Communication between Spanish-speaking patients and their doctors in medical encounters

SHARRY ERZINGER

C O M M U N I C A T I O N B E T W E E N S P A N I S H - S P E A K I N G

PATIENTS A N D THEIR DOCTORS

IN M E D I C A L E N C O U N T E R S 1

ABSTRACT. Little research in patient-doctor communication addresses the profound difficulties that emerge as Spanish-speaking patients seek medical services in the U.S. This study examines the interaction of language and culture in medical encounters between Spanish-speaking Latino patients and their doctors who have a range of Spanish language ability and a variety of cultural backgrounds. Initial ethnographic fieldwork investigated Spanish-speaking patients' perceptions of doctors' Spanish language skill as it relates to their medical service. To elaborate on these fieldwork findings, medical encounters were audiotaped for detailed conversational analysis. Data from the two methods illustrate how language and culture interact in accomplishing communicative tasks as doctors attend Spanish-speaking patients.

INTRODUCTION

The need for understanding the dynamics of communication is compelling in the face of mixed culturaldiversity in the U.S. Communication between patient and

doctor enables some to easily receive health services that others struggle to obtain. The equitable use of scientific advances hinges upon face-to-face interaction in clinical encounters. As Spanish-speaking patients see doctors, language combines with cultural qualities of communication to influence effectiveness of the medical encounter.

Subtle effects of personal communication influence how people receive health services. Research demonstrates that situational judgments during one-to-one interaction affect communication between patients and doctors who differ in gender (West and Zimmerman 1977) and class (Pendleton and Bochner 1980),

but few studies document how differences in culture and primary spoken language affect the direct provision of health services.

Language is but one analytic component of communication. Patients and

doctors interpret cues based upon a scaffolding of culturally determined beliefs and values that are reflected in their interactional behavior. Doctors and patients engage in active interpretation of verbal and non-verbal cues that determine subsequent responses to each other and are culturally defined. In addition to language, the intemational style or manner and the cultural rules underlying how patients and doctors respond to each other determine the course of their

communication in the medical encounter.

Culture, Medicine and Psychiatry 15:91-110, 1991. © 1991 Kluwer Academic Publishers. Printed in the Netherlands.

92 SHARRY ERZINGER

LANGUAGE, CONVERSATIONAL MANNER AND RULES OF CONDUCT

Various authors in the mental health literature address the issue of linguistic preference and cultural background of Latinos. 2 The U.S. has the seventh largest Hispanic population in the world (Cafferty 1985). Whereas each subgroup of Latinos has its own particular configuration of social class and health status characteristics (Schur et al. 1987), research that addresses Latino health care seldom attends to subgroup variation. Most research on Latino health care addresses Mexican-Americans as the target population; the fastest growing subgroup of Hispanics in the U.S., however, originates in Central American countries such as E1 Salvador, Guatemala and Nicaragua.

Review of the numbers of Latinos in the U.S. provides little information regarding their preferred spoken language because Latinos may or may not speak Spanish. Those who speak primarily Spanish represent a 'linguo-cultural minority', a term that reflects the status of the Spanish-speaking Hispanic patient in receiving services in health as well as education and employment (Gomez et al. 1985). A linguistic and socio-cultural analysis of each individual Latino(a) obviates stereotyping and provides an assessment of his or her particular cultural qualities (Malgady et al. 1987). Spanish-speaking patients and non-Spanish- speaking doctors may differ markedly with regard to aspects of care such as interpreter services (Kline et al. 1980).

Literature from mental health (Flaskerud 1986; Chaves 1979; Padilla et al. 1976) indicates that features desired by Latino patients in the manner of the health professional include simpaffa and personalismo, resulting from underlying respeto (Quesada 1976). The cultural attitude of personalismo is "formal friendliness" (Perez-Stable 1987); whereas a Latino patient views the doctor as an authority, he or she simultaneously expects personal warmth. Triandis et al. (1984) have described a configuration of communicative and personal qualities of Latinos as "simpatfa"; concern for others expressed through personal warmth may take precedence over the task at hand,

Personalismo and simpaffa are specific examples of features of communication that accompany the words of speakers; in a more general sense, such features are also known as "conversational style" or "conversational manner." Multiple examples illustrate how cultural dissonance in interpreting conversational style leads to miscommunication in cross-cultural encounters (Saville- Troike 1985; Gumperz 1982; Young 1982). Communication difficulties between members of different speech communities originate more from differences in style than from grammar and word use (Gumperz and Cook-Gumperz 1981). Tannen (1984) describes conversational style as an integral part of one's personality, reflected in speech: "In other words, style is not something extra added on like frosting on a cake. It is the stuff of which the linguistic cake is made" (Tannen 1984:8).

