Dimensions of Culture

(Copyright © 2008. All RightsReserved.)

(Need tips on working with interpreters? Click here)

Many of the private practices I have visited for the purpose of cross-cultural training are lucky to have staff and providers on their team who speak Spanish and other foreign languages. However, some practices are seeing patients from such diverse cultural backgrounds that it is impossible to have staff and providers capable of understanding all the languages of these patients. During cross-cultural trainings, we talk about the fact that patients from different cultures often nod their heads during conversations with healthcare providers, but this does not necessarily mean that they understand what is being said to them. Culturally, a head nod may be a gesture of respect, a way of saying, “Yes I am listening and being attentive. I recognize and appreciate your professional expertise.” The key question that comes out of this particular conversation in trainings is, “What can be done to make sure patients understand what is being said to them?”

The answer is twofold. First, it is absolutely critical in any healthcare situation that open communication take place, so don’t back off from asking questions in a culturally sensitive way.  Americans often experience paralyzing anxiety around political correctness, which definitely shuts down vital communication. You have to push yourself to reach beyond your comfort zone in many situations. Secondly, try your hardest to use the clearest English possible when speaking to non-fluent English speakers. Naturally, you don’t want to offend anyone by oversimplifying, but always be prepared to err on the side of simplicity to maximize understanding. The tips that follow can be adapted to a broad range of nonnative speakers.

TIP #1: Keep in mind, English is a difficult language. We take for granted in the US that much effort is made by people around the world trying to learn our language. If English is your first language, you may not realize you were lucky to learn English without much conscious effort and it is hard to appreciate the struggle of those who have to put great effort into speaking and understanding it. Consider this illustration of how difficult English is: If the word through is pronounced “throo” then why is enough pronounced “ee-nuff?” Why isn’t the word cough pronounced “coo?” Why is threw sometimes spelled through, and why do these two words that sound exactly the same mean two completely different things?
It’s also very difficult to learn which syllable gets the accent in English words: beginning (DEN-ver), middle (col-o-RAD-o), or end (cor-TEZ). In many other languages the accents are equal or they are indicated in the spelling of the word like Còmo està. Also consider the strange spelling of English words like science and since not to mention the illogical trio their, there, and they’re.

TIP #2: Keep it Simple. In work settings, we slip into our professional roles, often changing our way of speaking automatically so that we choose words like utilize instead of use. With limited English proficiency patients and families, the 5¢ word is always better than the 75¢ word.  Basics such as good, give, take, more, less will be better choices than positive, administer, increase, decrease. Keep word choice simple and keep sentences simple as well. Avoid run-on sentences. Americans tend to be uncomfortable with silence, so we ramble on if there’s a break in conversation. As we ramble, we tend towards more complex ideas rather than simpler ones. Allow some silence between simple phrases.

TIP #3: Give and Seek Feedback. Even if you are using simpler words and shorter sentences, you can’t be certain there has been communication until the receiver acknowledges it with feedback. Remember, head nodding does not count as feedback with people from many different cultures. Even with Americans, and definitely with children, head nodding is often a sign of partial comprehension. So you must ask clarifying questions.
There are two kinds of questions.

1. Close ended questions: These usually begin with do, did, does, is, are, will, or can. These can be answered with a simple yes or no – or a head nod. Avoid the use of close-ended questions with LEP patients because in many cultures people will frequently simply say yes even if they don’t understand you. If a person doesn’t want to contradict the doctor or other healthcare professional, nodding or saying yes is a way of keeping harmony in the interaction. A patient or parent may nod and then leave the doctor’s office with little understanding of what to do next. Or, the person may have no intention whatsoever of complying with the recommendations for treatment that were given for cultural reasons that were never discussed.
2. Open-ended questions: These usually begin with the 5 Ws – who, what, when, where, why (and how or how many). It’s not possible to answer these questions with a nod, shrug, or simple yes/no. For example, you might ask a patient/parent, “What do you think has caused this illness?” Or, “How long have you been seeing these symptoms?” “What are you most worried about?”

TIP#4: Not Understanding vs. Misunderstanding. Keep in mind that when people don’t understand you, you are more likely to get some indication of miscommunication than when they MISunderstand you. When there’s a lack of understanding, there’s often a break in the conversation. A person may ask you to repeat what you have said or you may read confusion in facial expressions. But when people misunderstand, they may be less likely to indicate this, especially if they come from an indirect and face saving culture. For example, the English words want and won’t sound very much alike to a nonnative speaker. You may say to a person, “I want to help you,” but she may hear “I won’t help you.” She may be perplexed that this is your response, but she may be very inclined to accept the word of a healthcare professional who is in a position of authority. She may perceive you as being uncaring, but certainly won’t say so. Many misunderstandings go unnoticed by both parties. Asking clarifying questions is crucial.

TIP#5: Speak Slowly and Clearly – NOT Loudly. Often when people don’t understand our language we treat them as if they are deaf or “slow” without realizing it. Articulate your words in shorter phrases rather than just speaking more loudly.

TIP #6: Repeat if Necessary. Much of what we gain from a conversation is the context or general content of the discussion. Our brains constantly fill in the missing information. If we don’t actually hear every word, we compensate. For example, if I say, “I left you a message on your______” you will almost automatically fill in the blank with cell phone, phone, or voicemail. Nonnative speakers will struggle to do this. So repeat key phrases and summarize key points. Also, make it clear at the outset that you are happy to repeat anything you say in conversation.

Tip #7: Avoid Acronyms, Idioms, Abbreviations. The medical culture has a language of its own that includes many acronyms such as ED, HMO, NPO, etc. Always take the time to say things the long way and avoid terms that will create confusion for nonnative speakers. It’s best when setting appointments to say “eight o’clock in the morning” instead of “8 a.m.” Common expressions and idioms can also block communication. If you say, “I’ll run that past the doctor,” an LEP patient may literally picture you running to the doctor which sounds urgent when you intended a casual tone. Imagine how confusing an expression such as “we can kill two birds with one stone” might sound in the context of a doctor’s appointment. I’ve often been surprised at the language people use in cross-cultural settings with nonnative speakers. Especially when we are rushed, tired or stressed our self-awareness slips. 

TIP #8: Write It Down, Demonstrate While Speaking. Providing simple notes about the key points of an office visit and expectations for patient follow up can be very useful to LEP patients and families. Written material with more detailed information about medications and treatments can also be very helpful in conjunction with thorough explanation in the doctor’s office. A really thorough explanation will include checking for understanding via open ended questions, gesturing while speaking, demonstrating the application of topical medications, etc. Even English learners who have had the benefit of formal education were probably exposed largely to workbooks and taped dialogues. They have little practice with actual conversation and can’t understand native speakers. For those persons who have had no formal schooling, written material may be beyond their capacity entirely, but perhaps someone at home can help translate what is written. That way they have a reference point for what was said in conversation with the healthcare provider. Written material can be taken away and read at a leisurely pace without pressure is often greatly appreciated.

Communicating with limited English proficiency patients is one of the greatest challenges for healthcare professionals. Having a fluent speaker on hand who is either a trained interpreter, a staff member, or adult family member is ideal, but not always possible. Hopefully, the eight practical tips covered here will prove helpful, along with adopting a determined mindset about overcoming the fear of making mistakes in conversation with culturally different patients. Being willing and able to ask questions in a culturally sensitive way is vital. For providers, it is also important to be familiar with the LEARN mnemonic: listen, explain, acknowledge, recommend and negotiate.