Geneva University Hospitals

2'167 beds 1'285 doctors; 3'479 nurses; 1'477

paramedical Personnel: 51% non-Swiss; 88 countries Patients: 51% non-Swiss, 88 countries 2007-09: major budget cutting exercise

Department of community medicine and primary care

SMPR

Free clinic for uninsured

Migrant health center

General medicine outpatient

consultations

Consultation for war and

torture victims

Dietician

Social workers

Context: Europe/Switzerland

European project: Migrant Friendly Hospitals

• www.mfh-eu.net/public/home.htm

Swiss « Migration and Health Strategy 2002-07” MFH named priority by Swiss Federal Public

Health Office WHO and Swiss “Health promoting hospitals

network” creates “Task Force on Migrant Friendly Hospitals»

• www.healthhospitals.ch/franz/

Our working definition

Cultural competence: The capacity of the institution and clinicians to identify, understand and respond effectively to the linguistic and cultural needs of patients

Strategies: HUG

Cultural competence training for clinicians

Interpreter services Cross-cultural consultation service Research/evaluation

Strategies: HUG

Cultural competence training for clinicians

Interpreter services Cross-cultural consultation service Research/evaluation

Cultural competence teaching objectives:*

• Familiarity with basic anthropological concepts

• Knowledge of common sources of cross cultural communication difficulties

• Understanding of how socioeconomic and cultural factors affect health, health care and health related behavior

• Recognition of the impact of physicians’ own cultural background on health care delivery

• Basic knowledge of key immigrant populations

• Basic knowledge of non-conventional medicine

• Ability to identify and address cultural aspects of health care, and to work effectively with interpreters

*Hudelson P, Stalder H. Diversité socioculturelle et formation médicale. RMS 2005;1:2214-7

1st year: Culture and communication

1st year: Sociocultural aspects of health care seeking

(2nd-3rd year: Anthropology of medicine)

5th year: Medicine and sociocultural diversity

Post-grad/continuing education:•“Cultural aspects of…”•“How and why to work with an interpreter”

Clinical « mini-ethnography»General culture:• Religion/spirituality• Customs (clothing, diet

etc.)• Communication styles• Decision-making styles• Sources of mistrust• Gender relations

Beliefs and practices related to illness:

• Explanatory model• Personal meaning• Use of non-conventional

therapies

Social context:• Family, social networks• Sources of stress• Sources of support• Legal status• Migration history• Level of integration• Previous medical

experiences

Develop a therapeutic alliance with the patient:• Problem definition• Treatment options

Language/literacy:• Language competency• Literacy level• Health literacy

(Manhattan Cross Cultural Group, 2004)

Strategies: HUG

Cultural competence training for clinicians

Interpreter services Cross-cultural consultation service Research

Interpreter services in Geneva Network of 90+ interpreters (50+ languages),

coordinated by the Geneva Red Cross Interpreters: immigrants, refugees, a few asylum

seekers Interpreters work for a wide range of institutions HUG/CRG convention HUG intranet site where interpreter list can be

accessed; hospital services contact interpreters directly

Services paid by departmental budgets

Use of interpreter services

Total # hours in 2006: 9504• 0% Geriatrics

• 0% Long-term care facility

• 5% Ob-Gyn

• 6% Internal Medicine

• 6% Neurosciences (includes dermatology)

• 7% Pediatrics

• 20% Psychiatry

• 54% Community Medicine

Challenges

Underutilization in many departments? Use of internal, ad hoc interpreters Agency:

• Sees interpreting as “secondary activity”

• Provides little/no training for interpreters

• Does not yet require certification for hiring

• Has no quality control procedures

• Has lengthy process for identifying/hiring of new interpreters

Currently no other interpreter services available

Certification in Switzerland

Granted by the “Association suisse pour l'interprétariat communautaire et la médiation culturelle” http://inter-pret.ch/

Requirements:• Completion of 2 training modules

• Attestation: language competency

• Attestation: 50 hours minimum interpreting experience

Cost: 2500 CHF ($2200) plus transport

Example of training content

Module 1: Intro to community interpreting• 96 hours of class time

• 8 hours small-group supervisions

• 65 hours individual work (reading, learning-process journal, written case presentation)

Module 2: Overview of specific domains• 63 hours of class time

• 8 hours small-group work (visits, tutoring)

• 45 hours individual work (reading, research, preparation of personal materials)

HUG: Activities (since Oct ’06) Qualitative situation analysis Creation of « Quality group » for interpreting Information/training sessions for interpreters Development of explicit HUG requirements Establishment of “incident reporting” system Improved intranet site Grand rounds presentation on language barriers Presentations in hospital newspaper and hospital television

program HUG list of approved interpreters (planned) User satisfaction survey (planned)

User satisfaction survey Frequency of contact with non-francophone

patients Use of and preferences regarding various

strategies for communicating with non-francophone patients

Familiarity with Red Cross interpreter service Satisfaction with the Red Cross interpreter

service Opinions regarding priority activities for

improving communication with non-francophone patients

How do you evaluate the quality of services provided by CRG interpreters: (Always, often, sometimes, rarely, never)

CRG interpreters are available when needed CRG interpreters arrive on time CRG interpreters introduce themselves and explain their role CRG interpreters have adequate language competency You have confidence in the accuracy of medical information

communicated by CRG interpreters If necessary, CRG interpreters ask for clarification during the

encounter before interpreting CRG interpreters ensure that you understand what the patient

is trying to communicate to you When necessary, CRG interpreters clarify cultural beliefs or

practices mentioned by the patient CRG interpreters maintain neutrality during the consultation

Future priorities

Systematic collection of patient language data to improve planning of interpreter services and monitor use

Require/offer training for hospital interpreters Offer information session for all new staff on

when and how to use interpreters Develop methods to evaluate quality of

interpreting

Strategies: HUG

Cultural competence training for clinicians

Interpreter services Cross-cultural consultation service Research

Cultural consultation service Aim is to help clinicians identify and address

cultural/linguistic barriers to care

CCS multi-disciplinary team: doctors, nurses, psychiatrists, anthropologist, cultural informants/interpreters

Services provided: in-depth evaluation, sociocultural information, referral to community resources, recommendations for culturally appropriate care/communication, etc.

