicine career. Regardless of the decrease in generalists or family practitioners, many health insurance policies require you to see a primary care physician first to get a referral to a specialist. But that’s a good thing, because it could save unnecessary waste of time and money.
Some primary care physicians (PCPs), sometimes referred to as “gatekeepers” by health organizations, especially insurance companies, actually specialize in a certain area of primary care. Internal medicine physicians, or internists, specialize in the diagnose and treatment of nonsurgical diseases in adults; family or general practice doctors, or GPs, treat patients of all ages for a variety of medical problems; pediatricians work with infants, children and adolescents. Some insurance policies consider gynecologists as PCPs for women’s health.
The physician/patient relationship has taken a back seat to finances, litigation, health insurance and pharmaceutical companies as our society has wallowed in healthcare reform and the economic crisis. Regardless, it’s a key component of the whole healthcare scenario, even as Congress is crunching the numbers for healthcare reform. And to just throw a small wrench in the works, it’s not just a matter of finding a doctor with a good personality and ranking credentials – many U.S. residents have to take into account the ability to communicate with a doctor who may not speak their mother tongue. “English-only” viewpoint aside, the reality is our melting pot of a country is made up of many cultures. Anymore, “cultural competency” is a buzz-phrase in the medical world that is starting to draw attention in medical schools and continuing education programs. Cecilia Rosales, MD, MS and associate professor of public health at the University of Arizona, feels that “the relationship … between [the] PCP and patient should be one that is long term and focused … the PCP must be sensitive to the differences between his/her cultural norms and beliefs to those of his/her patients.” And Dr. Rosales isn’t just talking about Latinos. Even though it’s the fast-growing minority group in the country, more and more refugees and immigrants are coming from Eastern Europe, Africa, and the Middle East.
Do you have a primary care physician, and if so, do you have the right one for you? How happy are you with his or her services? How about your abuelo? Does he understand his doctor? Just because he nods and keeps repeating “sí” doesn’t mean he knows what he’s being told – he could be sending a false message of comprehension. Although medical competency is most important, interpersonal skills are also valuable when considering your relationship with your primary care physician. We’ve compiled the following short list of traits of a good primary care physician, a few things to consider if you’re looking for a new PCP or to determine if your current doctor qualifies.
Of all the attributes of a good family physician, bedside manner is probably the most important to patients and their families. “Creating an environment in which providers and respective staff sincerely care, are willing to listen without judging, and treating patients with utmost respect is key,” says Dr. Rosales. Everyone wants a doctor they can talk to. Even the most knowledgeable physician cannot succeed with intelligence alone – personal interaction with patients is also of vital importance. In a study conducted in 2001 and 2002, patients were asked to describe their best and worst experiences with physicians at Mayo Clinic in Scottsdale, Arizona and in Rochester, Minnesota, to develop a set of characteristics of a good doctor from the patient’s perspective. The results? An ideal physician, according to the study, is humane, personal, forthright, respectful, confident, empathetic, and thorough (qualities that apply to good humans, not just doctors). According to the National Health Law Program, a good primary care physician should also help patients get the services they need and understand their care, and inform patients of all treatment choices, regardless of their health plan.
Although this could fall under “bedside manner,” cultural competency warrants its own heading. Cultural competency relates to the ability to interact effectively with people of different cultures. It’s not just about providing an interpreter to break the language barrier. Essen Otu, diversity and cultural competency director at Mountain Park Health Center, says, “Cultural diversity is broadening in Arizona … it’s an inevitable fact that our world is becoming more diverse. It’s important that we [as healthcare providers] ask a lot of questions and do our best to have a good grasp on the different cultures that come through our doors, and what those cultural beliefs are, especially around health care.” Beliefs, ideas, and behaviors – all of these need to be taken into account for a culturally competent physician and his staff to relate well with his or her culturally diverse patients. A patient who grew up in New York may want to be treated in a completely different manner than someone from Georgia, for instance. It can be that subtle. Another example: healthcare providers must understand that not all Spanish-speaking patients have the same cultural backgrounds and/or beliefs. A Mexican patient will have a very different set of ideas about medicine compared to a patient from Argentina or Cuba.
As a layperson, it’s hard to know if your doctor is at the top of his or her game. You can check the qualifications of a physician through Arizona Medical Board (www.azmd.gov), and get information about education, including residencies, internships and fellowships, and disciplinary action. You can also find out the number of open investigations on a physician and any malpractice suits filed against him or her within the last five years. This is all good information, but it would also be worthwhile to get the opinions of other patients under your doctor’s care and see what their experiences have been with their diagnoses and treatments.
