People from many varied cultures and backgrounds will likely walk through the doors of your practice, but how can we optimise the care and information they receive?
It’s normally reckoned there are around 6000 languages spoken in the world, and in modern Britain – at least, modern urban Britain – it sometimes seems you can hear most of them just by wandering through the city centre on a Saturday afternoon. Walk into a large NHS Trust in any large city and look at the staff, and this too is a reminder of the global village we inhabit. For those of us (like me, let me admit) brought up in a monolingual and monocultural environment, speaking only English, it’s a reminder that familiarity with and exposure to only one language is the exception rather than the rule.
But the multilingual and multicultural world brings challenges too. How do we work together, and support each other, if we struggle to make sense of each other’s worlds?
In general practice, the crunch point is often that patients and healthcare professionals do not speak the same language. This may, in some environments, be comfortably handled by employing a couple of speakers of the predominant local language; but in other areas, the number of languages used by the patient population far outstrips the capacity of the practice to employ speakers of the languages. And in any case, what if the one doctor who speaks the local language happens not to be very popular (which unfortunately can happen)? Or even a man, when a female patient may prefer to discuss her anxieties with a woman?
Enter, of course, the translator. Let me say at the outset that the research on this topic all tends in the same direction - it’s cost-effective to have a professional translator where there are significant language problems between patient and healthcare professional.1,2 But there are a fair number of caveats. For example, the ideal ‘professional translator’ is indeed, well, a professional. Every GP practice has stories of the family member translating for the mother who is too embarrassed to discuss her period problems in front of her son. Or the husband who tells the GP what he thinks the issue is, not what his wife thinks it is.
And then there is the really difficult thing. The perfect translator – but of course there is no such person – is translating at three levels simultaneously. The lay view of the translator is that, somehow, all languages say exactly the same thing in different words. To some extent, that is perfectly true. The same meanings are encoded in different ways, so that “La plume de ma tante” can be rendered, as every schoolchild knows, as “The pen of my aunt”.
Even in very basic ways there is more to it than that. Answer the phone in English and a tentative “Hello?” is quite likely. In Spanish, a brisk “Diga!” (“Speak!”) is what is required. Idioms also translate very poorly; I recall hearing a Chinese-speaking doctor once earnestly talking about the need for seatbelts, otherwise the steering wheel might crush your chest - and you will die of a broken heart.
Different languages do things differently, and behind them, different cultures do things differently too. This is the second level that the translator is working at. There are large areas of misinterpretation possible here: the South Asian patient who sits with courteously downcast eyes and is misunderstood as having, as the psychologists say, a flat affect. And it can be a problem for doctors too – a lot of the work my team undertakes is remedial support for doctors who have problems in non-clinical areas. Eastern European doctors are sometimes sent for support on the grounds they are “rude to patients”. But they aren’t - it’s just that, culturally, they are often more honest, more straight, and more willing to speak their minds.
I heard a story once of an American lady whose husband was British, suddenly realising how British she too had become when she fell downstairs at the dentist, broke two ribs, and picked herself up saying “oh, I’m terribly sorry”. British politeness at its slightly bizarre extreme, as learned only too well by a relative newcomer. There are, in other words, cross-cultural issues with large parts of the communication system, such as the expression of authority, or courtesy, or deference, which the translator needs to convey. This also means, often, capturing the way lay people describe nebulous feelings about symptoms to do with such areas as mood, or mental health. Often what is crucial here (thinking again of the patients whose hearts are literally broken) is the extent to which a concept like voices in the head is to be taken literally or metaphorically.
The exemplar of the ways in which patients use metaphors to describe a complex mixture of ideas has for years, in healthcare, been Krauze’s analysis,3 and Helman’s subsequent discussion,4 of the Punjabi phrase dil gharda hai¸which translates as “sinking heart” (apparently – I don’t speak Punjabi).
As Helman argues, the phrase rolls up “physical, emotional and social experiences into a single image”, and to understand the meaning, one has to understand the culture it springs from, and the way that all of these elements would be further deconstructed. That’s to say, Helman suggests, into issues of “honour”, for example, which to those from other cultures carry no resonance. This difficulty, the way in which the culture affects how we are to be understood, is always present – absolutely always: it’s just that, thankfully, because we are all human, and all share the same experience of the human condition, most of the time the differences are trivial.
And thirdly, for the interpreter, there is the question of what is routinely known as ‘communication skills’. A considerable amount of time and effort goes into teaching communication skills to health professionals and students, after all – but communication skills are highly likely to be lost in translation. The murmured “tell me more” which gets rendered as “the doctor wants more information”, the nuanced reassurance which becomes a brisk “you’re probably ok” – all the background context can disappear despite the translator’s best intentions.
Behind all this is the understanding that many of the great man-made disasters in history seem to have an element of poor communication at their heart. It’s been argued that the decision to bomb Hiroshima was taken after the Japanese authorities responded to a secretly conveyed American demand for surrender with a phrase that was translated as “we reject” rather than “we are considering” your proposal (see Skelton 20085 for a brief discussion of the pros and cons of this argument). The Tenerife air disaster of 1977, in which 579 people lost their lives, was due in part to an ambiguity as to whether the phrase “at take-off” used by a Dutch pilot, meant “we are now ready for take-off” or “we are now going to take off” – and so on.6 The issues here are known, for obvious reasons, as ‘human factors’, and the lessons learned over the years from the aircraft industry in particular are being slowly absorbed into healthcare training – witness the frequency with which simulation is used in training, for example with a dummy patient on a ward suddenly having a relapse of some kind, while a group of students have to decide what to do, and actually use the language involved in getting the correct things done in the correct order. There is another message here of course: the examples above are both, it appears, the result of people not sharing the same first language and hitting problems. But the truth is, there is quite enough poor communication going round even where those involved speak the same language.
How can one mitigate risk? The fact is that there may, at a particular practice, be dozens of first languages amongst the patient population, and it is obviously inconceivable that they can all be covered by staff. This is where a good translations service comes into its own, and it is at this stage that the value to patients, and the cost-effectiveness of the service, come into their own.
In addition to this, however, there is something much more tenuous. The stereotypical monolingual Brit, traditionally, shouts loudly at foreigners on the grounds that if they do so they’ll get through to them. A person like this, basically, can’t quite grasp the idea that people actually may not understand English. The truth is, though, that this is a stereotype with a grain of truth in it. For the monolingual, it can be difficult to make the mental leap into a world of other languages, other ways of thinking. It takes effort and exposure and a deal of reflection to help the penny drop. Making that internal effort can be a great help – even if we don’t speak all or any of the languages we might hear in our practice, we can at least understand what it is to be in another country, coping with the level of difficulty that not speaking a language entails.
1. Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Medical Care Research and Review 2005;62:255-299.
2. Karliner Leah S, Jacobs Elizabeth A, Chen Alice Hm, Mutha Sunita. Do professional interpreters improve clinical care for patients with limited English proficiency? A systemtic review of the literature. Health Services Research 2007;42(2):727-54.
3. Krause IB. Sinking heart: a Punjabi communication of distress. Soc Sci Med 1989;29:563-75.
4. Helman CG. Culture, Health and Illness: an introduction for Health Professionals. 3rd edn. London: Butterworth Heinemann. 1994.
5. Skelton John R. Language and clinical communication: this bright Babylon. Abingdon: Radcliffe. 2008.