Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud. In these podcasts, you get to listen in on my conversations with some truly remarkable people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding.

Today I’m talking with Barbara Hoekje who is Associate Professor of Communication in the Department of Culture and Communication at Drexel University. She also directs the English Language Center at Drexel.

Dr. Hoekja’s work is about furthering communication and understanding between people of different language and cultural backgrounds. For many years, she has worked with international graduate teaching assistants and international medical graduates in the United States.

Welcome, Barbara.

Barbara: Thank you. I’m pleased to be talking with you today.

Helen: In my healthcare and when I speak to groups of people working in healthcare, I’ve been noticing an increasing number of people who come from other languages and lands. I know that adds to our diversity and our wonderful tapestry of who we are. But honestly, sometimes I can’t understand what people are saying because their accents are so heavy.

I’m hoping that you can help us figure out how we all can help improve health communication, whether we’re the ones coming from another language or land or we’re the colleagues who try to understand.

Barbara: Thank you. I’ll try to do that. I thought a lot about it, and I’ve talked to a lot of people about this issue. I think it’s something we all are facing.

Helen: Are there more people from other languages and cultures working in the US healthcare system today?

Barbara: That is correct. This is happening more and more and will continue to do so over the next several decades. Really it’s because of the change in demographics in the US population. We’re all getting older. Those of us who were born after World War II, the baby boomers, are aging and we need more healthcare. We don’t have the US population to satisfy all of the healthcare needs.

Helen: Are people being actively recruited from other parts of the world to come over and work here?

Barbara: Yes. Hospitals are recruiting and there’s a general pull from our graduate medical education. There are many spaces for doctors from other countries to come work in under-served areas like rural areas, deep urban areas and some of the poorest areas in the country.

The latest statistics are something like 15% of all healthcare workers, including doctors, nurses, home healthcare aides and people working in senior centers and so forth, come from another language or culture. That’s almost one in five.

Helen: One in five comes from another language or culture?

Barbara: Yes. They come from another language or cultural background and are here in our healthcare system. We’re actually very fortunate for that because we need the help.

Helen: We need the help, and I think it’s magnificent when you look at the wide array of providers. Does everybody who is working in our system speak English?

Barbara: Let me say that they speak English because they have to pass English language tests to work here, but they will come from places with different first languages. Some of the major sending countries are places like China or Latin America, in the case of home healthcare workers where the first language is Spanish.

They may come from places in the world like India. India is actually a major sending country for doctors. The Philippines is a major sending country for nurses.

People grow up speaking English. They get their schooling in English. It’s one of the national or official languages of the country but it’s not the only language. These are multilingual countries, so people grow up speaking a variety of English that is a different world variety of English. They are very comfortable and have a very extensive and fully developed language, but it’s a very different kind of English.

Helen: I’ve done a lot of work with physicians and others in India, and I’ve noticed that the speech pattern seems to be faster and clipped. I have to listen that much harder to understand.

Barbara: This is right. Different varieties of English pronounce English differently, so an accent or different regional variety can have different sounds. It can also have a different intonation pattern or pacing.

Helen: Could you give an example?

Barbara: We can just talk about US varieties. Just within the United States we have different dialect areas. I was from Ohio. When I came to Philadelphia, there were words here that I had never heard before. An example is the word “pavement.” In Ohio, the word “pavement” meant where the cars would drive. In Philadelphia, it means sidewalk.

There are words with pronunciation differences and speech style. I know in the southern part of the United States it’s well-known that there’s a little bit of a slower pacing. Even within the US there are regional differences. One thing about having an accent is that no one thinks they have an accent.

Helen: I was just going to say as you were talking about this, “This is all about them. I speak in ways everybody can understand.” I don’t, do I?

Barbara: Helen, probably if anybody does, you do because you speak slowly, clearly and very distinctly. You’re really making an effort to pronounce each word, enunciate and be very clear. You just take extra special care in your speech as you talk.

