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A st...
ABSTRACT
This study focuses on the doctor-patient relationship between allopathic doctors and their patients in
the public...
structured interviews aimed to capture the perspectives (of allopathic doctors) on the current state of
pluralism, specifi...
METHODOLOGY
The fieldwork and materials consist of two parts. The first, a questionnaire (see below) completed by
ninety-t...
cultural acclimation; extensive Spanish communication studies spanning a complete month in the
classroom setting of Instit...
Participation Requirements
Structured Interview
RESULTS
Questionnaire Data
Table1
*The percent
includes only 83
participants in
total, 43 from
IMSS a...
Graph1
Graph 2
0
20
40
60
80
100
120
0 500 1000 1500 2000
AveragedA Scale-measured Preference Versus Average Reported
Dail...
Table 2
Table 3
Table 5
A
The averaged scale-measured calculation derives from the three value-types measure: útil, eficaz and valiosa. All
of the...
 Effects of endemic low education, specifically related to preventative measures actively sought
by the patient.
o Many p...
statement does not conflict with other project data, graphically demonstrating little correlation between
treatment-type p...
The weak questionnaire questions mainly refers to the scale measurement of preference in Q13,Q14,
and Q15; these questions...
understanding of the beauty and nature of tradition and traditional techniques, and equally through,
bettering of lives by...
8. Giovannini, P, and M Heinrich. "Xki yoma' (our medicine) and xki tienda (patent medicine)--interface
between traditiona...
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Final report healthcare preferences, Mexico

A study on the effects of income and education on preference between allopathic and traditional treatment-types and how medical pluralism impacts the allopathic doctor-patient relationships in Oaxaca, Mexico.

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Final report healthcare preferences, Mexico

  1. 1. --------------------------------------------------------------------------------------------------------------------- A study on the effects of income and education on preference between allopathic and traditional treatment-types and how medical pluralism impacts the allopathic doctor- patient relationships in Oaxaca, Mexico. ------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------ Principal Investigator: Richard Alan Russell Advisors: Carmen-Garcia Downing, Theodore Downing Sponsor: University of Arizona, The Honors College Date Fieldwork: May 20th, 2010 thru July 20th, 2010 Date Presented: February 9th , 2011 -------------------------------------------------------------------------
  2. 2. ABSTRACT This study focuses on the doctor-patient relationship between allopathic doctors and their patients in the public health sector of Oaxaca, Mexico in context of culturally prominent medical pluralism. Both allopathic and traditional treatment types that are widely available throughout the city constitute this medical pluralism. The original purpose of this study was to determine if income and education influence treatment type preference, but the study expanded to inquire into the doctor-patient relationship. The techniques used to collect data include a 36-question questionnaire with a comments section and a structured interview. Ninety-two questionnaire participants supplied usable data and six healthcare professionals were interviewed. The data supports the prominence of pluralism in Oaxacan healthcare and reveals no significant correlation between either income or years of education in relation to preferred treatment type. A patient’s pluralistic belief and usage of traditional and allopathic medical remedies can be somewhat problematic for allopathic doctors attempting to most effectively treat a patient’s acute illness due to: one, the doctors’ lack of information on proper co-prescription—combining allopathic and traditional medicines—which is further complicated by non-existent scientific literature investigating traditional remedies and two, the dualism between maintaining a patients faith and hope, while honestly, tactfully and respectfully sharing the benefits of modern allopathic studies and science. These shortcomings are exacerbated by time constraints that cause rushed visits, especially in the public healthcare sector, and together, these hurdles can hinder the allopathic doctor-patient relationship. Based on these observations, when considering allopathic treatment, re-evaluation of the importance of the doctor- patient relationship as an educational opportunity for the doctor and patient to share scientific and traditional-healing information likely will benefit both parties in both short and long -run. INTRODUCTION The research population is localized within the city Oaxaca De Juárez and nearby satellite communities. It’s important to know traditional healing alternatives are widely used throughout Oaxaca and the more localized research population.1 Likewise, allopathic medical services are also widely utilized. Most frequently urban citizens receive this allopathic treatment through federally managed and mandated hospitals. Instituto Mexicano del Seguros Sociales (IMSS) is one of the federal hospitals, and it serves, free of charge, all citizens of Mexico employed by a business. Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) is a similar institute, no costs, but for government employees.1,2 Previous research notes common positive and negative perceptions, held by the patients, and associated with each type of treatment, whether allopathic or traditional8 , and this project’s main goal is to determine if the variable factors of education and income affect or relate to preference between treatment types. Specifically, preference of these individuals is measured with implementation of questionnaires requiring participants to compare effectiveness, utility and price/benefit of both types of medicine on a scale (1-100). The questionnaire develops mostly quantitative grounds to consider allopathic and traditional treatment-type preference from the perspective of individuals categorized based upon education and income, and these grounds are further developed, and complemented, with