SPANISH-SPEAKING PATIENTS AND THEIR DOCTORS 93

Whereas conversational style refers to those behaviors that the patient and doctor incorporate into their communication, unspoken rules of conduct reflect basic assumptions that underlie behavior. Respeto is a rule of conduct in Latino interaction that roughly approximates the English translation, respect. The patient is culturally obligated by respeto to demonstrate deference to the doctor. The doctor, in turn, is expected to demonstrate appreciation for the patient as a person whose concem merits serious consideration.

Mishler et al. (1989) use attentiveness, facilitation and collaboration as analytic categories in a study on patient-doctor communication in English. In the present framework, attentiveness and facilitation would represent conversational manner. Collaboration is an underpinning attitude that affects many behaviors; thus it would be a "rule of conduct."

Research that uses conversation analysis to address interaction across gender, power and class demonstrate how physicians control topics that are introduced in the course at clinical encouters (Mishler 1984; West 1984). They may change the topic with questions that, to the patient, seem out of context with the previous discussion, and they often interruPt patients with questions or comments (Mishler 1984). Doctors' use of technical language and jargon in communication with patients is also problematic (Cicourel 1983; Shuy 1983). A general pattern of "dispreference" characterizes the doctor's dismissal of concerns expressed by patients (Frankel 1990).

Patients, on the other hand, interrupt with word fragments that remain unrecognized by their doctors. Male doctors interrupt female more than male patients; male patients interrupt female more than male doctors. Patients' attempts to change the topic of conversation are marked by hesitations, stammers and word fragments (West 1984), In terms of conversation analysis, stammers, hesitations and overlapped speech are signs of conversational non- cooperation (Marshall 1988). A patient's access to the meaning of questions and

educational information is contingent upon conversational cooperation in the encounter.

In the analysis of transcribed conversation, "communicative tasks" (Gumperz 1982) describe purposeful exchanges by each speaker. Consideration of the communicative tasks allows comparison within and across different conversa- tions. By considering the intent of the communication, analysis looks at the purpose of the speaker's action and its interpretation, as reflected in the hearer's response. Awkward and uncomfortable moments in the medical encounter

evolve from a conflict of the communicative tasks.

THE STUDY

This study took place over a period of two years at a family practice residency, located in an urban public hospital in California. The residency program has a

94 SHARRY ERZINGER

history of serving the contiguous neighborhood community of Spanish-speaking Latinos, most of whom are recent immigrants and refugees from Central America.

The research proceeded in two distinct conceptual phases; the first consisted of ethnographic observation and interview to explore communication issues of the Spanish-speaking patient. The second built upon specific findings of the first by obtaining audiotapes of medical encounters between selected patients and doctors for conversation analysis.

During fieldwork the researcher observed Spanish-speaking patients as they sought care from the family practice clinic and support services such as pharmacy and eligibility. In addition, detailed interviews were conducted with 20 family practice residents whose ability to speak Spanish varied across a broad range, from some who combined minimal vocabulary with interpreter services to others who spoke Spanish as a primary language. Of the residents interviewed, twelve were women; one was black, three were Latino and the remain- ing sixteen were white.

Detailed interviews were conducted with patients who attended the clinic for a variety of conditions including pre- and post-natal care, chronic disease maintenance and surgery follow-up; by chance, all of the 26 patients interviewed were women. They ranged in age from 21 to 64 years; all immigrated from Spanish-speaking Latin America or Mexico.