This kind of thing is a general tip for communication when you are speaking to people from other regional areas or with accents and certainly with people who speak English as a second language. Slowing down, speaking clearly and making an effort to communicate as carefully as possible is probably the number-one tip.

Helen: You’re talking about all of us who are talking with patients or families somehow. We should all take these tips whether English is our first language and whether we speak American English or English from another part of the world. We should all slow down and be clear.

Barbara: I think it’s just paying attention to communication, especially when you’re in a healthcare situation and you’re trying to get information about your own healthcare. You may be in pain or worried and fearful.

There are some specific difficulties or more barriers when you’re trying to get information about your healthcare than in other less stressful situations. I think communication becomes especially important when you’re communicating about healthcare.

Helen: Are the strategies you’re giving all the same whether we are the patient or the provider? Are we all supposed to be doing the same thing to communicate, or are there separate ways that we should be doing it when we’re the professional versus the person who arrives at our doorstep?

Barbara: Taken from the professional’s point of view, one of the things that happens is that you get used to speaking the technical language or jargon of your profession. You use a lot of acronyms and say a lot of things like CHF for congestive heart failure. It’s things like that that normal people not in that professional are not going to understand.

It becomes so familiar to you when you’re in a profession. That actually happens on the job wherever you are. You start referring to things in shorthand, or everybody knows what you mean when you say, “Level 1” or “Level 5” around here in our center. You’re referring to things that are very well-known in your profession or in your own setting.

For professionals, learn to communicate by not using what we could call medicalese and be careful about not using jargon. This is something for every medical professional. They should be aware of using medicalese.

Helen: We not only are dealing with our first language, but we’re also dealing with our second professional language. We have to realize that the people who are listening to us and communicating and interacting with us may not be speaking either one of them very fluently. Thank you for that.

One of your strategies was to slow down. I also have heard examples where people slow down so much that it sounds rude, belittling and often gets loud. How can people do this in ways that feel very welcoming?

Barbara: I’m thinking of a couple of things. I want to take a little detour because I want to really emphasize how important it is that people understand each other around healthcare and that they really are getting the information correct. I’m thinking of this model of communication that comes out of air traffic control.

Helen: We like planes.

Barbara: Imagine how important communication is when you are communicating between the air traffic controller and the pilot. This is one of the most high-stakes communication situations you can ever be in. It’s absolutely crucial that they understand each other. There are protocols that have been developed around communication in that setting, which is called a communication loop.

Redundancy is built into the system, meaning that there is a lot of confirmation back and forth. The air traffic controller says something like, “Flight 175, you may proceed to Gate 3.” Then the pilot has to say, “I heard you say Flight 175 can proceed to Gate 3.” Then the air traffic controller says back, “That is correct.”

The air traffic controller says something, the pilot reads it back and then the air traffic controller says that it’s correct and that they hear back. There are long protocols, and this is very important as part of their training. It is absolutely important that both sides of the conversation are part of making sure communication happens correctly.

One thing that is important for a patient or somebody who is getting information about healthcare is that we’re all in this together and we have the same goal. The goal is the health of the patient. It’s correct information for the patient so that the patient can get the information they need to get better. This is the doctor’s goal, the nurse’s goal and the patient’s goal.

If the patient or person receiving the information could say something like, “What you’re saying is very important to me. I want to make sure that I get it correctly. I may ask you to slow down. I may be speaking slowly myself but this is because what you’re saying is very important to me. Could you repeat that again and speak more slowly?”

You could also say, “I know you’re very busy and I know I’m speaking slowly. I want you to also slow down so I can understand you. I want to do my part in following your directions. I want to understand you. You have a lot of information that is important to me. I really want to understand what you’re saying, so I will repeat back what I hear. Is that okay with you?”

I think it’s really okay to be slow in your conversation, to repeat back information and to remember how important it is to make sure you understand what you’re getting. Be sure your doctor or nurse understands what you understand.

