Latino Culture: Decision Making

(Article by Daniel Catalaa, published Apr 15th, 2019)
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Comparison of Cultural Values

Anglo Culture: Medical decisions are based on personal autonomy, are patient-driven, and are affected by citizen socioeconomic factors.

Latino culture: Patients make medical decisions that are family-integrated, doctor-driven, and are affected by immigrant socioeconomic circumstances.

Patient-driven vs. Doctor-driven Decisions

In the States the patient is in the driver's seat and is the executor of all medical decisions. So long as they are conscious and coherent, the patient is in control. The medical provider takes on the role of explaining risks and benefits of proceeding with different options. The patient in turn will sign the papers and pull the trigger on whether to proceed or not and with which option.

The patient-doctor dynamics are very different for Latinos. The doctor's opinion is seen more as a medical imperative/directive and carries a lot of weight. The thinking is that the doctor knows best so the advisable course of action is to follow his recommendations. After all, there is no reason to second guess him, he is the professional and his expertise should be trusted.

Personal vs. Family-integrated

As a matter of courtesy, Anglo patients may keep their families updated regarding what is happening with their health, nevertheless medical decisions are viewed as personal choices. When facing an important medical decision, it is not unusual for friends to counsel the patient "You do what is best for you". The patient in turn will do their best not to burden anyone because of their illness and will try to be as self-sufficient as possible. They will get out of bed unassisted, use a walker of cane to get around, cook a meal with their one good hand, or drive or themselves to the hospital.

Latinos view themselves as an integral part of their families, so they will consult with their spouse or adult children regarding what to do. Latino families are large and tight-knit so the patient is always thinking how his/her decisions will affect others members. This additional level of consultation makes decision-making a slower process. On the other hand, family members will often be very supportive and involved with the patient's care and recovery, visiting them at the hospital, bringing home-cooked meals, providing baby-sitting, giving them a ride to their therapies, etc.

Citizen Socioeconomics vs. Immigrant Socioeconomics

Compared to immigrants, US citizens tend to be better informed about their rights, how the medical system works, and by the time they are adults they have been exposed to numerous public health campaigns. In addition to being fluent in English, they are also likely to have completed high school and often some college. Those who are internet-savvy, can do research online regarding their symptoms or illness. All in all patient take medical decisions primarily based on a risk-benefit analysis and insurance coverage, however other factors like pain tolerance or acceptable/desirable lifestyle play a part.

Instead, the medical decisions taken by first generation Latinos are closely connected to their immigrant socioeconomic circumstances. To understand why this is the case, it is important to realize that immigration acts as a strong filter, hence immigrants do not represent a cross-section of the societies they came from. Mexican lawyers, Salvadorean land owners, and Nicaraguan engineers have comfortable lives and zero motivation to leave their countries. Who will come then? The poor and destitute with meager access to education and job opportunities, natural disaster survivors, and war zone refugees, this is who is willing to leave behind everything, and often everybody, for better prospects.

On average, immigrants from Mexico and Central America have completed up to the 3rd grade of elementary school. In addition to not communicating in English, Latino immigrants may also be illiterate in written Spanish. They arrive with minimal economic resources and initially start working low paying jobs. They have a variety of legal statuses (undocumented, temporary visas, conditional residency, green card holder, naturalized citizens, etc.) some of which entail a clandestine existence. The lack of education, knowledge of English, financial means, and legal status, weigh heavily in the patient's decision making process.

Examples of Cultural Misunderstandings

Scenario A

Situation: A Latino patient is prepared for ambulatory surgery and is in a gurney in a holding area waiting to be wheeled into the operating room. The anesthesiologist comes by and, after a few questions about the patient's heart and lungs, he asks the patient if he prefers either local anesthesia, monitored sedation, or general anesthesia. The patient is bewildered because they have been asked to make medical decisions for which they have no training. Thy patient thinks "The doctor studied these things, he is the expert, so why doesn't he tell me what to do?". The provider is thinking: "Why can't the patient make up her mind? After all, I explained everything clearly. What's the hold up?"

Mitigation: Provider will be more directive with Latino patients actively suggesting the preferred option among those presented. The anesthesiologist could say "Of the options discussed, based on my years of experience, I think that monitored sedation is the way to go here. It will keep you comfortable but you will still be able to speak up or answer our questions". This is preferable over the "We could do A, B, C, or D; what would you like to do?" approach that lacks any accompanying recommendation at the end. Provider will allow time for patient to consult with family and extended home support network before an important decision is made, even if they are not present on the day of the consultation. After all patient may need to arrange for somebody to drive them, shop for groceries, babysit, take time off work, pick up mediation, etc.

Scenario B

Situation: A Latino patient is a no-show to her prenatal OBGYN appointment for the fourth consecutive time in two months. All attempts to reach her by phone go to a voicemail that is full. With reluctance the doctor decides to drop the patient to free up her schedule for other expectant mothers that need following. It is later discovered that the Latino patient had to take 3 different buses to get to her appointments. Her phone was damaged and she was waiting for her next paycheck to replace it. Eventually she heard the appointment reminder calls from the medical office, but they were in English and by the time she found somebody to interpret them for her, the appointments had passed. On top of that, her boss threatened to let her go if she took any more time off work for her appointments and she is afraid to speak up because of her illegal status.

Mitigation: When Latino patients are first seen, the provider and office staff explore the existence of any financial or legal impediments that could interfere with medical care. It will not be assumed that the patient has their own means of transportation, sufficient funds to make co-payments or to pay for over-the-counter medications, or that they can easily take time off work. It may not be the medical facility's responsibility to resolve these issues, but they should be aware of them and facilitates things when possible. For example, the patient could be seen at a satellite clinic that is closer to their home and easier to reach, or free pharmaceutical samples could be given to patients that are struggling financially.

This article is part of a series on Latino Culture and Healthcare.
View the main article here.