Medical Care

Imagine you are a doctor rushing to meet a new patient who all you know about is her name, Mrs. Haddad. Though the name sounds foreign, you are fluent in both Mandarin and Spanish, and your hospital has access to professional Cantonese, Korean, Toisanese, and Vietnamese interpreters, so you feel confident you will be able to communicate easily with her. Then you reach the examination room and are greeted by a silent woman dressed in a black hijab who only speaks Arabic. What do you do?

This is a rough description of how Alice Chen’s article Doctoring Across the Language Divide begins1. As Chen goes through the lengthy ordeal of treating Mrs. Haddad, she encounters many problems faced by doctors due to language barriers such as the reliability of Mrs. Haddad’s husband as an interpreter, the inability to ask personal questions, such as if Mrs. Haddad was being abused by someone, being unable to know what Mrs. Haddad’s expectations were for her medical treatment, and not being able to question Mrs. Haddad as to what aspects of her life might be causing these symptoms.

Frustrated by this ineffectiveness, Chew decides to find an interpreter through Mrs. Haddad’s Medicad plan. It is from this interpreter that Chen is able to open what she calls “suddenly, seamless communication,” with Mrs. Haddad, and learns that her patient’s age is around 39 instead of the officially documented 49, that because of this younger age Mrs. Haddad’s anemia is actually due to heavy, monthly periods instead the more likely reason for older women of colon cancer, and that the reason for Mrs. Haddad’s depression is because her son had recently been arrested for supposedly financing terrorism by owning a currency exchange business. During the arrest Mrs. Haddad was forced to the ground by a policeman who stood on her back with one foot, while she watched another officer point a gun at her son’s head. This incident was shortly described as “harassment” by Mrs. Haddad’s husband in earlier appointments, with no real account of the actions that took place.

After this interesting story Chew discusses the problems associated with obtaining interpreters which she so eloquently showed as being indispensible in the medical field1. She begins by reinforcing the need for interpreters by informing her readers that according to the 2000 census about a 50% increase of limited English speakers in the United States during the 1990’s. Chew then continues by describing the forming of a number of policies that are attempting to bridge this “language divide.” For example, the 2001 federal government’s national standards for Culturally and Linguistically Appropriate Services in health care has made many organizations refine or develop their interpreter services. However, it is Chen’s belief that these standards are considered more guide lines without any actual force of law and are thus forsaken by healthcare institutions.

Another problem addressed by Chew is the unreliability of the alternatives for skilled interpreters such as family members who may not possess the medical terminology to fully interpret one language into another or who may have reasons for altering a patient’s dialogue to suit their own means. Much like the experience Chew had with Mr. Haddad as interpreter1.

Another especially dangerous group to use as interpreters is children. This is because though they may have a full command of English their understanding of their parent’s native language is usually unreliable1. Also, in certain situations parents and elders may feel it necessary to withhold certain symptoms in order to protect the child. Furthermore if parents become dependent on children as interpreters the effects can be devastating on a child’s future. Chew gives an example of this by describing one of her patients who never finished high school because she was needed to interpret for her parents when her sister experienced chronic illness.

As for telephone interpreter services, Chew explains that this alternative is both extremely costly when dealing with long periods of time and obscure languages, and is inadequate when dealing with interpersonal issues1.

Seeing as how these alternatives fall short of their intended goal of open and unlabored communication, Chew end’s her report by proposing ways to fund medical interpreter services by reimbursing them through “direct, centralized payments” (similar to how our judiciary pays for qualified courtroom interpreters) or increasing payment to providers that care for patients with language barriers. Chew also proposes a national system of telephone interpreters much like the one established by the Australian government1.
In her story Chew showed a number of different problems faced with patients who have different languages than the medical staff who treats them, but what about interpreting medical information to a patient of the same language as the caregiver who only has little understanding of medical terminology. In Communication Techniques for Patients With Low Health Literacy: A Survey of Physicians, Nurses, and Pharmacists a study is conducted that shows the different techniques used by the three kinds of caregivers in order to communicate with their patients2. The study also attempts to show how each group favors certain techniques over others. These techniques include asking patients to repeat information, speaking slowly, presenting 2 or 3 concepts at a time and checking for understanding (termed the teach back technique), using simple language, and several others listed by the survey. From the study it was learned that each profession used only a few techniques far more often than others that were presented, and a tendency to use simpler techniques learned in the professional’s medical education was also found, while avoiding more complicated techniques such the (teach back) which was used by only 40% of the participants.

