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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