Tired but wryly triumphant: Culturally competent care for a Somali patient

On an afternoon in late September, Dr. Douglas Pryce and Dr. Osman Harare, the interpreter and patient advocate, emerged from an examining room looking tired but wryly triumphant. They had just finished negotiating, politely but persistently, with a patient who – just as politely but persistently – had refused to allow any blood tests because it was the holy month of Ramadan and he feared that having blood drawn might be a sin.

Finally, they telephoned an imam, who declared that there was no sin. The blood was drawn.

Dr. Pryce says that one of the great joys of working in a hospital like Hennepin County Medical Center in Minneapolis is finding ways to bridge such cultural divides – and knowing that his patients are better off because of it.

Advice to people of another culture: Find a medical provider and interpreter who respect your cultural beliefs and medical preferences.

Read another story about culturally competent care.

Thanks to Denise Grady for the source article in the New York Times of March 29.

A pictogram in return for another pictogram: Diabetes patient education

Consultations with Mrs. L are difficult: sometimes, she comes
without her diabetes logbook, or forgets to have the requested
HbA1c assay. Above all, she comes either alone or accompanied
by someone who, like herself, speaks nothing but Chinese. All I
can do, in order to understand her repeatedly high HbA1c
levels, is to look at her logbook and try to understand the
documented insulin doses and the blood glucose concentrations.

Recently, I admitted her to hospital. Firstly, we verified that
the technical aspects of blood glucose determination and
insulin injection were perfectly correct. I also told her that
I needed an interpreter. A Chinese neighbour who was fluent in
French came with Mrs. L on the following day. I first checked
with Mrs. L the basics of adapting insulin doses and began to
ask her questions through the interpreter. No answer. I
therefore asked the interpreter if he, himself, had understood
the meaning of the questions. He was positive. I then asked Mrs.
L to tell me what she thought of insulin. No answer. I realised
that she knew nothing about it and that the treatment made
absolutely no sense for her.

This situation reminded me of John Searle’s "Chinese room"
argument. Imagine a Westerner, speaking English but not
Chinese, in a room with a window. Through the window, a Chinese
person shows Chinese pictograms. The Westerner has a manual,
written in English, instructing him how to show a pictogram
specific for the pictogram he sees through the window. He is
not aware that the pictogram he sees is a question, and that
what he then shows is the correct answer. The Chinese person
outside cannot work out that the Westerner does not understand
Chinese.

In the case of Mrs. L, we doctors were the Chinese. We had no
direct way of recognising that the blood glucose determinations
or the insulin injections that she performed impeccably had no
meaning for her.

I decided to start her education from scratch. What is
diabetes? What is a normal glucose concentration,
hypoglycaemia, hyperglycaemia, etc? Repeatedly, I asked the
interpreter whether he understood and whether he thought that
Mrs. L understood. He was affirmative. I arrived at a problem—
how to verify that the dose of insulin was correct. At this
point, I was unsure whether the interpreter understood the
question, and I decided to stop the session, giving him another
appointment for the next day. In fact, I doubted the
interpreter’s comprehension of the real sense of what I had
said. It seemed to me that the Chinese room was now separated
from me by two walls and windows.

The next day, a different person accompanied Mrs. L to the
appointment—her nephew, also perfectly fluent in French.
Needing to go through my explanations all over again, I decided
to use another strategy and asked the nephew to imagine that he
was diabetic, and that he had to listen to my explanations as
if they concerned him, in order to give a meaning to the
therapeutic education. Only then would he translate the
information to his aunt. I had the sensation of trying to enter
the Chinese room by climbing through the first window.

To a lesser degree, this story may be relevant to many
consultations, even when there is no obvious language barrier.
It is vital that the patient understands the message as a whole
and not just the words, or else the treatment routines may be
analogous to nothing more than showing a pictogram in response
to another pictogram.

Advice for speakers of a foreign language: Get a good interpreter.

Thanks to Dr. Gerard Reach for the source article in the Feb. 16 issue of the British Medical Journal.

He doesn’t want to read the list: Illiteracy, patient compliance, and the electronic medical record

Dr. Erin Marcus’ story

Last year, the community clinic where I work began requiring patients to go elsewhere for their blood and urine tests. For some patients, this has posed insurmountable obstacles, for shameful reasons.

One patient, compulsive about keeping his appointments with me, consistently fails to see specialists I recommend, and to have tests performed elsewhere. He always has an excuse.

And so I am stuck with a pleasant, complicated patient and no way to monitor the effects of the medicines I have prescribed.

Why is he non-compliant? Probably because he can’t read the map or directions I gave him, though he’ll never admit it – like many patients. In fact, one in seven adults in the U.S. has "below basic" prose literacy, i.e., they cannot read simple text. It is particularly hard for these patients to navigate the healthcare system, and their doctors are left without basic diagnostic information they need to provide good treatment.

Our comment:
Too bad they didn’t have Dr. Kalow. My son’s former pediatrician was Dr. Bruce Kalow, the doctor you wish you had. On his own initiative, during evenings at home after seeing young patients in his working class Somerville, Massachusetts community, Bruce developed a medical software program. His program improves communication with his patients and their families, many of whom primarily speak Spanish and Portugese, often with low literacy in English. At the end of the visit, he types briefly into his personal computer, which prints a sheet for the parent (and the doctor’s office) about the diagnosis, treatment, prescription, and follow-up instructions. When needed, the program readily provides the information in Spanish or Portugese.

Advice: Tell your foreign-born friends with little English literacy to look for a nearby doctor who routinely provides written summaries to patients in their primary language.

Read the source story by Dr. Erin Marcus in the July 24 New York Times.