Time to Watch Our Language

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Publication:medicalindependent.ie

Date:27th April 2012

Time to watch our language

News Analysis | James Fogarty | 19 Apr 2012 | 0 Comment(s)

With rapidly increasing and diverse immigration and a health system highly dependent on the labour of overseas workers, James Fogarty assesses the communications challenges that this presents

The results of Census 2011 paint a picture of increasing diversity, as both ethnically and culturally. Ireland is becoming more mixed. According to the census, the country’s population increased by 8.2 per cent, bringing it to just over 4.5 million. However, the biggest increase in terms of population was in the number of non-nationals living in Ireland, which grew by 25 per cent in five years to 766,770. Many of these new Irish have brought with them different

religious and cultural beliefs. Consequently, doctors are being exposed to numerous new health beliefs and expectations. These beliefs may include the unquestioning acceptance of the doctor’s opinion, reluctance to be confrontational and, in palliative care, keeping the patient unaware of his or her true condition.

As well as the increase of emigrants, there has also been a 32 per cent rise in the Irish Traveller population, from 22,435 in 2006 to 29,573. However, Pavee Point, the organisation aimed at promoting traveller rights, estimates that this figure is actually closer to 36,000. The Irish health system relies heavily on non-Irish graduate doctors. As was recently reported in this paper, the OECD estimates that 35 per cent of doctors working in Ireland were trained abroad. The HSE’s National Intercultural Health Strategy, published in 2007, reported a higher proportion, with more than half of all NCHDs being categorised as non-nationals.

“Of this overall complement, foreign nationals comprised29 per cent of all interns,

57 per cent of all houseofficers, 76 per cent of all registrars and 20 per cent of all senior/specialist registrars,” the Strategy reported.

However, it also stated that,at the time of publication, little consistent information was available in respect of minority ethnic staff employed at different grades, positions and disciplines within the health services. Ireland’s dependency on doctors from abroad again came into sharp focus last summer as the HSE scrambled to recruit doctors from India and Pakistan in advance of the NCHD changeover. Despite this reliance on non- Irish trained doctors, and the increase of immigrants within the Irish population, are the Irish health service and training bodies doing enough to head-off potential problems in cross cultural communication?

Just arrived

In a report last year entitled The Experiences of UK, EU and non-EU Medical Graduates Making the Transition to the UK Workplace, the UK General Medical Council (GMC) said that some doctors come to the National Health Service (NHS) with “little or no preparation” for working in the UK.

“While there are some good local schemes for supporting doctors who are new to this country, there are too many examples of new doctors undertaking clinical practice with little or no preparation for working in the UK,” the GMC said.

The GMC reported that many overseas doctors have problems adjusting to the different cultural, ethical and professional environment in the UK. With this in mind, the GMC is planning to introduce an induction course for overseas doctors.

The process will require that doctors are given specific information about what their duties will entail, how the medical profession is regulated, and how the NHS operates. Crucially, the report recommended training in communication skills to help non-UK trained doctors handle sensitive situations and avoid misunderstandings.

Among British-educated doctors too, problems have arisen regarding cultural sensitivity. Dr Richard Scott was reprimanded by the GMC after it received a complaint from a patient’s mother. She alleged that Dr Scott, a practising Anglican, tried “to push religion” on her son. In Ireland a number of high profile Medical Council fitness to practise inquiries have also raised the issue of cultural diversity. Sudanese doctor, Dr Eltayeb Elmubark Abdel Gadir Elkhabir, was last month found guilty of professional misconduct for making inappropriate comments to a patient and failing to attend to a patient within an appropriate time frame. During the incident in question, Dr Elkhabir carried out a procedure he was not asked to do, and was reported to have said to the patient, whose daughter is a nurse at the hospital: “This is my gift to you, and she [patient’s daughter] will be your gift to me.”

During a fitness to practise hearing on the incident, Dr Elkhabir commented that in his country, people often do “favours for friends”.

Induction

Despite the health service’s dependence on non-EU NCHDs, there is no cultural induction course in Ireland. According to a spokesperson for the Medical Council, training of this nature is left up to the individual employer, although guidelines do exist. The guidelines recommend that “a programme of orientation and induction is in place for medical practitioners newly registered on the Supervised Division which includes, inter alia, induction on aspects of the health system, culture, customs, language and local policies, procedures, protocols and guidelines relevant to the scope of the supervised post”.

However, some non-EU doctors already working in Ireland believe the current induction system is sufficiently robust.

