Public Health Matters Video: The Significance of Language, Cultural Competency in Health Care

In this special episode of Public Health Matters, Dr. Christina Madison and special guest, Dr. Jose Cucalon Calderon emphasize the steps that need to be made in improving both language and cultural competency in health care. They also discuss Dr. Cucalon Calderon’s advocacy work—particularly in vaccine advocacy—in public health, preventative health services, and health equities in underserved communities.

Christina M. Madison, PharmD, FCCP, AAHIVP: Hello, everyone, and welcome to another episode of Public Health Matters, part of the Pharmacy Focus podcast series here with Pharmacy Times. My name is Dr. Christina Madison, and I am your host for today.

I am so excited to bring another extraordinary guest to you all today, Dr. Jose Cucalon Calderon, who is a colleague of mine that I have had the amazing opportunity to collaborate with and work with in the past. Through our efforts to get out information that is factual and accurate during the pandemic. We also follow each other pretty closely on LinkedIn and social media, and I'm always excited to see what new adventures he's getting into in the space of health advocacy, vaccine advocacy, and just being an overall wonderful pediatrician and incredible human. So with that being said, I'm gonna go ahead and let Dr. Cucalon Calderon introduce himself, and then we're gonna dive into some questions.

Jose Cucalon Calderon, MD, FAAP: Thank you very much Dr. Madison for the very, very nice and kind introduction. I definitely follow your work and your adventures as well, so thank you, I'm really excited and honored to be here today.

I am Jose Cucalon Calderon. I'm a general pediatrician by training and an associate professor of pediatrics for the University of Nevada Reno School of Medicine. I am board certified, I work in Reno, Nevada, as a general pediatrician within our community and our Medicaid pediatric clinic through the Renown Children's Hospital well services. I’m a native from Ecuador, I'm a native Spanish speaker, and being 1 of the few native Spanish-speaking pediatricians, I serve a large Latino, large Spanish-speaking community here in Northern Nevada. Given my path, my experience, and my background, I also served in multiple capacities, both at local and state level [as well as] national and international level, talking about preventive health services about helping families make [the] best evidence-based choices that are going to be beneficial for themselves and their kids. With the common things being tobacco prevention, tobacco cessation, vaccination, being able to access health care services, being able to understand health information and utilize it to make those beneficial choices.

Thank you very much for having me here today.

Madison: Of course, my pleasure.

So, with that being said, I want to kind of unpack a little bit of what you said there. I think that's pretty incredible. The fact that you are 1 of—I think the only—native Spanish-speaking pediatricians in Northern Nevada, which is pretty incredible when you think about how many individuals that that really encompasses. I don't know how larger practices, but that seems pretty daunting especially when I think about how important health literacy and language are really intertwined, and having someone who's a native Spanish speaker, I think makes so much of a difference when you are trying to communicate those preventative care needs and really help people navigate through the health care system, especially if they're new to this country.

Cucalon Calderon: Yes, so, my practice currently—I don't know the exact number—but I can say easily is over 60% in Spanish and most parents are born abroad. Their children are—most of them are—born here in the United States, and definitely there are differences in how people utilize health care service [based on] what they feel is important and how people also think about it. I always say 1 of the things that I can tell you is that where I come from, generally preventive health services is something that you can find in the bigger cities and maybe in some campaigns that send care groups or health fairs to different towns where people get vaccinated, maybe they get a diabetes test…and that is what health care looks for them. So, they end up showing up only to the doctor when they have a real problem, like needing to get a leg amputation.

Madison: Yeah, that's the biggest issue I think we see in general…going to and propagating health care facilities only for acute care needs, and not for maintenance, health, and wellness, right? And so, I always tease and say I'm an unlikely pharmacist that doesn't like medication and prefers for people to prevent illnesses versus doing chronic disease management, because really, once you have it, it's so much harder to manage [than] it is to prevent.