The fieldwork findings provided guidelines for selection of eleven patient- doctor dyads to audiotape for conversation analysis. By chance, all but one of the doctors and all patients in the taped encounters were women. Dyads were audiotaped in which patient and doctor had at least one previous clinical visit together because it was observed thatfrequent pauses for chart review interrupt first visits. The researcher also observed that a patient's acute physical discom- fort alters communication; thus the taped encounters were selected to represent non-acute clinical conditions. Only second or third year residents were selected, because communication between patients and first year residents seemed less systematic, possibly due to fatigue, anxiety or lack of experience.

Each audiotape records the entire medical encounter, including the physical exam and final comments. The researcher was not present in the room. Two of the eleven encounters were eliminated: one at the request of a doctor who felt the encounter was atypical of her performance, and one that the patient discon- tinued for personal reasons.

RESULTS

In the review of the transcribed medical encounters sequences of comments, questions and responses were analysed to the communicative tasks they


represented. Four communicative tasks emerged from the data for patients and four for the doctors. First, patients act with purpose to describe their concerns: fears, beliefs, new observations and uncertainty about past explanations. As the second task, patients assume responsibility for clarifying words and terms used by the doctor. Third, they work to obtain an adequate explanation either by challenging the doctor's advice or providing additional detail regarding their condition. Finally, only upon inquiry from the doctor, patients provide detail regarding their personal lives.

The first of the doctors' four communicative tasks is that of exploring symptoms. The second is to provide feedback regarding follow-up data in the medical record. Third, they explain and advise, repeating information as necessary. On occasion, the fourth communicative task appears when doctors try to understand patients on a personal level. Figure 1 summarizes the communicative tasks that emerged from analysis of the transcripts.

Patient

1. Describe her concerns. 2. Clarify information conveyed by

the doctor. 3. Obtain an adequate explanation. 4. Develop a personal relationship.

Doctor

1. Explore symptoms. 2. Interpret follow-up data.

3. Adequately explain and advise. 4. Understand patient's personal situation.

Fig. 1. Communicative tasks.

Overall success of the medical encounter is determined by how doctor and patient each assist in completion of the other's communicative tasks. Each participant in the medical encounter offers supportive or conflictual responses to the other. The following examples represent a more extensive corpus (Erzinger 1989) to illustrate the relationship between the cultural rules that underlie the encounter, the conversational style or manner, and the language of the par- ticipants.

The Spanish represented in these examples approximates the language spoken in the medical encounter as closely as possible. Grammatical errors and mispronunciations were transcribed as data rather than corrected. Transcription conventions for conversation analysis are noted in Appendix 1. Transcript segments were reviewed for accuracy by native Spanish-speaking researchers who have experience in conversation analysis.

96 SHARRY ERZINGER

Example 1: Supportive Communication

In the style represented in Examples 1 and 2, each doctor builds upon clues offered by the patient. The underlying rules of conduct imply that the doctor helps the patient elaborate her condition through respectful encouragement, illustrating respeto. The doctor's background responses, such as "si" and "umhum," encourage elaboration of the patient's own story.

Sefiora Rios 3 is an elderly woman who immigrated from Mexico 20 years ago. She has complicated medical problems that include diabetes, hypertension, and a recent urinary infection. This interview was a routine follow-up visit with her doctor whom she has seen periodically for one year. Dr. Silva is a resident in family practice whose family immigrated to the U.S. from Central America when she was young. Spanish is her primary language; English is her second.

The following excerpt occurred early in the visit. Within the first four exchanges between doctor and patient, the doctor inquired about how she had been feeling. "Ffjase, que no bien, doctor" ("just imagine, not well, doctor"), responded the patient. The doctor then inquired about lab values for her blood glucose to ascertain the appropriateness of her insulin level.

Example 1, Section 1

01 D. oh, pero est~i baja para ud. en el sentido (oh, but it is low for you in a sense)

1-

02 P. L para mi (for me)

03 D. porque ud. ha venido con m~is que trescientos (because you have come with more than 300)

v 04 P. [- con quinientos (with 500)

05 D. y quinientos y todo eso y esa azticar asf de trescientos, (and 500 and all that and a sugar like that of 300, and)

06 cuatrocientos, quinientos no, es muy bueno, por eso m~is que (400, 500, no, it is very good. that is why more than anything)

07 todo, por eso le dijo est,5 baja. ok. entonces este que es, (that is why she said it is down. ok. then given this,)

regresemos a como se siente ud. ud. me estaba diciendo (let's go back to how you feel. you were telling me)

que no se sentfa bien. (that you were not feeling well.)

