When clinicians and their patients speak different languages, patient care and clinical
outcomes suffer. Specifically, when patients have limited English proficiency (LEP)
they have worse access to care, receive poorer quality care, are less likely to understand
and adhere to care plans, and are less satisfied with their physicians and the care
they do receive.1
These data are not surprising: if a clinician and a patient cannot understand one
another’s words, there is little likelihood that the patient will be able to effectively
communicate his or her complaints or that the clinician will be able to effectively
communicate a diagnosis and recommendations. Yet, while it might seem obvious that
language barriers impede care and interfere with optimal clinical outcomes, significant
questions remain regarding how and why language differences affect care.1 For instance,
in this issue of the Journal of General Internal Medicine (JGIM), Cheng et al. demonstrate
that even when Hispanic patients are comfortable communicating in English during a
clinical encounter, they are significantly less likely to receive recommended health
services if they speak Spanish at home, when compared to Hispanic patients who speak
English at home. In this issue of the Journal of General Internal Medicine (JGIM),
Cheng et al. demonstrate that even when Latino patients are comfortable communicating
in English, they are significantly less likely to receive recommended health services
if they speak Spanish at home, when compared to Latino patients who speak English
at home.2 How do language differences outside the clinical encounter affect care within
it?
Also, what does the language concordant physician add to the clinical encounter that
a translation service does not? Research has repeatedly shown that when LEP patients
have a language-concordant physician, their clinical outcomes and satisfaction with
care are significantly better than outcomes for similar patients working with an interpreter.3–6
Several papers in this JGIM supplement corroborate this finding.7–9 Why is the translation
of a language during a clinical encounter a necessary but not sufficient condition
for overcoming language-based barriers to care?
One potentially helpful starting point for approaching these and other similar questions
is to consider that not all researchers studying language and language barriers in
medicine are necessarily studying the same entity. Some are examining language as
a shared structure or system, what the Swiss linguist Saussure famously termed langue,
and what we commonly think of as language (English, Spanish, or Russian, for example).10
This dimension of language includes the database of words used by a group of people
and the formal rules that guide the use of those words. Other researchers are examining
the use of language by individuals, what we commonly think of as speech and what Saussure
termed parole. This latter dimension encompasses not only the “database” but the gestures,
the delivery, and the context – social, cultural, historical, etc. – that give the
words and phrases from the database their full meaning in a given setting or situation.
Understanding, even in a cursory way, how these two linguistic dimensions differ,
and understanding which aspect a researcher is addressing, may allow us to better
perceive what is actually being examined in research on language barriers, what is
potentially being missed, and how to evaluate conclusions and solutions.
When language is considered to be simply a shared system of grammar and words (i.e.,
when considering langue), language barriers can be considered primarily a problem
of translation or “code-switching,” in which individuals who speak different languages
require a code-breaker (generally an interpreter) who can allow each party to decipher
what the other is saying.11 Clearly, the ability to provide this type of deciphering,
or translation, is critical to ensuring effective communication. When patients have
access to interpreter services (particularly when the interpreters are professionally
trained), patient comprehension increases, health care utilization equalizes, and
both LEP patients and their clinicians are more likely to be satisfied with the clinical
encounter.1,12,13
Research and policy that attempt to solve problems of translation generally have the
goal of improving the accuracy and efficiency of methods for translating words from
one language into words with equivalent or near-equivalent counterparts in another
language. Therefore, this work tends to focus on the logistics of interpreter services:
expense, training, availability, optimal interpretive modality, and the willingness
and ability of providers to offer services. Several articles in this supplement add
to this body research, examining, among other issues, interpreter training,14 medical
student training in the use of interpreters,15 barriers and potential barriers to
adopting interpretive services among private practice physicians,16 and optimal strategies
for providing interpretive services.8,9,17
When considered as speech (i.e., parole), however, language must be considered a much
more dynamic medium, constantly changing depending on who is using it and what he
or she is using it for. The field of sociolinguistics is based on the idea that speakers
are, first and foremost, social actors and that language is a symbolic resource used
by speakers to make sense of the world and their place within it. For instance, speakers
use language to demonstrate status or power (e.g., through the use of honorifics or
the use of medical jargon by a physician), to demonstrate belonging (e.g., through
the use of slang by teenagers to exclude parents or the choice to use or discard a
regional accent), to create art, or as part of ritual (e.g., prayers in church or
synagogue). Furthermore, not all actors will necessarily agree upon what types of
speech are “correct” in certain contexts and at certain times. Language, then, is
also negotiated and contested.18
Thus, linguistic differences are not just differences in words but also differences
in the concepts behind words and in the contexts that shape the meanings of words.18,19
Understanding the role language differences play in medical encounters and their impact
on clinical outcomes must necessarily include an understanding of the larger context
in which language takes place. Sociolinguists refer to this understanding as “communicative
competence.20” As explained by linguist John Gumperz, “Whereas linguistic competence
covers the speaker’s ability to produce grammatically correct sentences, communicative
competence describes his ability to select, from the totality of grammatically correct
expressions available to him, forms which appropriately reflect the social norms governing
behavior in specific encounters.21”
Medical anthropologist Richard Parker provided an example of the dangers of lack of
communicative competence in his work in Brazil during the early years of the AIDS
epidemic. Parker found that early AIDS prevention literature imported from the United
States focused primarily on promoting safe sex among gay men. However, in Brazil,
where the sexual culture is “characterized by its flexibility and its fluidity” (p.