One thing I did want to just touch on, before we get too far into a lot of the specific work that you do—and I love the fact that you're very forward-facing in the media because again, I think representation matters—how did you decide with your professional journey, because being a pediatrician and an academician, both of those things we have in common, how do you go from doing your day-to-day and being a great pediatrician to really seeing this desire to do vaccine equity and advocacy work? Because that is really a shift, and it’s very purposeful, so if you could maybe talk about how that came to be and what precipitated your journey professionally towards this, I think that that would be really helpful for the audience. Especially for those who maybe are considering doing more advocacy work in their own communities.

Cucalon Calderon: HPV vaccination…that is probably what they ended up putting me on that path. To be able to talk about not only the cancer prevention part piece of HPV, but trying to break down the stigma that was around this vaccine because more common than not when working with Latino communities, I was always getting the STD piece first. And that was always the big concern and that definitely played a part into that. Then families being able to actually talk about their concerns and be able to make that choice with the information that they were able to utilize, not only in the way that they are able to read and understand and use the information, but also in a way where they are able to also access the service, not only the information, because a lot of a lot of times we just don't have a good resource available in our community that will be able to provide that service at that specific time. So, what happens, or how do we end up being able to also mirror how people utilize health care to begin with and go where they are, and talk to them in the way that they can understand and they can access that service?

So, kind of like that interplay ended up doing it, COVID-19 and [the] influenza vaccination also had a recurring role in this. When the COVID-19 pandemic happened and we were talking about vaccinations, there were very few people across the state of Nevada who actually could speak in Spanish about evidence-based…

Madison: Yeah, you were so hugely impactful. I mean, as somebody who was on a lot of those panels and things with you, and just seeing you out front and being that beacon for the Latinx community, it was really lovely to see. And unfortunate kind of in the same vein, because I had no idea how few people we actually had that could speak authoritatively in [the] language and appropriately to such a large portion of our population here in the state of Nevada.

Cucalon Calderon: Absolutely. In the state, we roughly 30% of the population identifies as Latino or Hispanic and a large proportion of that population is Spanish-speaking, they might identify [Spanish] as the primary language, even if they are speaking English now more and more as they live here.

And then on the other side of things, is that we through the state now, according to data, are doing a little better where we are at the national average for physicians who identify as Hispanic or Latino—which is 6%.

Madison: I was just gonna ask what's the average. That doesn't seem like a very good benchmark.

Cucalon Calderon: So that is a very big gap in between that we are definitely trying to fill and we are definitely trying to encourage or show that there are people doing the work. So people who come from similar backgrounds who want to serve the same community can end up realizing, “Okay, that person is doing it, this background is similar, maybe I can see the person and I can see myself in that role, maybe I can see that person being my mentor. Maybe I trust him because [they] speak Spanish.” So, playing along with all of those things that we're trying to actually get off the ground, to the [University of Nevada Reno] School of Medicine. And then we also are trying to do some culturally humble training and that teaching our students and our residents that the patient is going to be the authority on why they do what they do and how they do it with what they have available. So recognizing that, and then recognizing the power of language to our medical encounters elective, are some of the things that we have that we have running right now and through our school of medicine, as well as including some of the programs through their pediatric residency. But the idea there, overall, is for people to identify themselves with a mentor or with somebody who is trying to make a difference, and for them to see themselves being able to do the same in similar manner.

Madison: I love that so much. "Medically humble." Tt's so interesting how language has such an impact, right? Being medically humble and being able to see yourself.

Also as someone who is a minority and didn't see anybody who looked like me in places that I thought may be that I might want to go, or even just underrepresentation within the media around medical health expertise, so that I also think is a big thing as well, because I know you do a fair amount of media and you do quite a bit of medical expert commentary for your local media market too. That representation is so important and seeing somebody that looks like you and sounds like you, it turns on a different switch in your mind that is not the same as somebody who may have the most authority in the world, but doesn't have the perspective of your lived experience or even that you can be medically humble towards that. Which I absolutely love that, I love that so much.

