Caring for special populations
BY SHERI PORTER
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The numbers tell the story. According to the 2002 Yearbook of Immigration Statistics, 15,697,123 legal immigrants arrived in the United States between 1986 and 2002.
It's a safe bet many family physicians are seeing a least a few of these arrivals.
FP Kim Yu, M.D., of Novi, Mich., said at least 30 percent to 40 percent of her patients are immigrants. "It makes my practice really wonderful," she said, while acknowledging that immigrants do present special health care challenges.
Barriers to health
Some of the challenges -- such as lack of insurance -- mirror those of the general U.S. population.
Other situations are unique to immigrants.
Patients often bring medications with them from other countries, said Yu. Unfamiliar drugs, generic brands and herbal remedies cause concern, especially when the accompanying product information isn't in English.
Yu also has patients who come to her for care but return to their home countries for some tests and procedures. "It's not the best situation for continuity of care," she said.
Cultural differences, such as holiday eating habits, may require patient education. For instance, how does a physician help a Muslim patient with diabetes control the disease during Ramadan, a time of fasting? "Teaching the patients without offending them is sometimes difficult," said Yu.
Chinese New Year presents the opposite problem. "Everyone eats and eats and eats. I try my best to get my diabetic patients to listen, but it can be hard to break those cultural traditions," said Yu.
Emotional and mental health issues loom large for immigrants, said FP Viviana Bianchi, M.D., of Davenport, Iowa, who sees many of these patients in her practice. Depression brought on by leaving one's native country can cause hard-to-trace physical symptoms.
Communication challenge
Estimates from the 2000 U.S. Census show that 17 percent of U.S. residents speak a language other than English at home. Hundreds of languages are spoken in the United States.
"I think I'm in a small rural place, yet I have patients from Korea, China and Vietnam," said Sabine Maas, M.D., of Banner Elk, N.C.
Understanding a non-English speaker's description of symptoms and making a diagnosis take time, she said. A Vietnamese patient brought a translating computer to her appointment to help her describe her symptoms. "It took 15 minutes," said Maas. "Finally a voice comes out of the computer and says, 'Pimple.'"
You may have questions about your obligation to patients with limited English proficiency, or LEP. For example, are you required to provide translation services? How do you provide them? Who pays for them?
Jane Perkins, J.D., M.P.H., who works for the National Health Law Program, prepared a 2003 report for the Kaiser Commission on Medicaid and the Uninsured about ensuring linguistic access in health care settings.
"The guidance that the federal government has provided over the past three years has recognized that one size doesn't fit all. What different providers receiving federal funding need to do will vary," said Perkins. (Physicians paid for services under federally funded programs are considered to receive federal funding.)
Try these resources
Perkins suggested that physicians go straight to the HHS guidance at http://www.usdoj.gov/crt/cor/lep/hhsrevisedlepguidance.html. Scroll down to Section V (page 47,314), "How Does a Recipient Determine the Extent of Its Obligation to Provide LEP Services?"
Another useful resource is a field report Perkins helped write, "Providing Language Interpretation Services in Health Care Settings: Examples from the Field," available as a PDF file at http://www.cmwf.org/publist/publist2.asp?CategoryID=11. Scroll down to the report title. For help using PDF files, go to http://www.aafp.org/pdf.xml.
Perkins said physicians should remain hopeful. "There is work going on, there are examples to be followed, there are funding sources to be tapped, and there is the recognition that this isn't going to happen overnight."
To reach writer Sheri Porter, e-mail sporter@aafp.org.
FP Report is published by the AAFP
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Copyright © 2004 by
American Academy of Family Physicians.