Elsevier

Social Science & Medicine

Volume 150, February 2016, Pages 49-56
Social Science & Medicine

Migrant encounters in the clinic: Bureaucratic, biomedical, and community influences on patient interactions with front-line workers

https://doi.org/10.1016/j.socscimed.2015.12.022Get rights and content

Highlights

  • Integrates bureaucratic, biomedical, and community analyses of clinical care.

  • Focuses on front-line workers' gatekeeping and its impact on patient care.

  • Examines the interplay of street-level bureaucrats, boundary-work and deservingness.

  • Considers differential migrant health treatment and deservingness beyond legal status.

  • Demonstrates U.S. Pacific neo- and post-colonial migration and community tension.

Abstract

Ethnographic research on the clinical encounter has focused almost exclusively on what happens in exam rooms—particularly patient-provider interactions—leaving much to be understood about other actors within the clinic. As part of a larger ethnographic study examining the impact of colonialism, transnational migration, discrimination, and gender relations on Chuukese migrant women's reproductive and sexual health outcomes in Guam, I conducted eight months of participant observation in three publicly funded health clinics, 24 interviews with health care workers, and 15 life-history interviews with Chuukese women between September 2012 and February 2014. Findings demonstrated differential treatment of Chuukese patients by front-line workers (FLWs), who engaged in “boundary work” with these patients. Further, care varied by clinic space and the actors in that space. This differential treatment and variation in care impacted Chuukese women's access to and experiences with health care in Guam. Utilizing the concept of “deservingness,” this analysis unpacks how FLWs, like Lipsky's “street-level bureaucrats,” are influenced by bureaucratic, biomedical, and community hierarchies, all contributing to differential patient treatment. This study concludes by calling for more integrated analyses of clinical environments which utilize Lipsky's concept to include community narratives of “deservingness” and incorporate the influence of clinic and community stratification.

Introduction

In my first day of observations at Island Community Clinic in Guam, a visible division of roles became evident: almost all the front-line workers were indigenous Chamorro women, and nearly all the nursing staff were Filipina. The providers—nurse practitioners, nurse midwives and physicians—were more ethnically diverse, but most obvious was the overrepresentation of white males from the U.S. mainland. What I was witnessing were the same layers of ethnic stratification in Guam within the walls of the clinic. The most marginalized group in Guam, Micronesian migrants, could not even secure jobs in the clinic, except for a few part-time low-level staff positions. The next group, the indigenous Chamorro of Guam, occupied the lowest full-time staff positions with the lowest pay, as front-line clerks and records personnel. Their jobs were repetitive, and frustrating, and they were often caustic toward patients. The nursing staff occupying the middle rung in the clinic hierarchy had more cheerful demeanors, but they, too were often short with patients. Then, there were the advanced nurses and doctors. With some exceptions these providers treated patients with respect. Given this early observation, it was the many actors patients encounter before they enter exam rooms who I quickly became interested in during my exploration of publicly funded reproductive health care for Chuukese migrant women in Guam, U.S.A. This article will focus in particular on one of the lowest social positions of the clinic: front-line workers (FLWs), and their interactions with the most prominent migrant group: Chuukese patients.

Particularly concerned with the great disparities in health found in marginalized populations, early anthropological work on “cultural competency” sought to understand how cross-cultural patient–provider interactions shaped care (Kleinman and Benson, 2006, p. 1673). Contemporary clinical work has continued to focus primarily on providers, however, leaving a paucity of research on other actors in clinical contexts such as FLWs, nurse assistants, and nurses, the variations in care provided in each clinic space, and the impact of these variations on patient experiences. This article seeks to add to the literature which examines health care encounters by addressing what happens when patients first enter clinic doors, and why this first step is integral to health care access and outcomes.

Efforts at making clinics culturally “competent” steadily gained in popularity throughout the 1990's (Jenks, 2011), yet they were followed by a seminal report released by the Office of Minority Health demonstrating the persistence of cultural, racial, and ethnic disparities in the medical field despite years of these cultural competency efforts (Good et al., 2011, Smedley et al., 2001). This report provided data to support the contention that health disparities still exist even when insurance, access, and lifestyle factors are controlled for, pointing to clinical bias or racism as the likely culprit (Good et al., 2011). Updated in 2011, the report outlined fourteen requirements and recommendations for Culturally and Linguistically Appropriate Care Standards (CLAS) to ensure institutions would provide “health care services that are respectful of and responsive to cultural and linguistic needs” (Smedley et al., 2001, p.5; Smedley and Mittman, 2011).

