What good is art when the viewer is blind to the colors you draw in?

Communication is an art that health care professionals are taught early in their medical education. We’re not only taught what to ask, but how to ask it. Beyond avoiding errors and misunderstandings, good communication builds the trusting relationships that are at the core of health care. It can be said that while medical knowledge constitutes the “health” aspect, it is communication that contributes to the “care.”

When we don’t speak a common language with our patient, however, the sophistication of this art is reduced to little more than color-me-in crayon scribblings.

It was during my Family Medicine rotation that I truly appreciated the gravity of this challenge and its consequences on the provision of optimal care. Many of the patients in Bahrain are migrant laborers from South Asia and often converse with locals in what is colloquially referred to as “broken Arabic”—a simplified, more direct form of the language. This often carries over into health care interactions, with one incident I recall showcasing, quite light-heartedly, the degree to which language barriers can be challenging. The conversation, complemented with hand gestures, went something like this:

Medical Student: You have diabetes?

Patient: Yes

Medical Student: How long diagnosed? When?

Patient: Two only

Medical Student: You, diagnosed with diabetes, two years ago?

Patient: Yes!

Medical Student: Medication for diabetes? Drugs, pills? [Again, hand signing the respective words]

Patient: No, no

Medical Student: ...But sure, you sugar high?

Patient: Two only, little

Medical Student: Two what…?

Patient: Two spoon only, chai chai

It was at this point that I realized the conversation was futile. Without available interpretation services, the drained, 8-minute-capped physician would continue to seek a state of mutual understanding with the patient until eventually giving in, inadvertently lowering their standard of care and accepting the suboptimal level of communication. With that, each time a foreign-speaking migrant laborer leaves the clinic, there would be a feeling of uneasiness—one that stems from a conscience questioning the quality of care the patient just received, or concerned for what lies ahead for this patient with minimal health and language literacy. In Bahrain, primary care is free of charge, so migrant workers comprise a large percentage of our patient population.

As I would witness foreign-speaking patients’ being walked through lengthy instructions during medical visits, the look of utter incomprehension reflected was enough to make the resident physician and myself spend several more minutes trying to distill the information. We’d use web-based translation services, sign nouns and act out verbs, throw in a mix of Arabic, English, and whichever Urdu words we knew, and write and draw things out… but, it was rarely enough, and as much as the patients nod their heads, we know that the compromised care we provided cannot be paralleled with the comprehensive, patient-centered care we strive to deliver. This plays into a vicious cycle of health inequity, under-serving already disadvantaged individuals.

During my rotation, one of my colleagues fortunately spoke Urdu, and so his help was often called for. Witnessing the patients instantly switch from confused to fully understanding was significantly eye-opening to internalized bias and prejudice.

The speech that we communicate is a reflection of the internal processes that take place within ourselves and is essential to our shared empathy and understanding as humans. Thus, incomprehensible speech, relative to the receiver, can be subconsciously mistaken for a lack of intelligence, or, more gravely, a lack of empathy-eliciting sentience and consciousness. Afterall, we are less likely to empathize with those that we cannot identify with and, least of all, those we cannot communicate with. And if we cannot empathize, we are less likely to develop the drive for compassionate prosocial action. As health care professionals, such creeping bias can carry detrimental consequences on the care we provide and is deserving, at the least, of more self-reflection and introspection on our end.

In theory, the solution to a language barrier is straightforward: refer to a licensed in-person or telephone medical interpreter and continue the conversation while facing the patient at all times. However, there are more than 7,000 languages and dialects spoken globally, and myriads of providers do not have access to professional medical interpretation services.

The following are a few recommendations for bridging this communication gap in the absence of professional medical interpretation services:

• Physicians should utilize the assistance of their multilingual colleagues, including nurses and other health care professionals, whether in-person or over the phone.
• Physicians can make use of online translation software or devices to help address language barriers; despite such apps for verbal communication, it’s also important to remember the importance of non-verbal communication in patient-provider interactions.
• Physicians must lobby for increased investment in professional interpretation services, as well as recruit providers and staff who are proficient in a diverse number of languages. Research demonstrates that just one-to-two trained professional interpreters or multilingual providers per health facility can substantially increase quality of care.
• Physicians may find it worthwhile to invest in learning or familiarizing themselves with the most commonly spoken languages within their patient population.

As one of my colleagues says, “If not us, then who will take care of them?” And thus, my colleague lengthens the appointment times for our migrant laborer patients, addresses all health maintenance and as many of their health concerns as possible, and provides them with free prescriptions from the health center. It’s these instances of added effort—that push to offer more—that define us as health care professionals, and as individuals.

Although we must always aim to paint in a color our viewers can see, when that isn’t possible, we must invest additional effort into transforming our art into a form that can be universally appreciated. Afterall, if not us, then who?

Acknowledgements: The author would like to thank Dr. Farishta Hussain for her valuable insights on the art of communication, as well as Professor Wayne Cunningham for his contributions and constructive feedback on this article.

**Feature photo obtained by standard license on Shutterstock.

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Saad I. Mallah is a fourth year medical student at the Royal College of Surgeons in Ireland - Bahrain, where he also serves as the Research & Innovation Officer and President of the Surgical Society. Since the inception of the COVID-19 pandemic in 2020, Saad has been an active researcher with the Bahrain National Taskforce for the Combating of the Coronavirus, working to address knowledge gaps from the region. He aspires to enhance health on a community and global scale by actively engaging with global surgery and public health initiatives, hoping to help establish universal access to quality health care through an exceptional practice of medicine, innovative contribution to research, and diligent humanitarian efforts.