Bridging the Culture Gap

With language skills in English, Spanish, and his native Indian tongue, pediatrician Raj Patel might be expected to have less trouble than the average physician adjusting to the demands of practicing medicine in an increasingly diverse America. Yet his office, like so many practices across the country, strains to bridge the language barrier and other cultural challenges presented by immigrant patients, most of them from Mexico and South America.

According to the 2000 U.S. Census, some 19 million people are defined as having "limited English proficiency" (LEP), and various estimates say anywhere from 38 million to 45 million people speak a language other than English at home. Such numbers are booming.  For instance, the portion of children in American schools with limited English skills now stands at one in 20 -- an 85 percent increase in the last 25 years.

At Sunshine Pediatrics in Rock Hill, S.C., perhaps 15 percent of Patel's patients are LEP, according to his wife, Shaila Patel, a pharmacist who manages the solo practice. Yet LEP patients account for 25 percent of the staff's and doctor's time, she says. In part because she and her husband are Indian-American -- she was born in the United States; he was born in India but grew up here -- they empathize with their immigrant patients and take in stride the special challenges they present.

"I remember hearing stories of what my parents experienced with my pediatrician in 1970," she says, when they were told to use formula instead of breastfeeding, for example. The immigrant families that turn up at Sunshine Pediatrics "speak less English than my parents did. They don't speak English, don't have cars and can't drive, can't get around ... and I look at them and think they're exactly the way my parents were."

Experts in so-called "culturally competent" healthcare agree that the challenge of providing adequate service to those with limited English skills and non-Western healthcare traditions is a serious and growing problem. Until recently, the issue has mainly been one for hospitals, since many immigrants, lacking insurance, use the emergency room as their primary source of care. But with immigrant populations exploding, private-office physicians are now being confronted with this daunting new task in greater numbers. 

Language and cultural barriers create several problems for physicians: they require more time to diagnose and treat patients, and raise the likelihood that a clinical mistake will be made and that the physician could be sued for malpractice. In addition, for practices that accept Medicare or Medicaid, LEP patients may represent a new cost center, since government regulations require they be provided access to appropriate care.

Communication counts

To provide adequate service to such patients,  physicians must be able to communicate effectively with them. That usually means having interpreters who not only speak the patient's language, but who are fluent enough to handle the precise translation necessary for a medical encounter. Effective communication also means physicians and staff must demonstrate enough patience and flexibility to encourage immigrant patients to speak up about what's bothering them and what they're doing about it -- something they may be reluctant to do if they think their doctor just won't understand.

Glenn Flores, MD, an associate professor of pediatrics, epidemiology, and health policy at the Medical College of Wisconsin in Milwaukee, wanted to gauge the quality of medical translation in a hospital setting. A research assistant recorded 13 encounters in which a Spanish interpreter was used, transcribed the encounters, and had two bilingual physicians and a bilingual sociologist analyze the transcripts.

The results were breathtaking. An average of 31 errors per encounter were recorded; of those, 20 per encounter could have had clinical consequences.

Among the mistakes:
A mother was told that she should rub an ointment on her child's entire body when the child had a rash only on her face. A mother's explanation that her child had already been swabbed for a stool culture went unrelated to the medical staff. One interpreter advised a woman to refuse to answer the doctor's personal questions. And others omitted important medication instructions and questions about drug allergies.

"It's a very big issue, and it's only growing by leaps and bounds" as the country's immigrant population continues to grow, says Flores. Research indicates clearly that LEP patients have more trouble getting medically appropriate care, even when an interpreter is present, he says. "We know that asthmatic children of LEP parents are more likely to be intubated, for example."

Quality medical interpretation is a problem at Sunshine Pediatrics, too. Raj Patel speaks some Spanish, but not well enough to be comfortable without an interpreter in the exam room. Even so, he's caught some interpreters translating his questions inexactly.
"He might ask, 'How many formula bottles does he drink in a day?'  and the translator might say, 'How much is he drinking in a day?' Those are not the same," Shaila Patel says. "The exactness is needed, and it's not always translated."

Hospitals are required by federal law to provide translators for LEP patients, and what few standards have been developed regarding healthcare organizations' responsibilities to them are intended mainly for institutions, not private physician practices. The rules are more flexible for private practice physicians. You may consider the volume of non-English-speakers in your practice before deciding what to do about medical translation, and the federal guidelines encourage voluntary compliance, de-emphasizing penalties.

Flores's research (and more recent studies) found that interpreters trained in medical translation make fewer errors. But even these professionals are not flawless. Moreover, there is not much agreement on how much training is enough, and there is no national certification process for medical interpreters.

"You're looking at a profession that's really just getting itself off the ground," explains Julia Puebla Fortier, director of the group Resources for Cross Cultural Health Care, a research, consulting, and advocacy organization, referring to medical translation. "It's just not there yet."