Cucalon Calderon: So, I have I have told this anecdote before, but I trained in Alabama, where there is a very low Latino population and I lived [there] for close to 7 years. At 1 point in time, I realized that nothing that I was doing was actually working out or [it was] not working in the way that I thought it would when trying to provide anticipatory guidance, trying to connect people with services, trying to talk about health care needs, all the stuff that we that we normally do during an encounter. And then I just decided to start asking people what did [they] do for this? And I started doing that and it definitely allowed for me to be able to…I was practicing cultural humility without knowing it, because I learned about what cultural humility was when I came here to Reno…but I had already been practicing it for over 4 years. Kind of like a survivor's guilt, based on observations that I had had with my patients, I started asking them like, “So how did this happen? Where do you guys go? How do you normally think about this? How do you normally choose?” and I started adjusting my plans a little bit more based on that, rather than just coming in and giving a recommendation and then moving on to the next person. So absolutely, recognizing that people are the authority of why they do anything is extremely important, especially in health care, because that can be the key to being able to successfully establish a relationship with a patient—or a parent, when we're talking about kids—to be able to continue utilizing health care services, especially for preventive health, vaccination, and taking their medication when they when they are prescribed something that needs to be daily, and coming to the appointments, and things like that.

Madison: Yeah, I think that it's so critical to have that perspective as we all navigate through this dysfunctional health care system—because it is, it's dysfunctional—and as much as we want to make a meaningful change, it's hard when you don't have the tools that you really need to succeed. I'm glad that you're at least able to kind of incorporate some of these things that you've learned and then impart those through medical education to your students, and then provide them with a space to practice those skills so that when they leave, they can hopefully take those skills with them to whatever community that they choose to live and work in later on. Which is good to know.

So, I'm curious, what do you think is like one of the most important issues that needs to be addressed and public and population health? I know, that's kind of a lofty, big question. But I'm curious, because I know you got started through your work with HPV. Which is incredible to me because I think that that is such a challenging topic and really a PR nightmare unfortunately, because of the way that the vaccination was initially marketed. And it goes to show how important it is to have good messaging when you bring something to market. I think if we had looked at it more like Hepatitis B and called it an anti-cancer vaccine versus associating it with sex, I think we would have been much more successful like places like Australia, which is on track to completely eliminate HPV-related cancers in their country by the end of this decade, and that was through mandatory HPV vaccination.

Cucalon Calderon: So, the biggest barrier…the most important issue is going to be what a trusted message and messenger is on public health. As we were chatting a little bit offline, right now, we have somebody that people trust who is going to run through his running for office, or somebody who is an elected official talking against vaccinating people.

Madison: Yes, we have quite a few of those right now.

Cucalon Calderon: That's exactly right. So, identifying who those trusted messengers are and then being able to recognize that missing and misinformation can come from really any place offering physicians, offering public health specialists, offering pharmacists, [offering] people who have scientific training, to be able to help manage and answer those questions and be upfront about communication and then allowing them to become the trusted messengers within their communities or the communities that they serve, I feel is probably going to be the way forward.

The legal implications of why people do [spread] misinformation, if they make money or not, if they do this or they do that, I'll leave that to the legislators and the legal system and all that stuff, but I can tell you what we can do. I feel that being upfront and recognizing [and] pointing out those situations, talking about the scientific data, and being able to communicate that effectively to our communities is probably going to be the biggest win—I feel—we can have.

So, let's look at tobacco [as an example]. By now, everybody knows that tobacco’s not good for you, like there is no—I don't think I have ever met anybody that still thinks that tobacco has health benefits, up to now, I have never met anybody who thinks that.

Madison: Yet, people continue to smoke, and now we have this new fancy version called vaping. Like, what is this? It's so crazy to me, and people do it in public places. You have to specifically tell people not to vape because they think, “Oh, it's smokeless, so I can do whatever.” And it's just bananas. But I love that you are doing so much with the tobacco cessation space. I know you're you work pretty closely with the Hispanic Medical Association, and I know that you've done quite a bit of different webinars and talks and things about it. But no, it's huge, we still have a lot of issues like with people smoking, even with smoke-free casinos, you still see people smoking.

