"I get the sense that for my foreign patients not yet in the mainstream, I bridge the gap to that mainstream," says San Fernando family practitioner Mary Oda, 71, who was born in the United States to Japanese immigrant parents.
"I speak Japanese with my Japanese patients and I have learned Spanish for my Hispanic patients because I can remember my own mother was thrilled to pieces when someone would make the effort to speak a few words of Japanese with her. During World War II, the Japanese-Americans, we were treated like second-class citizens, just like Hispanics now. I think my Hispanic patients feel that common bond."
Oda is one of many physicians with honed cross-cultural skills who practice in the San Fernando Valley.
The total number of such practitioners is not tallied by any official organizations; however, in 1989-90, the Medical Board of California issued 770 licenses to foreign-trained doctors. The membership roll of various ethnic medical associations in the area can help in sizing up the phenomenon.
For example, the Los Angeles-based Japanese-American Medical Assn. has 174 members. However, San Pedro internist Richard Iwata, the organization's president, is quick to mention that not all Japanese physicians in the region are enrolled. Likewise, the Los Angeles-based Iranian Medical Society lists 275 members nationwide, but one of the society's founders, neurosurgeon Mehdi Habibi, estimates that there are actually 400 to 500 Iranian doctors in Southern California.
These physicians typically attract foreign-born patients. Woodland Hills obstetrician Alex Abbassi, 53, who came to the United States from Iran 27 years ago, said about 40% of his patients are Iranian. Oda said two-thirds of her patients are from Japanese or Latino communities. Family practitioner Paul Puri, a native of the Indian state of Punjab, said 17% of his patients are Indian.
Sheri Broomi, like many patients, chose a physician because he speaks her language. Broomi came to the United States 2 1/2 years ago from Tehran and she manages to say, "I can't speak English very good," before letting her husband explain that early in her pregnancy, they consulted the Iranian Yellow Pages as well as Iranian friends before selecting Abbassi so she could converse in Persian with him and feel sure of what was going on during consultations.
Even when the patient has a solid knowledge of English, language can remain a stumbling block.
Edwin Harrison, a native of New Delhi, India, said he has been a regular patient at Dr. Surinder Puri's Northridge clinic because he found conversation with American doctors strained. "The American doctor thought I did not understand English and over-explained things," Harrison said.
There are times when a doctor's familiarity with a foreign terrain is vital. Family practitioner Puri, 52, who has been practicing at the Valley Urgent Care Medical Clinic in Northridge for seven years, said he relies on his Indian medical experience if one of his Indian patients comes back from a visit home with symptoms of malaria, for example.
"I can diagnose very quickly when a patient comes back sick, say, with severe enteritis," Puri said, "because I am familiar with diseases that occur in India, what kind of fever, symptoms they cause."
A good doctor-patient relationship goes beyond language or medical experience. It is built on a sense of trust and common background, said pediatrician Jung Kim, 41, who has operated a clinic in Reseda for eight years. South Korea-born Kim often serves as a cultural go-between for her patients, 60% of whom are from Korea. "You know the exact place they come from, their trade, which school they graduated from, so you know at what level she or he is. It's like a hometown feeling."
Kim, who was educated in South Korea before coming to the United States in 1974 for a postgraduate pediatric residency at New Jersey Medical School in Newark, said her Korean patients call her for information about diseases afflicting family members in South Korea, or with worries that their child doesn't eat well because she eats hamburgers, hot dogs and everything, but no rice. "It feels like family," Kim said.
New Korean mothers, she said, sometimes come to her with symptoms of postpartum blues and they miss the traditional mi yeuk gook (seaweed soup) and rice that is traditionally fed after delivery to increase breast milk and stimulate uterine contractions. Korean grandmothers worry over a daughter who is not following the traditional one-month bed rest after delivery.
"I explain it's OK. I smooth things out," Kim said.
Many patients view their doctor as a family member. Kathy Iwakiri, a 55-year-old woman from Osaka, Japan, who has been living in the United States for 33 years, said she has consulted Oda for 20 years, though she also sees other physicians. When an American doctor recommended surgery, she called Oda for an explanation in Japanese of the medical terms and reassurance.
"Dr. Oda could be like a sister," Iwakiri said. "I know I can tell her more personal problems, cry on her shoulder. You know, in our culture, we don't talk about sex. With Dr. Oda, she always tells me before I ask."
Oda said she understands the reserved nature of most of her Japanese and Latino patients and discusses such sensitive topics as marital relations in ways that don't embarrass them.
Abbassi said he has learned that examination styles are also often determined by a patient's cultural background.
In the 27 years he has practiced medicine here, he said he has found that American women seem to be most comfortable during examinations if the nurse is at the head of the exam table, while Middle Eastern patients seem to prefer the nurse positioned at the other end, next to the physician.
This awareness of cultural differences makes his patients feel relaxed, Abbassi said. He is not surprised, he added, when his Iranian patients tell him their problems in the typical Middle Eastern manner, packed with emotions. Nor is he taken aback when they voice even minor discomfort loud and clear. That, too, is natural in the Middle Eastern world, he said.
Expression and even tolerance of pain vary greatly from culture to culture, Abbassi said, adding that he simply takes extra care to explain ahead of time each step of an examination, treatment or surgical intervention and prepare his most sensitive patients for any discomfort.
Awareness of more mundane aspects of patients' lives, such as what their diet consists of, can speed diagnosis as well, physicians say.
"This newly arrived Japanese man came to me two years ago complaining he wasn't feeling well," Oda said. "I asked him what kind of food he was eating and he said, 'Meat three times a day because it is so cheap here compared to Japan.' I told him his body was made for tofu, fish and vegetables, and to go back to his Japanese diet, he would feel better, and he did."
Kim said she also considers the ethnic diet when she treats a child suffering from diarrhea and vomiting. She suggests the same diet of sugar water, Jell-O or Pedialite for the first day, regardless of the parents' ethnic background. However, she tailors her recommendations for the second day's diet differently. "If the family is Korean, I tell them to give mieum , which means rice cooked with extra water for an extra-long time, till it becomes a thick liquid. On the third day, I recommend juk , which is like mieum only even thicker," she said.
Dealing with foreign patients sometimes takes a special willingness to inform them on matters beyond the medical realm. "Typically, people newly arrived want to save money; they buy the cheapest insurance. They don't understand, or forget they then have a higher deductible," said Khatereh Abbassi, 25, Alex Abbassi's wife and office assistant.
"An Iranian lady called this afternoon for an appointment and asked if we could bill her insurance," Khatereh Abbassi said. "I found out she had a $2,000 deductible. The lady did come in and did pay, but I felt she still was under the impression that because she had some insurance, it should pay for everything."
Fear of difficult financial straits played a significant role when Harrison chose Puri as his family physician. Harrison, then unemployed and without medical insurance, says that if he had not been able to pay his medical bills during those tough times, he would have been less embarrassed to ask a fellow Indian to be patient and compassionate.
If foreign doctors appear to perform their special role well, it is perhaps because they, too, had to adapt to American lifestyles and still remember the strain.
Oda said she has an affinity for foreign patients and encourages them to stay true to their culture. "When I deliver a Hispanic baby and the mother worries about the bluish spot on the newborn's back or arm, I tell her, 'You and I, we have a common ancestor somewhere in Mongolia,' " she said. "I explain that all Oriental babies have that and her baby has it because of his Indian blood and heritage."