Dos and don'ts

Despite this haze of uncertainty, experts say there are some things you can do -- and avoid doing -- to ensure you're providing the best care possible for immigrant patients. Here are some dos and don'ts for practices with a significant (or growing) number of such patients:

• Do try to hire bilingual staff. You shouldn't compromise on the important prerequisites for your employees, but if two job candidates have roughly the same qualifications, it would be a great asset to have a staff member who can translate. On the other hand ...
• Don't hire someone just because she claims to be bilingual. As Flores's research and other studies demonstrate, even people who speak Spanish well enough to get by in casual conversation often are not fluent enough to translate effectively in a medical context. Puebla Fortier argues that at least 40 hours of formal training, and probably more, are required for medical translation competency.
• Of course, it's impossible to gauge someone's fluency without being fluent in the language yourself. But if a job candidate presents herself as bilingual, do explore in the job interview whether she's had any training in medical translation, whether she's ever had her fluency tested, and, if so, what the results were.
• If you can, do train front-office staff with enough Spanish to gather at least the necessary information to take a phone message and greet patients as they arrive. At Sunshine Pediatrics, for instance, Shaila Patel has prepared note cards with important Spanish words and phrases to help the front-desk staff ask a caller's phone number and the patient's name. She then returns the call.
• Don't use patients' family members as translators unless you have no other option or have reason to be confident in their abilities. Family members may not be fluent enough in English -- or may speak at home a hybrid of English and Spanish, sometimes called "Spanglish," that even further complicates the medical translation process. Be especially wary of using children to translate.
• Do consider using telephone-based translation services. These services generally charge by the minute, giving you the flexibility of treating the occasional LEP patient, and many offer languages other than Spanish. Again, though, be aware that gauging the quality of the translation is difficult if not impossible for a monolingual physician.
• Do consider setting aside one day per month for a clinic for LEP patients, and hire a qualified translator to come in for that day. Perhaps your local hospital could loan you one, or recommend someone, or maybe a nearby university with a foreign-language program could suggest a top-notch graduate student looking to make a little money and gain valuable experience.
• Do look for materials, written in Spanish, on conditions common in your practice, and hand them out to your LEP patients. The Internet is a good place to start. The Web site of the American Diabetes Association (www.diabetes.org), for example, has an entire Spanish section.

Puebla Fortier says that providing care to LEP patients often requires extra time and effort by already stressed physicians. Nevertheless, she says, the effort is worth it. Not only is it good medicine, it also reduces your liability, since physicians can be held responsible in court for clinical errors made as a result of language barriers.

"It is going to put a lot of onus onto the physician to want to be interested -- to want to meet the patient where they're coming from," she says. "But in the end, from the private physician's perspective, while it may be a burden to have to deal with that, it's a bigger burden to have to deal with the consequences of making a serious error in diagnosis or treatment because you picked up the wrong info from a bad translation."

Cultural differences

Yet communicating effectively with immigrant patients requires more than effective translation of their language. It also means being patient with non-Western cultural traditions. As long as the patient isn't doing anything dangerous, flexibility and understanding will go a long way toward establishing the level of trust necessary for a productive doctor-patient relationship.

Parents will sometimes arrive at Sunshine Pediatrics with cans of Mexican baby formula that friends or relatives bring with them from home. That makes Patel a little nervous, since he knows nothing about what's in the product or about the manufacturer's safety processes. His wife tells them, "We prefer you use one of the brands here, so Dr. Patel knows how many calories the baby is getting, what's in the formula, and so on." And sometimes patients will confess to using potentially harmful home remedies, such as giving water to a constipated baby, that the doctor warns sternly against.

But for the most part, Patel and his staff are tolerant of cultural differences. No one sneers at a parent whose child arrives wearing a bracelet with charms meant to ward off evil spirits, for example.
"For our Spanish families, a lot of them turn to each other," Shaila Patel explains. "So they do home remedies or other things that made sense to their families when they were growing up in Mexico or wherever, but to us may seem odd. I understand it, because some of them are things my grandparents did with my parents back in India. To me, it doesn't seem silly; it's just cultural practice. I see that and don't think twice about it."

Yet immigrant patients are aware that some of their traditions are not shared by -- and may be looked down upon by -- Americans. Consequently, they may feel stigmatized, and thus be reluctant to tell you about some of the things you need to know.

Dr. Arthur Kleinman of Harvard Medical School developed the following questions to ask patients. The questions, which help the patient explain a problem on his terms, are useful regardless of the language he speaks or the country he's from, but perhaps even more so when cultural barriers are at issue:

• What do you call the problem?
• What do you think has caused the problem?
• Why do you think it started when it did?
• What do you think the sickness does? How does it work?
• How severe is the sickness? Will it have a short or long course?
• What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment?
• What are the chief problems the sickness has caused?
• What do you fear most about the sickness?

"These are ways for the doctor to understand where the patient is coming from," says Puebla Fortier. "So if issues of spiritual causes for a particular illness come into play, for instance, or desire to use some kind of traditional remedy like an herbal treatment, is raised by the patient ... the doctor will know that's what's in the patient's mind. Hopefully, the doctor will be able to incorporate that in a sensitive way, so that will bring the patient more into partnership with the physician and hopefully improve compliance."

Bob Keaveney, editor for Physicians Practice, wrote about physicians' top practice management challenges in the June issue. He can be reached at bkeaveney@physicianspractice.com.

This article originally appeared in the July/August 2004 issue of Physicians Practice.