Shuangyu Li

Language barriers within primary care consultations: an increasing challenge needing new solutions

International migration is an increasing global phenomenon, particularly noticeable in the UK where removing barriers to travel and residence within an expanded European Union has brought a huge increase in new arrivals. Migration has increased the number of medical consultations where language barriers occur. This paper summarises findings from a review of the literature and explores the challenges posed within these medical consultations, particularly those in primary care. It highlights limitations to current consultation models and educational interventions to improve consultations across language barriers, and suggests future solutions to those problems.

Culture and health.

Planned and unplanned migrations, diverse social practices, and emerging disease vectors transform how health and wellbeing are understood and negotiated. Simultaneously, familiar illnesses—both communicable and non-communicable—continue to affect individual health and household, community, and state economies. Together, these forces shape medical knowledge and how it is understood, how it comes to be valued, and when and how it is adopted and applied. Perceptions of physical and psychological wellbeing differ substantially across and within societies. Although cultures often merge and change, human diversity assures that different lifestyles and beliefs will persist so that systems of value remain autonomous and distinct. In this sense, culture can be understood as not only habits and beliefs about perceived wellbeing, but also political, economic, legal, ethical, and moral practices and values. Although culture can be considered as a set of subjective values that oppose scientific objectivity, we challenge this view in this Commission by claiming that all people have systems of value that are unexamined. Such systems are, at times, diffuse, and often taken for granted, but are always dynamic and changing. They produce novel and sometimes perplexing needs, to which established caregiving practices often adjust slowly. Ideas about health are, therefore, cultural. They vary widely across societies and should not merely be defined by measures of clinical care and disease. Health can be defined in worldwide terms or quite local and familiar ones. Yet, in clinical settings, a tendency to standardise human nature can be, paradoxically, driven by both an absence of awareness of the diversity with which wellbeing is contextualised and a commitment to express both patient needs and caregiver obligations in universally understandable terms. We believe, therefore, that the perceived distinction between the objectivity of science and the subjectivity of culture is itself a social fact (a common perception). We attribute the absence of awareness of the cultural dimensions of scientific practice to this distinction, especially for macrocultures and large societies, which define only small-scale, microcultures as cultural. We recommend a broad view of culture that embraces not only social systems of belief as cultural, but also presumptions of objectivity that permeate views of local and global health, health care, and health-care delivery. If the role of cultural systems of value in health is ignored, biological wellness can be focused on as the sole measure of wellbeing, and the potential for culture to become a key component in health maintenance and promotion can be eroded. This erosion is especially true where resources are scarce or absent. Under restricted and pressured conditions, behavioural variables that affect biological outcomes are dismissed as merely sociocultural, rather than medical. Especially when money is short, or when institutions claim to have discharged fully their public health obligations, blame for ill health can be projected onto those who are already disadvantaged. As a result, many thinkers in health-care provision across disciplines attribute poor health-care outcomes to factors that are beyond the control of care providers—namely, on peculiar, individual, or largely inaccessible cultural systems of value. Others, having witnessed the ramifications of such thinking, argue that all health-care provision should, rather, be made more culturally sensitive. Yet others declare merely that multiculturalism has failed and the concept should be abandoned, citing its divisive potential.1 Irrespective of who is blamed, failure to recognise the intersection of culture with other structural and societal factors creates and compounds poor health outcomes, multiplying financial, intellectual, and humanitarian costs. However, the effect of cultural systems of values on health outcomes is huge, within and across cultures, in multicultural settings, and even within the cultures of institutions established to advance health. In all cultural settings—local, national, worldwide, and even biomedical—the need to understand the relation between culture and health, especially the cultural factors that affect health-improving behaviours, is now crucial. In view of the financial fragility of so many systems of care around the world, and the wastefulness of so much of health-care spending, a line can no longer be drawn between biomedical care and systems of value that define our understanding of human wellbeing. Where economic limitations dictate what is feasible, socioeconomic status produces its own cultures of security and insecurity that cut across nationality, ethnic background, gender orientation, age, and political persuasion. Socioeconomic status produces new cultures defined by degrees of social security and limitations on choice that privilege some people and disadvantage others. Financial equity is, therefore, a very large part of the cultural picture; but it is not the entire picture. The capacity to attend to adversity—to believe that one can affect ones own future—is conditioned by a sense of social security that is only partly financial. In this Commission, we review health and health practices as they relate to culture, identify and assess pressing issues, and recommend lines of research that are needed to address those pressing issues and emerging needs. We examine overlapping domains of culture and health: cultural competence, health inequalities, and communities of care. In these three domains, we show how inseparable health is from culturally affected perceptions of wellbeing. After examination of these key domains, we identify 12 findings in need of immediate attention: Medicine should accommodate the cultural construction of wellbeing • Culture should be better defined • Culture should not be neglected in health and health-care provision • Culture should become central to care practices • Clinical cultures should be reshaped • People who are not healthy should be recapacitated within the culture of biomedicine • Agency should be better understood with respect to culture • Training cultures should be better understood • Competence should be reconsidered across all cultures and systems of care • Exported and imported practices and services should be aligned with local cultural meaning • Building of trust in health care should be prioritised as a cultural value • New models of wellbeing and care should be identified and nourished across cultures We believe that these points are imperative to the advancement of health worldwide and are the greatest challenges for health. Together, they constitute an agenda for reversal of the systematic neglect of culture in health, the single biggest barrier to advancement of the highest attainable standard of health worldwide.