  3. 3. structured interviews aimed to capture the perspectives (of allopathic doctors) on the current state of pluralism, specifically concerning their notions of the doctor-patient relationship. BACKGROUND The people of Oaxaca remain severely economically challenged compared to the wealthiest of nations and are calculated to live in one of the poorest states of Mexico.4,18 Although, the poverty is not absolute and uniform because juxtaposed to the common, affluent individuals do reside in the urban centers and outskirts. Pueblos are rural satellite communities beyond these outskirts and constitute a large portion of the population of Oaxaca (see figure 1). 17 Note that in Valles Centrales, the location of Oaxaca de Juárez, a greater number of people reside in an urban setting. A large number of Oaxacan citizens are monolingual, speaking an indigenous language, and according to the 1993 governmental census, sixty-eight percent retain Indian heritage.4 Indigenous roots of traditional thought and practice are also common and they powerfully influence contemporary culture, even in major rural region. Traditional medicine is common throughout the world with origins in pre- colonial Indian, European and African heritages.4 Within Oaxaca traditional medicine is formally defined “the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.”3 The terms traditional, allopathic and alternative are not equivalent, and uniquely, the major practitioners of traditional medicine include shamans, parteras (midwifes) and curanderos (healers).4,6 Allopathy is any type of medicine involving biomedical, westernized or modern substance intake (i.e. pill or vaccination). Culturally prevalent health concerns in Oaxaca include gastrointestinal, spinal, oncologic, infectious, spiritual and mental affliction.5,8 Traditional practitioners often classify these ailments as a state of “disequilibrium” and unlike allopathy, include spiritual and mental factors in diagnosis. 7,8 Many Oaxacans prefer a combination of healing ideologies to cure these states of ailment. This dualistic approach is known as medical pluralism.7,9 Even more so, within the spectrum of medical pluralism, all consultations with allopathic doctors depend on a healthy doctor-patient relationship.11,15 The doctor-patient relationship’s impact extends to include actual patient health, prescribed regiment compliance and (indirectly) healthcare costs.11,12 Some studies highlight a single thematic component of this relationship, in which the patient expresses her own values, increasing her involvement in the treatment process, which concomitantly augments treatment satisfaction.10,11,16 So, often effective doctor-patient relationships include a doctor interpreting the psychological, the desires and the explicit requests, in context of each particular patient’s ailment and values, to pragmatically offer healing options.13 Fig. 1
  4. 4. METHODOLOGY The fieldwork and materials consist of two parts. The first, a questionnaire (see below) completed by ninety-two participants. The first fifty of these participants were from Hospital General, a facility under IMSS, located northeast roughly 1.53 miles from the center of the city, Parque Central del Zocalo. The following forty-two participants were from Parque Llano, a public park .64 mile northeast of this center. All questionnaire respondents were approached in the same manner. Each participant was read the title of the project and was briefly explained the premise of the project. If they met the selection criteria (see below), they were asked to participate. To all participants it was made clear that the questionnaire responses should only reflect their own thoughts, that any concerns or confusion should be directed to the PI and that the questionnaire could be read aloud or independently. The gender of all potential participants that were approached was not considered during selection; however, males did asked their wives to fill out the questionnaire for them or in place of them periodically. Illiterate (apparent or stated) persons at IMSS were excluded from questionnaire submission even though they did satisfy all participation requirements because of the complexity of certain questionnaire questions and time constraints. This selectivity sped the collection process and also accurately focused the sample population to represent an urban majority. Difference in methodology between the two questionnaire locations includes: participant selection criteria (but not participation requirements) and temporal factors. At IMSS, all individuals were waiting, not busy. Therefore, selection was based upon ability to communicate and understand Spanish; consequently, at IMSS persons appearing “elderly” (45+years) were specifically avoided, whereas participants appearing “younger” (21-45years) were presumed more likely to be able to answer the questionnaire accurately, with greater comprehension. In contrast, at Parque Llano, the apparent age of potential participants was not considered, and instead, unoccupied (not engaged in conversation or playing soccer, for example) persons were selectively approached. Temporal implementation differed in that each IMSS