08

09


10 P. Oh, sf, me siento mal ya /no se ni como vivo/el dolor (oh, yes, I feel bad now/ I do not even know how I live/the)

11 aquf en mis dfiones? (pain here in my kidneys)

12 D. L um hum/

13 P. no, no se me quita, hay dfas que lo tengo tan fuerte. (it does not stop. there are days that I have it so strong.)

14 D. [ - umhum

15 P. de hace ocho dfas para, para esta fecha no me he sentido (It has been 8 days from this day that I have not felt)

16 nada de bien (any bit well.)

17 D. cuando ud. dice nada de bien, qu6 es lo que ud. siente (when you say nada de bien, what is it that you feel)

18 que por eso se siente nada de bien? (for which you feel nada de bien?)

19 P. siento como si me est~i hirviendo toda la sangre como que (I feel as if all my blood is boiling is how I feel and)

20 me siento y luego no me dan las fuerzas y me tengo que (later I do not have strength and I have to)

21 acostar. (lie down.) " 1

22 D. L_ umhum, so, est~i cansada. (Umhum. so, you are tired.)

23 P. sf, muy mala/ (yes, very bad/)

24 D. [ - umhum/en los ultimos ocho dfas se ha (umhum/in the past 8 days have you)

sentido asf? (felt like this?) 25

26 P. sf/

Dr. Silva elicits information by helping Sra. Rios make her description clearer. Her style is one that encourages elaboration. She encourages the patient's explication of 'no bien' using the patient's own words on two occasions; first, in line 08 and again in line 17. Then she paraphrases Sefiora Rios' description of how she feels (line 22) and further paraprhases by checking out the number of

98 SHARRY ERZINGER

days in which the symptoms occurred (line 24). In the next example, Dr. Silva explores the patient's feelings of fatigue in an

attempt to assess the proper level of insulin, the medication that controls blood sugar (aztlcar). The doctor confuses the words insulin and az~car, and accepts correction from the patient.


01 P. no, no creo que la tenga tan baja. (No, I don't believe that I have it so low.)

r 02 D. L de despu6s de yo le subf

(from after I raised the)

03 la azticar, se acuerda? yo le subf la (sugar, do you remember? I raised the)

r 04 P. L la insulina/ (the insuline/)

05 D. insulina, la insulina, perd6n/se acuerda? no ha notado (insuline, the insuiine, pardon me/do you remember? have)

06 m~ls tal vez este sentimiento de fatiga y sentimiento de (you noted perhaps this feeling of fatigue and feeling of)

07 cansancio? (tiredness?)

08 P. no, porque yo creo que me siento un poco mejor asf como (no, because I believe that I feel a little better)

09 tengo la insulina/ (as I have the insuline/)

In spite of the fact that both are fluent Spanish-speakers, language remains an issue. Dr. Silva is a native Spanish-speaker; she respectfully accepts being a leamer in the situation and acknowledges her error by correcting herself and saying "perd6n" (line 05).

The demonstration of respeto is remarkable in this example as the doctor actively pursues the patient's vague descriptor in Section 1 (nada de bien, line 16) by a query of the term (line 17). Later in the transcript (Section 2), the doctor inadvertantly confuses 'azficar' for 'insulin'. When the patient responds with a correction the doctor accepts her correction with 'perd6n', another indication of respeto.

The doctor's manner or style of paraphrasing and using the patient's exact words encourages the patient's elaboration of her concerns while meeting the doctor's communicative task of exploring symptoms. The underlying rules that


govern this interaction imply the doctor's interest and concern, with a rapport that allows relative freedom of comment for both. The doctor's assistance in how the patient completes her communicative task of describing her concern illustrates simpatfa. The next example likewise demonstrates how a doctor encourages the patient's elaboration of her condition by her manner or style.

