ASK DOCTOR ALICE
Community Health Centers: Where Communication Counts

I recently decided to accept a new job at a San Francisco hospital. One of the most difficult parts of that decision has been telling all my patients at the community health clinic in Oakland where I currently work that I will be leaving.
“Where are you going?” is usually the first question, although some venture a guess: “Are you opening your own private practice?” “Are you getting married? Having a baby?” Many of them ask whether they can – or tell me that they plan to – switchover to my new practice.

I’ve developed close relationships with many of my patients over the years, the vast majority of whom don’t speak much English. Because I speak Mandarin, I am able to communicate directly with my Mandarin-speaking patients.

And thanks to trained medical interpreters, I also have close relationships with patients who speak Cantonese, Korean, Vietnamese, Tagalog, Mien, Cambodian and Arabic. I was reminded of this recently when I ran into one of my Cantonese-speaking patients on the street. She lit up when she saw me, took my hand, and started talking animatedly. I mustered the only reliable Cantonese I know, reminding her, “I don’t speak Cantonese!”

When my patients tell me they want to transfer their care over to my new practice, I have mixed feelings. On the one hand, I would love to continue being their doctor. On the other hand, I realize that good health care requires much more than just having a doctor you trust.

It’s about being an active participant in the entire health care experience: from making an appointment with the receptionist over the phone, to understanding the nurse who asks whether you need a flu shot, to discussing your diet with the nutritionist, to asking the pharmacist how to take your medications. It’s about being able to understand your diagnosis and treatment, and being able to advocate for yourself.

Many hospitals are highly committed to serving their patients who speak limited English. They hire medical interpreters, translate written documents, and post signs in different languages. But because they serve a larger, more diverse population with a wide range of linguistic, cultural and medical needs, they often cannot provide the seamless access for a specific population that a community health center can.

Asian Health Services, the community health clinic where I work, was established 30 years ago with the specific mission to serve the immigrant community here. To better ensure culturally and linguistically appropriate care, the clinic tries to hire people from the community. Nearly all the staff – from receptionists to doctors – speak an Asian language, with some staff members speaking up to six different language and dialects. In addition, the clinic has trained medical interpreters for the most common languages so there is typically no more than a few minutes’ wait for an interpreter.

Across California, community health clinics provide health care services to 3.12 million patients, according to 2002 data collected by the Office of Statewide Health Planning & Development. A recent survey of the state’s community health clinics found that services are being provided in 32 different languages. Spanish is by far the most common language, representing 90% of surveyed clinics. Among Asian languages, Tagalog is spoken in 23%, Vietnamese in 20%, Mandarin in 13% and Cantonese 11% of clinics.

Nationwide, 95% of community health clinic patients report that their doctor speaks the same language they do, and for those who do not speak the same language, more than half say that someone on staff at the health center interprets. Because of their smaller size and community-based care philosophy, community health clinics have been uniquely successful in adapting their services to the cultural and linguistic needs of the communities they serve.

A report released in 2004 by ACORN, the Association of Community Organizations for Reform Now, shows a very different picture for hospitals. In their study, testers called 70 different hospitals and visited 15 different hospitals located in urban centers around the country to see how easy it was for a Spanish-speaking patient to access care. In more than 50% of the calls, no Spanish speaker was available; in one case, the caller was told that due to the lack of interpreters, the caller should seek treatment at a different hospital. When they visited hospitals, they found even less interpretation services available. In nearly 60% of the visits, no Spanish speaker could be found. A number of the testers were asked to use their children as interpreters, while others were asked to try back later.

Hospitals in California are aware of this gap. Many are exploring ways to improve language access for their patients, including increased hiring of bilingual staff and use of innovative technology to increase access to interpreter services. But when my patients tell me they want to change to my new practice, we discuss what it would mean for them to change from Asian Health Services to a health care system where language may be a barrier at every step. Though I wish I could continue seeing them, I advise my patients to stay at the community health clinic, because clear communication is the basis for all good medicine.


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Editor: Akhtar M. Faruqui
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