participant was approached between noon and five post meridiem on weekdays between June 28th and July 9th , 2010. However, each Parque Llano participant submitted their questionnaire between July 6th and July 11th , 2010 between five and ten post meridiem; this includes weekend and weekdays. With these two differences, little unavoidable bias is introduced. The complete week following collection at Parque Llano involved interviews, and can be considered the second part of fieldwork. A total of six doctors were interviewed. One homeopath (originally a allopathic practitioner) and five allopathic, federally employed doctors. The structured interviews (see below) contained two areas of concern: personal thoughts on traditional/allopathic medicine and pluralism’s bearing on the doctor-patient relationship. Three (of five) allopathic doctors were interviewed simultaneously in conversational manner, allowing each doctor to both respond to the original question and other responses. All interviews were structured, but dynamic; the PI responded to the provided answers, probing in-depth for clarification or details. The data collected in each part of fieldwork was recorded differently. The questionnaires were stored both as hard copies and digitally within an encrypted database; whereas, the interviews were recorded on a digital recorder, formatted mpeg. Finally a minor note, ample preparation by the PI included:
  5. 5. cultural acclimation; extensive Spanish communication studies spanning a complete month in the classroom setting of Instituto Cultural de Oaxaca (ICO); professional and personal networking; two days shadowing allopathic doctors from an Anti-SIDA clinic and a major ISSSTE hospital; and review of fieldwork materials by multiple ICO, native Oaxacan, instructors. Questionnaire
  6. 6. Participation Requirements
  7. 7. Structured Interview RESULTS Questionnaire Data Table1 *The percent includes only 83 participants in total, 43 from IMSS and 40 from Parque Llano. 9 of the 92 total to submit questionnaires did not provide complete data.
  8. 8. Graph1 Graph 2 0 20 40 60 80 100 120 0 500 1000 1500 2000 AveragedA Scale-measured Preference Versus Average Reported Daily Income (pesos/day) Series1 Series2 0 20 40 60 80 100 120 0 5 10 15 20 25 30 35 40 AveragedA Scale-measured Preference Versus Years of Education Series1 Series2 X, Y-axis Correlation= -1.634E-3 X,Y-axis Correlation= -1.204E-1 IMSS Parque Llano IMSS Parque Llano
  9. 9. Table 2 Table 3
  10. 10. Table 5
  11. 11. A The averaged scale-measured calculation derives from the three value-types measure: útil, eficaz and valiosa. All of these averages are derived from all three value-types, two or just one (dependant on the participant’s choice to respond or not). B Pair-wise, meaning the participant also responded to the scale-measured value-type set as described, whether útil, eficaz, valiosa, or averaged scale-measured preference. C An effective total is the number of participants, partitioned from the original 92, that provided sufficient data by responding to the involved questionnaire questions (Qn). For example, all participants not answering Q30 or at least one question of Q18, Q20 and Q23 are excluded from all effective totals in the first two data tables because respectively Q30 measured the participant’s years of education and Q18, Q20 and Q23 all measured the participant’s daily income (pesos). Interview Data The interviews each contain details and idiosyncratic tonal regard best summarized into main ideas, which for the most part are shared by each of the interviewees and focus on:  The cultural definition of traditional/allopathic medicine. o The major difference resides within the origin of traditional medicine, how its historic prominence within the culture makes it almost an automatic aid to treat any primary symptoms. This can lead to poor prevention of serious diseases, and the doctors clarified that this historical prominence and its effects are best exemplified when parents or grandparents repeatedly treat their children with traditional treatments. The influence of immediate family is so strong, one of the doctors I interviewed saw his father suffer with additional epileptic seizers because his mother encouraged him to stop taking his prescribed allopathic pills, replaced by a simple tea composed mostly of lemon and water.  Superior nature of experimentally tested medicine. o All of the doctors I interviewed believed that when responsible for the life of a patient and when scientific data or experimentation supports the use of a particular medicine/practice, that the rigorously tested treatment-type is preferred over a treatment-type without records, and that traditional medicine lacks this type of rigorous testing.  Elements of patient faith. o A patient that truly believes in traditional medicine has faith in these practices. The example provided by one interview is a man that trips and falls, injuring himself. The man might visit a doctor and be prescribed powerful pain medicine and a cast; however, might not feel comfortable that the injury has been resolved until he travels back to the place he tripped to pour out mezcal on the ground. This ritual is a part of a complete treatment for the man, and his perceived condition is not fixed until it is complete.  Effective ways of handling conflictive pluralism. o Tactful honesty with the patient will always be best. If a patient with cancer, left untreated it will metastasize, asks the allopathic doctor about an herb tea to cure the cancer, then the doctor must tell the patient what information she has about cancer and what she knows about the tea. In cases like this, the doctor must decide how strong to condemn the usage of traditional medicine.