Education is not the only other language barrier that must be faced by health care professionals. In the article Communication Strategies for Nurses Interacting with Patients Who Are Deaf the importance of dealing with patients who are physically unable to hear is discussed3. For the most part learning how best to communicate with the deaf is no different than overcoming common language barriers. You first must assess the appropriate and viable method to use in communication, be it lip reading, written communication, technological instruments, such as teleprompters, or if standard American Sign Language (ASL) is usable. The most appropriate of these is chosen after considering the patient’s understanding of English and ASL, which is constituted by whether the patient was deafened before the acquisition of speech (pre-lingually deafened) or was deafened after the acquisition of speech ( post- lingually deafened), and of course the health literacy of the patient must also be considered.

If (ASL) is determined to be the best way of communicating with a patient then a professional interpreter is usually required, and even if an interpreter is available, healthcare professionals must use simple terminology in order for the interpreter to translate efficiently, seeing as how ASL is a language separate from English that has a unique syntax, structure, and cultural context of its own.

More important still are the words used to relate to patients who are either hard of hearing or completely deaf, which some in the Deaf (capital D) community consider to be a natural characteristic rather than a disability. Furthermore the cultural rules of polite and respectful behavior are different. For example, a doctor who does not look directly at the patient while talking, say while reading a chart, may be considered disrespectful.

As for the obtaining of interprets and the understanding of medical staff in how to access them, a large majority of professionals have been found to not to be aware of how to gain access to (ASL) interpreters, even though there have been laws passed that require their understanding of how to do so.

The ability to open communication with patients is a skill that seems to be neglected by most professionals in the medical field. If so, then perhaps an understanding of the repercussions of not opening communication with patients, and there by not gaining informed consent, should be covered. In Culture Communication in Ethically Appropriate Care by Fiona Meddings and Melanie Haith-Copper, the problems of using “western ethical principles” as a basis for how to treat patients of different ethnic and cultural backgrounds are described4. It is the view of Meddings and Haith-Cooper that the standard codes of ethics cannot be applied when treating patients from other cultural backgrounds. These codes must be flexible in order to respect cultural differences. However, the standard critique for insuring the ethically respectable care of patients, Gillion’s four principled model, calls for a culturally neutral stance. According to Meddings and Haith-Copper, this also means that providers must not use any of the previous feelings or awareness they have about patients in order to assess the best way to communicate with patients, this also means not taking the cultural values and beliefs of the patient into account. If this is so, a culturally neutral stance would seem to betray the other three principles of Gillion’s model, autonomy, beneficence and non-maleficience, and justice.

Autonomy is (in the medical context) the deliberate self-rule of patients which must be respected by informing patients thoroughly of proposed treatment and gaining their consent to being. It is the view of Meddings and Haith-Copper that assuming a culturally neutral stance can inhibit the ability of medical practitioners to communicate to patients. This is because a lack of “commonality (due to cultural disparity)” influences the type of information that a caregiver provides.

Meddings and Haith-Cooper also shows how autonomy has differing meanings in cultures other than the western ideal. The authors use the status of Egyptian, Muslim women as an example, where paternalism or the role of deciding to proceed or not with treatment and the decision of what treatment to pursue is given by the caregiver not the patient. Thus these women do not value their own ability to decide for themselves, thus making it impossible to gain informed consent. That is unless the caregiver understands this cultural disparity and can overcome it by engaging a client fully, understanding their hopes, fears, physical condition, and limits of intellectual understanding by employing a language in which the patients can interact.

