The communication quality between doctor and foreign patient

1. Introduction

While traveling is getting easier and migration is taking place frequently, cultural differences and communication problems have emerged as a new problem of today. The most important case communication is inevitable for a non-speaker of the native language is being a patient. Some undesirable outcomes may occur if the patient can not give the correct information.

With the recent migrations in the western countries such as Germany, France, USA, Canada, UK, Holland the number of non-speakers of the native language has become noteworthy. In Turkey, there is also an increase in the number of foreign patients with the real estate sales to the foreigners in the places such as Antalya and Bodrum. On the other hand, highly qualified healthcare professionals and competitive pricing increased the share of health tourism in the whole tourism income

(http://www.medicaltourisminturkey.org).

On the ground of the importance of communication, according to various resources, 80% of the medical mistakes are caused by giving incorrect information [13,8]. Having gained more and more importance recently, foreign patient-doctor communication and the gaps it has, will be evaluated with the view of knowledge management, and finally, the method developed to prevent the incorrect information translation will be introduced.

2. Literature Review

Foreign patients do not know the local language and therefore the language of the doctor is analyzed in detail. [1,2,10,14] In the basis of this study, lies the increase in the number of the non-speakers of the language of migrated country. For example in USA, 18% of people older than 5 years speak another language at their home (U.S. Census Bureau 2002: QT-P16, cited in Lee 2003:3). This information takes place in the article of Alexander and friends (2009) that contains interesting data about the non-speakers of native language:

“In Geneva, Switzerland, 43% of the population is foreign born and about 25% of the population speaks a language other than French at home.”

2.1. Culture

Edward Tylor’s definition is cited as the first definition of culture[15]. Tylor(1903/1988) defines as “culture or civilization, taken in its wide ethnographic sense, is that complex whole which includes knowledge, belief, art, morals, law, custom, and other capabilities and habits acquired by man as a member of society”.As one of the famous authors who has decoded the most about his studies on culture, Hofstede (2005:4) defines culture as “the collective programming of the mind which distinguishes the members of one group or category of people from another”. According to these definitions, language is critical for both underlined words. “Capabilities” are built by interpretation of language. “Collective programming of mind” programming codes are generated by language. We can say that culture is created by language.

The effects of culture on health care are similar to those of language. For example in Turkey (strong uncertainty avoidance and collectivist culture) women are willing to be consulted to a woman obstetrician ( H2 hospital Director of Quality Department), in USA (weak uncertainty avoidance and individualist ) there is no such problems. According Collins et al. (2002, cited in Lee 2003:5):

“Effective communication between patient and doctor is critical to good medical outcomes.”

So a woman patient form a different culture may affect the medical outcomes. In literature, several paper [2,6] use language and culture interchangeable but in this paper we will use the language as creator of culture.

2.2. Developed Methods To Pass Trough The Language Barrier

Information transfer (communication) between a patient and a doctor is generated in two ways. If the patient and the doctor speak the same language and their cultures are close to each other the transfer is established directly. If there are differences in the language and the culture of patient and doctor, a proxy is used. Followings are the proxies developed in the situation if the patients do not know the local language:

  1. Going to hospital with a friend or relative who knows local language and using him or her as translator.

    -In the deep interviews done with medical sector workers, most of the foreigners live in Turkey use this method, but if the friend or relative in the role of translator does not know the local language so much then some problems may emerge.

  2. Interpreter establishes the communication between patient and doctor.

    -This method is specially used in private health care enterprises in Turkey. Because of cost, increasing effects, interpreters are not chosen by patients who have no good economic welfare. In many countries the language requirements of interpreters are not defined, and non-medical professional interpreters are used widely. In the study of Karliner et al.(2007) “professional interpreters are associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to increase the quality of clinical care for limited English proficiency(LEP) patients to approach or equal that for patient without language barriers.” Also many studies showed that professional interpreters who do not know the culture of the patient may offend the patient and the patient may lose confidence [3] .-

  3. Translation of those who are not medical staff

    -This type of translation is more common among immigrants. Because of large numbers of Turks living in Germany, it is quite probable to find non-medical staff that knows Turkish in the hospital.-

  4. If the medical staff knows foreign language.

    -The manager of public hospital and the managers of H1 and H2 hospitals said that the most important communication problem of medical sector is medical staffs without foreign language.-

In these studies low content rates of the patients can be seen. The most satisfactory method is bilingual staff and the least one is translation of relatives/friends of the patient.

