Language and culture should never undermine a physician’s ability to provide equitable care, yet the reality is that they sometimes do.
Following are highlights from an article published in the AMA Journal of Ethics® (@JournalofEthics) with strategies for physicians trying to overcome linguistic and cultural barriers to equitable care. The article was written by a multidisciplinary team of authors from Memorial Sloan Kettering Cancer Center.
Using a hypothetical case of a 70-year-old Pakistani widow with limited English language proficiency, the authors also provided recommendations for how to respond to a family’s request to hide what’s really going on.
Three starter strategies
“The gold standard for communication with patients is matching them with clinicians who are truly fluent in their preferred languages,” the authors wrote, adding that the next best thing is having in-person professional interpreters. The “use of ad hoc staff or volunteer interpreters is justifiable by law only in emergency situations when a credentialed clinician or interpreter cannot be easily accessed.”
Family members don’t qualify, they noted.
“Federal, state and many hospitals’ policies prohibit bilingual family members’ serving as interpreters, except in emergency situations or when explicitly requested by the patient,” the authors wrote.
So how, then, should physicians respond? The authors recommended these three key interventions.
Talk with patients about their preferences early on. Engage patients in open—and documented—discussions about their preferences regarding the disclosure of diagnoses and other medical information.
“Unfortunately, time and logistical constraints might impede a physician from securing a medical interpreter for these preemptive discussions,” the authors wrote, adding that knowing a patient’s limited English proficiency status helps physicians and institutions better prepare.
Encourage using a medical interpreter. You might encounter resistance from families who consider interpreters—particularly those available via telephone and video—to be too impersonal. Point out that professional interpreters give patients access to more physicians and are a way of ensuring they get the best care possible.
Engage upset family members calmly, and make use of supportive services. Keep in mind that it can be difficult to determine the patient’s preferences. “In these circumstances, physicians should work to engage the family in a calm, productive dialogue and engage ethics consultants or other supportive services, such as social work or chaplaincy,” the authors wrote.
What if family asks you to lie?
Concealing the truth to a patient—or outright lying to them—is not ethically defensible. If a family asks you to do this, the authors wrote, follow these four guidelines.
Don’t overreact. This is crucial. You might feel the urge to reply, “Absolutely not. This is not how we do things here,” but the family could interpret this as a criticism, escalating the situation further or causing them to cut off communication.
Listen. Try to get to the bottom of family members’ concerns and the reasons behind their request.
“The request might be a reaction to the family’s fears and distress at its loved one’s diagnosis or a manifestation of a sense of duty to relieve the patient of the burden of worry, loss of hope, and responsibility for difficult decisions,” the authors wrote.
Acknowledge, empathize and relate. Letting the family know that you want to protect their relative from harm will help convey that you have the patient’s best interests at heart.
“Furthermore, explaining how truthfulness is vital to you as a human being might allow the family to relate to you as a person, not just as a physician,” the authors wrote.
Suggest alternatives. Explain how you can better serve the patient when everyone talks freely.
The February issue of AMA Journal of Ethics further explores racial and ethnic health equity in the United States.