As for the matter of Beneficence and non-malfeasance, the issue of being unable to open communication with patients of other language so as to know if a treatment is proving harmful or effective is presented. This means that in order to insure that treatment is beneficial and not determined to a patient’s health; the patient must be able to relate the symptoms he or she is facing. If this cannot be done; treatment could prove in effective or potentially harmful to patients.

The possibility of psychological harm also presents difficulties since a lack of communication may cause patients to feel vulnerable and inadequate when expressing their fears of their well being to non-responsive care-givers. It is also the belief of Meddings and Haith-Cooper that the misinterpretation of this quiet and defensive domineer may lead doctors to stereotype all non-English speaking patients as so.

Finally Meddings and Haith-Cooper discusses the lack of justice found in the dealings of patients with langage barriers. Specifically, the ability to access health services and the ability to communicate if unfair treatment has been placed upon a patient is covered. These two aspects have both proved unattainable to a large group of people since in order to be informed and use such services fully one must be able to understand and reply in English.

Though the language barriers found in patient/doctor relations are important, I believe that in order to analyze the language in the medical world one must also research the language barriers between medical colleagues and students as well. In the article It is not just work- It is also words by Murali Ramaswamy, the recent discovery of 15 Turkish physicists who have used plagiarized work on numerous occasions is discussed5. One of the physicists justified his actions with this statement “for those whose mother tongue is not English borrowing beautiful sentences from other studies on the same subject…is not unusual.” The physicists continues by saying the “the originality of scientific content should outweigh criticisms about language misappropriation, however the writer comments that it is important to remember that it is the responsibility of the scientist to meet the ethical standards established by the journals or societies in which they intend to be publish.

An even more disturbing occurrence of plagiarism is occurring in India where 20% of medical students feel plagiarism is an ethically sound practice, according to Gitanjali, in reference to copying during examinations. Such plagiarism suggests a lack of comprehension of the proposed material which could lead disaster in the workforce. This ethical view of plagiarism is due to the misperception of certain cultures as to the medical communities unfavoring one. Such communication in the Medical world could, be viewed as a sad reflection on how important Medical providers might view communication with their patients. After all, if medical professionals can’t break the language barrier with one another, how can one expect them to break it with an untrained, poorly health literate patient?

In closing, from these articles I have been led to believe that the accessibility to open and easy communication, without fear of incrimination or misrepresentation is a natural right of patients to receive their care givers. Modifying the current standards of insuring such accessibility to interpreters and the skills of medical providers to simplify communication, should be of great importance to those who believe in the very basis of why the medical world exists. To heal all of man kinds wounds no matter how you phrase it.

References

1. Chen A. Doctoring across the language divide. Health Affairs [Internet]. 2006 [cited 2008 Apr. 7] ; 25 (3) : 808-813. Available from Academic Search Premier: http://web.ebscohost.com.proxy. lib.utk.edu
2. Schwartzberg J.G, Cowett A, VanGeest J, Micheal SW. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. American Journal of Health Behavior [Internet]. 2007 [cited 2008 Apr. 7]; 31 (1): 96-104. Available from Academic Search Premier: http://web.ebscohost.com.proxy.lib.utk.edu
3. Chong-Hee Lieu C, Sadler GR, Fullerton JT, Stohlmann PD. Communication strategies for nurses interacting with patients who are deaf. Dermatology Nursing. 2007 [cited 2008 Apr. 12]; 19 (6): 541-551. Available from American Search Premier: http://web.ebscohost.com.proxy.lib.utk.edu
4. Meddings F, Haith-Cooper M. Culture and communication in ethically appropriate care. Nursing Ethics [Internet]. 2008 [cited 2008 Apr. 7]; 15 (1) : 52-61. Availiable from Academic Search Premier: http://web.ebscohost.com.proxy.lib.utk.edu
5. Ramaswamy Murali. It is not just the work- it is also the words. Indian Journal of Critical Care Medicine [Internet]. 2007 [cited 2008 Apr. 7]; 11 (4) : 169-172. Available from Academic Search Premier: http://web.ebscohost.com.proxy.lib.utk.edu