Cucalon Calderon: Well, and that's got to be part of the thing here, and that's where I was going [with that]. We were able to get that health information out…We just had a landmark year for when this first Surgeon General report came out—I don't remember what the exact date was like, I think it was like 50 or 65 years [ago], I don't remember—but without a trusted messenger who talked about the data, being able to start that process where now a much smaller percentage of the population continues to use the tobacco products, that wouldn't have happened without a trusted messenger. So what…people who are public health patients, people who are a primary care provider, people who are physicians, people who are working in health care overall, that's what we should aspire to be able to do, even if we do it on a 1-to-1 person on like in a 1-to-1 encounter, or if we're doing it on a large platform.

Madison: Yeah, I think it's so important to remember that sometimes it's not just what's being said, but it's [about] who's saying it that makes a difference of whether or not you move the needle, and whether or not someone actually feels like that call to action is something that is worth taking that next step. And a lot of times, it's just a matter of understanding someone's lived experience, or empathizing, or even just looking at things through a trauma-informed lens.

So many times, I've, you know, spoken to people and they've had such negative experiences with the health care system in the past, that even just them coming to you and being there for that appointment is anxiety- and trauma-inducing. And that it doesn't matter how well you think that you're portraying the information, it's just the act of them being there that's causing them distress, and it's like, how do you how do you get beyond that? How do you help someone kind of rethink and change their mindset around the difference between only accessing the health care system when they have an acute need versus trusting—because it's that trust factor. There's plenty of people who go to a doctor that they know, but just knowing somebody doesn't automatically instill trust. And so, when you have that trust, then you can really start making a difference. I think that for you, in particular, the great thing about having this language connection, is it's like another step forward towards establishing trust because you've already established that cultural connection. Sometimes that's much harder to do when you have 2 people speaking English, but maybe English is not their primary language.

Cucalon Calderon: Well, we also have to recognize that—talking as a Latino who comes from a very small country, very specific background, very specific population—Latinos are highly heterogeneous, and being able to recognize that, [often] allows for the conversation to go, to continue on until you're able to find what is important to them, how your interests align, and you're able to formulate a plan together. And again, that's where the cultural humility piece comes in.

There are a lot of differences between what health care understanding is, depending on where in the country you come from. So [if] you're from a city, you may have seen some preventive health services, if you are from a lower socioeconomic status community or more rural community…

Madison: Yeah, I was just gonna say that in rural areas, a lot of times, there's none of that. You only go to the doctor when something's really wrong.

Cucalon Calderon: Absolutely, and that's going to be the part where you kind of have to identify…I have families [come to my practice] that are from Central America, and Spanish is not their native language.

Madison: There are a lot of Indigenous languages and dialects that we have yet to properly ensure that we have accommodations for.

Cucalon Calderon: And we don't. I spoke to the [the tele-interpreter, LanguageLine] because I had a family from Central America who barely [spoke] any Spanish—though they were listening to Spanish speakers—both in the hospital and when they came to see me, they had a child who had complex health needs at the time. So…I went into the room, and I realized that—after just 3 exchanges—their Spanish was very limited. And I was like, “Okay, well, I asked him what language, they told me the language, and we don’t have any services for because it's extremely local, and the community is very small.” So, I talked to them about it, and they told me, “We can have somebody on a phone who speaks the language [who can interpret], but you have to let us know 2 weeks ahead of time to be able to get that person.” So it might help for a preventive health service if we ended up having 1, but that's really tough. That's a really difficult thing to do.

Madison: I saw that firsthand when I was at the health department. I worked really closely with our tuberculosis department, and we did refugee and immigration processing, and I would have people from these very, very small rural areas within the Philippines, or we had several refugees from Bhutan, and just all of these areas were—or even like different places in Ethiopia—there's just so many different languages. I feel like I became a citizen of the world when I had that job—I was there for 10 years—and just the cultural humility, like you said, it makes such a difference. Even when you may not speak the language fluently, but if you even just attempt to introduce yourself, or to be respectful of your elders, and to give someone a salutation, or to say “thank you,” it makes such a difference with the encounter. I think we can all do better when it comes to having in-language services. That's part of public health, that communication piece, and it's often forgotten because we tend to lean on the fact that a majority of the population is English- or Spanish-speaking, which isn't always the case.

