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Procedia - Social and Behavioral Sciences 237 (2017) 992 – 997

7th International Conference on Intercultural Education “Education, Health and ICT for a
Transcultural World”, EDUHEM 2016, 15-17 June 2016, Almeria, Spain

Challenges in doctor-patient communication in the province of

Malaga: a multilingual crossroads
Alberto Pino-Postigo *
Universidad de Málaga, Facultad de Medicina, Málaga 29071, Spain

Abstract

Conveying information in the healthcare context involves a very delicate process in order to achieve successful communication
and, hence, a quick response in terms of effective treatment and follow up on the part of the patients.
The following study covers a professional experience based on participation and observation of encounters with patients, analyzing
the communication in the healthcare context and the roles adopted by every participant. The analysis we present has been obtained
throughout some years as a clinical student with active participation during hospital training periods with doctors, nurses and other
healthcare co-workers in several hospitals, both public and private where communications with foreign patients have always posed
a hurdle in certain cases. The linguistic issues found in hospitals belonging to several areas of the province of Malaga, in which
several foreign cultures converge will be analyzed in order to reach a final conclusion together with the potential strategies including
multimodality that could be valid from the point of view of doctors to enhance communication when there are problems due to
several factors such as language barriers, dialects, mental health issues or disability challenges.
© 2017
© 2016TheTheAuthors.
Authors.Published
Publishedby by Elsevier
Elsevier Ltd.Ltd.
This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the organizing committee of EDUHEM 2016.
Peer-review under responsibility of the organizing committee of EDUHEM 2016.
Keywords: communication; patients; humanistic approach; technologies; multimodal resources

* Corresponding author. Tel.: +34658109688

E-mail address: alpino@uma.es

1877-0428 © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the organizing committee of EDUHEM 2016.
doi:10.1016/j.sbspro.2017.02.141
 Alberto Pino-Postigo / Procedia - Social and Behavioral Sciences 237 (2017) 992 – 997 993

1. Background

The most common scenario of doctor-patient interaction in Western medicine is generally associated with a
biomedical approach. Hence, health is seen as a biological phenomenon in which the doctor offers assistance to the
patient in order to provide diagnosis and prescribe treatment.
Humanistic approaches refer to those in which the patient is seen as an individual with whom engaging in empathic
communication to have a comprehensive view of the patient’s condition (Konner, 1987) (Lewis, 2012). In many cases
some cultural differences must be also observed in interaction as vital factors for achieving satisfactory
communication. Therefore, the aforementioned biomedical approach is the one generating asymmetry in discourse
between doctor and patient (Mishler, 1984, p.120), whereas the social approach focuses on the patient holistically,
being considered as a whole person with its own unique life and circumstances who, at that particular time, is
undergoing a certain disease (Cordella, 2004, p.25).
In most healthcare settings the interpreter or cultural mediator is the one who adopts the role of the person interested
in the patient’s health involving listening and engaging with empathy.
Lewis (2012) states that the low impact of humanistic approaches in medicine is due to the fact that physicians face
a role conflict:
The primary reason for the lack of humanism in medicine is that physicians, in essence, face a role conflict.
Ideally, the physician values communication, listening, and empathy, all of which are qualities that patients
desire from their physicians. However, doctors are not paid to use humanistic methods. Hospitals receive
funding for technology, and doctors are paid for examinations and procedures. In effect, medicine as charity
has been replaced by medicine as a business and a science. (p. 11)

