Beyond Translation: A Doctor's Guide to Cultural Healthcare Communication

Eyal Heldenberg (00:11)
Hi everyone, welcome to Care Culture Talks, a new podcast exploring how healthcare and culture intersect in our diverse communities. I'm your host, Eyal Heldenberg. I'm the CEO of No Barrier, where we develop AI medical interpreter solutions for healthcare providers. Today we're diving into the world of cross-cultural healthcare communication. I'm thrilled to be joined by Dr. Deborah Gilboa. Dr. Gilboa, welcome to Care Culture Talks.

Before we dive in, we'd love to hear about you and your journey in healthcare.

Dr. G (00:44)
Thank you, I appreciate that. So I'm a family doctor. I've been a family physician for 25 years now. But my journey, my professional journey began before I decided I wanted to go to medical school. I actually worked in theater and television and that's going to matter in this conversation because I got to work in my theater career with a particular cross-cultural population - I got to work at a theater for the deaf. This was theater done by and for deaf people and it was my first real exposure as an adult to people who lived in a majority culture but their language, their culture, a lot of their belief system, their way of interacting was really insular and very different.

Eyal Heldenberg (01:36)
Amazing. Thank you for the intro. On a personal note, we talked with, I think, dozens of dozens of providers in the last year and a half. And I remember my meeting with you, it was exactly a year ago, last January. And I remember it very vividly on how you took me to the four walls of the medical encounter where how provider and limited English proficiency patient, for example, or other cultural gaps that are in the room, how providers should handle it, what's your experience. So I'm really thrilled to discuss this exciting topic. Maybe kind of as a baseline, what originally drew you to working with diverse patient populations in your current role and before that?

Dr. G (02:26)
Well, there are a few reasons that I was really, I feel very lucky to have been hired at the federally qualified health center where I work. FQHCs are an American solution to serving folks who are under-resourced, underserved, minorities medically for some reason or another. So our health center opened in 2006 and our grant was specifically to serve religious, linguistic, and cultural minorities in our community.

And I, as I said, I was in theater. I did that for six or seven years and I decided I wanted to go to medical school. I went to medical school certain that I would become an emergency medicine physician because I'd volunteered for a few years as an EMT, an emergency medical technician. And I loved it. I loved driving in the ambulance. I loved going to people's houses and helping them with emergencies. I loved the pace and the urgency and the excitement. So I got to med school, sure I would be an ER doc.

And I spent lots of time in my first couple of years volunteering in the emergency department. I really enjoyed it. I like procedures. I like mess. I like solving problems, but I also like asking people about their history. I like understanding what got them to this point. And the longer I spent in the emergency room, the more I realized I kept wanting to meet this people, this person two years ago and convince them to take a blood pressure medicine or get a booster seat for their child in the car or understand why the loss of their dog led to this depressive episode. And every emergency medicine attending said, hey, you're really thorough, but you're not an emergency medicine doctor. You're a family care doctor.

And they were totally right. I did my first rotation in family medicine as a medical student. And I was like, this, this is what I want. I want relationships with people. I want to understand their family structure and their reasons for doing things and how to actually partner with them over the long periods of time to make them as well as they can be.

So when I, so that's the other reason that I was drawn to underserved populations is that family medicine has a real ethos of meeting people where they are and serving them while partnering with them the best we can so that they can be, I tell my students, I teach medical students, I tell them all the time, we have two jobs as a family doc. One is to make sure nothing terrible is going on, right? That they're not at risk of dying from, you know, that that headache is just a headache and not as Arnold Schwarzenegger said in a movie years ago, a tumor. And the other is to make sure that we prevent as much as it's possible to prevent. So we're sort of constantly trying to push two boulders uphill. Are you okay now? Fundamentally okay. Is there anything dangerous going on that I don't know or you don't know? And what are we doing now to prevent as many future problems as we can prevent? And that's really nicely aligns with serving people who, in general, don't have easy, comfortable access to care that they totally understand.