Cucalon Calderon: Absolutely, and our goal is for people to be able to utilize those services.

Madison: That’s the bottom line, you just want people to be able to have that access.

Cucalon Calderon: Yeah, and to be able to make beneficial choices for their health and for their family. So, if you are unable to get the information across to them, then that's not going to happen. On the other side of things, it is important…even more so in health care, where we know that talking about health literacy, where people are able to understand when they are in distress, actually drops. So, if you on top of that, have a language barrier, don't have access to health, who can do a follow-up or who can provide culturally sensitive care as a discharge…or you have an institution who doesn't have a health literacy plan…there are a lot of different ways how that can play out. But being able to do to get that information to the family, to the person, for that beneficial health choice to happen is really important. And then if [they are] not established with primary care, being able to continue having that relationship and fostering those appointments definitely will be the way to go.

Madison: Yeah, no, there's so many like nuggets of gold that you've been able to portray in our conversation today.

I'm just curious, what are some of the ways that you suggest that other health care providers—such as pharmacists—collaborate with providers such as yourself to improve the health and wellness of their community, is there any secret sauce that you think we can take away that's kind of the magic behind how you've been able to really foster this like community good in the Reno area, and how you've been able to really elevate talking about advocacy, vaccines, and preventative care [as well as] the need for more preventative care awareness?

Cucalon Calderon: Well, picking up the phone and making a phone call…being able to talk to people, people who are working with the same community, if you're seeing something again, and again, and again, and again, it's probably something within the system or the way that the care is delivered within that community that might need to change. Normally, systems need to be assessed from multiple viewpoints, and recognizing who your stakeholders are who can help you form a holistic view of what might be happening is really important.

I can tell you, when I came here 6 and a half years ago, I had a large portion of my Spanish-speaking families who were paying a referral for speech therapy or something, and they were never hearing back from anybody. So guess what I did? I ended up calling the family, they were in the office, and they told me “Oh, yeah, we have been expecting for 3 months a phone call, or something happening, and nothing.” So, I ended up picking up the phone [and calling] the place that I referred, either me or my office called and said, “Hey, this patient that I referred, I had the referral approved, what's going on?” [And they said,] “Oh, we were unable to get somebody who spoke Spanish to leave a message.” Something as simple as that. Or being able to talk to my phone to my patients, they were having a really hard time making appointments with us and what ended up happening was that the phone line that we had didn't have Spanish option.

Madison: Talk about something that is like such a monumental problem that could be fixed so easily.

Cucalon Calderon: Or we have another issue that I have brought up before…mental health is something that has carries a lot of stigma within the Latino community, so being able to get mental health management, it is really difficult because having nonmedication-based mental health services that are in Spanish is tough in town, we normally have a long wait time for most of those services. But then for the medication management—especially for patients who are on Medicaid—it also is extremely challenging.

So I was starting a [patient on] medication…I was seeing the patient back in—what, a month?—they would tell me that the medication got denied, I wouldn't get a letter from the pharmacy, I wouldn't end up getting a phone call from the pharmacist or from the family because I just had no idea what they had to do. So, I ended up bringing this up to the Washoe County Children’s Mental Health Consortium and then to the state, and apparently in psychiatry offices—the 2 psychiatrists that we had within the group who were invited also to comment on this—they told us that, especially for patients who are on any of the Medicaid MCOs, they were prescribing 15 medications, and they were getting 15 denials. And a lot of times, they weren't even hear about the denials until the patient showed up again.

Again, Medicaid management is really complex, choices made out of the budget that we have available is really hard, but if you have a moving target that changes every time and then you have 4 different ways of doing things and that changes twice a year, how are you going to find something that you can do? And then on top of that, if you're having a specific amount of time [in which] a physician is able to see a patient and you're having to devote the time to doing paperwork prioritizations, calling back, going into the pharmacy, seeing what ends up getting approved, what doesn't get approved, how fast it's going to change, that is extremely time-consuming.

