David M Smith and Dr. Bill Eggington, Linguistics
Communication between patients and physicians is perhaps the single most important issue in providing quality health care to a community. When segments of this community come from different cultural backgrounds and speak different languages, effective communication becomes more difficult. Over the last several years, Utah Valley has grown significantly more culturally and linguistically diverse. As a linguistics student with plans to attend medical school I wanted to research the current situation of cross-cultural care in the community and make suggestions for improvements in the future.
During preliminary research, I discovered that the largest of the hospitals in the area, Utah Valley Regional Medical Center (UVRMC), had created a task force to address issues in “cultural competency.” The main purpose of this committee is to determine the current needs of IHC (Intermountain Health Care) community facilities as related to cultural issues and find methods to address these needs. The task force had gathered data from administrators and personnel but wished to further speak with those acting as the primary source of care: physicians. My involvement centered in this area.
Working with the UVRMC Medical Director and the director of the IHC Physicians Division, I arranged to speak with a sampling of doctors across the valley. The IHC Physicians Division employs 22 physicians in 8 clinics from Highland to Springville. Four of these clinics are family practice, two are InstaCare facilities, and the other two provide services in internal medicine and pediatrics. UVRMC employs approximately 450 physicians, of which 95% also work out of independent practices. From this group of physicians I chose to speak with 15 doctors from the hospital and representatives from each of the 8 clinics. Some were unable or declined to meet with me, but in the end I was able to interview 21 individuals and observe for 4 hours at an InstaCare clinic. The findings presented in this report are derived from these experiences.
Current estimates by physicians place non-English speakers at anywhere from 1 to 20% of the patient base. The highest percentages are in emergency/walk-in facilities and especially on evenings and weekends. The most prevalent language encountered is Spanish—nearly all cases—but Asian and European languages have also been reported. In order to communicate with all of these individuals physicians seem to follow a pattern in using available resources. First, a physician’s own skills are employed. Bilingualism is quite high in the area and especially in Spanish. Second, children, friends, or relatives of the patient are used as makeshift translators. Third, doctors make use of bilingual office staff. And fourth, printed resources and/or AT&T language line services are used. Usage of such services is very infrequent, however, due to high costs, time involved to make appropriate connections, and the impersonal nature of phone conversation.
Nearly all individuals interviewed expect current patient demographics to continue with perhaps an increase in the number of non-English speakers in certain areas. One doctor suggested that because of the relatively high number of bilingual speakers in the area due to LDS church missions, non-English speakers are attracted to the valley. Whatever the case, no one expects current needs to diminish. Some of those coming to the community may learn English, but many will not—especially first generation immigrants. Often these individuals have the attitude that they are only going to be here for a short time before returning to their homelands. As such they feel no need to “adapt”.1 Even if they did learn English and to a certain extent “adapt” there will still be cultural differences—different attitudes towards health care—to overcome. And in stressful or emotional situations it is believed that the language used as a child is the language preferred.2 Thus a moderately good second-language English speaking patient may lose some of his or her proficiency in an emergency situation.
So what needs to be done? Research has shown that when physicians speak the language of their patients there is greater patient recall and treatment follow through.2 Thus those who are to any extent bilingual should use their skills but also know their limits. One individual I spoke with related how two Hispanic men had started laughing in disbelief when the doctor gave them his treatment recommendations. Apparently in his broken Spanish he had told them to take their medicine with a couple of beers! Perhaps such methods could be looked into to attract patients but at the expense of a rise in alcoholism.
Other ad hoc methods can also lead to problems. In the rush to find someone to translate, doctors often overlook the fact that children or relatives are personally affected by what is happening. I heard of a mother who had come to a clinic for abdominal pains and her seven-year-old daughter was used to communicate to her that the pains were caused by a miscarriage. No one would have ever considered using a seven-year-old girl in a similar situation without a language barrier, but in the rush to get on to other patients sometimes such things are overlooked. This scenario also illustrates why bilingual office staff are not a reliable source for help. Too often having someone in the office that can translate is hit and miss and to use them takes them away from the other responsibilities for which they were hired. In all of these cases, physicians, relatives, or office staff are rarely trained in the nuances specific to medical interpretation.
In short, IHC Emergency and InstaCare facilities have a need for on-site interpretation services in Spanish. This should include full-time positions at UVRMC and at least part-time positions at other walk-in/urgent-care clinics—perhaps evenings and weekends. In order to make these translators effective, too, physicians will need to have some training on how to use them and why it is important that they do so. Other current services available to treat non-English speakers of different languages should be continued and patient demographics should be monitored.
The findings of this study were presented to the UVRMC Cultural Competency Task Force in October of 2002.
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1 Haffner, Linda. “Cross-cultural Medicine: A Decade Later.” The Western Journal of Medicine. Sept. 1992: 256
2 Siejo, Rosa, et al. “Language as a Communication Barrier in Medical Care for Hispanic Patients.” Hispanic Journal of Behavioral Sciences. Vol. 13, No. 4, Nov. 1991: 363-76.