3. Data and Method

The aim of this paper is to improve communication quality between doctor and foreign patient. The research question is How can we improve the communication quality between doctor and foreign patient? Yin (1994) defined a case study as “an empirical inquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident.” Kohn(1997) states that “Yin suggests the methodology may actually be more powerful for explanatory purposes in its ability to answer questions of how and why”. In this paper by the definition of case study methods and the structure of the research question. Semi-structured interviews and observations are used for data collection and case study method is used for analyzing data.

3.1. Selecting Cases

In Turkey there are 5 types of hospital. H1 private and multi branch, H2 private unique branch, H3 private, multi branch and foundation supported ,H4 public hospital, H5 university hospital. Cluster sampling method is used because population is heterogeneous. The population is first divided into separate groups of elements which is called as clusters, H1, H2, H3, H4, H5. A sampling from the hospitals in service in different cities, eager to provide data and known as the best in their cluster, is generated. As some hospitals demanded during the negotiations, the clusters they belong to are mentioned instead of their names.

Table 3 -Hospital Characteristics in each Cluster

Cluster

Total Staff (approximately)

Total Branch

Is there a department for foreign patient?

Informant

H1

7500

17

Y

Hospital Director(M.D), Professor of PhysicalMedicine andRehabilitation

H2

450

1

N

Director of Quality Department, Head of Nursing Department,

Emergency Doctor(M.D),

Emergency Nurse,

Senior Staff of Public Relation

H3

800

4

N

Medical Director(M.D),

Manager of Human Resources

H4

1600

1

N

Head of Nursing Department,

Emergency Doctor(M.D),

Emergency Nurse,

H5

More than 10.000

1

N

Emergency Doctor1(M.D),

Emergency Doctor2(M.D),

3.2. Problems with patients who do not know Turkish

In some regions of Turkey, there are people who do not know the native language. We see that usually a relative or a friend of the patient help the communication as a translator (H1 Professor of PhysicalMedicine andRehabilitation).

During the deep interviews with H3 Medical Director, he says:

“Citizens from the eastern region of our country, and immigrants from Iraq, Afghanistan, and Africa come to hospital when they are ill, with a relative or a friend of them; and we intervene the patients with the translation of these people.”

The process goes on in two ways for the non-citizen patients. If the patient can speak English; as the public relations, nurses or the doctor can, the communication is established with the help of staff. But if the patient speaks a language other than the staff can do, then a translator is required.

Hospital Director in H1 hospital stated that:

“The number of our foreign patients that become ill in Turkey is less than the patients that was ill before coming to Turkey. We sent our doctors to other countries and enable them to meet doctors working in clinics and hospitals. In the next step, foreign doctor sends his/her patient to us. Before the patient arrives, we get the tests and diagnosis applied to the patient. We meet the patient at the airport and accommodate the patient according to his/her economic welfare. All the transportation and other needs of the patient are met by our department established for this purpose. Taking into consideration the countries most foreign patients come from, we employ that staffs who know their language.

Because the number of foreign patients in H1 hospital is more than other private and public hospitals, many applications were developed in accordance with the needs. For example, if the patient gets lost anywhere in the hospital and shows the card given to him/her to any hospital employee the problem is solved.

“In the frame of JCI accreditation, the patients and employee are not asked to identify themselves according to their room number. For the probability of being lost in the hospital mostly used sentences takes place in Turkish and in the language of the patient. When patient shows his or her need in own language, the Turkish translation takes place under it then the communication is established.”

In H2, H3, H4, H5 hospitals, patients usually come after they get ill in Turkey.

Quality manager of H2 hospital:

“Our patients usually come us after an illness in Turkey or according to the recommendation of their acquaintance who were satisfied from our service. Among our patients, there is a group which establishes contact with us before they come to examination and shows the previous cure documents, and the other group comes without any plan or foreknowledge.”

In 2007 the distribution of the foreign patients came to H2 hospital is as follows:

Many demographic features of the patients are:

64% are men and 36% women. 52% paid cash, 26% used assurance and 21% cured for free by the hospital. Foreign patient level in all hospitals is about 1%.

If we consider the graphic which Hofstede(2005:191) has drawn according to the cultures of the countries;

The patients coming to H2 hospital take place in all four areas. These patients took service in 15 different departments. In communication with these patients, proxies were used.

In 2007 H1 hospital’s foreign patients came from 69 different countries such as Afghanistan, Argentina, Germany, Angola, Albania, Austria, Azerbaijan, Kazakhstan, Russia, UK, USA, Canada, Finland, Czech Republic, India, Iraq, Iran, Vietnam, Uruguay shortly all quadrants of Hofstede’s culture dimentions.

