Keywords: Doctor-patient communication, language, language discordance, cross-cultural communication, health care disparities, barriers to care, patient empowerment, patient-centered communication.
Citation: Nambudiri NS, Nambudiri VE. “What brings you in today?” assessing and addressing potential cross-cultural communication gaps. J Participat Med. 2013 Aug 28; 5:e35.
Published: August 28, 2013.
Competing Interests: The authors have declared that no competing interests exist.
Physicians commonly use open-ended questions and statements to begin their history taking, including phrases such as “What brings you in today?” or “Tell me what I can help you with today.” Such questions empower patients to set the tone for the clinical interaction, provide opportunities to focus on the health issues and concerns that patients believe are most pertinent, and offer an invitation for patients to take an active, participatory role in their care. This open communication requires the physician to take the conversation in any direction: clinical, social, or some other direction.
With the migration of both physicians and patients around the world, the chance that both the patient and doctor in a given clinical encounter speak the same language begins to diminish. Approximately 25% of the United States physician workforce and greater than 30% of the United States primary care workforce is comprised of international medical graduates, many of whom come from nations where English is not the national language. Similarly, over 12% or 40 million individuals in the United States are foreign born and more than 20% of the United States population speaks a language at home other than English. Even if both the patient and physician are native speakers of English, differences in intonation, vernacular, culture, or idiomatic expression often still persist. Virtually every clinical encounter has the potential for a “cross-cultural” interaction between a provider familiar with the health care system and a patient who may not be as well versed in the culture of medicine.
The importance of language in communicating with patients has been the subject of much research. Studies have identified potential health care disparities stemming from language discordance between patients and physicians — situations where the caregiver and patient have different primary languages. Such communication barriers can impact overall health outcomes. For example, Spanish-speaking patients with limited spoken English communication have been demonstrated to have worse continuity of care and lower primary care quality (two critical determinants of long-term health). The use of interpreters has been demonstrated to improve the quality of care delivery for language discordant patients and physicians, but clinical discussions of topics such as mental health may still be limited even when they are used.
Given these trends, both patients and physicians should recognize the importance of language and communication in the delivery of health care. In medical school we were trained to ask open-ended questions, starting with “What brings you in today?” Listening to the patient’s response for the next several minutes about their own experience has taught generations of physicians more than hours of lectures or textbook reading on the topic. However, there are times when the communication that follows the initial open-ended question is less than perfect, due to language discordance or other factors. What can be done to address these potential communication gaps or cross-cultural language gaps?
From the physician perspective, starting clinical visits with open-ended questions is the first step to achieving successful patient-centered communication, and is associated with both improved health status and more efficient care. But when physicians feel time pressure, they are less likely to address their patients’ primary concerns. Additionally, physicians must be cognizant of differing norms and expectations among patients from different cultural backgrounds and work to provide culturally competent care, placing particular emphasis on circumstances where language or other communication barriers exist. As data continues to emerge concerning variations in patient perspectives on health care quality across different cultural groups, physicians should particularly encourage patients with limited language proficiency to elaborate on their concerns through open-ended interviewing techniques as a means of reducing disparities for this population. When encountering patients with limited English proficiency or with whom language discordance exists, relying on interpreters for assistance can result in enhanced clinical outcomes and safer patient care.
When asked an open-ended question by a physician, patients have the chance to prioritize their primary concerns or goals for the visit. One strategy to approach an appointment with the physician is for the patient to prepare a list of specific questions to be addressed prior to the visit. The use of lists or prepared questions by patients can be a useful tool to set the visit agenda, enhance patient satisfaction with the visit, and access higher quality information during a clinical encounter. Such patient activation — the engagement of patients in their own health care — has been found to be less likely in immigrant populations relative to US-born citizens from the same racial background. Furthermore, these populations tend to have a perception of lower quality of care and worse doctor-patient relationships. The findings of lower patient activation among immigrant populations suggest that efforts should be made to reach out to such populations to foster greater engagement in directing the course of their own healthcare.
Finally, health care systems factors can be useful in addressing or overcoming language barriers. Physicians with a self-reported fluency in a language other than English have been more likely to practice in areas with increased populations of patients with limited English proficiency. In sites of particularly high provider and patient density, creation of language-specific clinical services has been demonstrated to provide effective care within larger healthcare delivery systems. In the event that this is not possible, additional strategies for enhancing care for patients with limited language proficiency include having bilingual support staff available and broad training in cultural competency. Providing additional research  and funding  of strategies for improving access to such resources may greatly improve the quality of care delivered in language discordant clinical interactions.
Language and communication are critical components of human interaction and play a central role in medical care. Both patients and providers can improve the quality of care when faced with language discordance by recognizing the specific challenges at hand and working to apply some of the effective strategies outlined here. With an increasingly global physician workforce and increasing language diversity among patients, it is important to prepare the next generation of the physician workforce to deal effectively with increasing language diversity in order to help them diagnose and treat whatever ailment “brings you in today.”
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Copyright: © 2013 Navya S. Nambudiri and Vinod E. Nambudiri. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.