Example 2: Supportive Communication

Sefiora Lopez made her appointment some time ago as a routine visit for hypertension. In the interim, she incurred back pain from an accident at work. Sra. Lopez immigrated eleven years ago from Mexico and supports herself with housecleaning work. She lives in an apartment with family members and grandchildren.

Dr. Day is a resident who entered the family practice program with urban clinic experience. She describes her Spanish skill as passable and sees a fair number of Spanish-speaking patients on a regular basis.

Example 2, Section i

01 D. c6mo est~i? (how are you?)

02 P. muy mal. (very bad.)

03 D. qu6 problema? (what problem?)

04 P. tengo un dolor en la cintura/ (I have a pain in the waist/)

05 D. solamente en su cintura? (only in your waist?)

" 7

06 P. L no, es en una parte aquf. (no, it is in a part here.)

r 07 D. L ah, en su espalda/

(ah, in your back/) " 7

08 P. L desde

09 viemes? (since Friday?)

10 D. [ s f /

1I P. s~ibado, domingo, lunes, martes, cinco dfas (Saturday, Sunday, Monday, Tuesday, 5 days)

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12 D. [" a y a y a y

13 P. nohe

14 trabajado/ (I have not worked) - ' 1

15 D. h no puedes trabajar? (you cannot work?)

16 P. no, no puedo trabajar, porque no me puedo agachar para (no, I cannot work, because I cannot bend down)

17 nada. es un dolor como si (for anything. It is a pain as if)

- ' 1

18 D. h muy fuerte/(very strong) " -1

19 P. h muy fuerte.

20 D. antes, um este dolor tiene una problema con trabaja en su (before, um this pain do you have a problem with work in your

casa? (house?)

P. mi espalda es { } (my back is { }) q

23 D. h hmm

24 P. porque el viemes este como en el trabajo tiene una (because on this Friday like at work they have a

madera muy bonita/se le pone el wax/ (very pretty wood/the wax was put on/)

r--

25 D. hsf (yes)

26 P. termin6 de poner el wax y lo dejo que se seque (I finished putting the wax and left it to dry)

r -

27 D. h sf (yes)

28 P. y me voy a hacer, lo dem~is cuando ya termino limpio la (and I am going to make, the rest now when I finished cleaning

29 que es la cocina, tenfa una botella de pine sol con (the kitchen, I had a bottle of pine sot with)

I -

D. h sf/ (yes)

P. amonia/ (ammonia)

I -

D. h sf/ (yes)

21

22

30

31

32


As in the first example, Sra. Lopez and Dr. Day engage in well-coordinated sequences where the doctor encourages the patient's description by selecting a single word the patient uses. The patients' use of the word 'cintura' (line 04) is echoed by the doctor who uses the same word in the next question (line 05).

In addition to using the patients' words to encourage elaboration, this doctor vocally reinforces the patient's story by saying 's i ' repeatedly while she recounts the story of her back problem in lines 25-32. These background responses encourage the patient, and may indicate simpat[a. The doctor's absence of directive comments allows the patient an opportunity to continue her narration. The doctor proceeds with questions only after the patient has fully recounted the history of her back problem. The notable absence of interruptions allows Sra. Lopez to describe her condition sufficiently so that the remainder of the medical interview demonstrates few awkward or clumsy interactional features.

This doctor's manner is one of an active listener, who encourages the patient's communicative task as she describes her concerns. Because of the underlying rule of respeto, Dr. Day bases her assessment on the patient's expertise regarding her own medical condition. This particular doctor was one of the few whose transcript later includes the communicative task of 'understanding the patient's personal situation' as she inquires about the patient's personal life situation.

Such a careful and methodical quest for elaboration of the patient's concems contributes to an ease in communication that contrasts markedly with other interviews where the doctor's communicative task subverts that of the patient. The following three excerpts demonstrate conversational styles that conflict with the patient's communicative task of 'describing her concems'. Example 3 illustrates the consequences of unsatisfactory explanation that are demonstrated in the same patient's later resistive comments. Example 4 shows how doctors deter the patients' descriptions with premature explanations.

