S01E03 – How Deep Listening Can Improve the Doctor-Patient Bond with Natalia Rodriguez Vincente
Natalia Rodriguez Vicente is a doctoral candidate at Heriot Watt University at the School of Languages who is studying how patients who have no English at all access any health services and particularly psychiatry services, and how the presence of an interpreter affects the doctor-patient bond. How can this individual’s role assist in creating a heart-based relationship between the patient and the doctor? How does the differing of ethnic identities affect this bond?
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Welcome to our Heart Based Medicine Inspirations podcast with Natalia Rodriguez Vicente, talking about the role of a professional interpreter in assisting medical professionals in creating a heart-based relationship with patients of differing ethnic identities.
Natalia R. V.:
My full name is Natalia Rodriguez Vicente, and I’m a doctoral candidate at Heriot Watt University at the School of Languages.
So I’m doing a PhD for the last three years and a half. I’ve been studying how patients who have no English at all access any health services and particularly psychiatry services, and how the presence of an interpreter affects the doctor-patient bond, that kind of interaction. How is it different than monolingual interaction and an interpreter-mediated interaction? And how the presence, how a third-party can affect all that process or those dynamics and the way in which a doctor is trying to, you know, their wording. There’s certain protocols that they need to follow. There are certain strategies that they use. If an interpreter is not aware of those, how are they affecting that unintendedly? But through translation is that lost or is there anything gained by the language mediation process? That’s what I’m looking at.
So from a heart-based medicine point of view, I believe that as a doctor you want to come across as a competent, compassionate individual. And the way in which you use language plays a central role. Obviously there’s not a shared language between you and the patient, your capacity to do so is going to be hampered. But if you have someone by your side who is competent and who has been trained not just linguistically-speaking or interpreting-wise, but also who has been trained about what your values are and what heart-based medicine is about, then you have an individual who is going to help you come across as that competent and compassionate and empathetic individual. So I guess the role of an interpreter would be to help you do that, to help you do your job.
When we have training sessions with health professionals, I always say there’s a concept called duality of client. So an interpreter is not just there for the patient, is there for you to help you do your job. If, for you, coming across as a compassionate individual is central to your practice, an interpreter is there to help you.
We’re going to address what would be surprising for a heart-based doctor in terms of language and culture. But first we need to understand that it should be the clinician that should be culturally competent. So we need to have a clinician who knows that there are certain socio-demographic aspects that are going to affect the explanatory model that a person has over their own health. So why a certain condition came across the way in which you can treat that condition, the role that can be allocated to you as a clinician by that person, that can vary from culture to culture. So first of all, we need a clinician who is culturally competent. Baseline.
If you have an interpreter who is mediating that, that is helpful. But first you need to have a person who is open and who is humble enough to address the patient and who wants to learn about their own explanatory models that can be affected or shaped by culture. So firstly, if you have the good conditions, then a good interpreter is going to flourish because you’re going to have that partnership between a culturally competent doctor and an interpreter who is just going to enable you to communicate.
But we, so here at Heriot Watt, for example, we train interpreters. We do not train cultural mediators. Because there is not, we don’t believe in such a thing as one culture. You can’t have a stereotype of “In this country they do this or they believe that health is that.” You always need to go back to the person. So that’s why we talk about not even patient-centered care. We talk about person-centered care. You always go back to the patient.
If you approach that patient from a humble and wanting to learn about their own culture, then you’re setting the right conditions. An interpreter might help you if there are miscommunication issues. If communication breaks down, they are going to help you go back to the patient and ask the questions that you need to ask. But it’s not up to the interpreter to say, “In our culture we do this and we do that,” because that should be the role of a culturally competent doctor.
I don’t believe it should be the role of the doctor to be aware about absolutely every culture or cultural belief on the planet. But I think it’s a matter of mindset. I think it’s about the way in which they approach a person. It’s not up to the interpreter to be aware because for a Latin American interpreter, there might be so many countries in Latin America, they have sub-cultures, so it’s not up to the interpreter either to be aware about absolutely every one of them. It’s about the mindset and the openness and the willingness you have to learn about that specific patient in front of you.
