By the time she was 12, Tanya Kormeili, MD, had lived on three different continents—starting out in Iran and then moving to Italy before finally settling in the United States as a teenager. During those early years she learned to speak Farsi, Hebrew, Italian, and English to varying degrees—ultimately retaining Farsi and English after settling in Los Angeles at age 12.
During high school and college she added Spanish to her linguistic repertoire, but still found the medical Spanish course she took in medical school enlightening. “It made a world of difference in residency,” she says, because while she left high school possessing a familiarity with Spanish literature, she still didn’t know how to say key medical words like “nausea, vomiting, and diarrhea.” Communicating with patients would still have been a challenge if not for medical Spanish.
Right out of medical school, Kormeili began to benefit from her multilingual skills. When applying for her first-year internship, she discovered “county programs really liked my ability to speak Spanish.” It gave her an edge that landed her the spot.
Once in residency, Kormeili’s knowledge of Spanish helped although it wasn’t required or rewarded. She found “it made me super efficient because I didn’t have to rely on a third person [an interpreter]” to care for patients. In addition, knowing a patient’s language naturally helped build trust, she says. “It built a connection.”
Now in private practice as a dermatologist in Los Angeles, Kormeili finds her knowledge of Spanish and Farsi gives her a leg up. Besides improving patient communication, it helps set her apart. “Any niche you can create can be advantageous,” she says. Check out these other benefits of being a bilingual doctor.
English no longer our only language
With non-English speaking residents on the rise nationwide, the demand for bilingual or multilingual physicians who can keep pace is also rising. The Census Bureau reports that the nation is rapidly becoming more racially and ethnically diverse. Minorities now comprise approximately one-third of the population and will become the majority, outnumbering white Americans by 2042, when the nation is expected to be 54 percent minority.
At the same time, the Hispanic population is projected to nearly triple by 2050, from 46.7 million in 2008 to 132.8 million in 2050. In that year, Hispanic residents will represent 30 percent of the nation’s total population.
Other ethnic and cultural groups will also increase in proportion to the U.S. population. The percentage of Asian residents is projected to increase from 15.5 million to 40.6 million, or 9.2 percent of the total population by 2050.
Concurrent with the nation’s changing ethnicity, the number of Americans who speak languages besides English is climbing. Between 2000 and 2007, according to Census data, the percentage of residents speaking languages other than English rose at a double-digit rate. The number of 5- to 17-year-olds who speak languages other than English increased 12 percent from 9.8 million to 10.9 million. Among 18- to 64-year-olds, there was a 20 percent increase, from 32.8 million to 39.2 million. And in the 65 years and older group, the percentage of residents speaking languages besides English rose 19.5 percent, from 4.4 million to 5.3 million.
The converse is also true, with the number of Americans who speak only English declining. From 2000 to 2007, the percentage of residents ages 5 to 17 who speak only English fell from 81.5 percent to 79.5 percent. The decline for other age groups was similar; from 81.2 percent to 79.3 percent in the 18 to 64 category, and from 87.4 percent to 86 percent in the 65 and over range.
While English remains the official language of the United States, its position as the most commonly spoken language is dropping precipitously.
How the evolution of language is affecting medical care
The evolving ethnic makeup of the nation has repercussions on many fronts, including health care. The fact that many medical colleges now require their students to take a medical Spanish course as part of their training is one sign of the increasing importance of knowing a language other than English.
Medical schools in California, Florida, Illinois, Tennessee, and North Carolina currently require medical Spanish, and many other medical schools now offer it as an elective course, reports M. Brownell Anderson, the senior director of educational affairs for the Association of American Medical Colleges (AAMC) in Washington, DC. “In the past 10 years, we’ve seen much more interest in medical Spanish,” she says, as well as a rising interest in certification in medical Spanish. Medical students are recognizing the value of being able to communicate with Spanish-speaking patients without an interpreter as a go between, Anderson says.