Eyal Heldenberg (05:27)
Yeah, yeah. This is actually fascinating. I remember also from the talk that we had a year ago that you kind of guide me through different, I would say, anecdotes or kind of different use cases. Would you mind to kind of Dr. G to share with us one of, I would say, earliest cultural learning moments that really kind of opened your eyes in this FQHC settings?

Dr. G (05:52)
So the very first thing was well before I was a doctor, it was before I was volunteering as an EMT. I was working at Deaf West Theater Company in Los Angeles. I was the assistant stage manager on a show. The show was based on a book that maybe some of your readers have ever heard of called One Flew Over the Cuckoo's Nest. There's a movie also. And it's about an inpatient psychiatric facility. So here we are in rehearsal for this show about a psych ward. And the way we were doing the show, the three or four people, characters in the show that are the clinicians were English speaking hearing providers in an inpatient psych ward in the 1960s and all of the 17 patients the way we did the show were deaf and the show itself is about the barriers between in part about the barriers between the patients and the providers and here we were in rehearsal talking about with all of these deaf folks about the barriers they themselves as people experience between themselves and providers of any kind of medical care.

They were not inpatient psych patients, but they were all people who'd had really terrible experiences because of their language and cultural barrier, almost solely so different than the experiences I had had just as a hearing English speaking person who'd grown up in the US. They'd all grown up in the US, so it was not about an immigrant situation, but it was absolutely a linguistic and cultural barrier. Most of them were before, and this is something that'll make sense to your American audience, the Americans with Disabilities Act passed in 1993 requiring interpretation for people who were deaf. But these people had all grown up before then, so most of them had gone to the doctor as kids, understood absolutely nothing.

And then their parents, and this is something interesting, 90% of deaf people have hearing parents who don't sign, or picked up a little sign or did their best to learn, but were not fluent in their language or their culture, because deafness is absolutely a culture. And so they were really very much like if you or I moved to a country where we didn't speak or read the language alone, right? Moved there alone. So we would go to the doctor with maybe somebody we met there or someone we knew there, but we didn't have good communication with them either, even with our family members.

That was really what opened my eyes to how crucial clear, comfortable communication is that no matter what else happens, even if the doctor's fantastic, even if the treatment's exactly right, if you don't understand what's going on, if you can't clearly communicate what's happening with you, and if you really can't understand the plan or agree to it, it's almost impossible to get good care or to be healthy.

Eyal Heldenberg (08:37)
Amazing. You mentioned kind of the interpreter or the medical translator. Do you have any, I would say, settings or anecdotes that I would say the presence of the interpreter either was very helpful or maybe very negative? Like, what's the spectrum here?

Dr. G (08:58)
Well, I'm in a unique position because I worked my way through medical school as an interpreter for deaf and hard of hearing patients. So I had those experiences in theater. I thought, deaf culture is so interesting. American sign language is so cool. And then years later when I decided I was giving up theater and I wanted to go to medical school, I had to take some science requirements before I could apply to medical school. So while I re-enrolled in university, I had a bachelor's, but it was in theater.

So while I re-enrolled in university and took biology, chemistry, physics, et cetera, I also took classes in ASL and I became a professional interpreter. I needed that income for the year of applying to med school and getting through medical school, but I ended up spending those five years as an interpreter. And I had, for example, an experience where I was in the emergency department. I used to study at the med school and when my interpreting pager would go off, I would just go downstairs to the emergency department.

My interpreting agency loved this because I was always right there because medical students study all the darn time. And so I went down to the emergency department. I was seeing a patient who is having some pretty significant pain. One of the things about interpretation is that you interpret everything you hear. That's right. The ethic is I'm that person's ears and voice. So if I can hear it, if they were hearing, they'd be able to hear it. So we're in a room that is four different rooms divided by curtains. And I'm interpreting for the patient everything that's in my earshot.

And what ends up being in my earshot is a group of doctors, you know, an attending physician and some trainees who are talking right outside the curtain about my patient. So when the doctor comes in, my patient has questions about all the things they've heard. And this doctor looks at me very accusatorily and says, how did she hear that? She's deaf, but I'm just a vessel. So I sign "How did she hear that? She's deaf." And my patient says, "I have an interpreter. Would you like me to introduce you?"