Ignoring misunderstood words, curtly interrupting and not listening to the patient's story characterize a manner in which the doctor pursues her own diagnostic purpose using a logical form that is different from the patient's. The pursuit of diagnostic clues by means of questions that elicit a simple guided response is also known as 'branching logic'. In contrast to branching logic, the patient expects that the doctor will listen to her story; communication deteriorates when that expectation remains unfulfilled,

Example 3: Conflictual Communication

Sefiora Betancourt attends clinic regularly for prenatal care. She came to the U.S. two years ago from Central America with her two children and husband.

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She expresses a number of concerns regarding her pregnancy, including recurrent pain in the abdomen.

Dr. O'Neill is a resident in family practice who spoke no Spanish prior to beginning the residency program. Through considerable effort and the assistance of travel to a language school, he now has enough Spanish skill to provide regular health services for Spanish-speaking families.


O1 D. y entonces sefiora ahorita tiene cu~ntos meses? (and then senora now you have how many months?)

02 P. cinco/ (five/)

03 D. cinco meses?...humh, umkay y ud. tiene problemas con (five months?...humh, umkay and you have problems with)

04 dolores? (pains?)

05 P. sf, aquf me duele (yes, it hurts me here)

- 7 06 D. [ - le duele mucho?

(it hurts a lot)

07 P. sf /me duele, mucho/ (yes/it hurts me a lot/)

D. mucho? (a lot?) --1

p. L sf/ (yes)

D. por cu~into tiempo/(for how long/)

P. a veces, como por, media hora/ (at times, like for, half hour/)

12 D. media hora? um pero no todo todo los dfas? o cu~indo/ (half hour? um but not every every day? or when/)

13 P. tengo tres dias seguido/ (I have it three consecutive days)

- 1

14 D. [ - t r e s dfas, umkay/y tien/y qu6 es/ (three days, umkay/and / what is/)

15 y el dolor es por un media hora, sf, m~is or menos? (and the pain is for half hour, yes, more or less?)

08

09

10

11

16 P.

SPANISH-SPEAKING PATIENTS AND THEIR DOCTORS

17 D. una vez al dfa o no?

(once a day or not?)

18 P. una vez al dfa/ (once a day/)

l no, o m~is

(no, or more)

q 19 D. 1_ umkay y qu6 qu6, um c6mo se dice, um qu6 hora ud.

(umkay and what what, um how do you say, um what hour)

20 se siente ese dolor, en la mafiana en (do you feel that pain, in the morning in)

I - -

21 P. [-a veces/(at times)

22 D. la tarde o qu6? (the afternoon or what?)

23 P. a veces en la mafiana y a veces en la tarde/ (at times in the morning and at times in the afternoon)

24 D. y, e, um, tiene una relacfon a su comida? o no? (and, e, um, does it have a relation to your food or no)

25 P. no, no creo que sea la comida/

(no, I do not believe it is the food/)

26 D. y ud. come bien, mils o menos? (and you eat well, more or less?)

103

The patient's task o f describing her concem is subverted by interruption of the doctor 's branching logic. After looking at the chart the doctor knows she has concerns about abdominal pain, pains she is never allowed to fully describe due to the questions such as ' for how long' (line 10) and 'one time daily or no? ' (line

17).

Because Sra. Betancourt is never encouraged to describe her concerns, she later resists the doctor 's explanation of her pain on more than one occasion. After the physical examination, the doctor provides a lengthy explanation o f the

round ligament that often causes pain with increasing weight of the uterus in later pregnancy, an explanation the patient resists. The lengthy explanation immediately preceeds line 01.


01 D. pero hay posible es una infecci6n o inflamaci6n pero

(but there is possible it is an infection or inflammation)

104 SHARRY ERZINGER

02 horita yo no pienso. (butright now I do not think)

1

03 P. m sf pero a mi, a mi casa, sf, me duele.

(yes but at my, at my house, yes, it hurts.)