Helen: I want to confirm what I’m hearing from you, Barbara. You’re going to say it slowly and you want to make sure you understand. It sounds as though it’s almost the responsibility of the listener or the recipient of the message to set the context and the rules. Is that right?

Barbara: I think that is a very good way of putting it. It’s actually the responsibility of both parties, but I think it’s important for us to realize it’s not just the speaker or the doctor who is responsible for comprehensibility.

It is your responsibility as the listener to set the rules and say, “I’m part of this communication process. I want and need to understand. You want to make sure that I understand. We’re all in this together.”

Helen: I can think of a situation. In fact, I’m going back to see the doctor today. He’s a very nice, skilled physician and I’m glad that he’s treating me. However, he has a heavy accent. When he first diagnosed me with a diagnosis I didn’t expect and had never heard before, I didn’t know what he was saying.

I asked him what it was. It was actually an acronym. I asked him what it was, and then he gave me this great big, very complicated physiological explanation which was more than I wanted to hear. Then he went back to this very short phrase and said it louder. That didn’t help. I still wasn’t sure. Then I asked him to write it down, and he did.

I didn’t do all of the things that you recommended about setting the context. All I did was take that little piece of paper where he wrote down the diagnosis and I went home to Dr. Google and learned what I needed to learn. I’m thinking I missed some steps in there. Maybe he and I both missed some steps in there.

Barbara: I think you both missed some steps. First of all, your doctor repeating the information in long, technical phrases does not help anybody. One of the things medical school is really emphasizing now is communication skills. That’s actually a part of their training now because they’re realizing that for everybody, no matter where they’re from, communication is one of the essentials.

If patients don’t understand what they’re being told, then they can’t follow directions and the outcomes are not positive. For your doctor to just repeat it in a more technical way is not helpful.

For your doctor to repeat it in a louder tone of voice is also not helpful. This is something that is a good thing for all of us to recognize. If somebody doesn’t understand something, just repeating it louder is not going to help. You need to find a different way to say it.

The doctors need to really become conscious of this and do more listening. They need to listen to what you’re saying and pay attention to you. This would be a tip that I would give doctors.

A residency program director I know who supervises a lot of international doctors says that the doctors that are rated the mostly highly in communication skills are the ones that speak the least and listen the most.

Helen: I like that. Speak the least and listen the most.

Barbara: As people say, we have two ears and one mouth.

Helen: I like that a lot. What you’re talking about is so consistent with what we teach and talk about for health literacy. Communicate clearly and simply. Use words the other person can understand, and stop periodically to confirm understanding.

You referred to it as what the pilots do or the communication loop. Some work in health literacy is also called communication loop. Often we shorten that to the teach-back technique, which means putting responsibility on yourself at some point and saying, “I want to make sure I explained this really clearly when we talked about (whatever it was). When you go home, what will you tell your (mother, father, brother or aunt) about what we just said?” It’s confirming that key point that you discussed and certainly the role of listening.

How can people learn more about all of this?

Barbara: There are certainly a lot of materials that are widely available. For example, there are materials on non-violent communication. If you look it up, there is a whole series on that. It includes tapes for role playing.

I think resources where you hear models of communication are very helpful for people because you can listen to them and hear how other people would say it. We hear a lot. We can read tips on communication in the newspaper. They say to be assertive in your communication.

What does that mean if you’re not assertive, you feel embarrassed about being assertive or you’re afraid to bother somebody? You’re not going to know what to do. When you hear actual examples of role plays, I think that can help you with your language. You can practice and hear how somebody else would do it differently.

Also, you can prepare in advance. If you know that you’re going to go into the hospital, you may be nervous. Of course you’re going to be nervous.

My mother has a friend who is going into the hospital for knee surgery, and my mother was talking about the fact that her friend is really worried because there are a lot of nurses from the Philippines in the hospital where she is going.

That is very much to be expected because the Philippines is a big sender country and there are a lot of nurses from that background. They’re speakers of another variety of world English. My mother’s friend does not have a lot of experience with that community and with that accent, so she’s afraid of not being able to understand. My mother told me that she was helping her friend by role playing.

