Defining the Osteopathic Principles Within Cross-Cultural Mission Work
Brianne Feldpausch

"Gracias, doctorita." Directly translating to, "thank you, sweet doctor," these words occupy a special place in my heart after my two-week medical mission trip to Peru. After eight months of fundraising to purchase supplies, I anticipated our medications being the most highly sought after item I would offer, but I believe people craved my Spanish words of reassurance just as strongly. With Peruvians lining the perimeter of our clinic waiting, it may become easy to switch from a person-centered approach to the faster-paced, disease-centered mode. However, practicing our osteopathic principle of seeing each person as a unit of body, mind, and spirit remains just as important, and, as I learned in Peru, is essential when cultural barriers stand between healthcare providers and the patients they care for.

A Mother's Concern
"Quien está siguiente?" ("Who is next?"), I called out to the line of people huddled in shy groups along the sidewalk in the 90-degree sun of Iquitos, Peru. A concerned mother and her three children followed me into our clinic room, past three other patients surrounded by doctors and medical students, into the back corner. I asked the mother to sit in our solitary chair, and I knelt beside her. Twisting her hands in her lap, she looked at me with wide, worried eyes and asked me to examine her tallest and thinnest son first. The mother explained that *Samuel had been having nosebleeds multiple times each week for the past year. After finishing his history and physical exam (H&P), I explained we could perform a minor surgery to help reduce Samuel's nosebleeds. Nodding her head in reply, she whispered, "Gracias, doctorita." While waiting for the doctor to prepare materials, I scribbled away on our H&P form for Samuel. When my eyes drifted up from the paper, the mother tearfully caught my eye and hesitantly asked if Samuel would be okay. Disappointed in myself for not seeing the tears sooner, I put my arm around her in reassurance. As I rubbed her shoulder, I explained the procedure is fairly simple, and his nosebleeds should be much better after. I consoled her that I underwent the same minor surgery as a child and experienced few nosebleeds since then. Through tears, she repeated, "Gracias, doctorita. Gracias, doctorita."

The Avatar
With sweat running down my neck onto my scrubs, I called the next patient. From the moment *Maria sat down, she began listing the many concerns she had compiled since she last saw a doctor. Flipping her wrist over, she pointed to a winding blood vessel on her forearm and declared, "Primero!" ("First!"). Maria believed this blood vessel was a worm under her skin. I showed her my own forearm blood vessels and gently explained she had nothing to worry about. Seeing the relief on Maria's face, we continued with her H&P. Working alongside a translator that day, I asked Maria questions, then my attending physician asked the translator to inquire further. Before sending Maria on her way, I asked the doctor if we should be concerned about the pterygium, an encroaching of white connective tissue, covering Maria's iris. The doctor quickly looked up and stated, "I didn't even look in her eyes. Let me take a look." She should have been looking in the patients' eyes, not only to check her eyes, but also to establish a connection. The focus of the interaction had shifted from the patient to the translator.

A Conversation Without Words
Sitting on a wooden bench inside our boat along the Amazon River, I completed the medical history of the last of four children with their mother. My attending physician listened as I reported on each child, but his eyes were not on me. Instead, they looked with joy and laughter upon each child while examining them. Even with very limited Spanish, he connected with each patient. When needing to listen to lung sounds, he blew into a glove and demonstrated how to blow a glove finger, like a birthday candle. Sitting on his lap, the Peruvian children giggled as they attempted to "blow out" the birthday candle-like glove, while he smiled and listened to their lungs. Though he did not understand their words, nor they understand his, he cared for the body, mind, and spirit of his pediatric patients simply through the universal language of love. Despite his minimal understanding and use of Spanish, these simple actions let him overcome the cultural barrier to reach his patients in a way that the previous doctor, even with a translator, could not with Maria.

Unheard
*Daniel could not sit still as he expressively described his pain. His sun-worn hands fidgeted, and he kept standing up, then sitting back down. Not realizing only the high-school- student translator and I spoke Spanish, his eyes darted wildly between the translator, two medical students, the doctor, and me, while describing his pain with lavish gestures. He spoke so quickly that I barely understood him. With his face scrunched up, he became so dramatic that the student translator began laughing. But Daniel did not smile in return. Instead, his eyes whizzed faster between us as he searched for understanding. Then, as though at a last attempt for understanding, Daniel made a motion at his throat and told us he was in so much pain that he wanted to kill himself. Taken aback by this gesture, the translator laughed again as she repeated his statement in English. Seeing the hurt in his eyes, noticing no one else move, and feeling sick to my stomach, I took the two steps closer to him and placed my arm around his shoulders. Though I am not completely fluent in Spanish, and reassuring words are not specifically taught, I looked into his eyes and gently said, "Lo siento, señor. Vamos a ayudarle." Which means, "I'm sorry, sir. We are going to help you." With a deep breath, his face softened, his arms stopped fidgeting, and he tearfully whispered in return, "Gracias, doctorita."
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While these instances occurred in Peru, they could easily occur anywhere in the U.S. between an osteopathic physician and a patient of a different cultural background than the one he or she is accustomed to. Though easily ignored in a fast-paced environment when speaking through a translator, our holistic training as osteopaths guides us in seeking ways to prevent the language barrier from becoming a physical barrier. After reflecting upon my experiences and our challenges, my proposal is to work with native Spanish-speakers, specifically those who have been patients, to create a list of Spanish phrases of comfort and empathy. Along with encouraging providers to learn Spanish medical terminology, this list should be encouraged just as strongly.

As I discovered in Peru, language and cultural barriers do not necessarily prevent a doctor from connecting with his or her patient. By employing cultural humility and competence, along with empathy, eye contact, and active listening, we can creatively overcome language and cultural barriers to promote osteopathic principles in caring for each person as a unit of body, mind, and spirit, both in our local communities and around the world.