Some reports on American Medicine colleges (Weisman, 2006) state that there is an increasing interest on
promoting humanistic strategies in the training of physicians. Other research works based mainly in European settings
such as Rosiek (2015) also highlight the importance of the fact that the human being’s condition must be the focus of
the physician’s attention together with all possible related issues and all his fears, weaknesses and needs (Konieczna
& Slomkowski, 2015, p. 258). Effective communication with the patient is the prior condition to offering this kind of
understanding and care.
Communication Accommodation Theory (CAT) also supports the dynamic nature of communication. This
approach regards communication as a dynamic process, each party bringing their own motivations to the meeting
(Watson et al., 2015, p.59). This approach is necessary when analyzing encounters with different participants, with
different experiences and expectations. It can be applied not only to the speech styles but also to non-verbal information
(Gallois et al., 2005), as we considered that those elements influencing the decision of adopting a particular role go
beyond speech structure.
Accurate communication is capital both for interactions of physicians and patients who share the same mother
tongue and culture and for interactions where the patient and the doctor belong to different cultural settings, and hence
there is a language barrier, and in most cases cultural differences cause misunderstandings. Recent research and reports
(Angelli, 2015) put forward the need to standardize healthcare translation and interpreting in the European scope.
Multimodal approaches are also regarded as useful tools and aids for medical interaction with patients. Besides,
much of the work in the field of community interpreting focuses on research methods from a multimodal perspective
in search of evidence of active participation of the interpreter not only through textual analysis, but also by examining
a series of non verbal means of communication (such as eyes, paralanguage, visual gestures and body language, etc.).
Studies such as Pasquandrea (2011), Davitti (2012) and Bührig (2004) have provided us with new approaches to useful
resources for the interpreters to use in triadic encounters. These resources might be of interest for healthcare staff as
well.
994 Alberto Pino-Postigo / Procedia - Social and Behavioral Sciences 237 (2017) 992 – 997

Regarding medical research on multimodal communication strategies, many of the present studies has been
conducted in research projects such as Assanet for pregnancy† Trassadan for communication with foreign patients
(Verdugo, 2014) or EC+ (Calleja Reina et al, 2016) for severe disabled.
On the whole, these approaches have also proven to be extraordinarily helpful Bührig’s (2004), Civera & Orero
(2010), Cómitre Nárvaez (2016) and Verdugo (2014).

2. Hospitals in Malaga: overview

Throughout some years as a clinical student and integrated among doctors, nurses and other healthcare co-workers
in several hospitals, both public and private, I could observed that foreign patients have always emerged as huge
communication challenge.
Doctors from this geographical area usually get partly involved in a humanistic relationship with their Spanish
patients, a bond which disappears with foreign patients due to the linguistic barrier.
When it comes to the public healthcare system, most doctors have an intermediate level of English, which allows
them to communicate with worldwide patients, most of them European, and also foreign clinical students. The real
challenge arises when it comes to Subsaharian, Moroccan or Chinese patients. The vast majority of them come
accompanied with a relative who can act as an interpreter, in case they didn’t speak Spanish. The dependence on these
relatives increases should they had to be hospitalized. In most cases, healthcare workers tend to speak Spanish in a
louder, slower fashion relying also on visual gesturing and body language.
Regarding the east coast, these hospitals tend to host north European communities, such as German, Danish and
Norwegian citizens who settle down in villages like Nerja or Torrox. The regional hospital counts on a strong
volunteer-based interpretation service, made up by retired people from the aforementioned community. Thus, language
does not figure out a significant challenge to their healthcare attention as long as they have been living as residents in
the area for a long time and have found the resources to deal with them. Nonetheless, these volunteers do not receive
specialized language training, acquiring the appropriate terminology through practice.
On the contrary, the west coast, very well known for their famous places like Torremolinos (with an important
Dutch and British resident population) and Marbella (opulent Russian and middle-east Arab patients among many
other nationalities), rely almost entirely on the private sector. The companies behind these healthcare services know
their demand and often employ doctors who are highly fluent in English and additional languages even native Russian
or Chinese physicians.
Nonetheless, it is common to find foreign patients who have a basic or even a full command of Spanish. In this
context, the physicians start the interview in Spanish without checking their patients’ level of Spanish. As the interview
proceeds, little misunderstandings arise and the communication slows down, often reaching the point of complete
breakdown. At this point, the doctor often starts speaking in English, and as they move on, they continue speaking
English or Spanish. This language switch causes more confusion. In most cases, as the content of the interview process
does not involve vital details; they don’t follow up reassuring the patients. This, in turn, may affect the diagnosis
outcome.
Communication in the doctor-patient encounter constitutes the basis of an appropriate treatment; therefore the
communication may throw up undesired outcomes, if it is not accurate. There are three critical stages during the
interview: anamnesis, reporting and treatment prescription. Regarding the results and diagnosis, an additional
challenge raises: whilst during the anamnesis both doctor and patient use a common diary or basic health vocabulary;
when the physician integrates all the information resulting in an action plan that must passed on to the patient following
the deliberative relationship model, the doctor has to adapt the technical terminology he used prior drawing in a
common vocabulary so the patient grasp the main idea. This step, even hard with a Spanish-speaking patient, becomes
critical while informing a foreign patient. In these cases, physicians do not have time to prepare or think about the