Medical anthropologists argue that while these cultural competency efforts are generally well-intentioned, they are often misguided. For example, researchers critique the ways in which some cultural competency training activities create a static box of cultural beliefs that get attributed to particular communities or ethnicities, with no consideration for in-group diversity and identities (Guarnaccia and Rodriguez, 1996, Taylor, 2003a), essentially encouraging providers to stereotype patients (Carpenter-Song et al., 2007, Hunt and de Voogd, 2005), and continuing to ignore the culture of biomedicine (Carpenter-Song et al., 2007, Taylor, 2003a). This leads to clinicians blaming the patient's “culture,” with scarce attention to language, communication, social inequalities, or any other social aspects of their lives (see, for example: Carpenter-Song et al., 2007, Hirsch, 2003, Kleinman and Benson, 2006, Taylor, 2003a, Taylor, 2003b).

Some anthropologists attempted to further understand the impact of racism and clinical bias on health care delivery despite cultural competency efforts by examining other contributing factors. Willen (2012) drew from studies in the welfare context utilizing the concept of perceived “deservingness” of services. Willen (2012) defined health-related deservingness as something “conditional” that represents a “moral” as opposed to legal concept of what one believes people should receive; this fluid concept shapes patient–worker interactions (p. 814–5). Willen (2012) posited that while working to improve cultural competence is important in multi-cultural clinical spaces, if health care workers deem their patients as undeserving of their care, competency training alone may prove futile. A growing body of research is now examining the concept of deservingness in clinical settings, but there are still gaps to fill. While the emerging literature seeks to separate legal status from moral concepts, studies thus far have focused on “illegal” migrants, which can inevitably lead to the conflation of the two contributors. Further, while studies of deservingness have examined clinic services as a whole (Horton, 2004), and clinician perspectives (Willen, 2012), there are not explicit examinations of other actors involved in patient care.

More broadly, while some ethnographic work addressing clinical bias or racism has focused on nurse–patient interactions (see, for example: Jewkes et al., 1998, Spitzer, 2004), only a few ethnographies have specifically analyzed the role and impact of those who do not provide medical care, but do interact with patients. One early exception to this trend consisted of interviews with patients to assess their perceptions of receptionists; findings indicated that patients saw receptionists as controlling boundaries often outside of their scope of work (Arber and Sawyer, 1985). For example, patients described feeling as if they needed to “negotiate” in order to receive care (p. 914). Arber and Sawyer stressed the importance of this role in their findings, and posited that patient–provider interactions are no longer enough to consider, but the “triad of doctor-receptionist-patient must also be considered” (1985, p. 916). Despite thirty years of research encompassing the roles of other actors such as nurses, to date very few researchers have specifically addressed receptionist-patient interactions.

Of those who have studied receptionists since then, Alazri et al. (2007) examined the access provided via General Practitioner Receptionists' (GPR) roles as gatekeepers through appointment making for patients. Conducting interviews with GPRs, Alazri et al. (2007) found GPRs felt caught between managing the physician requests and the patients in front of them. This “in between” experience of roles was a source of stress, but also demonstrated the power GPRs have over patients in clinical encounters. Despite their job resting solely on following rules set by administration and health care providers, they still felt they had to exercise great discretion because of the unique needs of patients not always fitting standard protocols. Neuwelt et al. (2015) explicitly focused on receptionists' power in clinical encounters. They argued previous “inattention by researchers may well be in part because reception areas are considered to be banal and unspectacular spaces compared to medical sites …” but that it is actually a powerful space for negotiating access to care (p. 289). Conducting focus groups with 14 GPRs, Neuwelt et al. (2015) found receptionists were frustrated with having to manage multiple complex roles while dealing with both patient and provider needs, much like Alazri et al. (2007). Neuwelt et al. aptly observed the precarious position of these roles, on the “edge” of the “practice team” and as “de facto managers” controlling the front space of the clinic (2015, p. 293). Receptionists also expressed a common narrative of frustration having to manage certain “difficult” patients (Neuwelt et al., 2015, p. 290).

Bridges (2011) conducted an ethnography of an entire clinic, and in doing so added further analysis to this precarious position held by receptionists as “in-between” interlocutors. Bridges (2011) argued this liminal position is not only within the clinic, but also in the community. She found receptionists were closer in terms of ethnic and social identity to patients seeking publicly funded services than to the health care providers. Bridges (2011) observed ways in which receptionists sought to distance themselves from these patients, to whom they often mirrored socio-economically and ethnically, something Lo and Bahar (2013) termed “boundary work” (p. 72). In this article, I argue boundary work is part of what uniquely shapes receptionists' gatekeeping behaviors in publicly funded clinic spaces in Guam.