04 D. sf. (yes)

05 P. pero lo que yo digo que cuando estomudo es aquf que se (but what I am saying is that when I sneeze it is here that)

06 inflama, como que fuera un { } se me parte, usted me (is sore. so that it may be a { } that splits me, do you)

07 D. [ u m /

08 P. entiende? se me inflama/ (understand me? it hurts me/)

V"

09 D. ~- um cuando, (um when,)

10 P. se me infla (it swells up in me)

11 D. sf, sf, sf/ (yes, yes, yes/)

12 P. cuando voy a estomudar, entonces se me infla.

(when I am going to sneeze, then it swells up in me)

13 D. antes de su emberazada o qua?

(before your pregnant or what?)

14 P. antes tambi~n. (before also)

15 D. porque usalamente cuando ud. tiene emberazado no tiene,

(because usually when you have pregnant you do not have,)

16 c6mo se dice, inflamado o quistes a su ov~irio yo pienso que (how does one say, inflamed or cysts to your ovary I think)

17 ese dolor probablemente ahorita es un ligamento y.. @orque (that pain probably right now is a ligament and...because)

18 usualamente cuando tienen embarazado sus ovarios no (usually when they have pregnant their ovaries do not)

" 7

19 P. L_ no pero antes/(no but before/)

20 D. funcionado, m antes, sf, sf/ (functioned.) (before, yes, yes/)

21 P. antes de que yo estuviera embarazada se me inflamaba. (before I was pregnant it was inflamed)


22 D. tienen un quiste o otro inflamada de su ov~rio?

(do you have a cyst or other inflamed of your ovary?)

23 P. quiste de un ov~io?

(cyst of an ovary?)

24 D. quiste, a veces es un quiste cuando sus ovfirios estfin (cyst, at times it is a cyst when your ovaries are)

25 inflamada a veces es un quiste y su ovarios son grande como (inflamed at times it is a cyst and your ovaries are big)

26 un quiste... (like a cyst)

27 P. no es nada? (it is not anything?)

28 D. no no no. . .y entonces, si usted, est~i mejor, si (no no no. . .and then, if you, are better, if)

This section follows a lengthy explanation that has offered unsatisfactory information to the patient. She resists the information by repeating previous history. She repeats her concern that when she sneezes she has pain (line 05). It

appears that the doctor does not know the term 'es tomudo' (lines 5 and 12) and

does not alter the discussion to ask the meaning of the word. Rather, the doctor avoids her information by introducing a term that the patient does not know,

'quiste' (line 16). The doctor 's manner is one of persistent explanation with some degree of

professional intimidation as he uses a term that baffles the patient, 'quiste' (line 16 and 24). The patient recognizes that the doctor has not understood her (line 08) and repeats that she has pain with sneezing (line 12). The doctor responds with a query o f any history regarding cysts on her ovaries (line 16).

The patient believes that the doctor must understand her concern before she will accept his information. Her obligation to maintain respeto prevents her from spontaneously defining a word, estornudo, that he does not seem to understand. The remainder of their encounter demonstrates progressive miscommunication.

Example 4: Conflictual Communication

Sra. Olivas came to the U.S. from Central America three years ago, leaving two of her three children with relatives there. She is seen by Dr. Forest, who has traveled in Central America and sees a moderate number of Spanish-speaking

patients in her routine residency practice.

106 SHARRY ERZINGER


01 P. Siempre cuando camino me duele mucho este lado (Always when I walk this side hurts me a lot)

02 O. [1 sf, porque (yes, because)

03 tiene una ligamente, es a liga/round ligament, es una parte (you have a ligament, it is a liga/round ligament, it is a

04 de la uterus (part of the uterus)

- - 1

05 P. [-fitero? (uterus) r

06 D. Wy esa es la la la ligament y cuando la la la (and that is the the the ligament and when the the the)

07 uterus esui arriba entonces se, c6mo se dice pulls (uterus is up then se, how do you say pulls)

" 1

08 P. W presi6n? (pressure?)

09 D. presi6n, pulls/ (pressure, pulls/)

10 P. W pucha/ (push/)

11 D. pucha, sf/ (push, yes/)

Sra. Olivas barely provides a single line statement (line 01) before she is cut short by Dr. Forest's premature explanation of why she has pain. Not only is the patient cut short, but she is also enlisted in the doctor's groping for appropriate terms (lines 07-11). Throughout the rest of the interview the patient is not allowed to describe her pain in any more detail.

