Patient centeredness in medical encounters requiring an interpreter.

PURPOSE: Patient-centered interviewing is associated with greater patient satisfaction and better medical outcomes than traditional encounters, but actively seeking patients' views of their illnesses and encouraging patients to express expectations, thoughts, and feelings is difficult in encounters that require an interpreter. We sought to examine physicians' use of the patient-centered approach with patients who required the assistance of an interpreter. SUBJECTS AND METHODS: A cross-sectional sample of patients was videorecorded during visits with physicians at a multi-ethnic, university-affiliated, primary care clinic. Nineteen medical encounters of Spanish-speaking patients who required an interpreter and 19 matched English-speaking encounters were coded for frequency that patients mentioned symptoms, feelings, expectations, and thoughts (collectively called "offers"). Physicians' responses were coded as ignoring, closed, open, or facilitative of further discussion. RESULTS: English-speaking patients made a mean (+/- SD) of 20 +/- 11 offers, compared with 7 +/- 4 for Spanish-speaking patients (P = 0.001). Spanish-speaking patients also were less likely to receive facilitation from their physicians and were more likely to have their comments ignored (P <0.005). English-speaking patients usually received an answer or acknowledgment to their questions even if the physicians did not encourage further discussion on the topic. CONCLUSION: Spanish-speaking patients are at a double disadvantage in encounters with English-speaking physicians: these patients make fewer comments, and the ones they do make are more likely to be ignored. The communication difficulties may result in lower adherence rates and poorer medical outcomes among Spanish-speaking patients.

Evaluating health-care needs of the poor: a community-oriented approach.

PURPOSE: Concern has arisen over the provision of health care for the poor. In a project sponsored by a local community hospital, we conducted a telephone survey to determine unmet health-care needs of low-income families living in Orange County, California, and made recommendations to address those needs. METHODS: The survey assessed demographic characteristics and access to medical care of 652 adults and their families. RESULTS: In general, we found that the poor (incomes below 125% of the poverty level), the uninsured, and the Latino respondents had lower access measures than the nearly poor (incomes between 125% and 200% of the poverty level), insured, and Anglo subjects. However, insurance status was the strongest predictor of access in this low-income population. Important unmet health-care needs included prenatal care and preventive care. In response to our findings, the sponsoring hospital has instituted new health-care programs to help meet these needs. CONCLUSION: This community-oriented approach for improving problems of access to medical care for the poor may be appropriate for other localities.

DSM-IV hypochondriasis in primary care.

The object of this study was to assess the prevalence and correlates of the DSM-IV diagnosis of hypochondriasis in a primary care setting. A large sample (N = 1456) of primary care users was given a structured interview to make diagnoses of mood, anxiety, and somatoform disorders and estimate levels of disability. The prevalence of hypochondriasis (DSM-IV) was about 3%. Patients with this disorder had higher levels of medically unexplained symptoms (abridged somatization) and were more impaired in their physical functioning than patients without the disorder. Of the various psychopathologies examined, major depressive syndromes were the most frequent among patients with hypochondriasis. Interestingly, unlike somatization disorder, hypochondriasis was not related to any demographic factor. Hypochondriasis is a relatively rare condition in primary care that is largely separable from somatization disorder but seems closely intertwined with the more severe depressive syndromes.

Processing narratives of self-destructive behavior in routine medical encounters: health promotion, disease prevention, and the discourse of health care.

This study asked how patients and doctors process self-destructive behaviors that warrant preventive action, such as smoking, substance use, and sexual practices. Although many suggestions have appeared about how physicians should encourage health promotion and disease prevention by counseling patients about self-destructive personal habits, few studies have examined actual encounters to assess how patients and doctors communicate about these matters, and prior research rarely has considered the social context of self-destructive habits. The present research has been influenced by a growing recognition of narratives, embedded in the sociocultural context of medical encounters, as an important analytic focus in the study of patient-doctor communication. Our conceptual work extended perspectives from literary criticism, critical theory, and narrative analysis in the humanities and social sciences to focus on elements of sociocultural context, ideology, social control, underlying structure, and superficially marginal features of discourse in medical encounters. Based on a critical review of both quantitative and qualitative techniques in research on patient-doctor communication, we developed an interpretive method with systematic criteria to guide the sampling of encounters, transcription of recordings, interpretation of transcripts, and presentation of findings. We applied the interpretive method to 50 encounters selected randomly from a stratified random sample of 336 audiotaped encounters involving patients and primary care internists. As shown by two illustrative encounters, the discourse of health care reinforces ideologic principles of professional surveillance and individual control in dealing with patients' self-destructive tendencies. Contextual issues remain largely marginal features of the discourse, despite their pertinence to the goal of prevention. Narrative analysis provides a useful method to study the processing of self-destructive behavior in medical encounters. Future studies should continue to assess the variability of discourse in dealing with self-destructive behavior and should begin interventions to test the efficacy of differing discourse styles. Meaningful improvements in health-care discourse depend partly on difficult changes in the social context of medicine, including policies that address social conditions contributing to substance abuse and other forms of self-destructive behavior.

