Volume 60, Number 3 - Summer 2009

 

By Steve Osborn, MA

Communicating with patients, never easy to begin with, is getting even harder. At least that’s the conclusion an outside observer might draw after pondering the results of SCMA’s recent survey on cross-cultural medicine.

The informal eight-question survey, with an emphasis on “informal,” was e-mailed in early May to the 646 SCMA members for whom we have e-mail addresses, with a reminder notice going out 10 days later. Despite the usual press of work, 10% of membership (65 total) responded by the end of May, representing physicians from many different types of practices and specialties, as shown by Table 1.

These percentages are more or less in line with SCMA’s formal 2006 survey of all local physicians, which found a roughly 50/50 split between primary care physicians and specialists and determined that 66% were in private practice, 21% worked for Kaiser, and 13% worked for community clinics or government agencies.1 While not an exact match, the demographics from both surveys are close enough to support the notion that the latest survey is fairly representative of Sonoma County physicians, at least in terms of specialty and practice mode.

Whether the physicians are representative in terms of their cross-cultural experience is another question. But if they are, there can be little doubt that cross-cultural medicine is firmly entrenched in Sonoma County. The results of the very first question on the survey tell the story:

The answers ranged from 2% to 90%, with a dozen respondents reporting that 50% or more of their patients spoke limited or no English. Because of all those high numbers, the average percentage was a whopping 23%, whereas the median was only 10%. Even using the lower figure, it’s clear that a significant number of patients presenting in Sonoma County have limited English proficiency. In the absence of a common language, communicating with these patients could pose serious challenges.

The rest of the survey measured just how serious those challenges might be, and what physicians are doing about it. The first order of business was to determine which languages were in play. Thus question two:

To no one’s surprise, the nearly universal answer (97%) was Spanish, with one physician reporting Hindi and another Cambodian. The surprise came in the answer to the next question:

Nearly three-fourths (74%) of respondents said they spoke Spanish, an impressive number. Their self-assessment of fluency, however, ranged from “limited” to “fully fluent,” as shown by Table 2.

If Spanish were the only non-English language encountered in medical practice, the cross-cultural challenges might be relatively easy to solve. But Spanish is only the “most common” non-English language that doctors encounter. What about other languages? Thus the next question:

The answer, in short, was “lots.” Physicians reported encountering languages from all over the world, starting with Southeast Asia and Polynesia (Vietnamese, Cambodian, Thai, Lao, Tagalog, Samoan), moving up to East Asia (Mandarin, Cantonese, Korean, Japanese), then over to the Indian subcontinent (Hindi, Punjabi, Telugu, Sherpa), across the Middle East (Arabic, Farsi), into Africa (Tigrinya and other Eritrean languages), up to Eastern Europe (Russian, Polish, Slovak), over to Western Europe and South America (French, German, Italian, Portuguese) and finally to the United States, where a fair number of people speak American Sign Language (ASL). Table 3 shows the percentage of physicians who reported encountering each language group. (Because many physicians reported encountering more than one language, the percentages total more than 100%.)

What to do about such a profusion of Spanish and other tongues, short of becoming a polyglot? Question 5 listed several methods for communicating with patients who speak limited English and asked physicians to tell how often they used each method. Table 4 shows the results. (Physicians also listed other translation methods they used. The most common was writing for ASL speakers, with scattered reports of using dictionaries and miming.)

Table 4 indicates that speaking the patient’s language is the most frequently used form of translation, followed by using bilingual staff members and the patient’s family or friends. In-person or remote interpreters are much less frequently used. 

Frequency of use, however, is not necessarily a measure of effectiveness. Thus the next two questions:

Here the answers were sometimes at odds with the frequency results, as shown by Table 5.

One striking difference between tables 4 and 5 is the use of family or friends for translation. While this method is one of the most frequently used, it was also judged the least effective by 50% of the respondents—far more than any other method. The quandary is summed up in the comments physicians added to the survey. One noted, “We can’t afford to hire translators, so patients are told … to bring someone with them.” Another observed, “Family members are helpful but definitely provide incomplete translation, in both directions.”

A similar dynamic may be at play in the use of in-person interpreters. Even though such interpreters are infrequently used, 25% of the respondents judged them to be the most effective translation method. Physicians who have access to interpreters (such as at Kaiser and in Healdsburg—see sidebar) appear to use them frequently, with good success. As one doctor noted, “The most important thing is to use certified interpreters.”

In contrast, the infrequent use of telephone and video interpreters appears to mirror their perceived lack of effectiveness. Several physicians complained about the awkwardness of such translations, coupled with their lack of reliability. One pithy comment summed it up: “The phones are a very last resort and a pain in the butt.”

The frequency of using bilingual staff members corresponded with their perceived effectiveness, as did speaking the patient’s language. This last option, however, was also deemed ineffective by a significant number of respondents. The split in opinion appears to be related to the physician’s fluency in the patient’s language. The greater the fluency, the more effective it was to speak the patient’s language.

Statistics tell only part of the story of this informal survey. The other part can be found in the dozens of additional comments physicians made. These fell into several groups, with one large group consisting of complaints about the time and effort involved. “It’s very cumbersome and greatly extends the length of the visit,” wrote one doctor, with another adding, “It’s important but difficult to do in a fast-paced, busy practice.”

Another set of complaints revolved around whose responsibility translation should be. “We should not be responsible for communicating in their language” was a typical response, as was, “Shifting the onus and responsibility to the providers for mistakes feels lousy.”

On the flip side were physicians who enjoyed the challenges and rewards of learning another language. As one doctor observed, “Everyone who takes care of patients should make the effort to learn Spanish. It’s worth the time and effort invested.” But even if a doctor does learn another language, that’s no guarantee that all translation problems will be solved. As several physicians noted, cultural differences are important as well. “The words often do not convey the entire meaning,” wrote one. “Much is lost in cultural interpretation.”

Another physician wrote at length on this topic, noting that, “The cultural background is really important in understanding how the person understands anatomy, how the illness and relating symptoms are described, what diagnosis is acceptable and what treatments are expected (and therefore more effective).”

Finally, a couple of respondents used different words to make the same wry observation: “Speaking louder doesn’t help.” Humorous as it may be, that comment does summarize the challenges physicians face with cross-cultural medicine. The patients sitting across from you can hear what you’re saying, but that doesn’t mean they understand—and vice versa.