This literature demonstrates that FLWs act as gate keepers, and are situated in a space that signifies the boundary between patients and HCWs despite clinic policies to the contrary, but these studies present important limitations. While each study described provided important insights for understanding receptionists' roles, with the exception of Bridges (2011), they were largely based on one aspect of this triad, and relied on self-report. None of these studies triangulated patient and FLW perspectives with observations of the interactions between these actors in the clinic. Further, although these studies do explore differential treatment of patients by other actors, they have limited their analyses to the stress of lower positions in the clinic hierarchy (Bridges, 2011, Neuwelt et al., 2015), or the complex tasks required of such personnel managing several actors' needs (Arber and Sawyer, 1985, Neuwelt et al., 2015). The intricate ways in which these de facto gatekeepers manage that space daily through appointment-making, paperwork processing, and information provision in their role as “street-level bureaucrats” is still largely unexplored.

Several anthropologists have utilized concepts drawn from sociologist Lipsky's (2010) work when analyzing front-line workers in various contexts. Lipsky analyzed how workers within bureaucratic institutions—“street-level bureaucrats” (e.g., police, social workers, etc.)—implement public policies under time constraints and limited information available to them. It is within these workers' roles that exceptions to policies are made, providing workers with a degree of discretion in their tasks. According to Lipsky, street-level bureaucrats must simplify their jobs to cope with demands in these regularly underfunded and overworked environments. Marrow (2009), adding to Lipsky's analysis, found that discretion utilized in order to manage the flow can be employed by FLWs to bend the rules within the limitations of their roles.

I argue that these two elements shaping care—workers’ needs to simplify in the context of overwhelming workloads, and their need to assert power from the lowest position in the clinic hierarchy—are equally important to consider in an analysis of patient-FLW interactions. To date, these two aspects of patient–worker interactions are rarely analyzed together. Further, the literature is lacking analysis that also demonstrates how clinic hierarchies reflect and reinforce larger community stratification and narratives about who belongs, and thus deserves, quality healthcare. This paper merges each of these elements shaping FLW-patient interactions, concurrently analyzing the need to simplify work and the assertion of power and boundary-keeping from precarious clinic positions, both of which reinforce community narratives about who deserves care at Island Community Clinic.

Clinicians are but one actor in the clinic space who interact with patients, and we must continue to explore each of the spaces as distinct environments to understand the multiple factors contributing to the quality of patient care, access, and experiences. This study focuses on a less examined space: the front desk area, and the patients and FLWs who interact in it. Second, it considers the broader community's social, historical, and political-economic context to reveal the ways in which moral concepts of deservingness influence and stratify patient care. Considering Wayland and Crowder's (2002) argument, different perspectives on who and what constitutes a particular community impact health services in ways that are often un-problematized by community-based health care centers. In this case, differential views of belonging and deservingness between FLWs and Chuukese patients demonstrate the need for understanding such community contexts that shape these views. Third, this study adds to the growing literature on deservingness as it applies to cultural competency in the clinic by providing an example that explicitly studies care from outside the exam room and in a documented, “legal” migrant population. This article argues that FLWs in Guam mirror Lipsky's (2010) street level bureaucrats, attempting to improve their work flow by simplifying the patients with whom they work, and that this simplification often takes the form of invoking a moral discourse of who deserves care. Simultaneously, this moral discourse operates for FLWs to differentiate themselves—deserving, indigenous Guam residents—from Chuukese immigrant patients.

The findings reported in this paper are derived from research conducted in Guam, an unincorporated territory of the U.S. Guam has a long colonial history, a large and diverse migrant population, and a shrinking indigenous population marginalized in their own community through Guam's neo-colonial relationship with the U.S. The indigenous Chamorro of Guam endured several strangers in their land, from when Magellan landed in 1521 and claimed it for Spain, until present day when 30 percent of the island is U.S. military-owned (Rogers, 1995). As a result of various colonial government policies, Guam received migrants from the Philippines for several guest-worker programs over centuries, U.S. military families stationed on two bases, and most recently, Micronesians from the rest of the region whose newly-formed countries are in a Compact of Free Association (COFA) with the U.S.

