12 October 2009
MISSING THE CUE: RECOGNISING PARENTS WITH ENGLISH AS SECOND LANGUAGE
Good communication skills are an essential part of the doctor–patient interaction, both on the part of the doctor and the patient, and the patient's care givers when the patient is a child.1 In Australian hospitals, interpreter services are routine for people who do not speak English. However, there are many people who speak a reasonable standard of English as a second language (ESL) but may have some difficulty in understanding complex explanations and instructions. This is particularly the case in stressful situations such as medical encounters.
The 2006 Australian Census data show that Italian, Greek, Cantonese, Arabic and Mandarin speakers total 6.4% of the population.2 This is of importance to Australian doctors talking to patients, as well as interacting with colleagues who do not have English as a first language (EFL). There can be important repercussions in poor understanding in the doctor–patient consultation.
We wish to present an observation that was noted as part of the PhD of AK into the differences between EFL or native English speakers, and English as a second (or subsequent) language (ESL) or non-native English speakers in the doctor–patient consultation. Ethics approval was obtained from the University of Melbourne. Families being seen for routine paediatric ophthalmic consultations were invited to participate and signed informed consent. A clinician, DM, and his patients were observed and tape-recorded in a clinical setting, and patients and doctors were interviewed independently at the end of consultations. Prior to the clinical consultation, patients had already been seen by an orthoptist who takes a history and performs a visual acuity and eye movement examination, as well as provides eye drops as required. On entering the ophthalmologist's room, the doctor introduced himself to the patients and care givers, and asked if it was okay for the researcher to join them in the room. The doctor directed simple questions to verbal children such as, ‘Would you like to sit in the chair with mummy or daddy, or by yourself?’ Parents quickly conceded the child's wish and sat with the child or in a chair next to the child. Further simple questions about history, discussion of management and compliance, and understanding of the disease were usually directed to the child. When the doctor was no longer getting adequate answers, he transferred the discussion to the parents by requesting the child's permission to ask the parents: ‘Could we ask your Mum and Dad if X?’ This overhearing cue usually resulted in the parents answering the question without the need to repeat the question. However, in some cases, the question had to be asked again directly to the parents. Most parents with EFL took the cue, whereas all parents with ESL missed the cue. This scenario was so consistent that statistical analysis was performed (data provided).
Similar observations can be seen outside the patient consultation setting. For example, a student in the presence of Dr X (EFL) and Dr Y (ESL) was told, ‘You could ask Dr X or Dr Y to help you’. Without a further question, Dr X (EFL) responded, while Dr Y (ESL) needed to be asked specifically again. Although study of language usually does not lend itself to rigorous Fisherian analysis, this observation may be of use to clinicians who have patients or staff with ESL, to appreciate if they are fully understanding and likely to act on what they have heard. Further research in this clinical area would be of value. For now, when it is recognised that care givers have some difficulty interpreting information, it may be necessary to take additional time to ensure that all aspects of a treatment plan for a child are understood.