The « cultural formulation » outline

Cultural identity (including language & literacy) Cultural explanations of the illness Cultural factors related to the psychosocial

environment and levels of functioning Cultural elements of the clinician-patient relationship

(including language issues) Overall impact of culture on diagnosis and care

Lewis-Fernandez & Diaz (2002). The cultural formulation: a method for assessing cultural factors affecting the clinical encounter. Psychiatry Quarterly 73(4): 271-95.

CCS example

25 year old Cameroonian man, former asylum seeker, now undocumented. Does not speak French well; consultations conducted in English.

Followed regularly for hypertension; asks for a “test to know whether his future children will be healthy.”

Young female resident does not understand patient’s request; feels patient is asking for inappropriate exams. Patient becomes aggressive and dissatisfied, accuses resident of knowing nothing about medicine.

Linguistic and cultural barriers

“Well, I don’t speak very good English. I have to admit that, you know. And, well, neither does he. So often I have to ask him to repeat what he just said because I didn’t understand. And I think that made him angry…We had such a level of incomprehension and such a gap between what he expected from me and what I was offering him, that he became aggressive.”

Strategies: HUG

Cultural competence training for clinicians

Interpreter services Cross-cultural consultation service Research

Research activities: examples Improving communication between physicians and

patients who speak a foreign language Perceptions and experiences of residents regarding

the care of culturally and linguistically diverse patients Perceptions and experiences of medical interpreters

regarding cross cultural communication difficulties Cultural competence: development of tools to measure

clinicians' core knowledge, attitudes and skills Interpreter service user satisfaction survey

Improving communication

Intervention: Four 2-hour workshops for general medicine residents

Self-administered questionnaire to doctors and patients pre and post intervention

6 items on perceptions of the quality of patient-doctor communication

Bischoff et al. Improving communication between physicians and patients who speak a foreign language. Br J Gen Pract. 2003;53(492):541-6.

Results 1016 consultations: 40% allophone patients Languages: Albanian, Serbo-Croatian, Somali,

Spanish, Arabic, Portuguese, Farsi Physicians:

• Higher satisfaction with French-speaking patients, both before and after intervention

• Higher satisfaction with trained vs ad hoc interpreters• Use of trained vs ad hoc interpreters increased

Patients:• Satisfaction of allophone patients greater post-

intervention

Bischoff et al. Improving communication between physicians and patients who speak a foreign language. Br J Gen Pract. 2003;53(492):541-6.

Interpreters’ recommendations

Be aware of potential sources of misunderstanding

Have basic knowledge about patient’s country of origin

Be sensitive to translation difficulties Adapt to patient’s communication style Discuss communication issues with

interpreters

Hudelson P. Improving patient-provider communication: insights from interpreters Fam Pract. 2005 Jun;22(3):311-6.

Evaluating physicians’ core CC knowledge, attitudes and skills

N=619 (306 hospital doctors, 176 private doctors, 137 medical students)

Response rate: 29.8% private docs; 52.2% hospital docs; 54.2% medical students

35.4% general or internal medicine; 21% psychiatry

On average 30% of their patients = immigrants 70% reported receiving no CC training

Findings

Patients’ lack of French rated #1 source of difficulty with migrant patients

83% consider professional interpreters very important for ensuring quality care

41% strongly agreed that hospitals should always provide professional interpreters

58.6% rated highly their ability to work effectively with a professional interpreter

Findings

Patients’ lack of French rated #1 source of difficulty with migrant patients

83% consider professional interpreters very important for ensuring quality care

41% strongly agreed that hospitals should always provide professional interpreters

58.6% rated highly their ability to work effectively with a professional interpreter

BUT: no correlation between self-rated ability and knowledge of key elements of working with interpreters

Exercise: a clinical vignette

An orthopedic surgeon is to see a patient that was referred to him by a general medicine physician. The patient only speaks Swahili. The surgeon has planned for a longer consultation than usual, and has scheduled a professional interpreter.

The patient and the interpreter, who do not know each other, arrive simultaneously for the consultation.

The doctor greets them, invites them to sit down, and then turns to the interpreter and says: “Ask Mr. Z what brings him here today.”

Indicate everything that the doctor forgot to do or could have done better.

Answers we were looking for:

Speak directly to the patient Introduce the interpreter to the patient Explain confidentiality Ask patient if he accepts the interpreter Meet with the interpreter beforehand to

discuss objectives of the consultation

What we got:

22% gave no correct answers 39% gave 1 correct answer 30% gave 2 correct answers 8% gave 3 correct answers 1% gave 4 correct answers 0 gave all 5 answers

Conclusion: challenges

Raise awareness of language barriers as a quality/safety issue

Encourage use of professional interpreters in the face of budget cuts

Train clinicians to work with interpreters Monitor interpreter needs and degree to

which needs are being met

Conclusion: collaborations

HUG

Red Cross interpreter

service

WHO Health Promoting Hospitals Network

MedicalSchool

Other interpreter services

Culturally and linguistically competent

hospital

Federal public health

office

And finally…

What are your ideas for strengthening professionalism and quality among agency interpreters?

Thank you for your attention!

Patricia Hudelson, PhD

Medical Anthropologist

Department of Community Medicine & Primary Care

Geneva University Hospitals

Patricia.Hudelson@hcuge.ch