163), the relationship between sexual behavior and sexual identity is less direct
than it is in the United States. Parker describes two parallel systems: the medical/scientific
system, in which terms like “homosexual” and “heterosexual” are understood in much
the same way that they are in the United States, and a “folk” system, in which men
who have sex with men do not always identify as homosexual, particularly if they are
considered the “active” partner in the relationship, and in which transgression, the
breaking of official rules of behavior, is often one of the goals of sexual activity.
Thus, imported AIDS prevention literature that urged “safe sex” among gays and homosexuals
was rendered ineffectual in a context in which the term safe sex seemed an oxymoron
and in which many at-risk individuals did not identify as gay.22
Dohan and Levintova’s article in this issue of JGIM provides another example of the
critical need for communicative competence in clinical scenarios.23 The authors demonstrate
that the word “cancer” holds different meanings for Russian émigrés in California
than it does for their medical providers. For providers, the word represents a disease
entity to be treated. For many émigrés in the study, the word “cancer” was almost
unspeakable, representing a death sentence and loss of hope. As an informant in their
study notes, the émigrés are “coming from a culture where the treatments that are
available here simply did not exist. There’s no treatment, there’s no cure, there’s
no hope.23” Dohan and Levintova suggest that these alternate understandings of the
word contributed to tension and mistrust between providers and some of their émigré
patients. Thus, whereas the word “cancer” might be amenable to direct translation
(cancer in English, paκ in Russian), the meaning behind that word, the context in
which that meaning developed, and the use of the word may vary dramatically between
languages and cultures and may significantly impact the success or failure of the
clinical encounter. (We should also note that the cultural norm of nondisclosure of
cancer diagnoses has been found in other cultures as well, including, in the past,
in the United States.)24–26
To decrease the possibility that a clinical encounter will be derailed by communicative
incompetence, research and policy must consider not only the role of translation in
clinical services but also the role of interpretation, in the full sense of the word.
That is, it must consider interpretation as a process of communicating ideas and the
context in which those ideas take shape.11,27 In studies of medical interpretation
among the Inuit in Canada, O’Neil and colleagues found that most problems in communication
between the Inuit and health-care providers arose not when interpreters were unable
to adequately translate words but, rather, when they were unable or unwilling to interpret
the cultural and social milieus from which those words and their meanings arose.28,29
O’Neil and colleagues have argued convincingly, based on their findings, that interpreters
are often much more valuable to the clinical encounter when they serve not just as
“linguistic conduits” but as cultural brokers as well.29 Interpreters and émigrés
interviewed in the study by Dohan and Levintova echo that suggestion, noting that
“interpreters could help address cultural differences in disclosure and social differences
in treatment expectation if they were trusted to move away from ‘word by word’ translation
and to broker relationships between care providers and patients.23” The notion of
interpreters as cultural brokers is an attractive one, a potential remedy for the
problems arising from attending exclusively to langue in interpreted encounters, without
sufficient attention to parole. Yet this solution, like any, will require development
and study. Some readily apparent drawbacks include the possibility that cultural brokers
might make assumptions about a patient’s cultural affiliations and preferences, based
on ethnicity, age, or other characteristics; might substitute his or her own interpretation
of cultural norms when they are not shared by the patient; or might use “cultural
appropriateness” as a blanket excuse for not transmitting information that is uncomfortable,
rather than inappropriate, to divulge. In our experience, these problems already exist
in many interpreted encounters. Making the issue of cultural brokering explicit should
help bring them to the surface so that providers, patients, interpreters, and researchers
can face them head-on.
Other avenues to more holistic interpretation also warrant consideration and study.
Interpreters should not be the only ones attending to the cultural and contextual
aspects of language and communication. As has been loudly advocated in recent years,
providers must be also trained to recognize the importance of cultural dimensions
of communication among both LEP and English-speaking patients. We do not believe that
it is appropriate, or even possible, for a provider to be versed in the complex cultural
and contextual milieus that influence the parole of every patient in every situation.
However, he or she can be cognizant of the role of culture in communicating with patients,
and develop the skills to elicit information about context and culture, one patient
at a time.30
Finally, it is worth noting again that studies have found care to be better in language-concordant
encounters.3–9 This benefit may stem simply from a more accurate and complete transmission
of words in an “unfiltered” exchange. We suspect, though, that it may also reflect
the ability of bilingual/bicultural providers to attend to both langue and parole—both
words and the context that gives them their full meaning. Studies demonstrating better
communication between racially and ethnically concordant patients and providers support
this assertion.31 An important part of the effort, then, to reduce language barriers
between patients and providers is to increase the linguistic and cultural diversity
of the healthcare workforce and to give patients greater choice in selecting providers
whom they can understand and who can understand them.
Ultimately, if we are to effectively care for the millions of Americans who do not
consider English their first language, we need to attend to both their langue and
their parole. We need to provide clear, proficient language translation so that patients
and clinicians can understand each other’s words. However, we also need to ensure
that physicians have the opportunity to understand not just what a patient says but
also what that patient means when he or she speaks. This may be the more difficult
task. We might start by simply recognizing that the two tasks, translating langue
and interpreting parole, are in fact quite different and that research or policy addressing
one does not automatically take the other into account. From that starting point,
it may be more possible to recognize not only what we know but also what we may be
overlooking and how to go about filling the gaps in our knowledge and practice.