“The patient will never care how much you know, until they know how much you care.”
S. Terry Canale, MD
In healthcare, most complaints about doctors are related to communication problems rather than to clinical incompetence (Stewart et al., 1999; Ha et al., 2010). Widely reported among them are an inadequate explanation of diagnoses or treatments, patients feeling ignored, misled, and a lack of understanding of patient and family perspectives (Stewart et al., 1999).
In doctor-patient interactions traditional approach, the discourse is controlled by physicians requested responses to specific successive questions that shaped the meaning of the conversation (Paget, 1983). This approach, that used to follow a paternalistic communication model, assuming and expecting a dominant role for physicians in treatment decision-making and strongly contributing to power differentials in the medical encounter, started to be questioned in the 1980’s. This questioning was prompted from the fact that not all diseases have a single best treatment, physicians are not always highly knowledgeable, and therefore not always in the best position to make decisions (Charles et al., 1999). On the opposite end of the paternalistic model, an informed model places all decision making in the hands of the patient once provided with all necessary information to do so by the physician or healthcare team (Charles et al., 1999). Nowadays, is generally acknowledged that patients are more likely to experience better health outcomes by following a shared-decision making model. In this model, patients, upon mutual agreement with clinicians, reach decisions based on the best clinical evidence, consistent with their own values, which can reasonably be implemented. To that end, patients need an understanding of the disease as well as the risks and benefits of treatment options, and clinicians need knowledge of patients’ values and health preferences and beliefs (Street Jr., 2009). Hence, clear communication is a must.
It is in this latest doctor-patient communication model, which can be deconstructed into three consecutive phases: (a) Information Exchange, (b) Deliberation, and (c) Making a Decision, where professional interpreters may be most needed for LEP and Deaf/Hard of Hearing patients. Although interpreters play a significant role along the whole process, their intervention would be most useful at the beginning of the interaction, when there is an exchange of information between parties, and thin up as the interview advances. I trust interpreters would be required during deliberation, only for clarifications or if questions arise, and by the end of the interview, to reach a definitive agreement.
In theory, everything appears very straightforward. However, communication between doctors and patients is not always an even path as the process can be jeopardized by multiple factors. If sometimes communication is already difficult in itself, it can also be plagued with overlaps (errors in transition timing) and interruptions (violations of speaker turns) as well as incomplete answers due to those cases of simultaneous speech, adding an extra layer of potential misinterpretations (West, 1984). Other known barriers to good communication are patients’ anxiety and fear, doctors’ burden of work, fear of litigation, fear of physical or verbal abuse, and unrealistic patient expectations as patients come loaded with their own perspective, experiences, and knowledge, along with society’s peer pressures (Ha et al., 2010).
In the medical setting, asymmetrical communicative power is conducive to misunderstanding as it tends to weaken patients’ capabilities of communication, by generating doubts about what they are told, due to their beliefs about organizational settings and their own skills in expressing their views, feelings, and emotions (Cicourel, 1983). Shuy (2005) defined three types of interference to an effective exchange of information during the medical interview: (1) The use of jargon or specific vocabulary, as very few physicians are taught to communicate significant aspects of their field to other individuals, and are generally unaware regarding receptive competence to patients’ language as patients may have particular medical, social, or regional vocabularies. (2) The existence of cultural differences such as the use of a vernacular dialect and the world vision that this entails, in addition to the fact that dialect speakers tend to get worst treatment, have to wait longer for service, are considered ignorant, and are told what to do rather than being asked what they would like to do. (3) The structure of the discourse; the doctor-patient medical interview is not a normal conversation, as it mostly contains only questions by one speaker and answers by the other. In this case, the rules of interruption are also different from those of normal conversation.
Where would an interpreter be most needed to help with LEP and Deaf/Hard of Hearing patients when any of those communication interferences occur, I am asking myself? In which circumstances, and to what extent, may we assist in securing the unsteady and fragile bridge of communication by overcoming the language barrier and associated cultural gaps? I trust interpreters would be of real help untying for the healthcare provider cultural knots and intricacies of the patients’ culture as patients are confronted with the culture of medicine. The interpreter, although only to a certain extent (with extreme care in not changing the speaker’s meaning and register), can also help to address some specific uttered jargon or particular vocabulary. However, the interpreter is virtually handcuffed in dealing with the possibilities of structuring the discourse, as ultimately this capacity is in the hands of the provider.