And then I've had another situation where a good interpreter for American Sign Language should stand just behind the provider and a little off their shoulder so that the deaf person can look right at their provider, see facial expression, make connection, feel like it's me and you, and glance just up over their shoulder to see the language that they need. And all interpretation is done in first person. You know that if you've ever listened to someone interpret a big speech or anything.

So I'm just behind this doctor's shoulder, which he did not love. And because it's uncomfortable to have someone behind you, especially when they start talking to you. So he says to this patient, "How are you feeling today? Why are you here?" And she says, "Well, my back has been hurting for two weeks and it's just getting worse and worse." And this guy turns around, looks at me and says, "I'm not here to help you. I'm here to help her."

But then I've been the provider who was trying to use an interpreter and it was falling apart and I couldn't figure out why. And I had to turn to the interpreter and say, speaking to the patient, so I'll, you were my patient, I said, "Mr. Heldenberg, I'd like to ask the interpreter for a little support because I think what I'm saying to you isn't making as much sense as I would like it to. And I think I'm missing some cultural cues. Is it okay if we get their help?"

And having the interpreter be, and a lot of our interpretation at the office that we use is phone. So the interpreter can't see me or see the patient remembering that I don't need American Sign Language interpretation. We use video platforming for that with our deaf people who need that in our office use that with our deaf patients, but most interpretation is only voice. So saying, can you help me? And when the patient said okay than saying interpreter I'm wondering I get the sense that the questions I'm asking don't make sense to this person can you help me and this person just gave me such great information just like a flood like they've just been waiting to be asked and so I had to learn that the interpreter when used correctly can be an amazing resource in addition to a great technician.

Eyal Heldenberg (13:29)
Got you. Have question. Do you think there is a difference between ASL interpretation settings and just regular Spanish or like a vocal interpreter?

Dr. G (13:43)
The differences that I see are one, sign language interpretation is legally mandated if the patient wants it. Like, so the way the Americans with Disabilities Act is interpreted, whatever form of support in communication that my deaf patient wants, they get, right? They decide. So if they want to write back and forth, if they were comfortable with that, which would be surprising, because it's still in the language that they're not usually totally fluent in, but if that's what they wanted, fine. If they wanted lip reading and no interpreter at all, strange because only 40% of English letters show up on your lips, but if that's what they want, that's what they get.

If they want their family member to interpret, I can say, here's why I don't think that's a great idea, right? They're gonna have trouble asking you about your sexual history. They're gonna have trouble not injecting their own opinions about what you should do, you know, and just straight interpreting. But if that's what they want, that's what they get. With language interpretation, we have ethics that require us to get great professional interpretation. But in most states in the US, we don't have laws that require it. So I think that's one difference.

I think another difference is being able to see facial expression and body language and all that goes along with sign. So when you don't have that, I think it's different when you're not. And then I think just the last thing is so many languages are native to more than one country. So for example, I might get a great Spanish interpreter, but if they themselves are from Spain and my patient is from Guatemala or Costa Rica or Puerto Rico or some other, you know, there's so many different places where Spanish is spoken.

Same with English, right? If English isn't the native language of the provider and we get an English interpreter, that English speaking interpreter could be from so many different places that they're not necessarily culturally competent in the patient, even though they're linguistically competent.

Eyal Heldenberg (15:34)
Gotcha, so you managed to see that the dialect could play a kind of a major role in the communication channel, right?

Dr. G (15:43)
You're right. It's good. So there's a dialect issue. Spain Spanish is really different than certain Central American Spanish's or Spanish from South America. So there's there's slang and accent and dialect all that, but also culture. So here's an example of a cultural thing. The way we indicate yes and no nonverbally changes by country.

I learned this when I have Nepali patients. We have, we see a big Nepali population. And if you were telling me something, if you were my provider and you're like, I've really been worried about your blood pressure. And I agreed. My cultural response is, yeah, I sort of tilt my head to the side. Like, I don't like this. I squint one eye, but I'm nodding, right? And you get just from that motion, I see what you're saying, even though I don't love it.

