I am continuously meeting providers who are seeking out new ways to connect meaningfully with patients.
The practitioners I meet want to be able to speak clearly and convincingly to any patient. Even–and especially–when there are significant cultural differences.
Some of them have told me they feel like a better doctor when they can share their knowledge with anyone.
What do you do when you feel there’s a cultural gap between you and your patient?
Drawing a line from language to health
The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care were issued in 2000, and revised with multi-sector input in 2013. They are designed to draw attention to and address health disparities and ensure “effective, equitable, understandable, and respectful quality care and services.”
What do these standards have to do with language use, besides medical interpreters? Quite a lot.
Recent research on unconscious bias has shown how public health, medical care, and human service providers can unintentionally contribute to racial/ethnic health disparities.
And some of this unconscious bias manifests itself through language.
This is both an individual and organizational issue. Cultural mismatches in speech and language patterns in institutions are a source of negative outcomes, as found in research based on culturally-relevant, culturally-sustaining pedagogy over the last 30 years.
It’s not easy being intentional with your words
We can all tend to think of the ways we use language as normal, natural, value-free, or neutral. No big deal.
There is an allegory in anthropology and ethnography, that my former professor Brian Street retold several times. It’s used to remind (and caution) researchers about perspective.
In short, it’s that the fish would be the last creature to discover water.
Among other things, this means it’s hard for us to notice our own language. Regardless of the occasion, our language reveals our perspective on what linguist James Gee calls “being ‘normal,’ ‘acceptable,’ ‘right,’ ‘real,’ ‘the way things are,’ ‘the ways things ought to be.’”
So, how hard is it to notice what’s right in front of us?
This study of medical specialists showed that when providers watched themselves on video communicating with different patients, they scarcely noticed differences that were clear to researchers. This was true even though these providers had been extensively trained in, and were enthusiastic about, intercultural communication.
There’s nothing really wrong (or surprising) about this. It’s just a reminder that we all need support in examining what we take for granted. Including our language use.
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Conversations about care are also conversations about culture
I was talking with a patient who is an immigrant, whose native language is not English, and who has a Ph.D. from a U.S. university. She explained some of her experiences in the linguistic and cultural landscape of the medical encounter:
“If they say ‘stomach’ or ‘tummy’ [I can understand], but if they use anything medical, I cannot get it. It’s very difficult for people to keep asking questions. Sometimes when I have the medicine, I smile and nod and then go home and google it and read.”
Interestingly, this patient indicates a language barrier—that (from my outsider perspective) has nothing to do with the fact that English is her second language. Rather, it is with the differences between medical language and everyday language.
For this patient, that language barrier is reinforced by a kind of social pressure she feels to not ‘keep asking questions.’
This account is in line with prior research findings that Ethnic minority patients can be less verbally expressive than White patients.
This reminded me of something I heard Neurologist Neil Busis say at a NAM meeting on clinician well-being:
“At its essence communication is getting a story out and getting it out in language real people use.”
He encouraged providers and researchers to “be adaptable to our story, our language, our audience.”
The right words for the right patient at the right time?
Multiple providers have spoken candidly with me about unwritten rules and expectations around being perfect as a physician, and what that means for communication.
I bring this up because I have been wondering about how such pressures might lead providers to feel they should somehow be able to anticipate what to say to any patient, no matter their cultural or linguistic background. To have all the answers ready.
The right words for the right patient at the right time.
That sounds good, and it’s a nice goal, but I wonder if it has unintentional side-effects.
Of course, patients do not all think or speak the same way. Yet we often want to put people in categories, even though we know at some level the world doesn’t work that way.
The good news is you don’t have to ‘figure it out’ about a whole culture or social group (as if that were even possible).
Patients have been shown to place more importance on a provider engaging in patient-centered communication, than on the provider’s ethnic background. Even when patients perceive a language barrier, they believe it will be ‘less pressing’ when a relationship is established with the provider.
One tool for quick use
I’m inviting you to think about your own communication, and what you take for granted, so that you can begin to see opportunities and possibilities.
Stop and think of one idea, or fact, or process, you explain often.
- What is it? Why do you usually explain it to patients?
- How do you say it? think about the actual terms that you use.
- Can you say this in another way?
If it’s important, know how to say it in at least three different ways. Not just different vocabulary. (Here are 10 different ways you could try)
Also: Have the same information available in multiple modes. That means audio or video recording, images, and text. Offer them all.
One thought to go deeper
Your best resources for patient communication are the people in the room with you.
Yes, patients aren’t necessarily ready to open up and answer questions, or to be put on the spot. They, too, are distracted and thinking about multiple things.
The differences between you and your patient are important. But I think there’s a fine distinction between focusing on the gap and focusing on bridging the gap. It can be tempting to linger, for instance, on all the information patients are not giving you, or on all the ways you’re not getting through.
So rather than getting lost in the distance between you, focus on what you have in common: these few minutes. You are in the same place at the same time for the same reason, with similar (if not the same) goals.
For this time, at least, you are on the same team.