By Ryan Foley
Around 300 million years ago, the Earth was a simple place. The fragmented continents that span the planet today did not exist. Pangaea, a single super continent reigned supreme, its borders bound by the cool waters of a global ocean. 200 million years ago Pangaea began to split into many continents, each riding atop massive tectonic plates. Over the millennia, each of these continents developed independently, forming unique ecosystems, weather patterns, flora and fauna, and eventually hosting populations of humans who multiplied and diversified, spreading across our little oasis in space. Now, in an age of globalization and massive cultural integration, countries like the United States are feeling rumblings along communication fault lines much like those generated by the strained movements of the Earth’s crust. When communication strains under cultural pressures in health care, the results can be tragic; however, when interpreters and health care providers appreciate one simple contrasting factor in cross cultural communication, disaster can be avoided.
The culture of the American health care system, otherwise known as biomedical culture, is quite unique in that its cultural style of communication is fundamentally incompatible with that used by 95% of Limited English Proficient (LEP) patients in the United States. And while patients and health care providers come together with the shared goal of addressing illness, a fault line in communication occurs as the cultural forces on both sides clash, at times with quite volatile results. Professionals recognizing the contrasts between these styles can thus be prepared to reduce the impact of their coming together and dramatically improve the quality of each interpreted encounter.
Every person on the planet has the ability to communicate using two primary communication styles: high context and low context. Cultural groups tend to show a strong preference for one or the other when interacting with others in the community.
Understanding derived from high context communication is dependent on how, what, why, when, and where something was said and who the conversation was between. The vast majority of Earth’s non-English-speaking population is made up of high context communicators. Have you ever communicated to a close friend with nothing but a look? Yes? Then you have experienced high context communication. Your friend understood the meaning of the look from the context of the situation in which it was given.
Understanding low context communication on the other hand, is dependent on the actual words used and the logical progression of the dialogue in the conversation. While Germans are famous low context communicators, it is the dominant style for most English speakers, especially in important situations. The courtroom is the home of the lowest context dialogue typically seen. Those who speak must answer only the question being asked and must avoid adding contextual details if not specifically invited to do so.
When a doctor is logically working through a diagnosis, she is following a process built around low context communication and can become easily frustrated when a patient tries to add contextual information. Such is the case when a patient answers the question, “What medication are you currently taking?” with a detailed description of all medication he has ever taken as well as other medications that have helped his friends with similar complaints. He feels that adding context is needed for his case to be understood. She feels the information is superfluous. He is looking for a personal solution; she is looking for a rational one. The ground rumbles.
There are three basic kinds of faults that form when two tectonic plates interact. The reaction to the conflicting forces at play between the plates determines the result. With this in mind, let’s analyze how a savvy interpreter can prevent three common faults that may easily occur when a low context medical communicator interacts with a patient who uses a high context style.
In geological terms, Normal Faults occur when the two sides of the fault pull apart and one side drops down in relation to the other. Often, when there is a disconnect between patient and provider, the patient becomes disempowered, feeling misunderstood. He pulls away in the sense that he takes whatever the provider has to say into account, but feels that she, the provider, does not truly understand his situation. His own personal solution will likely involve only partially following medical advice and only providing partial information for the provider to work with.
What can the interpreter do to avert the “Normal Fault” situation?
- Interpret everything, even if the patient seems to be repeating information. The more context the patient can give in the early stages of the interaction, the shorter the subsequent interactions will be.
- When there is implied meaning that may be missed by either side, interpret it explicitly. Interpret what was said (intended to be understood) not simply the words that were spoken.
- Verbally interpret nonverbal communication from the high context communicator that the provider may miss. Facial expression, tone, and gestures are much more important in high context than low context communication. Trust between the provider and the patient may be lost if the patient doesn’t feel like he is being “listened” to.
As two tectonic plates collide and experience colossal compressive forces, one will have the tendency to move up and over the other. This is termed a reverse fault. The biomedical culture can be seen as cold and machine-like to many LEP patients. Low context communication is task-centered, designed to be systematic, with the goal of working towards a rational solution. Many times questions and statements from providers come across as too direct, lacking attention to cultural and personal values. The majority of LEP patients, being high context communicators, are looking for a personal solution. When there is no bridging this gap, the powerful figure of a doctor can overpower the patient and seem dismissive, almost oppressive at times.
What can the interpreter do to avert the “Reverse Fault” situation?
- Interpret everything the provider says, giving just as much importance to questions they may ask that may seem to be unimportant at first. Savvy providers are now asking questions like, What do you think is wrong? What do you think caused the problem? What have you done to try and make it better? Who else have you seen about the problem? What complications do you fear? They are doing this in order to help increase buy-in from the patient in the treatment by making the solution seem more personal in nature.
- When necessary, due to a serious cultural misunderstanding, provide both parties with the necessary contextual information quickly and transparently. An interpreter should never talk to one party without addressing the other.
- Be sure to reflect the provider’s caring tone in your interpretation, including the facial expressions and gestures you may use.
Strike-slip faults are faults in the earth’s crust in which the walls on either side slide against each other horizontally, not up or down. In a scenario where the patient does not feel disempowered but rather conspired against or in some way wronged, the friction caused reduces the likelihood that the patient will follow through on the treatment plan suggested by the provider. Many times these disagreements are based on cultural misunderstandings rather than true mal intent on one side or the other. After all, both parties are there for the same reason: to address the illness.
What can the interpreter do to avert the “Strike-slip Fault” situation?
- Be prepared to re-interpret messages that may have been misunderstood, maintaining transparency by letting the other party know that a reinterpretation is about to happen. Interpreters are not perfect and should be modest enough to make corrections as needed. A misunderstanding could have occurred in the case where the interpreter failed to make explicit a key piece of information that was implied in the source message.
- Remember to interpret disagreements in structures in the target language that match the intent of the speaker. Disagreement is personalized much more readily among high context communicators. If the provider disagrees with the patient on a matter and intends no disrespect, this must be reflected in the interpretation.
- Make sure the tone, facial expressions and gestures that you use match the intent of the provider. Many LEP patients are sensitive to conflict expressed through nonverbal communication. A poor interpretation can create a basis for conflict that may be absent in the original message.
Geologists tell us that centimeter by centimeter the continents are drifting together once again, but the crossing of borders and mixing of peoples from all over the world is happening at a lightening pace. Communication fault lines crisscross every health care system in the United States, raising the threat and number of dangerous miscommunications. Unlike the physical forces at work on Earth’s tectonic plates, these cultural rumblings can be minimized. The more physicians and interpreters are aware of cultural differences, especially between high context (LEP patient) and low context (biomedical staff) communication styles and apply corrective strategies, the safer and more productive an environment we create in health care.