Well, it turns out that that as I understand it for a Nepali patient is, and this only makes sense, real sense to your folks who are on video, but it's whipping your chin to the side, looking to the side and making a sound that sounds like a sound that from an Israeli would mean absolutely not. Absolutely not, right? Absolute judgment and negativity. And so I was reacting to it because I have an American and Israeli cultural background of like, these people hate what I'm saying, totally disagree. Finally found out by talking to the interpreter and asking more questions that this is the same as nodding vigorously for me. So it's agreement.

Eyal Heldenberg (17:21)
Nice.

Dr. G (17:24)
It's not enough to be amazing at this, right? It is certainly better than nothing to just have the language, but there's more than the language. There's more than vocabulary to interpretation.

Eyal Heldenberg (17:37)
In this example, how did you practically learn that the interpreter kind of managed to bridge this gap or you just...

Dr. G (17:44)
No, I called it out. said,

I hear that you're saying you agree and you'll take this medicine because those are the words they used. It feels to me from your facial expression and your body language that what I'm saying doesn't sound right to you. Can you help me understand?

Eyal Heldenberg (17:52)
Hmm.

Got you.

Dr. G (18:04)
And the patient's words were back to me after that through the interpreter was, no, I have thought a long time about taking a medicine for this. I think I should. And I thought, okay. So I had that experience a few times and I finally asked, and this is one of the things about being in a family medicine practice with patients for a long time. I have some Nepali speaking patients who've been in the U.S. little longer whose English is great. And I could say, hey, help me understand something.

Eyal Heldenberg (18:27)
Hmm.

Yeah. Yeah. And going along those lines of, of, um, different, different cultures. also remember for up from our previous, uh, previous call that you kind of identify different, would say different categories, groups, cultures around the world, because you serve, I think it told it around 59 languages or something like that. So you, you've seen people from all over the world, probably in your practice. I don't know if you have like,

a some property or I don't know some cultures or something that you already know a like how you should approach or what you know what you learned about different categories of of cultures

Dr. G (19:13)
So the first thing I've learned is that like you don't even know what you don't know. So when we first started seeing, I'm gonna pause I'll and say your video froze for me. Can you still hear me? Great. That's fine. When we first started seeing patients who were Nepali, the laws in Pennsylvania covering patients who are coming in through the immigration program that they were coming in through.

Eyal Heldenberg (19:24)
Yeah, yeah, yeah, I'm.

Dr. G (19:40)
they had to be seen by a physician within 48 hours of getting to the United States. They were coming from a non-WHO country. We were worried about infectious disease and all kinds of things. So they would come in for these new patient visits within the first 48 hours. I walk into the room, there's often a room full of a family and I walk in and I do what I would do for someone, for anyone, which is I walk into the room, I introduce myself.

I say hello, I ask who everybody is, I go, I wash my hands and I sit down. And somewhere in that 30 seconds or 60 seconds, I was losing people. They were just shocked. But I also couldn't figure out, I mean, they're still jet lagged. For people who'd never in their lives been on an airplane before, many of them had never been in a car until the last little while, who, and I wondered, I'm definitely confusing them or putting them off in some way.

Eyal Heldenberg (20:25)
Mm-hmm.

Dr. G (20:37)
Is it being in a doctor's office in the first place? Is it something that happened before I got to them? Is it me being a woman? Is it the fact that I had been taught and told to greet them by placing my hands together and bowing my head and saying, Namaste? Am I doing that in the wrong way? Am I doing it to the wrong person? Should I not be doing it at all? Is that we have indoor running water or I use paper towels to dry my hands that I then threw in a trash can and then I sat down? Did I sit down at the wrong moment? Did I?

faced the wrong person, should I not address the children, should I start by addressing the older person? Like, I don't even know what I don't know about that first 60 seconds where I'm setting the tone for what will may very well be a years long relationship. So I was like, I just got to ask. And we, in our practice, we counted several years ago and at the time we were seeing patients from over a hundred countries speaking 62 different languages. And I speak three.

Eyal Heldenberg (21:31)
Wow, it's a lot.

