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A fifty-year-old Mexican woman named Sandra Ramirez came to the ER with epigastric pain. She told the nurse that she had been experiencing the pain constantly for the past week, but denied any nausea, vomiting, diarrhea, or constipation. There had been no changes in her diet or bladder or bowel function. She revealed that when she had experienced similar pain in the past, she was treated with an unknown medication that helped her greatly. The nurse who was interviewing her had just been introduced in class to the concept of the 4 C’s, so she also asked the patient what she thought the problem was. The patient called her condition “stressful pain,” and elaborated that it wasn’t the pain that caused stress, but that stress caused the pain. It turned out that the medication that had helped her in the past was Xanax. She had stopped taking it eight days earlier; the pain began seven days ago. Had the nurse not gotten the patient’s perspective on her condition—that it was related to stress—they would have done just a standard abdominal workup and perhaps not discovered that it was due to anxiety.

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Emma Chapman, a sixty-two-year-old African American woman, was admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.” When her nurse asked what she thought caused her heart problems, Mrs. Chapman said she had sinned and her illness was a punishment. Her nurse finally got her to agree to the surgery by suggesting she speak with her minister. If she hadn’t learned about Mrs. Chapman’s religious beliefs while asking what she that was the cause of her heart problems, she might not have thought to contact her clergyman.

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Olga Salcedo was a seventy-three-year-old Mexican woman who had just had a femoral-popliteal bypass. Anabel, her nurse, observed that Mrs. Salcedo’s leg was extremely red and swollen. She often moaned in pain and was too uncomfortable to begin physical therapy. Yet during her shift report, her previous nurse told Anabel that Mrs. Salcedo denied needing pain medication. Later that day, Anabel spoke with the patient through an interpreter and asked what she had done for the pain in her leg prior to surgery. Mrs. Salcedo said that she had sipped herbal teas given to her by a curandero (a traditional healer; see Chapter 12); she didn’t want to take the medications prescribed by her physician. Anabel, using cultural competence, asked Mrs. Salcedo’s daughter to bring in the tea. Anabel paged the physician about the remedy and brought it to the pharmacist, who researched the ingredients. Because there was nothing contraindicated, the pharmacist contacted Mrs. Salcedo’s physician, who told her she could take the tea for her pain. The next day, Mrs. Salcedo was able to go to physical therapy and was much more motivated and positive in demeanor. Although it took some time to coordinate the effort, in the end, it resulted in a better patient outcome. Had Anabel not asked what she had been using to cope with her pain, it is likely Mrs. Salcedo would have delayed physical therapy and thus her recovery.

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Jorge Valdez, a middle-aged Latino patient, presented with poorly managed diabetes. When Dr. Alegra, his physician, told him that he might have to start taking insulin, he became upset and kept repeating, “No insulin, no insulin.” Not until Dr. Alegra asked Mr. Valdez what concerns he had about insulin did he tell her that both his mother and uncle had gone blind after they started taking insulin. He made the logical—though incorrect—assumption that insulin caused blindness. In this case, the patient expressed his fears, and because the physician was competent enough to pick up on them and explore them, she was able to allay them. In many cases, however, unless the physician specifically asks about concerns, patients will say nothing and simply not adhere to treatment. By asking, the health care provider can correct any misconceptions that can interfere with treatment.

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A 35-year-old Jewish woman went in for a baseline mammogram.  A lump was discovered.  When discussing it with the radiologist, the woman questioned him about all the possible treatments if it turned out to be cancerous, as well as all the side effects of the treatment.  The radiologist had little patience for her questions; he repeatedly told her they should wait until after they get the results of the biopsy before they start discussing the side effects of chemotherapy and radiation.  The woman, however, felt that she had to know everything possible about the potential negative outcome; only through knowledge could she feel a degree of control.  The lump turned out to be benign, but she went into the biopsy procedure much more relaxed than she would have had she not known every possible eventuality.

