Nephritis, nephrotic/syndrome and nephrosis
The health care provider should be aware of the complex issues that surround the delivery of health care from the patient’s viewpoint. Calling the medical society for the name of a physician (because a “family member has a health problem”) and visiting and comparing the services rendered in an urban and a suburban emergency room are exercises that can enable us to better appreciate some of the difficulties that the poor, the emerging majority, and the population at large all too often experience when they attempt to obtain health care. Members of the health care team have a number of advantages in gaining access to the health care system. For example, they can choose a physician whom they know because they work with him or her or because someone they work with has recommended this physician. Health care providers must never forget, however, that most people do not have these advantages. It is indeed an unsettling, anxiety-provoking, and frustrating experience to be forced to select a physician from a list. It is an even more frustrating experience to be a patient in an unfamiliar location—for example, an urban emergency room, where, quite literally, anything can happen. The film by Michael Moore, SICKO, paints a most painful picture of the modern health care system. Books, such as J. P. Kassirer’s On the Take illustrate the complicity of the health care system and big business; and T. R. Reid’s, The Healing of America: A Global Quest for Better and Cheaper, and Fairer Health Care serve to illustrate other aspects of the complex health care system we live with today. Yet, people entering the system ought to be familiar with all aspects of it and many issues not mentioned, such as the costs of procedures and medications.
Another barrier to adequate health care is the financial burden imposed by treatments and tests. There are other issues as well. For example, a Chinese patient—who traditionally does not believe that the body replaces the blood
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taken for testing purposes—should have as little blood work as necessary, and the reasons for the tests should be explained carefully. A Hispanic woman who believes that taking a Pap smear is an intrusive procedure that will bring shame to her should have the procedure performed by a female physician or nurse. When this is not possible, she should have a female chaperone with her for the entire time that the male physician or nurse is in the room.
More members of the emerging majority must be represented in the health care professions. Multiple issues are related to the problem of underrepresentation— the demographic disparity—that is ongoing because there are inadequate numbers of people from emerging majorities. Many of the programs designed to increase the number of emerging majority students in the health care team have failed. Difficulties surrounding successful entrance into and completion of professional education programs are complex and numerous, having their roots in impoverished community structures and early educational deprivation. Although society is in some ways dealing with such issues—for example, initiating improvements in early education—we are faced with an immediate need to bring more emerging majority people into health care services.
One method would be the more extensive use of patient advocates and outreach workers from the given ethnic community who may be recognized there as healers. The people can provide an overwhelmingly positive service to both the provider and the patient in that they can serve as the bridge in bringing health care services to the target community. The patient advocate can speak to the patient in the language that he or she understands and in a man- ner that is acceptable. Advocates are also able to coordinate medical, nursing, social, and even educational services to meet the patient’s needs as the patient perceives them. In settings where advocates are employed, many problems are resolved to the convenience of both the health care member and, more impor- tantly, the patient!
The nettlesome issue of language bursts forth with regularity. There is al- ways a problem when a non–English-speaking person tries to seek help from the English-speaking majority. The more common languages, French, Italian, and Spanish, ideally should be spoken by at least some of the professional people who staff hospitals, clinics, neighborhood health care centers, and home health agencies. The use of an interpreter or translator is always difficult because the translator generally “interprets” what he or she translates. To bring this thought home, the reader should recall the childhood game of “gossip”: A message is passed around the room from person to person, and by the time it gets back to the sender, its content is usually substantially changed. This game is not un- like trying to communicate through a translator, and the situation is even more frustrating when—as can often be the case in urban emergency rooms—the translator is a 6-year-old child. It is, obviously, far more satisfying and prod- uctive if the patient, nurse, and physician can all speak the same language. All institutions must follow the mandates of Title VI of the Civil Rights Law. In fact, in many institutions there are professional interpreters available, however,
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they may not be present 24 hours a day. Telephone devices and some computer- generated programs are available, but costly.
Health services must be made far more accessible and available to members of the emerging majority. I believe that one of the most important events in this modern era of health care delivery is the advent of neighborhood health centers. They are successful essentially because people who work in them know the people of the neighborhood. In addition, the people of the community can contribute to the decision making involved in governing and running the agency so that services are tailored to meet the needs of the patients. Concerned members of the health care team have a moral obligation to support the increased use of health care centers and not their decreased use, as currently tends to occur because of cutbacks in response to allegations (frequently politically motivated) of too-high costs or the misuse of funds. These neighborhood health care centers provide greatly needed personal services in addition to relief from the widespread depersonalization that occurs in larger institutions. When health care providers who are genuinely concerned face this reality, perhaps they will be more willing to fight for the survival of these centers and strongly urge their increased funding rather than acquiesce in their demise. In rural areas, the problem is even greater, and far more comprehensive health planning is needed to meet patient needs.
In the beginning of this text and throughout it, I used the metaphor of climbing stairs to reach CULTURALCOMPETENCY. However, this can be seen, too, as a journey. Thus, the road, or ascent, to CULTURALCOMPETENCY is simi- lar to traveling on a road to anywhere. It takes time and thought and active participation. It is a learning experience wherein you discover countless facts (especially about yourself), a dynamic process in which you face a number of obstacles on the road: