Tiffany Sorrentino

Washington, Maine
Sophomore, Biology
Utah State University

IÕm Not A Patient, IÕm A Person: A Discussion Of Caregiver-Patient Relationships In Peruvian Biomedicine

INTRODUCTION

I am interested in studying the caregiver-patient relationship in the Peruvian biomedical culture. Specifically, I would like to compare any similarities that may exist between hospital care in Trujillo, private clinic care in Trujillo, and a 24 hour/day clinic in Huanchaco. As a biology student who hopes to become a biomedical professional in the United States, I am aware of and recognize the import and necessity of an open and comfortable caregiver-patient relationship. I am also attentive to the fact that the definition of such a relationship is diverse for different cultures. For this reason, it is imperative for me to experience, first hand, the caregiver-patient relationship in another country. Because of the extensive immigration of peoples from South and Central America to the United States, there has been a large increase in the number of Latin Americans that receive medical care in the United States. However, many of these Latin Americans may very well have different expectations of their biomedical doctor than persons who were born in the United States. For this reason, I believe it is important to be familiar with the different types of expectations that Latin Americans have of their biomedical professionals. This type of knowledge is best obtained by actually going to a Latin American culture and immersing oneself in it. This insight provided will be an invaluable additive to my ability to interact in a culturally sensitive way with various persons in my care.

BACKGROUND

Biomedicine has traditionally been known for its emphasis on purely empirical data. Diseases have conventionally been viewed by many doctors as problems that exist only as manifestations of the physical body. Therefore, it stands to bear that the treatment of these diseases has also focused heavily on the restoration of the physical body to the state in which it existed prior to the disease. However, in recent years there has been a growing recognition of the fact that a disease affects not only the body, but a personÕs mental state and hence their entire life. This acknowledgement of the person as a whole has led to an increase in the necessity of biomedical doctors to concede that patients function as a whole and within a cultural system and must be treated accordingly if an effective treatment is going to be accomplished. Because of this emerging trend in biomedicine, it has become increasingly important for future and current medical students to take an active interest in learning another culture and to practice cultural and personal relativism with all their patients.

This particularly humanistic approach to biomedicine has fascinated me for years. As a child growing up my mother used alternative medicine and biomedicine therapies according to whichever she felt would work best for a particular situation. As such, I never developed any reason to doubt that either discipline was completely valid. However, as I grew older I did recognize differences in the manner of treatment of the patient by the two different types of professionals. When my mother visited the chiropractor or massage therapist, there was usually a lengthy discussion about the state of my motherÕs affairs. How was her weight loss goal coming along, how were the co-workers at work treating her, how were her children doing in school? The alternative healers were always very interested in ascertaining the entire picture and being able to completely envision my motherÕs life. Such a discussion did not usually occur when we visited our biomedical doctor. Although he was friendly and extraordinarily knowledgeable man, his main interest lay in the physical ailments that afflicted us. It was rare that his questions ventured into the realm of the emotionally personal.

The older I grew, the more I wished that the two approaches to healing would merge. I desired for my biomedical doctor to treat me with the same respect, deference, and affability that the alternative healers did; and I wanted my alternative healers to have the same type of recognition and prestige given to them by the general public as my biomedical doctor. I wanted my biomedical doctor to prescribe herbal medicines first and then antibiotics, and my alternative healers to understand the necessity of using a more biomedical approach when necessary. Above all else, I wanted both professions to understand me for whom I was, as varied in my beliefs as I might be, and treat me accordingly, in a manner that was appropriate unto me.

Because of my desire for this type of treatment and my exponentially growing interest in medicine, I came to the conclusion that the only way to find the type of doctor I was looking for was to be that doctor. I made that decision by the end of my sophomore year in high school. As of yet, nothing has deterred me from that path, in fact all of the things that IÕve encountered since have only convinced me more that there is a growing need for a type of doctor that is willing to incorporate alternative healing approaches as well as biomedical knowledge.

