Suffering from bacterial gastritis, a Somali woman in St. Paul, Minn., visits several providers but does not take the medication they prescribe.
Yet when met with a smile and a greeting in her native language by Fozia Abrar, M.D., the patient complies with the same recommended treatment.
"She trusted me more because I knew the culture and I knew the language," says Abrar, herself a native of Somalia. She practices internal and occupational medicine at the International Health Clinic and other facilities run by the private Regions Hospital in St. Paul.
"I see a lot of other patients--Hmong, Vietnamese, Bosnian, Russian," Abrar says. "It is difficult to know greetings in all the languages. But as I conduct an interview with an interpreter, I try to pick up on something about the patient's background. It relieves anxiety and shows respect."
As the population becomes more culturally and linguistically diverse, more clinicians are learning that clear communication and sensitivity to each patient's health perspectives can have serious impacts on outcomes, patient satisfaction and the bottom line. Meeting the financial challenge of providing interpretive services is a legal necessity for most practices, but many physicians say it pays off over the long term in improved care.
More than one in 10 U.S. residents are foreign-born, according to the U.S. Census Bureau. About 18% of residents older than age 5 speak a language other than English at home. Of those, 19.5 million speak English less than "very well."
Every country has traditional health beliefs, Abrar says. Somali patients, for example, might think that back pain is caused by a bad relationship with their parents or guilt over something they did.
"It is always good to learn about their culture, to know who you are dealing with," she says. It might cost time and money, "but you save more money by not getting a misdiagnosis, by improving quality of care."
Arthur Kleinman, M.D., has spent 30 years working on cultural issues in medicine. He says a great body of evidence shows culture does matter in clinical care.
"Cultural meaning and practices can influence disease onset and the course of disease," says Kleinman, professor of medical anthropology and psychiatry at Harvard Medical School. "This we know very well for infectious diseases, mental illness and a variety of chronic medical conditions.
"We also know culture influences help-seeking, compliance, the quality of doctor-patient interaction and how one evaluates outcome vis-a-vis patient satisfaction," he continues. "We know all these things. But how do you bring this to bear in the doctor-patient relationship?"
The government, for one, is taking a stronger stance on the issue of linguistic barriers as part of the attempt to eliminate health disparities.
In August 2000, the HHS Office for Civil Rights issued policy guidance for the implementation of Title VI of the Civil Rights Act of 1964, which prohibits discrimination on the basis of national origin. The law requires that healthcare providers who accept federal money ensure meaningful access to and benefits from health services for individuals who have limited English proficiency.
Hoping to give organizations even more cohesive direction toward achieving cultural competence, HHS' Office of Minority Health recently released 14 national standards for culturally and linguistically appropriate services in healthcare, called the CLAS standards.
Among these are four mandates that echo Title VI language requirements.
HHS could use punitive remedies to deal with a language violation, either by withholding federal funds or referring cases to the Department of Justice, but it has done neither in recent years. Officials say the department prefers to work out voluntary settlements that share best practices and provide technical assistance.
"Through the context of a settlement agreement, we'll work out what a clinic, for example, is going to do in terms of providing interpreter services or how it will notify people about their rights," says Robinsue Frohboese, principle deputy and acting director of the civil rights office. "We try to be practical and specific in the kinds of remedial steps they can take."
Frohboese highlights solutions such as the use of telephone interpreter services, sharing interpreters among providers and linking with a community's language "bank," or existing pool of multilingual residents.
Doctors must find solutions to the culture gap or face loss of market share, less successful treatment, questions of informed consent and even malpractice suits, says Ira SenGupta, lead trainer and program manager at the Cross Cultural Health Care Program in Seattle. CCHCP seeks to ensure full access to culturally and linguistically appropriate healthcare through a combination of cultural competency training, interpreter training, research, and coalition building through outreach, education and advocacy. Noncompliance and unnecessary office or emergency room visits can be avoided by clear communication, SenGupta says.
SenGupta teaches providers concrete skills for using interpreters effectively. Simply calling on a family member or an untrained bilingual staff member may not be enough to translate precise medical terminology, she says.
Telephone interpreters charge up to $4.50 per minute. Professional in-person interpreter fees range from $17 to $100 an hour, depending on whether the interpreter works independently or through an agency.
Though charges vary, a daylong cultural skills training session with SenGupta costs about $2,500.
"(Interpretation) is a liability and risk management issue," SenGupta says.
"It seems expensive upfront, but it's a healthcare business imperative. Communication is the most important diagnostic tool a physician has."
The AMA and all 50 state medical societies have fought what they contend are unfunded mandates to provide these costly interpretive services. In a letter sent last April to HHS Secretary Tommy Thompson, the AMA said one doctor was required by the rule to pay $237 for an interpreter, while Medicaid reimbursed just $38.
"Forced to absorb this type of cost," the letter stated, "many physicians will decide not to treat any Medicaid patients."
"The problem the AMA highlighted is that mom-and-pop docs can't afford a translator," says Elena Rios, M.D., president of the National Hispanic Medical Association. "But the physician interested in reaching a new market can think of this as value added. Investing in these services can reap benefits."
The Census Bureau reports that the Hispanic population increased by 58% from 22.4 million in 1990 to 35.3 million in 2000.
Although the majority live in the South or West, Hispanics represent between 6% and 24% of the total population in certain counties in Arkansas, Georgia, Iowa, Minnesota, Nebraska and North Carolina.
In December, the Robert Wood Johnson Foundation announced an $18.5 million initiative called Hablamos Juntos (We Speak Together) to evaluate new mechanisms to eliminate language barriers in Hispanic healthcare.
Participants will use the money to develop and test economical translation systems for use by doctors, nurses and other healthcare workers.
Rios says she believes that more government agencies and private foundations will fall in step to fund research in better and more affordable translation options.
"It will move slowly," Rios says, "with a trickle-down effect as model programs become established and there is understanding of what works and what doesn't."
Sunita Mutha, M.D., an internal medicine practitioner at the Mt. Zion campus of the University of California-San Francisco, urges physicians not to look at cultural competency as one more burden in a highly regulated profession.
Doctors who learn how to consider a patient's beliefs, values and expectations for treatment, she says, are in fact acquiring a low-tech, affordable tool that improves quality of care and eventually pays for itself.
More than being just a trend or marketing opportunity, cultural competence is a teachable skill, Mutha says. It begins with a clinician's willingness to respect the backgrounds of all patients and to look at his or her own cultural biases and those of medical science itself.
"What we're teaching is an entree on how to communicate with whomever walks through the door," says Carol Allen, associate director of The Network, a program of the not-for-profit Center for the Health Professions at UCSF. Allen is a co-author with Mutha of a new curriculum for teaching cultural competency skills to healthcare providers.
"It's up to the organization to get more detail about the specific population in the community they are serving," Allen says.