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News
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February 19, 1999 FORUMHMS Develops Multilingual
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| Nora Nercessian and Daniel Federman created a series of phrase books in response to needs expressed by physicians and medical students to communicate in an ever-increasing variety of languages. |
This was not a revelation--to Federman or to any physician or medical student who sees diverse patient populations during the course of a day. Yet it marked the beginning of a series of meetings on the subject held by Federman and Nora Nercessian, assistant dean of alumni affairs and special projects, with community leaders, physicians, HMS students, nurses, and interpreters on the Quad and at affiliated hospitals. "The message from all sides was unanimous and alarming," Nercessian says. "Communication with patients from diverse backgrounds is one of the challenges house staff and medical students have to face in hospitals and outpatient clinics, and it will only get worse in the years to come."
Communication Breakdown
Many of the house staff were frustrated and concerned over their
inability to communicate with the growing number of patients who
speak no English, while they watched the number of languages their
patients spoke grow ever greater. These tongues include--but are
not limited to--Spanish, Russian, Cantonese and Mandarin Chinese,
Portuguese, French, Creole, Vietnamese, Italian, Greek, Yiddish,
Mon-Kmer, Korean, Japanese, and German.*
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"...the patient's
vulnerability in a time of medical need is increased by linguistic
isolation."
--Nora Nercessian |
The worst stories came from two types of patient–doctor encounter: urgent care and work rounds, where linguistic barriers pose a special problem in the absence of prescheduled interpreters and where timely diagnosis and treatment are crucial. So Nercessian and Federman decided to create a linguistic tool, Communicating with the Patient, a series of phrase books that can be used until an interpreter arrives on the scene. "The intention was not to replace the qualified interpreter," Nercessian says, "but to bridge the gap between patient and doctor and make use of the precious time before an interpreter is available."
They designed Communicating with the Patient as a set of phrase books including Urgent Care, Work Rounds, and Comprehensive Review of Systems. The first two consist of a selected number of questions to deal with an immediate, specific, and sometimes urgent situation. But they also wanted to make a third resource available, the review of systems, in the event that detailed questions on the patient's condition become necessary. While the first two books are designed to be carried by the caregiver, the third and longer one could be available in designated areas, like the nurses' station or emergency room.
In recent years, the Harvard teaching hospitals have made significant inroads into making qualified interpreters available. But hospitals throughout the country are wrestling with the same issue, and for that reason, the concept of a medical phrase book is not novel. You see them displayed at the Longwood Coop, for example. The difference between what is already on the market and Communicating with the Patient is, first, that the questions in Urgent Care and Work Rounds are tailored for specific encounters and offer only those questions that are necessary for a given situation. The second difference is that the questions are phrased so patients need only nod or shake their head in reply. The doctor asks the question using phonetics and need not know Haitian or Cantonese or Spanish to understand the answer. "The design of the questions also carries a special message," Nercessian adds, "that the caregiver must recognize the dignity of the patient and that the patient's vulnerability in a time of medical need is increased by linguistic isolation."
Culturally Sensitive
The phrase books represent the cumulative efforts of several HMS
faculty and HMS students who had felt the need for such a series
during their clerkships and were instrumental in the initial stages
(particularly Clara Chang, Tony Chen, Channing Yu, and Chi Huang).
A grant from the Robert Wood Johnson foundation has made it possible
to finalize the initial series and proceed with the translation
of the set into three languages--Haitian, Cantonese, and Spanish--although
there is no limit to the number of languages that could be used.
"Before the task of translation begins, the phrase books will be
discussed with Haitian, Chinese, and Spanish community members to
make sure that the questions are sensitive to the cultural values
that the language represents," Nercessian says. This may mean that
some questions will need to be rephrased. The final set of phrase
books will include questions in English and their translation into
a particular language and its
phonetic representation.
*According to the 1990 census, more than 31.8 million Americans, or 14 percent of the U.S. population, spoke a language other than English. This represents an increase of almost 38 percent since 1980, when 23.1 million, or 11 percent, of Americans spoke another language.
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