My mother’s friend is also hard of hearing, so she’s also afraid that she won’t be able to understand because she can’t hear very well. One of the things they’re going to do is put a sign on the door and talk to the nurse’s station in advance.

My mother is going to go with her. Having an advocate go with you is always a really good thing to do. Have somebody with you who can help you.

Put a sign on the door that says, “This patient is hard of hearing. Please speak slowly, clearly and loudly.” Just make people aware of communication needs in advance.

Also check in at the nurse’s station and say, “This patient is hard of hearing and is concerned about communication. She really wants to make sure she gets the right information. This is an area of concern, so please pay attention to that.” I think you can do some things to help prepare the situation in advance.

Helen: It sounds like you can prepare ahead of time. Give the context, think about this and be aware of all the changes that are happening in our healthcare system. This is going to be happening more and more, and that’s a good thing. It’s just different than it used to be. In the moment, you can go back and forth and confirm understanding in there.

I want to get back to the question I raised a while ago and tie it in with an issue you mentioned about that welcoming tone and how we can do this in ways that are welcoming and respectful yet non-condescending.

You used a term about non-violent communication, which is not a term I had heard before. That sounds a little scary to me. How can we create this welcoming tone in healthcare which has anxiety-raising situations?

Barbara: In the big picture of things, I think we all have to become more familiar with people who are different than ourselves. I know that’s a big-picture thing, but I really mean that.

I’m thinking of another situation. I have some family friends whose mother has Alzheimer’s and has been in a care facility for several years. She is being taken care of by nurses and healthcare aides from a Nigerian background.

My friends are working and not able to be with their mother as much as the nurses and the healthcare aides are. Now that their mother is actually spending time hearing stories that the nurses and aides are telling about their childhoods in Nigeria, my friend’s mother thinks that she also was a child in Nigeria and is telling my friends things that happened to her. They didn’t really because she grew up in New Jersey.

The point is that because we can’t be there, the most intimate people in our lives are being taken care of beautifully by people from other countries. Over time, getting to know people, their lives and how they live is helpful.

This is especially true if you, your mother or one of your family members is in a long-term care situation with people from other countries.

Start to find out about them. You can ask, “What was your life like? Who is in your family?” Then we develop a larger world family. This is actually who we are as human beings.

I think that we should learn to appreciate the journey that the healthcare workers, doctors, nurses and aides have been on to get to the United States.

I’ve worked a lot with people on their communication. I see them here at our center coming in after a long day’s work. As we know, doctors work unbelievable hours, and nursing is hard.

These are people that are concerned about their language and are coming in during odd hours when they can, on weekends and evenings to try and work on their communication because it’s very important to them.

They know it can be a barrier. Usually if they’re referred to the center, it’s because there has been a problem and somebody hasn’t understood them.

I see from my side how much people care, how much they want to help, how much they study, how much they’ve worked, and how hard their lives have been to get to the point where they can be here and provide healthcare.

Set the welcoming tone from the point of view of the patient. Yes, you are the patient. You are the person who has the right to have information expressed as clearly as possible to you. You should understand that and make sure you do everything you can to make that happen.

In terms of being welcoming, realize that the doctor is a human being on a long journey who has really worked hard to be that person to give you that information. The doctor really wants you to understand and to be seen as a good doctor.

Helen: Thank you so much for that. I loved how you framed that. We are all part of this larger world family. Thank you so much for being a guest on Health Literacy Out Loud. When I go to my doctor today, I’m going to think of him in a slightly different way and know that we are all in this together. Thank you, Barbara.

Barbara: You’re very welcome. Thank you.

Helen: I’ve learned so much from Dr. Barbara Hoekje and hope that you did too. Health literacy isn’t always easy. For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com. While you are there sign up for the free e-newsletter, “What’s New in Health Literacy Consulting?”

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Did you like this podcast? Did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.