The no-shows were wreaking havoc with the appointment schedule at Bailey's Health Center in Falls Church. Week after week, follow-up visits were missed when patient after patient failed to come, call or cancel.
Most were immigrants from Central America, and frustrated staff members started asking questions -- and discovered yet another disconnect between American medicine and foreign culture.
The patients had known all along that they couldn't come back on the dates given to them, it turned out. But to refuse an appointment, to somehow say "no" to medical authority, would have been extremely impolite, if not unthinkable.
The scheduling snafus at Bailey's, a storefront facility off busy Route 50, dramatize the challenges that a diverse population poses to doctors' offices, clinics and hospitals. Bridging that cultural gulf has become a top priority of the medical universe because much of the health care system remains ill-prepared. The result can be inadequate care and, in extreme cases, can risk lives.
"This isn't singing 'Kumbaya,' " said Harold Ross, whose Silver Spring consulting firm, Cook Ross Inc., has created an Internet program that offers medical providers extensive background on ethnic and religious groups. "If physicians truly embrace what this means, it will require a complete overhaul of not only how we practice medicine, but how we train for medicine."
Ross recalls his firm's early work at a Michigan hospital where Vietnamese women were becoming dehydrated after giving birth. The staff did not realize how some Asian cultures divide life into hot and cold periods and strive for balance between them. The days following birth are considered a cold time, and women are supposed to consume only warm fluids and food.
"And what does a good nurse bring to the bedside of a hospital patient? Ice chips and cold water," Ross said. Consequently, the new mothers were drinking little to nothing. The solution was to ask them what temperature they wanted their water to be.
Ross remembers thinking, "Wow, how many other things are like this?"
Plenty, it became clear.
'Better medicine'
Cultural nuances are why a Hmong man would be insulted if a doctor looked directly at him during a lengthy conversation and why a Salvadoran woman who feared mal de ojo , or the evil eye, would seek a folk medicine healer, a curandero.
At Bailey's, where 10 percent of patients speak Arabic, Farsi or Urdu as their primary language, cultural norms were the reason a breast self-exam program for Muslim women several years ago took place before regular business hours and involved only female staff. The center agreed that no male employees would be on the premises.
"It all gets down to basic respect," said Christina Stevens, program director of the Fairfax County Community Health Care Network. "And it's better medicine."
Even for those on the receiving end of routine encounters, the experiences can be unsettling. Lubaba Mohammed, a young Ethiopian woman who lives in Prince George's County, was taken aback by the information she was asked during medical appointments. The doctors' manner seemed so forward, she said.
"You are surprised when they ask you questions, especially [about] a woman thing," Mohammed recounted, her toddler daughter balanced on one hip. "You are afraid to speak, to explain. You never used to back home. You are shy."
But she has since become Americanized: "If I have a problem, I have to talk. If I don't talk, it gets worse. That's what I learned."
Teaching doctors a more sensitive approach often falls to organizations such as the Delmarva Foundation, which is based on the Eastern Shore but focuses on health care quality nationally. The foundation recently launched a cultural education project that offers tutorials and other resources to physicians in Maryland and the District.
"It is not a peripheral or marginal or sometimes issue," said Michael Tooke, the foundation's chief medical officer. Yet in the project's first three months, only three groups signed on.
More progress is occurring at the public and nonprofit clinics that provide primary care to low-income communities.
Understanding without asking
At the Community of Hope clinic in Northwest Washington, what started as a trickle of patients several years ago now numbers hundreds of Ethiopians and Eritreans, not just younger ones like Mohammed, but elderly men and women who uniformly list their birthday as "1/1" -- because they do not know for sure when they were born.
The clinic's staff continues to adapt to patients' health needs, whether figuring out diet and nutrition counts for such traditional foods as the sponge bread injera or focusing on concerns linked to past tragedies. Medical Director Kate Sugarman can identify the signs of torture in those native lands. Back pains hint of brutal beatings. The lattice pattern on patients' knees reveals that they were forced to crawl for hours at a time across rough sand and gravel.
"You see those scars, the tiny dots," Sugarman said. She always aims for an empathetic response.
And at the Pregnancy Aid Center in College Park, which three decades ago opened its doors as a counseling service for university students, patients now come from countries where female circumcision is a rite of passage. Such radical anatomical refiguring precludes the usual pelvic exam and greatly complicates childbirth.
In Montgomery County, where a quarter of residents are foreign by birth, a network of ethnic-specific clinics continues to expand. There is a church-based clinic for residents from Haiti and French-speaking Africa, another designed to serve Latino day laborers. The newest program, opened in a Gaithersburg market, targets Koreans. Each is a collaboration of a community group and the nonprofit Mobile Medical Care Inc., whose executive director considers cultural understanding as essential to health care as a stethoscope or X-ray.
How else, Robert Spector asked, might a doctor discern which patients can be touched and which cannot? In certain cultures, only the husband or eldest son is permitted to make medical decisions. In others, "it's the whole family."
The collaborative's biggest success, the Pan Asian Volunteer Health Clinic, operates every Tuesday evening in a county building in Silver Spring. Virtually every person who signs in is Chinese born or raised, as are the volunteer doctors and assistants. Their shared backgrounds mean easier communication when patients describe symptoms or the herbal remedies they have tried.
"Everybody speaks the same language," said M.K. Lee, deputy director of the Chinese Culture and Community Service Center, the partner that helps MobileMed recruit staff. If a patient complains that "I've got fire in my mouth," the staff immediately figures: fever. "Every Chinese physician knows what that means," Lee said.
Contrast that with the confusion that can arise in other settings.
"It's harder to describe what you feel," said an older woman named Qi Chen. In Beijing, Chen was a university professor. She lives in Potomac with her daughter and baby-sits her 9-month-old granddaughter. Both were with her recently at the clinic as Chen waited to see a doctor about pain in her elbow. Someone had told her it probably was tennis elbow. "But I don't play tennis," she replied.
Changing education
An article last year in the Journal of the American Medical Association cited "the need for significant improvement" in physician training. It detailed a survey in which a quarter of more than 2,000 final-year medical residents said they were insufficiently prepared to deliver care to new immigrants or those with beliefs not in line with Western medicine.
"You make assumptions about patients based on how they look, how they speak, the clothes they have on, and, truth to tell, patients make assumptions, too," said Yolanda Haywood, an assistant dean at George Washington University medical school. In keeping with national accreditation standards passed in 2001, the school incorporates cultural questions into a required four-year course, the Practice of Medicine.
Dealing with varied backgrounds and beliefs takes time, which the pressures of managed care do not easily accommodate.
"You have to first have this little chat," Director Mary Jelacic said of her African patients at the Pregnancy Aid Center. Then the doctor or nurse moves on to the actual health issue, which may be tucked within a meandering, lyrical narrative.
"It's like peeling an onion," she said. "It takes a long time to get to why the person is here."