The black box in somatization: unexplained physical symptoms, culture, and narratives of trauma.

Stimulated by our clinical work with patients who manifest unexplained "somatoform" symptoms in the primary care setting, this article addresses a theoretical black box in our understanding of somatization: how does culture mediate severe stress to produce symptoms that cannot be explained by the presence of physical illness? Despite various problems in his explanation of hysteria, Freud broke new ground by emphasizing narratives of traumatic experiences in the development and treatment of unexplained physical symptoms. Except in anthropologically oriented cultural psychiatry, contemporary psychiatry has traveled away from a focus on narrative in the study of somatization. On the other hand, recent interest in narrative has spread across many intellectual disciplines, including the humanities and literary criticism, psychology, history, anthropology, and sociology. We operationally define narratives as attempts at storytelling that portray the interrelationships among physical symptoms and the psychologic, social, or cultural context of these symptoms. Regarding somatization and trauma, we focus on the ways that narrative integrates the cultural context with traumatic life events. In explaining the black box, we postulate that extreme stress (torture, rape, witnessing deaths of relatives, forced migration, etc.) is processed psychologically as a terrible, largely incoherent narrative of events too awful to hold in consciousness. Culture patterns the psychologic and somatic expression of the terrible narrative. Methodologically, we have developed some techniques for eliciting narratives of severe stress and somatic symptoms, which we illustrate with observations from an ongoing research project. In designing interventions to improve the care of somatizing patients, we are focusing on the creation of social situations where patients may feel empowered to express more coherent narratives of their prior traumatic experiences.

When nurses double as interpreters: a study of Spanish-speaking patients in a US primary care setting.

The United States is experiencing one of its largest migratory waves, so health providers are caring for many patients who do not speak English. Bilingual nurses who have not been trained as medical interpreters frequently translate for these patients. To examine the accuracy of medical interpretations provided by nurses untrained in medical interpreting, we conducted a qualitative, cross-sectional study at a multi-ethnic, university-affiliated primary care clinic in southern California. Medical encounters of 21 Spanish-speaking patients who required a nurse-interpreter to communicate with their physicians were videorecorded. Encounters were transcribed by blinded research assistants. Transcriptions were translated and analyzed for types of interpretive errors and processes that promoted the occurrence of errors. In successful interpretations where misunderstandings did not develop, nurse-interpreters translated the patient's comments as completely as could be remembered and allowed the physician to extract the clinically-relevant information. In such cases, the physician periodically summarized his/her perception of the problem for back-translation and verification or correction by the patient. On the other hand, approximately one-half of the encounters had serious miscommunication problems that affected either the physician's understanding of the symptoms or the credibility of the patient's concerns. Interpretations that contained errors that led to misunderstandings occurred in the presence of one or more of the following processes: (1) physicians resisted reconceptualizing the problem when contradictory information was mentioned; (2) nurses provided information congruent with clinical expectations but not congruent with patients' comments; (3) nurses slanted the interpretations, reflecting unfavorably on patients and undermining patients' credibility; and (4) patients explained the symptoms using a cultural metaphor that was not compatible with Western clinical nosology. We conclude that errors occur frequently in interpretations provided by untrained nurse-interpreters during cross-language encounters, so complaints of many non-English-speaking patients may be misunderstood by their physicians.

Managed care in Latin America: the new common sense in health policy reform.