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A 27-year-old pregnant Mexican woman who had been living in the US for two years went to see a genetic counselor at the urging of a friend.  XFAP tests indicated the possibility of Down syndrome in her unborn child.  She declined the offer of amniocentisis, however, based upon the manner of the genetic counselor, who told her not to be afraid and to do whatever she wanted.  The patient later said she interpreted the lack of directiveness as an indication that the positive screening was “no big deal” and that if there were any real danger, the counselor would have insisted on the test.

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A middle-aged Mexican female patient suffering from acute liver cirrhosis with abdominal ascites, began to experience extreme shortness of breath. The physician, a liver specialist, asked her to sign consent for an abdominal tap.  The patient refused, saying, “I am going to wait until my husband arrives.”  The physician was not happy with her response as he felt it was necessary to do the procedure as soon as possible.  Fortunately, the patient’s husband arrived within an hour, the paracentesis was done, and her shortness of breath was minimized.

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An African American man in his 40s, suffering from diabetes and hypertension presented to his physician, complaining of “feeling poorly”.  When questioned, he admitted that he was not taking his insulin regularly; only when he felt that his sugar was high.

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A Chinese woman in her 60s was diagnosed with cancer and scheduled to receive chemotherapy.  She was unaware of her diagnosis, due to her son’s insistence.  The staff was uncomfortable with having to withhold this information from her, so they asked her whether she wanted to know her diagnosis and why she was receiving chemotherapy medication.  Her answer was no.  She said, “Tell my son; he will make all of the decisions.”  They resolved the matter by having hersign a Durable Power of Attorney, appointing her son as legal decision-maker.  They were thus able to remove the legal and ethical obstacles to her care.

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Bobbie, the nurse, had two patients who had both had coronary artery bypass grafts. Mr. Valdez, a middle-aged Nicaraguan man, was the first to come up from the recovery room. He was already hooked up to a morphine PCA (patient-controlled analgesia) machine, which allowed him to administer pain medication as needed in controlled doses and at controlled intervals. For the next two hours, he summoned Bobbie every ten minutes to request more pain medication. Bobbie finally called the physician to have his dosage increased and to request additional pain injections every three hours as needed. Every three hours he requested an injection. He continually whimpered in painful agony. Mr. Wu, a Chinese patient, was transferred from the recovery room an hour later. In contrast to Mr. Valdez, he was quiet and passive. He, too, was in pain, because he used his PCA machine frequently, but he did not show it. When Bobbie offered supplemental pain pills, he refused them. Not once did he use the call light to summon her.

Nurses usually report that “expressive” patients often come from Hispanic, Middle Eastern, and Mediterranean backgrounds, while “stoic” patients often come from Northern European and Asian backgrounds. As a young Chinese man told me, “Even since I was little boy, my family watched dubbed Chinese movies, and by watching many of the male protagonists state ‘I’d rather shed blood than my tears,’ it is imbedded in my mind that crying or showing pain shows my weakness.” However, simply knowing a person’s ethnicity will not allow you to predict accurately how a patient will respond to pain; in fact, there are great dangers in stereotyping, as the next case demonstrates.

Mrs. Mendez, a sixty-two-year-old Mexican patient, had just had a femoral-popliteal bypass graft on her right leg. She was still under sedation when she entered the recovery room, but an hour later she awoke and began screaming, “Aye! Aye! Aye! Mucho dolor! [Much pain].” Robert, her nurse, immediately administered the dosage of morphine the doctor had prescribed. This did nothing to diminish Mrs. Mendez’s cries of pain. He then checked her vital signs and pulse; all were stable. Her dressing had minimal bloody drainage. To all appearances, Mrs. Mendez was in good condition. Robert soon became angry over her outbursts and stereotyped her as a “whining Mexican female who, as usual, was exaggerating her pain.”

After another hour, Robert called the physician. The surgical team came on rounds and opened Mrs. Mendez’s dressing. Despite a slight swelling in her leg, there was minimal bleeding. However, when the physician inserted a large needle into the incision site, he removed a large amount of blood. The blood had put pressure on the nerves and tissues in the area and caused her excruciating pain.

She was taken back to the operating room. This time, when she returned and awoke in recovery, she was calm and cooperative. She complained only of minimal pain. Had the physician not examined her again and discovered the blood in the incision site, Mrs. Mendez would have probably suffered severe complications.