Dr. G (21:35)
And I think that's pretty cool, but it's not nearly enough and it's not the majority of my patients by any stretch. So every time I encounter people either speaking a language that I don't speak or from a country that I just don't know enough about, I know I've got to ask and that when I ask, I'm getting one person's opinion. And when you've talked to one person, you've talked to one person. So the more I can ask the

better I'll do and I probably still won't get it right. But as I tell my medical students all the time when they take the time to learn from me before we walk into a room for a deaf patient, just how to fingerspell their own name, like to say hi, I'm, and then finger spell their name, even though they won't be able to sign any of the rest of the encounter and I'll interpret for them, my patients just, they feel really understood and seen with that effort.

So one of things that I do is, especially when I'm seeing kids, but I try to do it with everybody, is I learn a greeting in every language for patients that I see.

Eyal Heldenberg (22:39)
Nice,

this is nice gesture, right? Kind of...

Dr. G (22:43)
And it's just

a gesture. It's just a gesture, but I have found that it breaks down a lot of barriers and it builds a lot of trust.

Eyal Heldenberg (22:50)
Yeah, yeah. You know, I've heard from different providers that, you know, in different areas of the world, there are different beliefs around healthcare, approach, around... I wonder if, like, when you kind of approach kind of a new patient coming in from... Like, how do you handle... Maybe you already know their culture or kind of...

Dr. G (23:16)
Would you like to hear stories about when I've got it really wrong? that useful? So one of the times that I got it really wrong, and I want to say it's not only cultural, it's also generational. So the story I'm going to tell you might not be true at all of Turkish people who would be my age or your age or younger, but I was seeing a much older Turkish patient and told them

Eyal Heldenberg (23:19)
Alright, let's do it. Let's do it.

Dr. G (23:44)
told this man, and I think the gender is important in this case, told this man, I had to tell him about a bad diagnosis and like right off the bat because he had a growth that seemed almost certainly cancerous to me and he didn't want to follow it up. So I needed to be really clear that I, that this was likely life threatening and that if he chose not to follow it up, which is his right, I needed to know that he understood what he was consenting to, right? That this could very well kill him and soon.

in older Turkish culture as his grandson explained to me afterwards. Because, so I threw the interpreter, explained this to him, and the man lunges towards me, like physically, aggressively. And his grandson and his daughter really like caught him and pulled him back and talked to him and said things that were too fast for the interpreter to catch and all that. And the grandson asked me if he could talk to me outside. And I said, okay.

Eyal Heldenberg (24:29)
Wow.

Dr. G (24:43)
And he said, there's an older belief in our culture that if someone gives you bad news and you hurt them or kill them, then the bad news doesn't happen to you. And I was like, that's super useful information.

Eyal Heldenberg (24:55)
Wow. Wow.

It's not in America, right?

Dr. G (25:03)
It was in America that it happened, but they were right really recent immigrants and it was clear to me that his adult daughter and adult grandson didn't see it that way and I don't even know if he really saw it that way or if it was just the fear and that you know the anger we often have anger when we hear something really frightening but whatever it was I probably didn't handle it well even if we'd been the same culture I was you know, like I'm sure there are things I could have done better about delivering the news and

Eyal Heldenberg (25:05)
Yeah, yeah, of course.

Dr. G (25:30)
If I'd known that, I still don't know what I would have done differently because, and this is an interesting problem, my medical ethics say, I can't not tell him. So it would have left me with a problem anyway, but I went and I read about it afterwards, because I was like, really? And it turns out really. And just because something's really far from what seems reasonable or rational to me doesn't mean it's not reasonable to someone else and true for them.

Eyal Heldenberg (25:33)
Yeah, because you have to do it, right?

Yeah, yeah. Was there any medical translator there in that room, in that scene?

Dr. G (26:05)
In the room, no, we were using a voice interpreter who write through a phone, like speakerphone, which is how we normally do our interpretation.

Eyal Heldenberg (26:07)
voice interpreter.

So I wonder if you had a case where the medical translator was kind of the bridge who would say, hey, Dr. G stop, I need to explain you something cultural. Like, was there any something that did like a time-out thing?

Dr. G (26:26)
Right? Yeah. Yeah.