This article presents the results of the comparative research project, "Managed Care in Latin America: Its Role in Health System Reform." Conducted by teams in Argentina, Brazil, Chile, Ecuador, and the United States, the study focused on the exportation of managed care, especially from the United States, and its adoption in Latin American countries. Our research methods included qualitative and quantitative techniques. The adoption of managed care reflects the process of transnationalization in the health sector. Our findings demonstrate the entrance of the main multinational corporations of finance capital into the private sector of insurance and health services, and these corporations' intention to assume administrative responsibilities for state institutions and to secure access to medical social security funds. International lending agencies, especially the World Bank, support the corporatization and privatization of health care services, as a condition of further loans to Latin American countries. We conclude that this process of change, which involves the gradual adoption of managed care as an officially favored policy, reflects ideologically based discourses that accept the inexorable nature of managed care reforms.

A hierarchical classes analysis (HICLAS) of primary care patients with medically unexplained somatic symptoms.

This study used a clustering model, Hierarchical Classes Analysis (HICLAS), to examine patient groupings in a multiethnic sample of 1456 patients using primary care services at a university-affiliated community clinic in southern California. Somatic symptoms, psychiatric diagnoses and disability were studied using a survey instrument that included portions of the Composite International Diagnostic Interview (CIDI), the Diagnostic Interview Schedule (DIS) and the RAND-MOS Short Form Health Survey's (SF-36) 'physical functioning' dimension. HICLAS identified 11 clusters of patients with distinct patterns of medically unexplained somatic symptoms. These patient clusters varied with respect to psychiatric diagnoses and symptoms, gender, immigration status and disability. Results of this study suggest that the type of presenting symptom(s) and their various combinations may have diagnostic and prognostic value in primary care settings. These new findings may lead to further refinement of current diagnostic constructs for somatizing syndromes.

Financial barriers to medical care: a prospective study in a university-affiliated community clinic.

Access to medical care in the United States is deteriorating, particularly for the poor. The authors evaluated patients who could not afford medical care recommended by physicians in a university-affiliated clinic that serves a predominantly indigent population. The authors determined the patients' demographic characteristics, their medical problems, and the types of care for which financial barriers existed. In addition, the authors compared the patients' demographic characteristics and medical illnesses with those of a control group of patients from the clinic who did not experience financial barriers to medical care. Of the 1,950 patients evaluated, 94 (4.8%) were unable to afford care recommended by their physicians. Sixty-seven percent were US citizens, 73% were unemployed, 63% had monthly family incomes of less than $500, and only 33% had health insurance. The patients had a variety of medical problems, ranging from hearing loss, for which they could not obtain hearing aids, to breast masses, for which they could not obtain mammographies or biopsies. When compared to patients who did not experience financial barriers to recommended care, the study patients tended to be poorer, more likely to be undocumented, more likely to be uninsured, and less likely to have acute, self-limited illnesses. Our findings support the argument that the nation's current piecemeal approach to providing indigent health care may lead to serious financial barriers to access in some localities.

Managed care and the geriatric patient-physician relationship.

As managed care proliferates in the United States and other countries, its structure has patterned changes in patient-doctor relationships, including those between older patients and their physicians. The physician as gatekeeper now limits the access of the patient to information and services. Patient trust in the physician, essential to an effective patient-doctor relationship, will be damaged under this system of care. Additionally, examples from medical encounters demonstrate that many of the problems in the doctor-older patient relationship found under fee for service will remain, including the lack of attention to the contextual issues of health care of older adults.

A critical theory of medical discourse: ideology, social control, and the processing of social context in medical encounters.

The personal troubles that patients bring to doctors often have roots in social issues beyond medicine. While medical encounters involve "micro-level" interactions between individuals, these interpersonal processes occur in a social context shaped by "macro-level" structures in society. Examining prior theories pertinent to medical discourse leads to the propositions: (a) that medical encounters tend to convey ideologic messages supportive of the current social order; (b) that these encounters have repercussions for social control; and (c) that medical language generally excludes a critical appraisal of the social context. The technical structure of the medical encounter, as traditionally seen by health professionals, masks a deeper structure that may have little to do with the conscious thoughts of professionals about what they are saying and doing. Similar patterns may appear in encounters between clients and members of other "helping" professions. Expressed marginally or conveyed by absence of criticism about contextual issues, ideology and social control in medical discourse remain largely unintentional mechanisms for achieving consent.

Is our work dangerous? Should it be?