There’s not such a thing as a monolithic culture that we’re working with. We are working with a person. Because even a culture might have an impact on a person, but see, all the ways in which you react to those cultural values are individual. That’s why we talk about person-centered care. So yes, an interpreter is going to help you communicate, but you still need to have that mindset and that willingness to interact on a sort of, on an individual kind of foundational level.
So in a heart-based clinic, let’s say, that needs interpreters in order to offer their services. And if you want the interpreter to align with your values, you need to make that interpreter, you need to make them feel that they are a part of your team. So they need to be empowered in that sense. They can’t feel as “Oh, I’m here to do an hour job because I have been hired for an hour and then I go away.” They need to feel part of the setting. And that way, they’re going to internalize the values. So if they understand that they are working in partnership with the doctors and they are part of the team, they are a valued part of the team, by extension they are going to express that to the patients that they see. But for that to happen they need to feel part of the team.
We have a concept in interpreting studies, it’s called briefing. Do you know what briefing is? Briefing is when before the formal consultation, an interpreter and a doctor, in an ideal world where everyone has time for that, would agree on what the goals for the session are. Is it an assessment? Is that a followup interview consultation? And then the interpreter could say in a briefing, “On the grounds of what you just told me, these are the cultural issues that might come up.” Then you have the formal consultation.
And then you have a debriefing. If something that is culturally relevant came up during the session, then in a debriefing, in a kind of separate consultation, dyadic, intimate consultation between the doctor and the interpreter, they can talk about those cultural aspects. That will be a practical way in which you can promote a partnership between a doctor and an interpreter where culture can be raised and talked about. You can’t do that in a consultation because it’s a healthcare consultation. It’s the health of the patient. If something came up but you can discuss that, but you know, time is important so you can discuss all those things in an informal debriefing after.
So there’s two working models for interpreters. So normally they are freelancers. So one day, imagine on a Monday, you are at the sheriff court. On a Tuesday you are in an inpatient psychiatry clinic. And on Wednesday you are somewhere else. Then there’s a limited number of interactions that you might have that you may have with a doctor. So that is one model. That’s the predominant model now. So we are kind of far away from that ideal model.
There is another model for interpreters to work, which is when they become in-house interpreters, in a hospital, let’s say. So they are used to communicating with the nurses, with the doctors. They are used to the environment. They are used to the terminology. That is what happens in the US, for example. It’s not the case in Scotland just now.
But in that working model, interpreters seem to feel more empowered to tell the doctors, “Oh, this may be a cultural issue. Let’s work around this.” So yes, in an ideal world, interpreters will be in-house. They are part of the healthcare team, and that enables them to communicate with the members of the healthcare team. But we are a bit far away from reality just now.
But in an ideal world there would be parts of it. But that would mean that they would get enough work to spend every day at the hospital and make a living out of it. But at the moment that is not the case because they need to juggle. They need to work in different settings to get an income.
I think if you are trained on heart-based values and if you see the value of that new approach, I think it will give kind of a new meaning to your job. Because we as interpreters, we see so many people across a wide range of services. It’s very easy to become detached from our clients. And I believe that’s the same with doctors. It’s the same with nurses. But if they are trained, which we are not because it’s not a core part of our practice. It’s kind of a complement to our professional capacities, isn’t it? Because … Anyway, if we are trained on those new values, I believe that we give a whole new meaning to what we do because you stop seeing the patient as a number, as a patient. You start seeing the person. But for that to happen, we need to be trained on that because we are linguistic experts and we are all about the meaning and the cultures, et cetera, et cetera.
A heart-based medicine approach is a medicine issue. It’s not a linguistic issue. But if we are trained, if we approach, if we are told about what heart-based medicine is, then we can internalize it and then we can express that through our work.
There’s two factors we can discuss here. There’s the individual factor and there’s the systemic factor … Factor, sorry. Individually speaking, if we’re talking about a person who is trained about heart-based medicine, then I think it’s about individual preferences in the same way that there are doctors who not really build therapeutic relationships, there are other doctors that might not think necessarily all the time about the impact of what they are saying on the patient. So in the same way that there are individual differences in doctors, there are individual differences in interpreters. But if we are trained, we can make up for that.