However, even medical colleges that provide medical Spanish courses are not teaching a second language, Anderson is quick to point out. “They’re teaching specific
skills,” she says, not producing physicians fluent in their chosen language. Yet the movement towards more medical Spanish training is a recognition that “we can’t assume everyone speaks English or understands it,” says Anderson.
Knowing other languages is certainly beneficial, but being able to say, “tell me where it hurts” and “use this inhaler twice a day,” isn’t enough. Being able to speak a dialect is only one aspect of foreign language mastery; reading and writing are equally critical for doctors who need to prescribe medication and convey treatment instructions. Fortunately, some doctors recognize the difference between fluency and proficiency.
Cuban-born Pedro Suarez-Solar, MD, a hospitalist at St. Mary’s Health Center in St. Louis, grew up in a household where Spanish was spoken almost exclusively. His mother didn’t know how to speak English and his father knew only broken English, so Spanish was their common bond.
So confident was he of his Spanish fluency that in high school he asked to take French to fulfill his foreign language requirement, rather than Spanish. He wanted “to learn a new language,” but his mother was not yet convinced of his mastery of his first language. She gave him permission to enroll in French on one condition: he first had to write a letter to his grandmother in Spanish (one she could understand) and he also had to read and understand her response. Suarez-Solar quickly appreciated that simply speaking a language was not enough—he also needed to be able to read it and write it in order to fully communicate. Spanish class it was.
Looking back, Suarez-Solar says he appreciates the experiences of living in a Spanish-speaking household and studying the language. Beyond learning a second language and being part of another culture, knowing Spanish has also benefited his career. When he began interviewing for physician openings, he was asked if he could speak, read, or write in Spanish. “Saying ‘yes’ was a good thing,” he says.
How speaking another language can benefit providers
Jacqueline Sutera, DPM, a surgical podiatrist in private practice in midtown Manhattan and northern New Jersey, found her fluency in Italian and proficiency in Spanish served her well when she applied for her current position. “It was a big advantage,” she says, adding that her Italian background and linguistic abilities opened the practice to a broader patient base.
She was born to immigrant parents and was raised speaking Italian, which made learning additional languages easier. Sutera studied medical Spanish at the New York College of Podiatric Medicine, but also found she could understand other languages to varying degrees because she could pick out the common sounds. It was her Italian and Spanish, however, that netted her a job offer from a prominent podiatry practice.
With two Jewish male doctors running City Podiatry originally, hiring a female doctor who spoke Italian and Spanish immediately expanded the ethnic populations the practice could serve. “More than a couple of times patients have said they picked me because of my Italian background and proficiency in Spanish,” says Sutera. All things being equal, she has found that patients prefer to deal with a doctor who can speak their language or who understands their culture and background. Kormeili agrees. Language becomes a common bond that benefits both doctor and patient, she says.
In addition to attracting Italian ladies who like to talk about their families back in Italy during appointments, Sutera says she also receives referrals of Spanish-speaking patients from other physicians. Once word got out that she was bilingual, Sutera has had little difficulty attracting patients. Being bilingual “makes you more marketable,” she says, although not all doctors play up the fact that they speak languages other than English. That’s a mistake, she says, because “patients would choose you if they knew you spoke their language.”
Having witnessed how patients are drawn to her through language, Sutera’s practice makes sure to market her linguistic skills. For example, her listing in the Aetna insurance directory identifies her as bilingual, which is how a lot of patients have found her. Her knowledge of Italian and Spanish will also be highlighted prominently on the practice’s revamped website, which is underway.
That is not to say that being bilingual is a guarantee of special consideration or review, however. At some hospitals, being bilingual affords the candidate some extra attention, but at other hospitals, it is given no extra weight at all. Raymond Mayewski, the medical director of the University of Rochester Medical Center in Rochester, New York, reports: “Recruitment of any professional staff is based on our need and their qualifications. While being multilingual is often helpful and desirable, it is not used in making our physician hiring decisions. We have an excellent, readily available interpreter
In fact, on-staff interpreters are the communication solution for most hospitals and medical practices. Without an entire staff of bilingual health care providers who are able to speak a wide range of languages; there will always be a need for interpreters (those who handle verbal communication), and translators (those who deal with the written word).