Three case histories show how work in the medical social sciences--to the extent that such work reveals the origins of health problems in social structures of wealth and power--can become dangerous enough to threaten one's livelihood and in some instances one's very life. In this presentation, I encourage critical and engaged scholarship by referring to examples of dangerous work that should receive more attention: social medicine in Latin America and the critique of managerial ideology in the United States. Although social medicine has become a widely respected field of research, teaching, and clinical practice in Latin America, its accomplishments remain little known in the English-speaking world. For centuries, indigenous cultures in Latin America have held belief systems linking social conditions to patterns of illness and death. Latin American accounts of social medicine's history emphasize its European origins, especially in the contributions of Rudolf Virchow. In the United States, with the impact of the Flexner Report (1910) and its supporters, Virchow's vision of social medicine went into decline. On the other hand, in Latin America, social medicine flourished as a focus of education and research. Since social medicine's "golden age" during the 1930s, teachers, researchers, and practitioners have produced major achievements despite the dangers of this work, which in several instances have included torture, imprisonment, or death. An ideology favoring managerial decision making in the United States has influenced crucial policy decisions, and the justifications for these decisions have manifested symbolic politics in addition to the evaluation of factual evidence. With ambiguous empirical support, managerial ideology has fostered the general growth of managed care, the implementation of Medicaid managed care by state governments, the expansion of managed care in rural areas, and the impact of "evidence-based medicine" on policy and clinical decisions. If the occupational risks of critical work in the medical social sciences are not taken, we forfeit some of the most important gifts offered by "the sociological imagination."

Changing the structure of medical discourse: implications of cross-national comparisons.

In the discourse of medical encounters, social problems arise frequently. Such problems typically derive from work and economic insecurity, family life and gender roles, aging, and conditions that foster substance use or other self-destructive behavior. The structure of medical discourse tends to marginalize the social issues that generate personal troubles in everyday life. Long-range strategies to alter medical discourse aim toward basic modifications of power and finance in the larger society of which medicine is a part; such strategies seek to change the contextual issues that create personal troubles on the individual level. As shown by the examples of the Soviet Union, eastern Europe, and China, social revolution does not necessarily resolve the micro-level contradictions of the doctor-patient relationship. In contrast, the Cuban revolution apparently has succeeded in transforming both the context and the structure of medical encounters. Short-range strategies in countries such as the United States involve more direct ways in which patients and doctors can alter their communication. These alterations involve reducing devices of language that maintain professional dominance, avoiding the medicalization of nonmedical problems, attempting not to marginalize contextual issues, and encouraging active attempts to change social conditions that generate personal troubles.

Narratives of aging and social problems in medical encounters with older persons.

This study asks: How do older patients and their doctors deal with social problems in the discourse of routine medical encounters? Our research has been influenced by a growing recognition of narratives as an important analytic focus in the study of patient-doctor communication. We attempted to advance theoretical knowledge by emphasizing elements of sociocultural context, ideology, social control, underlying structure, and features of discourse that appear marginal to medicine's technical tasks. Based on a critical review of both quantitative and qualitative techniques in research on patient-doctor communication, we tried to move methodologically beyond prior work by developing a new interpretive method with systematic criteria to guide the sampling of encounters, transcription of recordings, interpretation of transcripts, and presentation of findings. We applied the interpretive method to 50 encounters selected randomly from a stratified random sample of 336 audiotaped encounters involving patients and primary care internists. As shown by illustrative encounters, a characteristic narrative structure and sequencing emerge, which tend to marginalize contextual problems, to leave them incompletely expressed, and to reinforce ideologies of stoicism and individualism.

Narratives of Somatizing and Non somatizing Patients in a Primary Care Setting.

Somatizing patients, who comprise approximately 20 percent of the primary care population, often present physicians with recurrent but confusing combinations of symptoms without organic explanations. Illness narratives presented during initial medical encounters with primary care physicians were examined qualitatively to determine if the narrative structure, chronological development of symptoms and temporal frame differed between somatizing and non-somatizing patients. Following a structured interview to identify somatization tendency and co-morbidities of depression and post-traumatic stress disorder, 116 patients' encounters with primary care physicians were video-recorded and transcribed. Somatizers demonstrated a narrative structure that was similar to that of non-somatizing patients, but they used a thematic rather than a chronological development of symptoms and they did not convey a clear time frame. Somatizing patients with a co-morbid psychological condition focused on concrete physical sensations, were unable to provide contextual history or chronological organization, and did not develop a temporal frame. The narratives of somatizing and non-somatizing patients differed sufficiently to warrant further research for use as a clinical aid in the diagnosis of somatization.