I've I've almost never had that happen. I have on occasion with Muslim patients had someone an interpret a male interpreter say to me with a female patient. I think it will be insulting for me to ask the patient this.

Eyal Heldenberg (26:48)
Mmm.

Dr. G (26:50)
And if it's a question about reproductive health or sex or anything like that. And so in that case, I've said, okay, interpreter, please interpret. I would like to end our call with this interpreter and call back and ask for a female interpreter. Is that acceptable to you? And I have to say that every time that's happened, the patient has been like, yes, that would be great. So that's the one time that I've been, I think, really helpfully corrected.

Eyal Heldenberg (27:05)
See you then.

Dr. G (27:20)
But, now I've learned to just ask, you know, and it's something that I have known about certain populations, but not about other populations, you know, so I just, had to learn and I'm grateful for anybody who's willing to teach me, but I also have heard stories from other providers who were just not getting good answers or they, sometimes you get an interpreter who isn't great. Like, I mean, we have to, we have to, think, talk about how not all interpreters are thinking strongly about ethics, like, like those examples, but also,

Some of them.

I sometimes worry that they don't understand the maybe my English is too medical or I've seen this with medical students who being interpreted. They use English that's too medical where an English speaking patient might be like, what does that mean? I understand. Right, needs, well, or the interpreter needs to be able to say, I'm sorry, this is the interpreter. I didn't understand what you said in English. Can you say that differently? And then I'll interpret it and then say to the patient in their language, I'm sorry, I had to ask for a clarification. We're going to try this again.

Eyal Heldenberg (28:07)
Yeah, it should be simplified.

Mmm.

Yeah.

Dr. G (28:22)
I've had interpreters do that, but I think a lot of interpreters, well, I don't know a lot. I know I've had the experience of some interpreters not. My Spanish is pretty receptively fluent, but I can't speak Spanish fluently. So I use interpreters and I've definitely heard interpreters as I've time and again, heard family members. When I say something, what they say is not what I said. And, and so I'm lucky to work at a place where we get

Eyal Heldenberg (28:45)
Mm-hmm. Mm-hmm.

Dr. G (28:50)
interpretation, even if a patient says, well, it's okay, I can just use my family member where we say, I'd prefer to use a professional interpreter. And we only don't if the patient refuses, as opposed to a lot of situations in which the provider, because it's darn expensive, right? Interpretation is really, really expensive. And you can wait, right? If it's a dialect, if I need an interpreter who speaks Karen from Myanmar, we've waited.

Eyal Heldenberg (29:01)
Mmm.

Dr. G (29:20)
an hour sometimes for that interpreter. And that's really logistically complicated in an office or in a hospital. So you can see why providers want to err on like, they said we could use a family member. Great, let's go. But in our office, we have guidelines that we try really hard not to use family members unless everybody's known well, the situation has like no potential, you're just there to get your blood pressure checked and the patient's really comfortable wants to use that person.

and that person wants to be used because what happens a lot is you get an English fluent, nearly adult or barely adult grandchild who would rather not be in that position. They were there to drive the person or go with them on the bus, make sure they got there okay and make sure that they understood when the next appointment was and what prescriptions they should pick up. They don't want to be the medical interpreter, but the grandparent wants them to be. So making sure that both family members really consent.

Eyal Heldenberg (30:03)
Yeah.

Hmm.

Dr. G (30:18)
is another really important ethical thing. But I wanna get back to how it can be really hard when you're speaking something and you have this feeling that the interpreter isn't being straightforward, entirely straightforward about clearly interpreting, either that they're adding their opinion, but more concerning. I tell my students all the time, if you say something and then you hear the interpreter speaking in another language,

but they use a bunch of the words you used in English with that accent, probably that's because that language doesn't have those words. I was giving a women's reproductive health lecture at a refugee center that had people who spoke 12 different languages. So I was speaking a sentence at a time in English. Each of the little groups of women had a language interpreter. And I was talking about ways to prevent pregnancy. I'm talking about this, I'm talking about that. But when I get to condoms,

Eyal Heldenberg (30:52)
Hmm

Dr. G (31:13)
I then hear all these different languages, condom.