Interpreters fill the gap
Ten years ago, Phoenix Children’s Hospital of Phoenix, Arizona, had three staff interpreters and one translator. Today, that number has climbed to 24 interpreters and four translators filling 13 full-time equivalent (FTE) positions. This expansion is in response to the rapid growth of the Phoenix area’s Hispanic population, says Irma Bustamante, the language and cultural services manager at the hospital. The state of Arizona has the fastest growing Hispanic population in the nation and more than 50 percent of Phoenix Children’s Hospital patients are Hispanic, driving the demand for Spanish-speaking health care providers there, as in other parts of the country. However, smaller language communities are also cropping up and creating a need for expertise in Arabic, Vietnamese, Somali, Mixteco (a Mexican indigenous dialect) and Karen (a Burmese dialect), she says.
Since the hospital’s goal is to meet the needs of patients within 15 minutes, providers frequently turn to telephonic interpreters for assistance. Using matching telephone headsets, doctor and patient may communicate with each other using a live interpreter on the line to translate between English and the patient’s native language.
Although “studies have shown that if the provider is able to communicate directly with the patient, that is the best case scenario,” says Bustamante, “unless physicians and nurses are bilingual interpreters must fill the void.”
Calling in an interpreter isn’t as simple as it sounds, however. “Training has to be provided for doctors to know when to call them in,” says Bustamante, because sometimes doctors don’t recognize that they are missing key pieces of information from patients. “You only hear what you can understand,” she says, and sometimes physicians don’t realize what they have missed if the patient is speaking a language they are not familiar with, or if the patient’s English is incomplete. The physician, too, may not realize that the critical pieces of information about the patient’s condition are missing, or that he has not grasped all the details conveyed.
In the case of written information, whether provided by the patient or offered by the physician, free online translation tools may also bridge the gap. Two of the largest are: • Yahoo’s Babel Fish and Google Translate. To help physicians determine when an interpreter is needed and how best to get them involved in a patient’s case, the Association of American Medical Colleges (AAMC) has developed a handy interpreter guide (additional details provided under “Interpretive Resources,” see sidebar).
Language learning for physicians
Established physicians interested in learning a second language have several options for gaining “communication competency,” says Linda Materna, PhD, the director of the Center for International Education and a professor of Spanish at Rider University in Lawrenceville, New Jersey. While doctors will not be fluent upon completion of any of these various tools or courses, they would be equipped to engage patients in conversation about concrete topics and to read materials in
the foreign language at the level of say, a newspaper.
Materna suggests starting with a software-based instruction program like Rosetta Stone, which provides speaking, reading, and writing instruction in a variety of foreign languages. After completing the full program, students will most likely be at a low-intermediate level of competency and will be able to have basic conversations, she says. Other options include watching videos online or watching foreign language television or listening to the radio. Such “unguided experiences” can be beneficial but lack educational structure.
A step up from the self-guided program is a private or group tutor through a company like Berlitz, which has the advantage of personal feedback during training.
Community college or continuing education courses for adult learners are also beneficial. These courses are often focused on conversational competency, however. If learning Spanish in greater depth and focusing on the acquisition of medical vocabulary is your goal, check with your nearest medical college—many now offer medical Spanish courses.
Given how little free time most physicians have, Materna would not recommend a traditional college foreign language course unless the course had an evening format or a condensed and accelerated delivery of instruction. Otherwise, “the pace is too slow and too time-consuming.”
For those who can take a week—or better yet, two weeks away—an immersion course in a foreign country is perhaps the best approach, Materna says. Even better, she suggests, is to start with a software program like Rosetta Stone and supplement it with the study of a grammar book, in hardcopy or electronic form, which has exercises with answer keys. Follow that with an immersion program. “You could advance quickly” with such a combination.
The advantage of an immersion program is that it increases familiarity with both words and culture. It’s almost impossible to fully understand a foreign language without understanding its culture or context, according to Materna.