Dr. Forest's rule defines the patient as her instructor of language; she expects that by using terms of English such as uterus (line 04), round ligament (line 03) and pulls (lines 07 and 09), the patient will be able to assist her. The doctor imposes this weighty responsibility upon the patient while she maintains dominance and authority. Throughout the transcript she provides no conversational acknowledgement of the patient's work as Sra. Olivas provides vocabulary alternatives.

Respeto obligates the patient to conform to the position ascribed by the doctor. The patient respectfully offers vocabulary alternatives and weaves simple terms into the conversation that the doctor can easily understand. The doctor remains abrupt and interrupting. The doctor indicates neither simpaffa


nor respeto, while altering the patient's role to include language teaching. Although the patient expressed other issues to the researcher before the interview, she denied to the doctor that she had further questions at the interview's

conclusion.

CONCLUSIONS AND IMPLICATIONS

Spanish-speaking patients and their doctors encourage, clarify, accomodate and challenge each other's statements within a framework of what each considers appropriate for medical interaction. While completing the communicative task of describing her concern, the Spanish-speaking patient is obligated by the cultural rule of respeto to defer to the conversational direction of the doctor. In retum, the doctors demonstrate respeto with a wide range of variability.

Conversational cooperation is fostered by a doctor whose manner encourages the patient to recount her concern, and whose rules allow for a demonstration of interest in what Mishler (1984) calls the patient's "lifeworld." The search for mutually understandable words and the demonstration of interest in the patient's lifeworld reflect the doctor's respeto and simpatfa. A focus upon the patient's clinical condition and an imposition of branching logic result in non-recoverable miscommunication. The doctor demonstrates little respeto through being unapproachable and treating the patient as an unacknowledged conduit of

information. While the need for Spanish-speaking health personnel is compelling, the

acquisition of medical Spanish by itself offers limited redress. In conjunction with the articulation of understandable questions, the doctor's conversational manner must reflect an ability to listen, understand and encourage the patient's responses in Spanish. Moreover, the patient's efforts to teach misunderstood terms can assist in transcending difficulties of communication when their efforts are respectfully acknowledged and appreciated.

The present study uniquely applies conversation analysis combined with ethnographic fieldwork to elaborate upon what some vaguely describe as a "language problem." Conversational cooperation and non-cooperation have not been previously illustrated among speakers who differ in culture and language. In addition, the framework for analysis of medical interaction has seldom included patient and doctor who differ in culture, language or class.

A series of medical encounters that frustrates the patient's need for explanation leaves Spanish-speaking patients without resources that are comparable to those of the English-speaking patient. Although the medical resource appears to be available, the limits of its informational content alter its effectiveness.

Respeto has a depth of influence for the Spanish-speaking patient that

warrants amplification through research such as that presented here. Because

108 SHARRY ERZINGER

cultural qualities such as simpat£a and personalismo have no precise equivalents

in English they can only be defined through illustration. Analysis of conversa-

tion to search for tangible examples of these cultural qualities enables enrich-

ment o f description so that the art, ability and implications of communicat ing

across cultural differences become more explicit.

c/o US Embassy San Jose APO Miami, FL 34020, U.S.A.

NOTES

1 The author would like to express appreciation to the reviewers for the thoughtful detail of their comments on the original version of this paper. 2 'Latino(a)' is the author's preferred term; at times 'Hispanic' is used in the text to indicate the preference of cited authors. 3 Fictitious names are used to personalize patients and doctors.

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APPENDIX 1

Transcription Conventions

/ Major tone boundary, signals end of utterance.

Interchangable with (.).

? Questioning intonation, rising inflection.

• .. Pause, three seconds or more.

, Minor pause in statement.

{ } Unintelligible speech.

l atching, no pause between utterances of two speakers.

Indicates coordinated statements.

Overlapping, simultaneous talk. A sign of wanting to speak while the other has the floor; may demonstrate background agreement or disagreement with

the current speaker.

] Interruption. Abrupt barge into the current speaker's words.

( ) Translation of Spanish into English.

Documents

Communication between Spanish-speaking patients and their doctors in medical encounters