In literature LEP (limited English proficiency) concept is used but limited Turkish proficiency, limited Arabic proficiency, limited Chinese proficiency are also problem. When we look at the problems about the culture and language, the cases in USA and Europe countries are common for all countries and should be solved in all countries.

In mostly used method, using proxy, the main problem is the transfer of the knowledge. Knowledge changes while transferring from one place to another, so knowledge can not be transferred but translated.

For example; in communication with simultaneous translation the question of Turk doctor “Neyin var?” is translated as “what is wrong?”or “obligation” word is used. But the purpose here is to ask “What seems your chief complaint today?” In the article of Holden et al(2004) which includes usual examples, the following part takes place:

“For example, Japanese speakers of English are influenced by the notions of politeness. Rather than categorically refusing a request, Japanese might say: ‘I’ll think about it’ (which means “there is no way I am going to do anything about it.’; or, often with a great sucking of breath between clenched teeth: ‘That’s very difficult’, meaning that something is a sheer impossibility.”

3.3. Specific Situation

Patient Name : Y.S.

Year : 2008

Age : 48

Nationality : Greece

“The patient comes to Bursa because of the dead of a friend of him. He goes to emergency with stomach ache. He is alone. The patient speaks English and Greek. After he turns to information desk, he is taken to the emergency doctor. The emergency doctor knows only Turkish. A professional interpreter is called. Patient tells the interpreter that when he first comes to the emergency he could not express himself to the hospital employee and he needs immediate cure. In addition, he says that he was depressed even before the therapy and if he didn’t have to, he would not come to a Turkish doctor.”(Interpreter, H2 hospital Emergency Doctor(M.D), Emergency Nurse, Senior Staff of Public Relation)

As we can understand from these expressions the patient has a negative point of view against Turkey because of the dreary events between Turkey and Greece in the past. This point of view is considered as a code given form the society he lived since his childhood [18] As the patient has to wait despite the emergency, he uses accusatory expressions.

He says that “the doctor in the emergency is young and inexperienced”.

That the translator is easy-going and that he mentions the negative behaviors of the patient after the examination has been an important factor in the success of the treatment.

“After the therapy blood test and abdominal USG are demanded. Then gastroenteritis is diagnosed and his prescription was filled.” (Emergency Doctor)

“After making a good bargain, patient lowers the price and pays in cash.”(H2 Director of Quality Department)

Because of the proximity of a less individualist society and relatively low prices in Turkey, the patients says that he also has a tooth ache and wants to see the therapy room for teeth. After seeing the room he takes a tooth therapy, as well.

4. Solution

In this article we stated that knowledge is translated not transferred. Culler(1982) states that “every understanding is a misunderstanding.”[4]. If every understanding is a misunderstanding then communication between different cultures using different proxies is a distorted understanding. To establish the communication in mother language gains importance. “Communication between physicians and patients is fundamental for medical care.”(Joos et al.1996, cited in Lee et al. 2003).

The solutions are developed in a way that the patients take less time of the proxies. Physician reads the report in his/her own language both audibly and visually, and may also provide videos and audios in the language of the patient[5,19].

The method developed in the scope of this article is a little more different. Native speaker doctors prepared the questions for diagnosis in their own language as well as the answers to such questions. Until the diagnosis the patient chooses the questions in own language then physician and patient gets the printouts in their own languages.

The forgotten point in the developed audio and video based system is, while answering physician’s question without the system patient uses own language and physician does not understand. Videos are important in one-way communication as giving information about how the test will be done like as urine test.

How can we solve communication problems between foreign patient and doctor? Can XML be a solution?

XML is defined by the W3C:

“Extensible Markup Language (XML) is a simple, very flexible text format .Originally designed to meet the challenges of large-scale electronic publishing, XML is also playing an increasingly important role in the exchange of a wide variety of data on the Web and elsewhere” (http://www.w3.org/XML)

We can use xml for information transfer from one language to another one. We use transfer because native speaker doctors prepared the questions for diagnosis in their own language as well as the answers to such questions. Foreign patient and doctor use software in their own language, culture and words.

Foreign patient and doctor information transfer process can be modeled as below:

Both foreign patient and the doctor can see every question in their native language and culture.

4.1. Software

This software can support all languages. When we add a new language program XML file is extending.

When we add a new language it will be located in this section:

<DesteklenenDillerstr>

<string>en</string>

<string>de</string>

<string>tr</string>

<string>fr</string>

<string>new language code</string>

</DesteklenenDillerstr>

I have only migraine data for testing software in Turkish, French, German and English languages. Let’s think that our doctor is a Turk and patient is a French native speaker.