“I don’t think one- or two day obligatory courses would help much. Rather there should be a mandatory period of clinical attachment, maybe for three to four weeks under a consultant, for doctors new to Ireland before they take up their first post in Ireland. It might help them understand the culture and practices better,” said Dr Narayanan Subramanian, Vice Chair of the Overseas Medics of Ireland organisation. Dr Subramanian suggests that these clinical attachments would not involve clinical decision-making; rather the doctor would observe the consultant and other NCHDs in the team for a period of up to three months. He pointed out that, at the moment, these kinds of attachments are optional and unpaid.

“Most of the Supervised Division doctors in fact did this clinical attachment when they were waiting to sit the special exams for the Supervised Division and subsequent registration,” he added.

All doctors taking up a new post are expected to undergo an induction programme in their respective hospitals to acquaint themselves with the policies, procedures and practices of the hospital.

At the moment, non-EU doctors must pass a number of “robust” tests before taking up their positions, many of which doctors from inside the EU do not have to sit.

“When a non-EU doctor wishes to practise in Ireland, they first do the English language test, usually IELTS, and they are required to score a certain higher level average before they can even apply to the Medical Council to process their papers. IELTS is not required for EU doctors,” Dr Subramanian said, a fact that the Council is campaigning to change.

Doctors applying to the Supervised Division must provide proof of proficiency, which can be supplied in the following ways:

• a current Academic IELTS Certificate (dated within the last two years) with an overall band score of 7.0 and a minimum score of 6.5 in each module

• have passed another equivalent English language test

• a higher qualification listed in the registration rules which was obtained through English

• satisfactory proof that the basic medical degree and internship training were completed through English in a country where English is the language spoken by the vast majority of the population.

After the Council has verified the candidate’s documentation, explained Dr Subramanian, he or she is required to sit a written test to examine medical knowledge. This test can be taken outside of Ireland online.

“Again this is not required for doctors from EU countries,” he added. As the last part of the registration process, candidates are required to sit a practical exam in Dublin, the TRAS-2. According to Dr Subramanian,

this test examines the doctor’s communication abilities, covering such issues as “being sensitive in conveying bad news, dealing with difficult scenarios, and being able to demonstrate skills as would be required of a doctor practising in Ireland”. However, he added that again this is not required for doctors from EU countries. In preparation for this lengthy pre-registration pro attend short-term training courses conducted in England before the final, as the equivalent exam (PLAB 2) in the UK is similar to the TRAS-2 practical exams,” he said.

While these doctors may be rigorously assessed on their ability to work in the Irish setting, how accommodating is the Irish system to the candidate’s own beliefs and cultures?

Cultural

The 2007 HSE’s National Intercultural Health Strategy stated that the Executive was proactively taking measures within the health services to integrate and manage cultural diversity in medical teams. According to the document, the HSE undertook a number of projects to promote integration.

“Some healthcare settings include managing diversity as part of their management development programmes,” the Strategy reported.

“These and other actions should be considered for further development and replication to other professions.

The overall human resources strategy and approach of the health services... should consider how to mainstream and replicate these and other initiatives,” the Strategy recommended.

Whether the HSE has implemented the strategy’s recommendations is not clear, as the Executive has not responded to MI queries on the matter. Despite this lack of clarity, Dr Subramanian said that in his experience, the HSE does accommodate overseas doctors’ cultural and religious beliefs.

“As far as I know, and from the colleagues I have met over the years, the HSE does accommodate non-EU doctors to practise their cultural beliefs as long as it does not interfere with patient safety or care. There is no issue around many of our female Muslim colleagues wearing scarves over their heads, as is culturally expected with some of them. There is also no issue around non-EU doctors praying in the hospital residences according to their own religious beliefs. Usually the consultants of these non-EU doctors are quite understanding of the NCHDs’ cultural beliefs in my experience,” he explained.

Others, however, feel that more support should be given to non-EU doctors working in Ireland. Dr Frances Meagher, Director of the Student Selected Component Programme at the RCSI, said that an induction course similar to the one planned by the GMC would be useful.

“Trainee doctors from overseas are parachuted into Ireland to support the health service and that can be very difficult for them,” she said.

Recently, Dr Meagher was involved in running an exam for the Medical Council assessing the clinical competence of doctors recruited overseas.

“An aspect of that exam was communication skills, and it became clear in the course of that examination that a number of the doctors who were planning to take up jobs in Ireland had a bit of work to do in terms of being able to communicate competently and effectively,” she explained. She stressed that this result was not a negative assessment of clinical competence, as these doctors may be quite senior, having many years of clinical experience in their country.

“It’s a lot to ask of them, just like Irish doctors if they were parachuted into another culture and asked to operate effectively and communicate effectively with patients,” she remarked.