In the current view of the western culture of medicine, where a diagnosis is primarily viewed as a cognitive process rather than an interpersonal one, patients’ questions may be seen as constituting an interruption of the physician’s deductive thought process (West, 1984). Therefore, physicians risk a great deal when mutual understanding eludes their patients and themselves as misdiagnoses, mistreatments, and charges of malpractice are among their possible outcomes. But, how are doctors get to know which words might not be familiar to patients? And how are patients to know, while talking with physicians, when they have been heard incorrectly? And, if patients’ failures to confirm are not noticed by their doctors, valuable pieces of information can be easily missed. During actual appointments though, doctors and patients have no way of assessing one another’s reactions if not by observing the other party’s responses at that time, although one obvious mean to this end is asking about it directly. But even though in our everyday practice we constantly hear providers ask patients at the end of most clinical encounters if they have any further questions or concerns, it is well known that those types of invitations do not generally achieve their stated aims (West, 1984). Independently of the patients’ healthcare literacy level, misconceptions need to be modified by means of awareness and education programs. Otherwise, there is a high risk for individuals to make potential inappropriate healthcare decisions (Gansler et al., 2005).
As it happens, in the face of unavailability of a professional healthcare interpreter, clinics and providers in general demonstrate, to save the day, a widespread tendency to jump onto the raft of anybody minimally acquainted with the patient’s language. This is something that we see quite often. (Oh! The daughter was here, and she was glad to interpret for her father.) However, this apparently benevolent attitude withdraws patient’s independence in relation to family members, as no one knows exactly the nature of the information that this eager to help individual really conveys and/or hides (voluntarily or involuntarily) from the patient and/or provider. Consequently, as interpreters, and for the patient’s benefit, we have to stress out to clinics and providers the need of professional healthcare interpreters in any of their forms (in person, video remote, and over the phone) rather than engage to the task any untested individual who claims knowledge of the patient’s language (ad hoc interpreters). At that point, during encounters, interpreters should remember to avoid intervening beyond the assistance an English speaking patient would receive as there is a strong risk for over welcoming our role. We must keep always in mind English speaking patients before acting outside the role of a conduit as the interview conductor is the medical provider, not the interpreter.
• Charles, C. et al. 1999. Decision-making in the physician –patient encounter: revisiting the shared treatment decision-making model. Social science & Medicine 49:651-661.
• Cicourel, A.V. 1983. Hearing is not Believing: Language and the Structure of Belief in Medical Communication. pp. 221-239 In: Fisher, S. and Todd, A.D. The Social Organization of doctor-patient Communication. Center for Applied Linguistics, Washington, D.C.
• Gansler, T. et al. 2005. Sociodemographic Determinants of Cancer Treatment Health Literacy. Cancer 104(3):653-660.
• Ha, J.F. et al. 2010. Doctor-patient Communication: A Review. The Ochsner Journal 10:38-43.
• Paget, M.A. 1983. Hearing is not Believing: Language and the Structure of Belief in Medical Communication. pp. 56-74 In: Fisher, S. and Todd, A.D. The Social Organization of doctor-patient Communication. Center for Applied Linguistics, Washington, D.C.
• Shuy, R.W. 1983. Three types of Interference to an Effective Exchange of Information in the Medical Interview. pp. 189-202 In: Fisher, S. and Todd, A.D. The Social Organization of doctor-patient Communication. Center for Applied Linguistics, Washington, D.C.
• Stewart, M. et al. 1999. Evidence on Patient-Doctor Communication. Cancer Prevention & Control 3(1):25-30.
• Street Jr., R.L. et al. 2009. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling 74: 295-301.
• West, C. 1984. Routine Complications: Troubles with Talk between Doctors and patients. Indiana University Press, Bloomington, IN. xiv, 199 pp.