Doctor select question in his/her native language “ÅŸikayetiniz nedir?” and patient see this question in his native language “Qu’est ce qu’il vous arrive ?”.

<Soru Text=”ÅŸikayetiniz nedir?” ID=”1″>

<Texts>

<DictItem Text=”What seems your chief complaint today? “>

<Culture CultureStr=”en” />

</DictItem>

<DictItem Text=”Åžikayetiniz nedir?”>

<Culture CultureStr=”tr” />

</DictItem>

<DictItem Text=”Welche Beschwerden haben Sie?”>

<Culture CultureStr=”de” />

</DictItem>

<DictItem Text=”Qu’est ce qu’il vous arrive ? “>

<Culture CultureStr=”fr” />

</DictItem>

</Texts>

CultureStr for doctor is “tr” and for patient is “fr”. If we add a new language this section will be extend. <DictItem Text=”In new language “> and <Culture CultureStr=”New language code” />. Screen shot:

5. Conclusion

Translations done by ad hoc interpreters and professional interpreters who does not know patient’s culture are equivalent according to the transfer of the knowledge but are not equal. Because of this, these are the translation of knowledge rather than transfer of knowledge. Our solution can be a solution for knowledge transfer problems and limited all language proficiency. What we need is only questions for every complaint, what doctor are asking to their patients. It is not easy but if we do this, a visit to a foreign country will be much safe and a patient will have a chance to chose his/her doctor in which country he/she wishes.

Every understanding may be a misunderstanding because what we understand may be different from what is said by others. We understand equivalent of what said by others, not equal. By this project we are trying to extend understanding. As we mentioned before according to varied resources 80% of the medical mistakes are caused by wrong information (wrong information transfer). If we extend enough equivalent it will be nearly equal, at this point medical mistakes will decrease.

6. Acknowledgement

We gratefully acknowledge the support of Yalçın Aytek ÜstündaÄŸ, Asst. Prof. Dr. Mehmet Erçek, Didem Parlak, Ä°smail Cahit Görmez, Asst. Prof. Dr. Melike Åžahiner, Asst. Prof. Dr. Åžule Ã-ncül, Prof. Dr. Zeynep Güven, Dr. Demet Dinç, Dr. Ã-mer Aydın, Dr. Ünal Egeli, Senem Kayas, Dr. Suna Yıldırım and Onur Uslu.

7. References

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[3] Collins KS., Hughes DL., Doty MM., Ives BL., Edwards JN., and Tenney K. Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. Findings from the Commonwealth Fund 2001 Health Care Quality Survey. New York: Commonwealth Fund.

[4] Culler J. On Deconstruction, New York: Cornel University Press 1982.

[5] Galvez E and Stronks A (2007) “Hospitals, Language, and Culture” Joint Commusion International(http://www.jointcommission.org/NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-C4ACD4BF8BD3/0/hlc_paper.pdf Last accessed Agust 2009)

[6] Gale DD. Cultural Sensitivity Beyond Ethnicity: A Universal Precautions Model. The Internet Journal of Allied Health Sciences and Practice 2006:4(1):1-5

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[8] Joint Commition International. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_25.htm Last accessed: June 2008

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[13] Packard, C.Finding Links between Healthcare Safety, Communication, and Cultural Norms and Assumptions. Carle Selected Papers 2009 Vol.50 No.2 : 55-58 (http://www.carleconnect.com/CSP/CSP%20Fall_Winter%2007/13.Packard.pdf Last accessed Agust 2009)

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[15] Vatrapu R., and Suthers D. “Culture and Computers: A Review of the Concept of Culture and Implications for Intercultural Collaborative Online Learning. IWIC 2007: 260-275

[16] Hofstede G. And Hofstede GJ. Cultures and Organizations Software of the Mind. McGraw-Hill. 2005

[17] Yin, R.K.Case Study Research, Design and Methods, 2nd ed. Newbury Park, Sage Publications, 1994.

[18] Hostede G.and Hofstede GJ. Cultures and Organizations: Software of the Mind, Second Edition, McGraw-Hill, New York, 2005.

[19] http://pgsi.com (Last accessed Agust 2009)

8. Corresponding Author

Serkan Türkeli, Acıbadem University, Faculty of Health Sciences, Department of Healthcare Management, Istanbul, Maltepe, Turkey,Tel:(0090) 505 488 84 45, Fax:(0090) 216 589 84 85 E-Mail:, Web:www.nasnim.com/serkanturkeli