When I arrived at college, I had the good fortune to find a work study job in Utah State UniversityÕs Anthropology Department. The faculty in the Anthropology Department only further encouraged and validated my aspirations. One faculty member in particular, Dr. Bonnie Glass-Coffin was insistent upon the fact that biomedical doctors should have training in the social sciences in order to better understand and treat the patients with whom they worked. Dr. Glass-Coffin was so adamant about this that she suggested to me that I take her Medical Anthropology course in the spring semester of 2004, which I did. During the course of the semester, Dr. Glass-Coffin had mentioned several times that she was conducting a field school in Huanchaco, Peru during the summer of 2004. I had originally not been interested in going because I am a Biology major. However, Dr. Glass-Coffin asked me one day if I as interested in going. I thought about it briefly and I came to the conclusion that it would be the perfect opportunity to study another countryÕs biomedical culture. I reasoned with myself that such an experience would increase my marketability to medical schools as well as increase my understanding of Latin American expectations of biomedical doctors. This experience, I told myself, would be extraordinarily useful in becoming the type of doctor that I wanted to be.

When I originally set off for Peru, I thought that I would be studying the differences in training methods between Peruvian biomedicine and American biomedicine. However, that changed, when I realized that most of the data I was collecting focused much more on caregiver-patient relationships. Since this was truly what I was interested in anyway, I readily changed my research question to be able to study the caregiver-patient relationships in more depth.

METHODS

In order to accomplish my research in Peru, I have conducted many eight participant observation exercises in various biomedical settings. Because of the fact that when I first came to Peru, my Spanish skills were lacking, the bulk of my early research focused mainly on detailed descriptions of the places which I visited as well as body language and physical actions. The different places in which I conducted my participant observation include a private clinic in Trujillo, which is a place where only those persons who have money can go for medical care because of the high expense, as well as Hospital Regional, which is a place where the destitute usually go for medical care, in which I observed a class in which nursing students from San Pedro University bathed four different patients in a stroke ward. I also spent several says, not consecutively, with a doctor in Huanchaco who runs a 24 hour a day, 7 days a week clinic.

In addition to these three places I also visited a health outreach program in a shanty town near Trujillo with nursing students as well as spending a day with medical interns at Chocope Hospital. These two visits, although helpful in creating a basic understanding of the biomedical health system in Peru were not examined due to time constraints.

DISCUSSION

During the period in which I did my research, I noticed one outstanding similarity among all of the professionals that I studied: there always existed a social relationship that was both intimate and compassionate between the caregiver and the patient. In all situations the patient was treated more like a respected friend than a prospective client. The doctors and nurses I observed went beyond the realm of courteous in their conversations with the patient. I believe that this social relationship was accomplished by the fact that in every situation that I studied, the same caregiver dealt with the patient from the beginning of the visit until the end of the visit. In observing this process time and again, I found an emerging pattern in each visit that consisted of three social moments that helped to build and solidify the social relationship between the caregiver and the patient. The first social moment occurs when the caregiver greets the patient. The second social moment includes the attention to whatever medical business may be at hand. The third consist of an open dialogue between the caregiver and the patient. These three distinct phases are manifested in slightly different ways in each of the locations that I visited due to differences in required duties of each professional. However, all three parts are distinct and present in all situations that I studied.

The following is an excerpt from my notes concerning a doctors appointment in the 24 hour a day clinic in Huanchaco:

I'm already sitting in the doctorÕs office as the doctorÕs 5 oÕclock appointment walks in. It is two women, neither older than thirty. One of the women is very obviously at least 6 months pregnant, if not more. When they both enter, both Dr. Luis and his wife Ingaborg are there. They go through the elaborate process of kissing and hugging everyone hello before theyÕve come more than three feet through the door. The doctor excuses himself very briefly, and smiles brightly at both women and then walks into the back room. He returns very shortly. Dr. Luis and Ingaborg invite the women to sit down, saying, "Please, sit, sit." As she is inviting them to sit down she has her right hand on the pregnant womanÕs left shoulder. She almost guides her to the chair. Once the women are seated, Ingaborg walks around the back of the desk and sits in the doctorÕs chair. Ingaborg is always smiling, and it is a sincere smile. She and the two women begin to talk, and over the next 7 minutes the conversation ranges from views on the mayor, to how horrible the weather had been lately and finally to a discussion over what sex the child shall be. The woman says that everybody says the baby will be girl; the doctors, her husband, her mother, everybody. However, she says, she knows it will be a boy. Her first child, she says, was a girl, and this baby is totally different. "He sits differently in my stomach," she says. Ingaborg is leaning forward in her chair, listening intently, smiling easily and nodding in understanding.