It’s a double-edged sword if you have to wait weeks to schedule an appointment with your primary care physician. Being that busy could be an indication of how good he or she is. It’s also the current state of affairs – doctors need to book heavily to make up for the high cost of running their practice, including liability insurance. Of course, if you’re a proactive, relatively healthy patient who forecasts your annual exam months in advance, a doctor with a packed schedule may not faze you. But if you’re someone who is not quite so organized, or have health issues that may require more spontaneous access, you may want to start asking friends and family about their PCPs and find out if they’re availability is more user-friendly. If your doctor books weeks in advance but accommodates patients with acute illnesses, like a sinus infection, then you’re probably in good hands. When you do have your appointment, do you have to wait an hour or more every time, even with a scheduled appointment? Is your doctor rushed, or does he or she rush you. As far as follow-up goes, if you have to wait more than a week or call the office yourself to find out test results, this could be a concern.
Office and office staff
We all like to be treated like humans, not a burden, right? Envision your doctor’s office and staff. Do you get a live person on the phone when you call? How happy and attentive are they when you show up for your appointment? Is the overall office environment cheery or dreary? A rude staff is a sign of an unhappy work environment, which starts with the doctor and how he treats his employees. Next time you’re at a doctor’s appointment, casually ask, “How long have you worked here?” If the friendly nurse or receptionist says six months, then maybe it’s too soon to tell by their tenure. If he or she says six years, and is still pleasant, then you’re in a good place. Although this may be stating the obvious, being treated in a convenient, clean, well-organized and modern facility is important as well. Any extras, like comfortable seating and current magazines in the waiting room, or small touches like hand lotion in the bathroom, show that the practice takes the patient into consideration by providing a favorable physical environment.
As in any relationship, both parties involved are responsible for making it successful. The same applies to the bond between doctors and patients – it’s not just up to the doctor.
Culturally competent doctors will:
• Be aware of the role of cultural health beliefs and be able to sensitively and appropriately negotiate treatment options.
• Ensure data on the patient’s culture and language is recorded and integrated into the organization’s management information systems.
• Keep an updated profile on the demographic and cultural characteristics of his or her patient population.
• Have a strategy to recruit a diverse staff representative of the demographic characteristics of his or her patients.
• Retain a bilingual staff or interpreter service for patients with limited English proficiency, and assure the language assistance is competent.
Good patients will:
• Come to visits on time and prepared to clearly voice the purpose of their visit that day. Verbalizing your goal will help lay the foundation for the problem getting resolved.
• Bring a prioritized list of questions and concerns to ask the doctor, as well as a list of prescriptions so the doctor is informed of all medications.
• Monitor their physical changes, but refrain from self-diagnosing based on Internet research or self-prescribing medications based on direct-to-consumer drug marketing.
• Have some “cultural humility” in order to help the doctor better understand the cultural contexts in which their patients live.
• See a doctor who has the skills matched to assess their particular circumstance.
Our nana’s values
The cultural diversity of patients is broadening daily. According to the U.S. Department of Health and Human Services, Office of Minority Health, Arizona has the sixth largest Hispanic/Latino population in the country, and that includes Central and South Americans, Puerto Ricans, Cubans and other Hispanics. What’s important for doctors to know about their culture and health beliefs?
Respeto y dignidad. Healthcare providers are viewed as authority figures who must be respected, but Latino patients expect to be respected as well, especially when the provider is younger than the patient. The nod of the head may be a sign of respeto, not necessarily understanding or agreement. Patients want to establish a relationship with their doctor built on trust, mutual respect and dignity.
Familismo. Family cohesion or familismo is very important in the Latino culture. Janey Pearl, PIO/Latino Outreach Coordinator with the Arizona Department of Health Services, says, “Often a patient may not feel comfortable in making medical decision without family consultation. Familismo may also be a powerful protective factor from adverse health behaviors.” Important decisions are often made by the extended family, not the patient alone.
Simpatía y personalismo. The impersonal, neutral attitude of many U.S. doctors is often seen as negative by Latino patients. They prefer a physician who is polite and pleasant, even a little conversational. Patients want their doctor to show an interest in their life; otherwise they feel if a doctor doesn’t display some friendliness, he or she doesn’t really care about them.
Folk/traditional medicines and illnesses. Latinos are generally traditional in their healthcare practices. Older patients may still rely on the traditional role of curanderos or use herbal remedies from the local yerberia, of which there are several in metro Phoenix. It’s important for doctors to be culturally aware and sensitive to traditional health beliefs, and the variance of it due to acculturation, education and socioeconomic level of the Latino patient.