  12. 12.  Effects of endemic low education, specifically related to preventative measures actively sought by the patient. o Many people prefer to use traditional medicine until symptoms worsen, until necessary to use allopathic medicine or visit the hospital.  The harmonious nature that can pervade a doctor-patient relationship with pluralistic co- prescription and understanding of the patient’s culture and beliefs/faith in this culture. o The only concern mentioned regarding co-prescription is the continued belief, if not strengthening of trust, in traditional medicine or allopathic medicine when only one medicine actual effectively treats the ailment because the treatment effects cannot be attributed with certainty to either medicine. This can lead to inflated faith in less effective treatment; the ensuing damage can expand to include large groups of people or entire communities because of misdirected treatment-praise shared with others. DISCUSSION Unique benefits of the questionnaire include “historical” and hypothetical question types, a comments section and integration of checks/averages. The advantage of factual and hypothetical questions is the distinction between actual behavior versus insight into participant consideration or thought, reflection. The most striking example, the ratio of participants that prefer traditional or allopathic treatments more but visit allopathic or traditional practitioners (equally) or more often to participants who consult their preferred type of doctor more often (Table 5, Q3, Q10, Q11). This question directly compares participant thoughts to their “historical” actions. The comment option expanded the possible information to glean from each participant’s response and some of the most insightful comments include clarification on why some questions were left blank and how the cultural concept of both spirit and body apply to preference. The similar, repeat-questions of the questionnaire allowed for averaging and more accuracy of effective data. The integrated checks confirm data; for example, if a person indicates that a final level of education was primaria, the reported number of years of education should be no greater than 7 years, which includes an additional year of leeway, based upon public schooling tiers. These facets increased the investigation-value of the questionnaire data. The questionnaire spans numerous topics of interest and measures income, preference and level of education. The application of the analyzed questionnaire data clearly supports the statement: Pluralism in the city of Oaxaca (Table 5, Q4, Q5) is not composed solely of static preference (Table 5, Q12), and considering that many patients do not receive their most preferable treatment-type (Table 5, Q10, Q11, Q3) and that the population feels more scientific information (Table 5, Q36) and/or income (Table 5, Q24) can affect preference, then, to improve the healthcare, an increase in the doctor-patient science- based information exchange and decrease cost of treatment would help. The first note regarding this statement is that further investigation is necessary to better understand what these induced preference changes might be; particularly, would the preference of an individual with increased income favor traditional or allopathic treatment-type. Regardless, it can be assumed any person with more knowledge (correct information) and financial freedom will select the most improved treatment-type, which no matter what equates to better healthcare, at least from the perspective of the individual. Secondly, this
  13. 13. statement does not conflict with other project data, graphically demonstrating little correlation between treatment-type preference and education and income level (graph 1 and 2). Based upon interview extrapolation, during which nearly all doctors (also) agreed that increased education would alter patient preferences (specifically toward preventative medicine and to a lesser, biased degree, allopathic treatment), one main subtly explains why the graphs merely appear to be discrepant. The subtly: interviewed doctors consider the factor of time and possible trends dependent on time, which includes any “cascading” cultural changes; statistically, too, correlation does not determine causality. An explicative example regarding the first subtly, the same correlation values could be obtained ten years from now, even if the linear regression lines (in black) shift upward (or downward) on the y-axis; this shift equals change due to some force, that regardless of the correlation constant, is hypothesized to possibly be augmented scientific education or income by the very people that would experience the change. Everything, this statement, all the data and the project in whole only retain investigational value, though, if the sample population precisely models the stated research population of Oaxaca without major deviation. To obtain a more reliable sample population with minimal bias from the research population (see Introduction) methodological changes were made as necessary. Primarily, the discovery that ~81% of the possible participants on the premise of IMSS traveled from pueblos, required the PI include another questionnaire location with more urban participants, the Parque Llano participants. Another population detail accounted for, the correlation between socioeconomic disadvantage and site of questionnaire collection; the first fifty surveys from IMSS represented participants with a lower spectrum of reported daily income. Thus, collection at Parque Llano offered an alternative pool to randomly (as possible) select from to add to the (should be primarily urbanite) sample population. Even with these acknowledgements and improvements, the sample population in future studies will be predefined based upon contemporary census data from the federal government. This will have immense effects on the veracity of the results and applicability of the investigation, and it is worthwhile to compare these investigation results to this census data. Overall, the challenges of this project reduce the accuracy and precision of data, but do not render the results insignificant. Specifically, some challenges include: unexpected language barriers, mildly frequent low participant literacy in Spanish and weak questionnaire methods. The language barrier includes (Spanish to English) translation by a non-native PI and a high number of participants, whom primarily spoke an indigenous language (in addition to Spanish). However, the interference of Spanish to English translation are nearly negligible because assistance from several native Spanish and Oaxacan professionals familiar with the cultural intricacies of healthcare, guided and proofread both the questionnaire and the structured interview. Also, participation required a level of Spanish literacy enabling comprehension of read or spoken questionnaire questions. In particular, participants at IMSS required more explanation and found it more difficult to understand some questionnaire questions. This is attributed to a greater presence of rural dwelling participants—therefore greater indigenous language usage, lower levels of Spanish language education—that traveled, often several hours, seeking hospital care for a family member. In the future, either a translator or more linguistically inclined PI could serve to rectify these language hindrances.