Beyond the 'dyad': a qualitative re-evaluation of the changing clinical consultation

Objective To identify characteristics of consultations that do not conform to the traditionally understood communication ‘dyad’, in order to highlight implications for medical education and develop a reflective ‘toolkit’ for use by medical practitioners and educators in the analysis of consultations. Design A series of interdisciplinary research workshops spanning 12 months explored the social impact of globalisation and computerisation on the clinical consultation, focusing specifically on contemporary challenges to the clinician–patient dyad. Researchers presented detailed case studies of consultations, taken from their recent research projects. Drawing on concepts from applied sociolinguistics, further analysis of selected case studies prompted the identification of key emergent themes. Setting University departments in the UK and Switzerland. Participants Six researchers with backgrounds in medicine, applied linguistics, sociolinguistics and medical education. One workshop was also attended by PhD students conducting research on healthcare interactions. Results The contemporary consultation is characterised by a multiplicity of voices. Incorporation of additional voices in the consultation creates new forms of order (and disorder) in the interaction. The roles ‘clinician’ and ‘patient’ are blurred as they become increasingly distributed between different participants. These new consultation arrangements make new demands on clinicians, which lie beyond the scope of most educational programmes for clinical communication. Conclusions The consultation is changing. Traditional consultation models that assume a ‘dyadic’ consultation do not adequately incorporate the realities of many contemporary consultations. A paradox emerges between the need to manage consultations in a ‘super-diverse’ multilingual society, while also attending to increasing requirements for standardised protocol-driven approaches to care prompted by computer use. The tension between standardisation and flexibility requires addressing in educational contexts. Drawing on concepts from applied sociolinguistics and the findings of these research observations, the authors offer a reflective ‘toolkit’ of questions to ask of the consultation in the context of enquiry-based learning.

Interaction—A missing piece of the jigsaw in interpreter-mediated medical consultation models

In 2015, at the International Conference on Communication in Healthcare in New Orleans, USA, we formed a symposium panel to discuss and debate how interdisciplinary research can inform interpreter-mediated medical consultation training. In all our work, a recurring theme is not just the strengths but also the shortcomings of the guidelines proposed in the textbooks and widely used in medical education. This paper is an account of our multidisciplinary reflections on a prominent issue of the lack of attention to interaction in communications, which shed light on the limitations of these guidelines and clinical communication models. We propose that an international network be established for all stakeholders to foster interprofessional and interdisciplinary collaboration for research and clinical interventions, and to inform training and policy making.

Nine Types of Turn-taking in Interpreter-mediated GP Consultations

Abstract This research investigated the systematicity of turn-taking organisation in naturally occurring GP consultations where either a professional or an ad hoc interpreter was involved to mediate language discordant doctor-patient talk-in-interaction. I found that participants systematically organise their turns to speak, following one of the nine types of turn-taking organisation identified in this study disregarding the patient’s native language and culture, the type of interpreter and their interpreting proficiency. The effect turn-taking organisation has on communication varies in different contexts. Teaching doctors about the cause and effect relation between turn-taking and communication outcomes may help them improve their clinical communication.