The COFA agreement with the U.S. and Micronesia is the result of a 40-year “strategic trusteeship” that commenced at the end of World War II. With this Compact, three new nations were formed, and the U.S. funded education, economic, and political development in exchange for the right of denial of foreign entry and military power. The emergence of the COFA is of significant importance to this project because it allows citizens of COFA nations to travel, live, and work in the U.S. with the status of “nonimmigrants.” COFA “nonimmigrants” began moving into the U.S. rapidly after the COFA agreement, starting with nearby Guam for better education, jobs, and access to health care (Bautista, 2010, Hezel and McGrath, 1989, Marshall, 2004).

Even in the early years after the COFA, the Chuukese dominated the migration pool in Guam (Hezel and McGrath, 1989). Chuuk is the most populated state within the Federated States of Micronesia, one nation created by the COFA (Levin, 2010). Chuuk is also the poorest state, with a deteriorating health care system (Feasley and Lawrence, 1998), creating further impetus to move.

There is tension between and among each migrant group and the indigenous Chamorro population. The U.S. military keeps largely isolated on the bases, finding the locals to be too foreign for them. Filipinos represent 25 percent of the island and have become a permanent community in Guam (Census Bureau, 2013), but tension over them occupying the best jobs exists—as does rhetoric in the Filipino community that the islanders (both Chamorros and other Micronesians) are lazy, so they come and do good work—thus deserving the good jobs. Micronesians make up the third largest group, having migrated through the COFA. It is estimated that Chuukese migrants represent 78 percent of all Micronesian COFA migrants in Guam (Hezel and Levin, 2012).

What is deemed the Compact Impact is frustration caused by the perception that citizens from Compact countries, and Chuuk in particular, move and use Guam's resources without adequate reimbursement by the U.S. federal government (Levin, 2010). Resentment and discrimination toward COFA migrants, although technically stemming from U.S.-sanctioned migration and un-kept promises for reimbursement, is often instead directed toward the Chuukese migrants themselves. Rhetoric about the Chuukese coming only to give birth for U.S. citizenship, food stamps, and welfare is widespread among the indigenous Chamorro community, as is the stereotype that all Micronesians are ‘primitive’ and ‘backwards’ in contrast to the ‘modern’ and ‘westernized’ Chamorros (Bautista, 2010). The structural and social vulnerability of Chuukese migrants is visible through disproportionately high poverty levels, homelessness rates, and poor health outcomes (Haddock et al., 2009, Hezel and Levin, 2012). Further, their symbolic community role is as the latest migrants who arrive “sick” and “uneducated,” thus placing a “burden” on Guam, as recently delineated by Guam's Governor (Daleno, 2013, p. 1).

Section snippets

Methods

As part of a larger study examining how transnational postcolonial migration, racism, gender inequality, and poverty interact to create poor sexual and reproductive health outcomes and experiences for Chuukese women in Guam, this study examined both the clinic and the community as cultural entities. The clinic has been cited as “ground zero” for playing out cultural themes that reflect and impact the status of migrants, and reflect their status in the community (Castañeda, 2010, p. 6; Chavez,

Results

In an attempt to understand how patients experienced the entire clinic, Chuukese women were approached upon arrival for anything related to women's health, and after assessing their qualifications, I asked permission to follow them throughout the process. Thus, observations started where patients started: at the front desk, followed by medical records processing, and ending as women left the building. Methodologically, this made for a more hectic recruitment environment that was also quite

Discussion

Engaging with Lipsky's work, Weiner et al. (2004) discuss how front-line bureaucrats—those who have first contact with patients, like the FLWs at Island Community Clinic—are supposed to verify insurance, registration, and make appointments, but they are caught between administrative responsibility and patient care. Despite often being in “non-decision making roles,” FLWs act as “housekeepers” in ways that require considerable discretion (2004, p. 306). Adapting to their responsibilities,

Conclusion

This article argues that each space and worker in the clinic is shaped by larger community narratives of power, belonging, and deservingness. Further, the FLWs—rarely the center of inquiry when examining health care interactions—play a vital role in health care delivery in clinics. While officially FLWs have little power, they are actually de facto gatekeepers to care. In those clinic environments in which FLWs are overworked and underpaid, such as Island Community Clinic, they make their jobs

Acknowledgments

This research was supported by the University of South Florida Department of Anthropology Fathauer Dissertation Fieldwork Travel Grant, and the University of Guam College of Liberal Arts and Social Sciences Scholarly Research Faculty Grant. Thanks are due to the incredible staff and patients at Island Community Clinic, as well as Heide Castañeda, Karen E. Dyer, Hannah L. Helmy, and three anonymous reviewers for their insightful feedback on earlier versions of this manuscript. Further, I would

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