  14. 14. The weak questionnaire questions mainly refers to the scale measurement of preference in Q13,Q14, and Q15; these questions were too complex. The error was discovered after initiation at IMSS, and was not corrected mainly because the effects hopefully were controlled for during questionnaire administration with extensive explanation and breakdown, if necessary. In the future Likert scales and more straightforward means could be utilized, even if limiting the depth/range of answers. The positive facets, shortcomings, solutions, and conclusions discussed above comprise the noteworthy points regarding the questionnaire and general investigation results and procedures. CONCLUSION In Oaxacan allopathic treatment, respect of patient value or preference for traditional treatment by the doctor remains a delicate situation centered on the patient’s wellbeing and faith. Because patients’ assign preference—which is not always in accord with “historical” accounts of treatment-type received—on the basis of personal ideas, knowledge, experience and values, this component of the doctor-patient relationship is highly variable and unique to each patient. The degree of cumbersomeness a pluralistic treatment-type preference introduces to the doctor-patient relationship, from the perspective of an allopath in Oaxaca, appears to exist only when co-prescription is interfering with the allopathic treatment of a serious ailment. The interference often imputes to the lack of trust of the allopathic treatment by the patient or actual unpredicted substance interference, and in both cases more rigorously confirmed data on the traditional treatment-type would be valuable to the allopath. Most often though, the patient is permitted to complement the treatment with any desired means and the pluralistic conflict is minimal provided the patient informs the doctor about all other current treatments. An extended investigation might attempt to determine whether the costs of pluralism outweigh the benefits of this belief system for patients and/or allopathic doctors based upon population health and livelihood, or explore the depth of cross-cultural translation of these current results to a similar culture consisting of traditional and allopathic treatment-types or more specifically the contemporary American healthcare system woven extensively with alternative, naturalistic and allopathic healing methods Unfortunately, due to the flood of patients receiving situational optimization of aid at IMSS, ISSSTE and the like, a paternalistic model—the doctor elects the patient’s best interest12 —automatically dominates, as there is only time to consider the patient’s physical pains and chart data.16 This means that the element of the doctor-patient relationship that’s always unique to each patient because of personal values, yet pertinent for the most effective treatment of both individuals in the short-run and the entire Oaxacan people in the long-run—through generationally-rippling improvement, (potentially) inducible through medical-health science education—is sacrificed. If so, the importance of increased doctor- patient interaction, which includes information exchange during increased consultation time between both patient and doctor of a scientific, culturally-relevant and value-based nature, will allow patients to draw from their own augmented, updated stocks of knowledge, creating more satisfaction (plus the medical health corollaries) while concomitantly adding benefit to the Oaxacan people in whole, through promulgation of new information increasing both the faith in science and its exactitude and the
