Buenas tardes. ¿En qué le puedo ayudar? If you could understand that, you might be one of the almost 37 million people living in the United States who identify Spanish as their primary language.1 If you couldn't, then you just might be getting a sense of what so many in this country experience when they meet with their healthcare provider.
As healthcare providers we have a duty to recognize and promote the value of diversity as we hold the dignity of all human beings as our primary responsibility.2 While being bilingual isn't required in order to honor those values, making a small effort to communicate in another language with patients can go a long way.
Medical Spanish Education
The graduate PA program at Idaho State University is making such an effort for current first-year students. Starting with the class of 2013, students will have the option of taking part in a specially designed crash course in medical Spanish. The purpose of the pilot program is not to produce fluently bilingual providers but rather to give these future PAs additional tools to reach out and improve patient care. Program director Paula Phelps, PA-C, said, "I felt like we owed it to our patients to make the effort to meet them where they are."
In my experience, that is the biggest challenge -- stepping outside of the comfort zone to try something new and potentially embarrassing. Reaching out to your limited English proficiency patients doesn't require you to go back to school but it does require you to put in some extra time. Your efforts to meet on common ground will be appreciated and will strengthen the therapeutic relationship. While this article will focus on Spanish-speaking patients, the same principles apply to other situations.
Communicate Clearly for Better Outcomes
Clear and direct communication between patient and healthcare provider is at the foundation of good patient care. In one study, without translation services, Spanish speaking patients were significantly more dissatisfied with their clinical encounters than patients who spoke English. Specifically, a large proportion of Spanish-speaking Latinos reported that they were very dissatisfied with answers to their questions and explanations regarding prescribed medications as well as receiving reassurance and support from their doctors.3 This puts Spanish-speaking patients, and others that face language barriers, at risk of receiving lower quality care and suffering poor health outcomes.
Before translation services were readily accessible, however, clinicians were forced to work with whatever was available. Sometimes this meant trying to communicate with rudimentary language skills or relying on a bilingual family member, which is still a common practice. While this is generally frowned upon today, it has been documented that those practitioners who do obtain proficient language skills improve satisfaction with care.4 Despite foreseeable inadequacies, patients were happier and did better. In particular, bilingual providers have been shown to improve outcomes among Spanish-speaking patients with hypertension and diabetes.5
Professional Interpreters: Too Good to Be True?
It's important to understand that even the best of intentions can be misunderstood and knowing a few words and phrases doesn't qualify you as a medical interpreter. The advent of telecommunications makes professional translators available practically anywhere in the world. Whether by phone, video or an in-person translator, healthcare providers should use a professional interpreter whenever possible.
But that still doesn't solve what seems to be a growing problem. There's a cultural disconnect that communicating through a third party does nothing to resolve. While professional translators assist in the accurate exchange of information, their use can be cumbersome and often do very little to build rapport. A recent study found that despite the availability of interpreters at a local health department clinic, differences in satisfaction existed between Spanish- and English-speaking patients. The study controlled for purpose of visit and time spent waiting. Spanish-speaking patients were more likely to report problems getting an appointment and less likely to report having their medical problems resolved when compared to those patients who spoke English.6
We've seen the care of limited English proficiency patients move from one extreme to another. The move from lay translators to professional ones may have improved technical accuracy but leaves a gaping hole in the patient-provider relationship. The solution? We must adopt a hybrid system. We need to encourage foreign language training in healthcare providers without disregarding the enormous asset we have in professional interpreters. This is especially appropriate in areas where a single ethnic group may make up a large percentage of the population.
Do Your Homework Now
So what can you do right now to reach out to your Spanish-speaking patients? First of all, you must try and put yourself in their shoes. If you're having trouble empathizing, tune in to a foreign language radio station and imagine that what you hear is the reaction you get when you walk into your doctor's office complaining of chest pain. On a more practical note, set a goal to conduct a brief physical examination asking only "yes" or "no" questions. Don't bother with the grammar, just learn the phrases and perfect the pronunciation. Google Translate, available online as well as on many mobile platforms, can be used to customize your exam. You might ask a knowledgeable friend or staff member to review your work.
You can also check out Working Spanish for Medical Professionals by Stacie McEniry. This reference book includes a step-by-step pronunciation guide. Another great resource is the free website "Medical Spanish for Healthcare Providers," at www.practicingspanish.com. Smartphone users should check out a great Spanish-English dictionary app called SpanishDict or the Medical Spanish podcast by Molly Martin, MD. Both are available at no charge.
Having lived outside of the United States, I've experienced firsthand how difficult life can be when you can't communicate. It can be downright terrifying! But as I've worked with individuals of diverse backgrounds, I've also seen how grateful patients are when you make an effort to reach out -- even if it's only a small one.
Russell Singleton is a second-year physician assistant student at Idaho State University.
1. United States Census Bureau. Language spoken at home: 2010 American community survey 1-year estimates. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_S1601&prodType=table.
2. American Academy of Physician Assistants. Guidelines for ethical conduct for the physician assistant profession. http://www.aapa.org/uploadedFiles/content/Common/Files/19-EthicalConduct.doc.
3. Morales LS, et al. Are Latinos less satisfied with communication by health care providers? J Gen Intern Med. 1999;14(7):409-417.
4. Baker DW, et al. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275(10):783-788.
5. Perez-Stable EJ, et al. The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes. Med Care. 1997;35(12):1212-1219.
6. Welty E, et al. Patient satisfaction among spanish-speaking patients in a public health setting. J Healthc Qual. 2011. doi: 10.1111/j.1945-1474.2011.00158.x. [Epub ahead of print]