For physicians who must rely on interpreters, these professionals provide a crucial service for patients and doctors, but there is a cost involved that can add up, especially in private practice. While hospitals typically have interpreters on staff for physicians to turn to, private practice physicians are more likely to call in independent interpreters who work on an as needed basis and bill by the hour.
By relying on her own bilingual skills instead of having to call in an interpreter, Sutera says it takes less time to see a patient. In the end, that translates into more patients seen and more revenue generated for City Podiatry. Career-wise, that is a significant benefit she brings to the table.
English as a Second Language
Just as doctors in the United States are grappling with the challenge of learning medical Spanish to cope with the ever-rising numbers of Spanish-speaking patients, a similar scramble is occurring in medical tourism destinations—countries where Americans are traveling for medical treatment.
A 2008 report by the New York City-based accounting firm Deloitte & Touche estimated that as many as 750,000 Americans went abroad for health care in 2007, with that figure expected to rise to 1.5 million in 2008. Because overseas treatment is generally paid out-of-pocket, those most likely to travel abroad for treatment are the under-insured and the uninsured, whose ranks are growing with the rising costs of health insurance.
For example, an uninsured patient forced to pay cash for the removal of a painful gallbladder is looking at approximately $15,000 to $20,000 out of pocket in the United States. For a few hundred dollars you can go to Costa Rica or the Philippines, two of the most common healthcare destinations in the medical tourism industry, where such a surgery will cost a fraction of that amount.
One such provider of medical tourism services is Globalized Healthcare (GHC), whose CEO Amy Holcomb is based in Los Angeles. Among GHC’s practice guidelines, says Holcomb, is that GHC will offer “safe, affordable health care choices in the patient’s native language.” Which means that English-speaking patients are entitled to services provided by English-speaking doctors; and, according to Holcomb, GHC is committed to hiring only bilingual, English-speaking physicians.
Like their counterparts in the United States, international physicians, including Julio Arias, MD, experience the advantages of being bilingual. Based in Panama City, Panama, Arias specializes in cosmetic and orthopedic surgery of the hand. He received his medical training from the University of Panama, supplemented with additional study at Yale and the universities of Arkansas and Pennsylvania.
Although Spanish is Arias’ primary language, he began studying English in early elementary school and continued through high school. As a teenager, he spent summers living with English speaking families in the United States and Canada, “which is when I really became the most fluent,” he says. To achieve his goal of attending a good American college, Arias knew he’d have to speak English well. He attributes much of his college success to his English language skills. “Having gone to a top college—which I credit to knowing English well and doing well on the SATs, etc.—it opened doors to residency programs and subspecialty programs that I would not have had access to before,” he says.
Now as a practicing physician, Arias finds his ability to speak English and understand American culture enables him to provide better patient care. He says, “It helps to gain [patients’] trust and put them at ease, knowing that I can understand everything they are saying. That I not only understand their language, but their culture, is a big comfort to them.” Because of that familiarity with American culture, Arias can also make “necessary adjustments in treatment plans and decision making” to better suit his American patients.
Arias is likely to rely on his English skills to a greater degree in the coming years, as the number of English-speaking patients is on the rise in Panama; not only those coming from the Unites States, but from Canada and Europe as well.
Like Arias, El Salvador-based Roberto Zelaya, MD, began learning English as a second language in preschool—his first language is Spanish, and he also speaks French. Zelaya specializes in bariatric and weight loss surgery and is a member of the International Federation of Surgery for Obesity (IFSO). Trained at Louis Pasteur University in France, Ohio State University Medical Center in Columbus, Ohio and the Hospital Clinic of Barcelona in Spain—he is now the owner of Gastrointestinal Surgery and Endoscopy Clinic.
Without English language skills, Zelaya would have been at a distinct disadvantage in medical school and in practice, he says. Since he wasn’t able to speak his native language to his patients, his English had to be good. “During my training, I was only able to speak English to communicate with my tutors and patients. For sure knowing other languages, especially English, opened doors for my career.”
If not for his abilities, would he be as successful? Arias says, “I am sure I would not.”