  15. 15. understanding of the beauty and nature of tradition and traditional techniques, and equally through, bettering of lives by fostering a long life of health. Currently, medical pluralism is undeniable within Oaxaca. The results that 46 of 82 patients are receiving medical treatment-types they do not prefer most (Table 5, Q11, Q12, Q3) and that 78 percent of participants believe more scientific information can change their preference (Table 5, Q36), both conflated with findings from studies on patient satisfaction and values and from this investigation’s clarified understanding of the culturally specific doctor-patient relationship, support the cruciality of instructional interaction in every allopathic consultation. Whether faith in traditional treatment-type is condemned or condoned by the allopathic doctors of Oaxaca, will largely affect the culture in the long- run and the doctor-patient relationship in the short-run. Currently this faith appears to be handled with an honest explanation of the allopathic doctor’s extent of knowledge. This should include sharing with the patient how more modern scientific, allopathic treatment originates and the reliability of results based upon extensive research that form the basis of allopathic treatment. These study results warrant further investigation for two reasons. One, there is room for major methodological improvement on sample population definition and on faulty or incomplete questionnaire questions. Two, the opportunity exists to greatly improve the understanding of the effects of medical pluralism and patient treatment-type preference, respecting the doctor-patient relationship, to ultimately improve the lives and work of both patient and doctor. SOURCES 1. Field experience and information shared by Dr. Cruz, a doctor from Oaxaca. 2. Author unspecified. "Ley Del Seguro Social." Instituto Mexicano Del Seguros Sociales. Diario Oficial, 07 Oct 2009. Web. 21 Mar 2011. <http://www.imss.gob.mx/NR/rdonlyres/57FC57A6-A635-4315-B35C- D2F3B0C67DB6/0/LSS.pdf>. 3. Qi, Zhang. "Traditional Medicine." World Health Organization. WHO, 2011. Web. 21 Mar 2011. <http://www.who.int/medicines/areas/traditional/en/index.html>. 4. Zacharis, Steffi (2006) ‘Mexican Curanderismo as Ethnopsychotherapy: A qualitative study on treatment practices, effectiveness, and mechanisms of change’, International Journal of Disability, Development and Education, 53: 4, 381-400. 5. Von der Pahlen, María Constanza and Grinspoon, Elizabeth(2002) 'Promoting Traditional Uses of Medicinal Plants as Efforts to Achieve Cultural and Ecological Sustainability', Journal of Sustainable Forestry, 15: 1, 81 — 93. 6. Information received through conversation with Professor Abraham, who works for the Instituto Cultural Oaxaca (ICO). 7. Haro, Jesús A. "Sentido Histórico y Pertinencia Actual De La Medicinia Traditional Mexicana." Centro De Estudios en Salud y Sociedad. EDESPIS-Seminario de Desarrollo Intercultural, 05 Nov 2009. Web. 21 Mar 2011. <http://portalescolson.com/boletines/325/Medicina%20Tradicional%20Mexicana.pdf>.
  16. 16. 8. Giovannini, P, and M Heinrich. "Xki yoma' (our medicine) and xki tienda (patent medicine)--interface between traditional and modern medicine among the Mazatecs of Oaxaca, Mexico.." Ethnopharmacol. 121.3 (2009): 383-99. 9. Higgins, Cheleen M. "Integrative Aspects of Folk and Western Medicine Among the Urban Poor of Oaxaca." Anthropological Quarterly. 48.1 (1975): 31-37. 10. Linn, Lawrence S and DiMatteo, M. Robin and et al. "Consumer Values and Subsequent Satisfaction Ratings of Physician Behavior." Medical Care. 22.9 (1984): 804-12. 11. Kaplan, SH, and S Greenfield. "Assessing the effects of physician-patient interactions on the outcomes of chronic disease." Medical Care. 27.7 (1989): 110-27. 12. Donavan, JL. "Patient deision making. The missing ingredient in compliance research." Int J Technol Asses Health Care. 11.3 (1995): 443-55. 13. Bourne, Dorothy Dulles. "Doctor-Patient Relationship." Antioch Review. 10.2 (1950): 225-31. 14. Delbanco, TL. "Enriching the doctor-patient relationship by inviting the patient's perspective." Ann Intern Med. 116.5 (1992): 414-8. 15. Delbanco, TL. "Quality of care through the patient's eyes." British Medical Journal. 313.7061 (1996): 832-3. Print. 16. Shadowing two doctors, one at IMSSTE and another at a SIDA clinic in Mexico. 17. Governmental Census. "México en Cifras: información nacional, por entidad federativa y municipios." Instituto Nacional De Estadística y Geographía. N.p., 2011. Web. 01 Feb 2011. <http://www.inegi.org.mx/sistemas/mexicocifras/default.aspx?ent=20>. 18. Census Data. "Información por entidad." Cuéntame. INEGI, 2010. Web. 11 Feb 2011. <http://cuentame.inegi.org.mx/default.aspx>.

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