Eyal Heldenberg (31:17)
Because

they don't have

Dr. G (31:20)
Well, and I want to know because there are languages in which they absolutely know what it is, that's just the word, or was it because they've never heard this word before or this idea doesn't exist? So I stopped and I said, has anybody ever seen this before? And I held up a condom and one woman of 50 was like, yeah. And I was like, okay, we're gonna go back and start with, does anyone have a banana? Anyway.

Eyal Heldenberg (31:34)
Mm-hmm.

Yeah, yeah,

yeah. Yeah, it's a great example of those. It kind of relates to how do I simplify the doctor's English to whatever the other language as an interpreter. But what do I do if I don't have the words, I don't have the way to exemplify to the patient what's the...

What's the topic? And I also take from your last story that the gender of the translator sometimes can play a big role, especially, for example, female patient sensitive.

Dr. G (32:26)
Right,

a really big role. Some cultures are really matriarchal, some are really patriarchal. And so the gender, I've been in a different situation with a patient from an island that happens to have a really matriarchal culture. And it became clear to me after several visits that this patient felt like because I was a woman and the interpreter was a woman, they had to do what we were saying.

Like there was no role left for that patient's autonomy or choice. The patient themselves felt like, but women told me to do this. And so it's not only, gosh, we can't always have male interpreters. Like it really depends on the culture and the situation. After I found that out, it became clear to me, we had a really pretty clear conversation using the interpreter that this person would feel like they could say what they really thought more if their interpreter was male. Great.

Eyal Heldenberg (33:21)
By the way,

technical question, can you choose the gender of the interpreter or you don't get to choose that? You can cry.

Dr. G (33:28)
We can try. So if

it's for a really common language, we can always ask, but they will often say either, nobody's available right now, or yes, but that person's busy, I don't know how long it'll be because you never know how long an interpreting session is gonna be. And so if it's a more rare language or whatever it is, it can make the difference between having interpretation and not.

Eyal Heldenberg (33:51)
Got you. All right. Perfect. I think we already mentioned it, but a couple of practical questions and recommendations from your end. What are some immediate steps providers could take to improve their cross cultural communication?

Dr. G (34:08)
One is just trying to remember all the time that you don't know what you don't know. And one of the best clues for us that we don't know what we don't know is what we thought would happen after a visit didn't happen. The patient didn't get the test or isn't taking the medicine or doesn't feel any better or whatever. And that happens all the time and for a bunch of different reasons, but it makes us ask more. And we should all do what we were taught to do in training, which is once you've gone over the plan with the patient, ask them to tell you the plan. It's not patronizing. It is...

good medicine to say authentically with no condescension, okay, I've explained what I think would make the most sense to happen now. Can you please tell me what you heard and what your plan is? And hear it back from them, even though it's through the interpreter, hear it back from them and see where the gaps are. When you do this, when you speak the same language and you have the same culture, you often find big gaps. So that's really helpful. And then,

The other thing I think is too...

Let your patient know that you expect to get it wrong sometimes and that you are counting on them to let you know when they see something that you're not understanding, not just about the language, but about what makes sense to them or if there's a piece of the history that they feel like you should have asked about and you didn't, or if they're gonna try something that culturally makes sense to them and you would like to know about it because it's gonna influence their health. So I have.

I have patients from certain cultures who still use cupping. So for your medical folks who are listening, they'll know that that's heating up like cups, like tea cups, heating them up with steam inside and placing them on a patient's back or chest to help with respiratory issues. And the research is really pretty clear that this does not help with respiratory issues, but it does sometimes dangerously burn people. And listen, my dad has some scars on his chest from being cupped as a child.

This is in lots of different cultures and it's not that long ago in almost every culture. But if a patient's going to try something that may not help in my experience but isn't going to hurt, that's one approach. If they're going to do something that we know can lead to, is pretty likely to lead to problems, we have an ethical obligation to say, I appreciate that that's been part of your experience. Here's why I'm worried about that.