Dr Meagher believes that communication and cultural sensitivity courses should not be reserved for non-EU doctors. This is a sentiment shared by Ms Helen Kelly, Lecturer in Communications, and Coordinator of the Language and Communications Programme at the RCSI.

“What I find, ironically, is that this kind of effective communication is often lacking in our own population,” she said. “A lot of the breakdown of communications is on the part of British and Irish doctors, making presumptions as native English speakers.

Communication training has to be on both sides and while non-EU doctors would certain benefit from some training, likewise all members of staff should be upskilled. Unfortunately, I don’t think a lot of the older medical practitioners out there now would necessarily have had this training as part of their degree, and would be lacking in those skills I imagine.”

In the western world, the doctor-patient relationship is the primary focus of communication, with other healthcare workers contributing. This is not the case in many parts of the world. For example, in Kuwaiti culture, patient autonomy is not seen to be something to be prioritised.

“The belief is often that the family of a patient should hear any bad news and then possibly break the news to the patient, or at least be present with the patient when the news is given,” said Dr Meagher.

“Part of our brief is to open the students’ eyes to alternative ways of practising medicine. It’s very much a Western view that we have, but that’s not to say that it’s the only one or, indeed, the right one.”

Patients

As part of the communications course, Ms Kelly recounts a seemingly harmless miscommunication which resulted in a serious patient safety incident. Citing Trinity Academic Dr Gillian Martin’s three year study, Take Your Insulin Before Tea, Ms Kelly tells students to be careful not to make presumptions that the patient understands cultural references. “Take Your Insulin Before Tea recounts a very serious breakdown in communication between a diabetes nurse, a patient and a doctor where they were discussing when a patient should take his insulin. The nurse said tea time and the patient then went off and took his insulin every time he had a cup of tea,” she said.

A doctor’s ability to communicate effectively with non- Irish patients can depend on the presence and quality of translators. Dr Ann MacFarlane teaches communications at the University of Limerick. She believes professional interpreters are essential to healthcare.

“I published research with my colleague Hans Pieper when we worked together at NUI regarding GP registrars. We worked with them in relation to their learning needs when working with a culturally diverse patient population. We found that problems which crop up during the implementation of installing an interpreter, but also trying to identify a solution to those problems.”

With the lack of trained interpreters, patients and doctors are having to find other solutions. Currently, a lot of translation is being done by family members and friends, a far from ideal situation in terms of patient confidentiality, Dr MacFarlane believes.

“There’s plenty of evidence to say that it’s not as accurate or effective, and there’s a lot of compromise. You have a whole lot of issues in relation to ethics too; there are instances of children interpreting for parents and being exposed to information they are too young to handle. It also puts a lot of burden on friends who have competent English and this can put a strain on the friendship because it’s not always the case that they are available to come to the GP’s office,” she said

Even less ideal, there is evidence of patients arriving to GP clinics with notes describing their condition. Situations have also arisen where a child will teach a parent a phrase but when the GP responds the mother or father cannot understand. Lack of effective communication becomes more disturbing when one considers that, according to the HSE’s multicultural strategy, between 10 and 35 per cent of those seeking refuge in European countries have suffered torture.

Many asylum seekers and refugees suffer from significant mental health problems, including depression, psychological disturbances and posttraumatic stress syndrome.

“Many of these problems develop and/or increase after arrival due to post-arrival stresses. Their mental health is adversely affected by social isolation, pre- and post-arrival trauma, culture shock, language barriers and fear of deportation, coupled with a lack of understanding about services, poverty and poor housing,” the strategy went on to say.

Frustration

“For the service users, for parents of young children or people with complex social and medical problems, it is very distressing. And it is incredibly frustrating to keep going to a GP surgery where they feel there is a breakdown in communication. Equally, we know from research that GPs feel that frustration too; they feel concerned that they can’t give the kind of quality communication that they would like, and yet they feel frustrated that it’s so difficult to use interpreters,” Dr MacFarlane said.

These issues have long been identified. In the HSE’s strategy, a number of doctors reported feelings of frustration and helplessness in respect of communication with minority patients. Furthermore, access to GPs was described as often problematic by migrants, travellers and asylum seekers. There were reports of patients being refused acceptance onto a GP’s list, as well as perceptions and experiences of racism and discrimination, and a lack of understanding around entitlements and ways of using the health services.

Patient satisfaction with services also varied considerably, the strategy went on to say, with complaints that symptoms were not adequately investigated. Patients also reported that questions and discussions were rushed, and that medication was prescribed without examination or explanation as to its purpose or potential side effects.