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Because no national health program assures entitlement to basic services, advocates must cope with barriers to access on the local level. The authors report several strategies that a community-based coalition has used to improve indigent care in one county. Research strategies have involved short-term investigations of barriers to needed services. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor. Legal strategies have involved the participation of attorneys who represent clients unable to receive care. Although such advocacy efforts do not guarantee access, they can substantially improve the availability of local services.

The social origins of illness: a neglected history.

Although interest in the social origins of illness has grown recently, the sources of this concern in Marxist thought have received little attention. Friedrich Engels, Rudolf Virchow, and Salvador Allende made important early contributions to this field. Engels analyzed features of the workplace and environment that caused disability and early death for the British working class. Virchow's studies in "social medicine" and infectious diseases called for social change as a solution to medical problems. Allende traced poor health to class oppression, economic underdevelopment, and imperialism. These analysts provided divergent, though complementary, views of social etiology, multifactorial causation, the methodology of dialectic materialism, an activist role for medical scientists and practitioners, social epidemiology, health policy, and strategies of sociomedical change. The social origins of illness remain with us and reveal the scope of reconstruction needed for meaningful solutions.

The micropolitics of medicine: a contextual analysis.

Certain features of the doctor-patient encounter "medicalize," and thereby depoliticize, the social structural roots of personal suffering. The critique of medicalization holds that medicine has become an institution of social control, that the health care system helps promulgate the dominant ideologies of a society, and that the doctor-patient relationship is a major site where these developments occur. This paper presents a contextual analysis of medical encounters, drawn from a sample of tape-recorded doctor-patient interaction in medical practice. The doctor-patient relationship manifests problems that arise despite the best conscious intents of well-motivated participants. Conveying the symbolism of scientific medicine, messages of ideology and social control reinforce current relations of economic production and reproduction in work, the family, leisure, pleasure, sexuality, and other areas of social life. Ambiguities within the doctor-patient relationship both reflect and help reproduce broader social contradictions and structures of oppression. The medical encounter is one arena where the dominant ideologies of a society are reinforced and where individuals' acquiescence is sought. A vision of a progressive doctor-patient relationship must include a conception of how that relationship contributes to fundamental social change.

Capitalism, socialism, and the physical quality of life.

This study compared capitalist and socialist countries in measures of the physical quality of life (PQL), taking into account the level of economic development. The World Bank was the principal source of statistical data, which pertained to 123 countries and approximately 97 percent of the world's population. PQL variables included indicators of health, health services, demographic conditions, and nutrition (infant mortality rate, child death rate, life expectancy, crude death rate, crude birth rate, population per physician, population per nursing person, and daily per capita calorie supply); measures of education (adult literacy rate, enrollment in secondary education, and enrollment in higher education); and a composite PQL index. All PQL measures improved as economic development increased. In 30 of 36 comparisons between countries at similar levels of economic development, socialist countries showed more favorable PQL outcomes (p less than .05 by two-tailed t-test). This work with the World Bank's raw data included cross-tabulations, analysis of variance, and regression techniques, which all confirmed the same conclusions. The data indicated that the socialist countries generally have achieved better PQL outcomes than the capitalist countries at equivalent levels of economic development.

A critical theory of medical discourse: how patients and health professionals deal with social problems.

Criticism of social context does not generally appear in medical encounters. When contextual issues arise in medical discourse, messages of ideology and social control may become apparent, usually without the conscious awareness of the participants. By easing the physical or psychological impact of contextual difficulties, or by encouraging patients' conformity to mainstream expectations of desirable behavior, encounters with doctors can help win patients' consent to troubling social conditions. Seen in this light, doctor-patient encounters become micropolitical situations that do not typically encourage explicit statements or actions by health professionals to change contextual sources of their patients' difficulties. A critical theory influenced by structuralism suggests that the surface meanings of signs in medical discourse prove less important than their structural relationships. In addition, a theoretical approach adopting elements of post-structuralism and Marxist literary criticism emphasizes the marginal, absent, or excluded elements of medical discourse. Contextual features that shape a text include social class, sex, age, and race. Through the underlying structure of medical discourse, contextual problems are expressed, marginalized, and managed.