“Could you please see this patient? He speaks Spanish only.”

Xiomara Nieves-Alvarado, MD

I was born on the beautiful island of Puerto Rico. We speak Spanish, and we learn to speak English, but our culture very much speaks Spanglish. Growing up, I was fortunate to have had the chance to see the world since I was a toddler. My parents always wanted to be together and never left me with grandparents or babysitters when they had an event on the mainland. Little by little, my dad was asked to travel to Europe and Mexico; his duties required him to be on the fly all the time. This gave me the opportunity to see different cultures before the boom of globalization, as well as to make friends everywhere I’d go, which I still keep.

When I started my residency at Duke, I felt very happy that the diversity of patients was such that one moment I would be talking to a person in English when suddenly, I would need a translator to speak mandarin. My favorite was when I was called by a team because there was a Spanish-speaking patient, and no one on the team spoke Spanish. I have never felt insulted in response to these requests. In fact, I find great meaning in doing these interviews myself to make sure the entire context of the interview is well understood. Now, where is the challenge?

One challenge is determining how to communicate to my supervisor that I am not concerned about a patient’s seemingly excessive use of religious content. I have heard translators emphasize to psychiatrists when a patient says, “Thanks to the Lord,” “If God allows,” “God sees everything,” or “I just listen to God and live wholly.” These sayings, in the raw translation, could be interpreted in so many ways. Now, when you ask the patients specifically about their thoughts, if God speaks only to them, if God gave them special powers, or if they are God themselves, they mostly answer “no.” On the same note, when Hispanic patients say “Me quiero matar”(I want to kill myself), “Yo me quería morir”(I wanted to die), or “Mátame”(Kill me), there may be no real intent of dying. These are used mostly as a figure of speech in embarrassing or painful situations. Lastly, some psychiatrists tend to use the affects and tones of the patient’s relatives as part of their assessment of family dynamics and structure. Whereas that can be appropriate in many cases, it is important to consider how the field of medicine is seen in other countries. From my experience, Hispanics tend to be very patriarchal when it comes to medical evaluations, interviews, and medical recommendations. Usually, the doctor has the last word, and that is what will be done. I have encountered this dynamic being misleading to some American psychiatrists who may not recognize that families will not fight or question medical decisions or interventions. At times, they don’t even ask. It is important to keep in mind that just because they don’t ask for visitation hours or ways to be of help, it doesn’t mean that they are not invested and emotionally affected.

The message behind these examples is that it is critical to be able to recognize the difference in dynamics, to provide the opportunity to ask for thoughts, and to differentiate between exact words and figures of speech when we are evaluating our patients. There is nothing better than listening to the entire cultural context instead of focusing only on specific words. Hence, it is important to study history, to travel, and, if possible, to ask patients and families to describe where they come from and how they have done things in the past.

I face this every time I have a Hispanic or Latin patient on my caseload. It demands much emotional presence that cannot be put into words because, in the end, it might as well be called an “instinct,” but it is not. It is not an instinct. It is an active search for patterns among many individuals with similar demographics that leads me to make my assessment. This is what I understand as cultural competence and what I am continuing to work towards, expanding my knowledge and cultural experience.

About the Author:

Dr. Nieves-Alvarado is a psychiatry resident from Duke Psychiatry Residency program. She is originally from Puerto Rico and practices psychiatry in both English and Spanish. She received her medical degree from the Universidad Central del Caribe School of Medicine in Bayamon, PR, before moving to North Carolina to complete her residency at Duke University Hospital.

About the Work:

Narrative of my experience in residency being a Latina with a bilingual background and broad cultural experience.