So, we were able to support a letter that we ended up sending to the office—I think it was the office of Medicaid at the state level—and coalition building, finding how large this problem was being able to find other stakeholders who are seeing the same thing from different viewpoint, and then offering a recommendation and a call to action was what we ended up doing. So, advocacy begins with identifying a problem and then looking at the scope, and then being able to see what you can do about it to change it or to or to improve it. I don't like the word change. Sometimes you have to just improve things. But that's got to be the way, that wouldn't happen without being able to talk to people who are also delivering care to these families, and then also asking the families because they will tell you how things look on their side. They really have a relationship where we are trying to do the right thing for our kids, and most people want the best for their kids and not being able to carry out a care plan when they have already agreed to it, that generally is not what they want. So, being able to talk about that and being able to connect with people, chat, make a phone call, ask what happened, look back at how that ended up playing out on both sides, and then offering a recommendation or maybe a solution…It will be the biggest recommendation I can I think I can [give].

I am really happy that this year Immunize Nevada ended up awarding [Silver Syringe award] to pharmacists this year, and I am so happy to see that. Because that means that pharmacists are an extremely trusted resource to be able to go and get people vaccinated, and making the choice to get vaccinated can be difficult if you don't understand why you're doing it. And that's going to be the space that we have in between talking, being able to direct people to the right resource, being able to start as a trusted provider, and then finding people that are serving the same community would be the would be my specific recommendation.

Madison: This has been such a great conversation. I could probably chat with you for at least another hour, but I know that your time is valuable, and I want to make sure that we kind of end this episode with a little bit of a question that I tend to ask people. Sometimes they're appreciative, and sometimes they're not, because they're like, “Oh goodness, lots of things that I can say.”

I always ask my guests, if there was 1 thing that you could tell your younger self, what would it be and why? Now that you have all of this infinite knowledge?

Cucalon Calderon: Well, to be honest, sometimes your best is just good enough. That's probably going to be a big 1. The other 1 would be if something doesn't feel right, it’s probably not.

Madison: Trust your gut, trust your feelings, yeah.

Cucalon Calderon: And be a little bit more trusting of how you feel about something specific, a specific situation, something [specific] that happened, probably those 2 would be the bigger ones. You asked me for 1, but I think both are complimentary.

Madison: Yeah, I would agree.

So, if people would like to find you on social media, or see and follow your advocacy work, where would they be able to do that?

Cucalon Calderon: My LinkedIn would be the best resource. It's my name, Jose Cucalon Calderon. LinkedIn is open resource, if you do a search on Google with my name, that that's what shows up. That and some articles. Some of my work also gets highlighted regularly through the Nevada Chapter of the American Academy of Pediatrics as well as the National Hispanic Medical Association webpage. But if you want to look at exactly what adventures I'm involved in at the time—like Dr. Madison mentioned earlier—it will be my LinkedIn for sure—Jose Cucalon Calderon.

Madison: Wonderful. Well, I hope that everyone listening and watching got as much out of this conversation as I did, and I'm just so grateful that we have such a wonderful advocate in our state, and I'm glad that you moved from Alabama all the way here to Nevada, it's kind of funny…so, Renown [Regional Medical Center] [was previously called] Washoe Medical Center, and I was actually born there. So it's interesting, every time I hear anything about Renown, I'm like, “Oh, that's where I was born.” And so, [I] definitely have ties to Northern Nevada, but in general, [we should be] thinking about ways we can make an impact, and it doesn't have to be this grand hairy audacious thing, it can be just as simple as having that poignant conversation with the family and allowing for them to talk about what their concerns are, and having them leave feeling fully informed and wanting to care about what next steps they need to take for their health and wellness. I think if we just start there, and we start from a service lens, you can't really go wrong. And going back to your comment your best is good enough, and that's okay. I love that.

Cucalon Calderon: And we are happy to partner with everybody. With primary care providers and physicians, we are really happy to partner up with families, with our patients, with other public health-trained workers, because we definitely are here to be able to support your health needs, and we definitely are always looking at being able to do things better. As well as of course, in an evidence-based scientific and informational way.

Madison: Well, thank you so much. Again, my name is Dr. Christina Madison. I am your host and remember, public health matters.