So a person can be really good in … They can have a really good intuition and they cannot really build therapeutic relationships. A person might not. But if that … Another person might not. But if that person is empowered and they are trained, you can make up for that individual variation, if you will, that’s the individual factor.
But then there are systemic factors. And you know, as interpreters, our codes of practice are trying to protect us and protect the patient. So they advocate for a model that says accuracy is of the utmost importance over anything else you do. You are there to provide a translation to the professional because they are the ones in charge of the session.
So there’s kind of a conflict between what we are normally told by the settings in which we work and the values of heart-based medicine because that will tell us, “You need to get involved.” Accuracy, impartiality, those are the core values of what an interpreter does. But probably interpreters do want to get involved but they need to to be careful as well because they don’t want to endanger that primary relationship that is created between a doctor and a patient. They don’t want to get involved with that because just think about it. There is a person in front of you who shares your background, who speaks your language, who’s listening to you, who can listen to you directly. And then there’s a doctor who can only do so through that person. Emotionally, you are naturally going to lean towards a person who’s close to you. Because they might not only share a background, they might even share the experience of migration. We see that all the time with refugees. They might have very traumatic journeys into their home country. So naturally, you’re going to lean on that person.
So obviously codes of practice and codes of conduct and our protocols want to refrain, they want to prevent us from getting involved in the primary relationship. So we will need to find the balance between we want to be accurate, we want to be impartial, but we also want to be heart-based to the extent that we are not endangering the primary relationship, which is what we are there to honor, to foster, to promote.
So an issue with time, and we see that in the public services, time is a scarce resource. And just wanted to say that I’ve been in GP sessions, I’ve seen interpreter-mediated GP sessions where I felt that the patient felt truly listened to. And I’ve seen specialist, I’ve seen sessions with a consultant for an hour where I saw that the patient was not being listened to.
So even if you feel as a doctor that you need to do more with less time, I don’t think it’s about working harder or working … I think it’s about working differently. It’s about making a person, the patient in front of you, feel listened. So if you … You kind of, you need to reorder your communication priorities in a way. So you listen to the patient first. What are the anxieties that have brought them to the session in the first place? And then you streamline the conversation towards what you believe should be done.
So we have an acronym, it’s called LEARN. So first of all, you listen to the patient. And then you explain what you believe is happening. Then you acknowledge what the patient might be thinking about their own condition. You recommend what you believe should be done, but then specially for it. And then you negotiate.
So what I’m trying to say with this is you need to listen, especially when culture might be an issue that might be affecting the way in which a person is understanding their own health condition, you need to engage in a shared decision-making process with that person. You need to acknowledge that for them religion might be a factor. They might allocate different roles to their family in that health condition. There might be spiritual reasons. There’s no way you can know or an interpreter can know.
But you listen. You acknowledge that. And then you engage in a shared decision-making process in order to … Because that’s how you get to see the person, not just a patient, and also that is going to enable you to find the assets. What’s important for that person? What are the strengths of that person? What drives that person? If religion is an issue, you take that and you incorporate it in the conversation. You accommodate to the person that is in front of you, and then you work around it. You are going to do what you want to do anyway. And you have a biomedical way of seeing things. You still do your job. But just incorporating those little factors in the conversation, that is what is going to let you see the person. An interpreter could help you and could assist you in that quest.
When we have an interpreter, we do not have dyadic, monolingual communication anymore. It becomes a triadic encounter, where we have several dyads. For a heart-based encounter to happen that is interpreter-mediated, we need to have that heart-based approach across all dyads.
So first of all, you would need to start that with the doctor-interpreter dyad. If they have a briefing, for example, they know each other, they trust each other, then you create a working relationship in the first dyad. And then a heart-based value is going to underpin that relationship. That’s the first dyad.
The second dyad, if an interpreter has that kind of relationship with a doctor and he’s aware of heart-based values, an interpreter is going to extend that to their own relationship with the patient. That’s the second dyad.
By extension, the third dyad will be the ultimate relationship between a doctor and a patient, which is the primary relationship. If a heart-based approach underlies the first two dyads, then as a result, you’re going to have a heart-based relationship.
This has been a Heart Based Medicine production. Thanks for listening.