Eyal Heldenberg (36:34)
Yeah. Yeah. Yeah. Yeah. I'm taking it from me that there is need to kind of empower the patient in the room to get to this crystal clear communication that he or she would feel comfortable to share, to touch. I don't know, dark sides. Sometimes they didn't want to share something, but if you empower them and kind of give the room and especially even time, because I guess those encounters

Dr. G (36:34)
and just let them know what your concerns are.

Eyal Heldenberg (37:04)
can be long, right? But the practical thing is give the space, give the time, give the empowerment so they could feel they could share something like that, right? Am I getting it right?

Dr. G (37:18)
I think you're right. I know that a lot of providers we hear give it time and we think, well, now I'm three hours late, right? I say often to my patients that I, something I learned from a residency teacher of mine, which was I got 35 minutes behind about 10 years ago and I haven't caught up. But really one of the advantages in primary care and anything but emergency care is if it's not going to be longer, it might just need to be more frequent. So if you've only got

Eyal Heldenberg (37:46)
Mm.

Dr. G (37:47)
minutes to see this person, can somebody see them back in a few weeks instead of a few months and build that trust over serial visits as opposed to trying to take the hour and a half it would take to build trust in this one moment. If nobody's in danger, then we can take longer, more visits to build trust instead of trying to get to it this time.

Eyal Heldenberg (37:53)
Yeah.

Yeah, yeah, it makes sense. I think we almost done. Maybe just kind of wrap up. Maybe you already mentioned it with the Turkish case. Do you have a way to navigate situations where the cultural practices differ from your standard medical protocols?

Dr. G (38:29)
My students will often say to me, well, I can't judge them. And I have to say, judging is part of your job. As a provider, part of your oath is to use your best judgment. And so if you have a patient who is determined to do something that you in your best medical judgment believe is dangerous, you know, if they, and I don't have an example of a culture that does this, but if they said,

while this child has seizures, so, and this happened 200 years ago in the British Isles, we'll leave it outside so that the fairies can change it back to a normal human child from the demon that we believe is inside, you would actually have to call Children and Youth Services on that family, right? You can't allow that child to have their life put in danger for a cultural belief. But if nobody's in danger, and that's the majority of the time, if your patient is not in danger, then saying,

Eyal Heldenberg (39:05)
Yeah.

Dr. G (39:26)
That's interesting to me. I haven't learned about that. Will you teach me about that practice? Can you help me understand how that helps or what you've seen with that or what you know about that? And often, like anything we ask people about in medicine when they haven't been trained in medicine, they may say, I don't know. I guess I just heard about it. I don't know that much about it. Or I've never seen it work, but someone in my family told me that maybe I should try this. Then you might be able to partner with them and say, okay.

I totally understand why that, you you know that person and you trust that person and we've just recently met. I have used this thing I'm recommending a bunch of times with kids, cause I see kids or with adults and I've had a lot of success with it. Would you be willing to try it and reach out through your interpreter, through your grand, your adult grandson, whatever, in a week and let me know how it's going. And if that's not working, we can talk about other ways to try and approach it.

Eyal Heldenberg (40:16)
Amazing. All right, think we're kind of on the closing side. Maybe last question, kind of a future for what do we see as the biggest opportunity for improving cross-cultural healthcare communication?

Dr. G (40:34)
I think in the short term.

You may not want to use this, but I actually think it's true. I think in the short term, it is actually large language models and what AI has to offer us because in the long term, I hope that it is finding ways to both better educate providers and help everyone in healthcare about what we don't even know about cultural differences and helping patients know that they need to give us a cultural history along with and what that means. But I think in the short term, if I had both

access to affordable, constantly available communication in every spoken language that exists in the world, and a growing database of ways that culture can support health and ways that cultural differences get in the way of health, just to know that that was being constantly learned and learned and and adapted for generations and gender differences and belief systems and...

I think in this way, if we harness it right, computers can really only make us better at our jobs.

Eyal Heldenberg (41:40)
Amazing answer. I totally agree that AI and LLM could actually mesh everything together from language, culture and context into those four walls, into the medical encounters. So I totally agree on this vision. All right, we're done with this episode. Dr. G, thank you very much. Like every time I see you, I learn a lot and appreciate your participation in care culture talks. Thank you very much.

Dr. G (42:09)
Thanks for having me.

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