The next part of the interaction occurs as a rather abrupt change from the first section and consists of attention, by the biomedical professional to the patientsÕ medical needs. This section of the interaction is the one that varied the most between the three locations that I observed because of the fact that each biomedical professional had different duties they had to perform concerning the patientÕs medical needs. However, in all three situations, it was evident via nonverbal communication, that it was the patient who was the most important person of the relationship in this phase. In both of the doctorsÕ offices neither doctor diverted their attention from the patient by writing anything down or looking anywhere except at the patient during this part of the visit. I found that the doctors and sat and engaged in active listening with the patient. For anyone who has taken a communications course, they know that active listening is just as important, if not more so, to a mutual understanding than the verbalizations. First, it reinforces and validates the person who is speaking, encouraging them to be more open and feel more at ease. Second, active listening allows the listener to engage in the nuances of body language and truly ascertain what the other person is trying to communicate.

In the hospital, with the nurses, the importance of the patient was displayed in the nursesÕ deference toward the patients that they were bathing. This respect for the patient was most evident in one scene that I witnessed where a nurse was attending to an 82 year old female patient who had been in coma for over two weeks. This nurse explained everything that she was doing to the patient as she did it. At one point she said to her, "Now, little grandmother, donÕt worry, IÕm going to wash your face now, but I will be careful not to get the soap in your eyes." Even though the patient could not understand her, the nurse continued to illustrate that the patient was the central person at that point of the relationship.

This next excerpt from is from my notes of the private clinic visit and illustrates the openness of the doctors to questions:

Robin, Professor Glass-Coffin and I are sitting in the doctorÕs office of a private clinic in Trujillo, Peru. Robin has been suffering from a sore throat as well as conspicuous white pustules in the back of her throat that were causing her pain. The doctor had removed the pustules, much to RobinÕs chagrin, and now, the three of us were sitting in front of the doctorÕs desk. He was explaining that the pustules were actually food bits that had become lodged in tiny out-pockets in the back of her throat that had become infected. Robin was disbelieving, saying that she had never had that happen before to her in her life, and how could that happen? The doctor was patient in explaining to her that sometimes, due to whatever reason, food gets caught back there and will get infected. He then prescribed her three different medications. One was an antibiotic to help cure the infection; the other was a gargle, and the third was for the pain. He explained why she was to take each medication and how. Robin, being a skeptic of biomedicine, asked plenty of questions. What would the gargle do? How strong was the antibiotic? The doctor was patient with her, and answered all of her questions thoroughly. Never once did I get the impression that he was annoyed with her.

The fact that each of these three social moments works to create a close relationship between the caregiver and the patient is dependent upon the fact that it is the same caregiver who enacts all three phases. If each social moment was enacted by a different caregiver, there would not be a sense of continuity for the patient. The foundations built in one part of the relationship would not effectively carry over to the next part if the caregiver was not the same.

CONCLUSION

Many problems presented themselves during the course of this field school. For me, the first problem that I had to deal with was my ineptitude with the Spanish language. This made it difficult to collect any kind of spoken information for the first several weeks of the field school. If I were to come back, I would want to be more proficient in the language.

Time was the second large problem. We were only given five weeks to set up social contacts, collect the data, and then write the paper. During this time, I felt as if I didnÕt have enough time to collect the base of data that I wanted to. If, in the future, I had more time to repeat this exercise, I would visit the other hospital in Trujillo as well as the hospital in Chocope. I would also like to visit more than one private clinic in Trujillo as well as visit some of the rural posts in which the doctors have to do service after they finish their medical schooling. I feel that by visiting more places I would be able to find more similarities in the different sectors of biomedical health in Peru.

If I had even more time to study the biomedical system here in Peru, my real interest would lie in ascertaining why I have begun to see this pattern of the same caregiver seeing the patient throughout an entire visit, and why each visit I observed followed the same pattern of having three definite social moments. I am postulating that part of the reason for this pattern is culture. The culture here one in which social relationships are of utmost importance. In that light, it is understandable that the caregiver and patient would form a social relationship as well as a professional relationship. However, I am also inclined to wonder if there is any formal training, or any indication at all in the method of training in Peru that predisposes the biomedical professionals here to form a social relationship with their patients. However, that project would also take more than five weeks.

The final problem that I encountered dealt with how and when to take field notes. It is difficult to take notes in the field. Very often, you are talking with someone, and to take notes interrupts the flow of the conversation, or in my case, severely limits all understanding I have of the conversation if it is being spoken only in Spanish. I found it useful to take notes whenever the doctor was talking to the patient, or to sometimes excuse myself from the scene, telling whomever I was working with that I was feeling sick to my stomach because of some of the things I saw.