†
http://www.asanec.es/xicongreso/images/ponencia1/Proyecto_Humanizacion_Perinatal_2013.pdf [Retrieved: 22nd May 2016]
https://www.campussanofi.es/2014/08/21/tradassan-una-app-para-facilitar-la-comunicacion-con-pacientes-extranjeros/# [Retrieved: 22nd May
2016]
https://sites.google.com/site/ecplusproject/ [Retrieved: 22nd May 2016]
 Alberto Pino-Postigo / Procedia - Social and Behavioral Sciences 237 (2017) 992 – 997 995

possible paths the conversation might leads to, so they see themselves forced to confront this stage only with their
previous knowledge of the foreign language. Hence, their vocabulary becomes limited in trying to explain the outcome
of the diagnosis process and treatment options with a restricted range of words which are often repeated in the same
interview, preceded by a short pause coinciding with the search of a more appropriate word, which in most cases
cannot be sourced.

3. A critical case: limited communication skills and resources

Let us move on to the analysis of a practical case observed from the point of view of the physician. A British mid-
age person hospitalized for more than 20 days in the Intensive Care Unit at a Malaga Hospital due to complicated
bacterial meningitis. The patient in a coma and on life support ventilation experienced no significant improvements
monitored by electroencephalographic observations every 5 days. The patient’s family comes every day at hospital
visiting, asking the physicians for their progress report. The staff had different English levels, from false beginners to
high intermediate level. We must bear in mind there were 55,877 British residents according to INE’s statistics for
2015 in the province of Malaga; therefore it is the largest group of potential foreign patients 1. At first, the medical team
had to brief the family members of the seriousness of the case, which was reinforced by the condition of the patient
undergoing no significant improvement after three weeks of appropriate treatment. Then important decisions had to
be made, so doctors set a meeting with all the relatives involved in the care of the patient, all sat down around a table.
Then, they explain the severe brain damage the patient has suffered and the point of no return it leads to. From this
point, doctors show the two possible medical procedures that could be taken. On the one hand, the first approach
consists of going on with the life support ventilation after practicing a tracheotomy, as long as the patient cannot longer
continue for more than four weeks with an endotracheal tube, and transfer him to the neurology services, as long as he
remains in consciousness weak but stable state. The possibility of becoming conscious again from the coma is real,
but his functional state would be completely dependent for the rest of the patient’s life. On the other hand, the second
approach would be to turn off the life support machine and to continue administrating palliative medication to the
patient, not to be confused with euthanasia.
In this context, the patient’s relatives insisted on asking about the importance of the brain injury and the results of
the diagnostic tests. The doctors, in their attempt to clarify previous briefings, kept repeating the information using the
same vocabulary. Due to the fact that they had no support images, reports or any other help to sustain their
explanations, the relatives who did not seem to feel fully informed agreed a few days period to communicate their
final decision.

4. Multimodality improvement: gestures, body language, and environment support

We suggest a standardized protocol to provide quality attention and care to the patients, with a range of freedom
for the physician to use the tools provided, choosing the best ones depending on the case, in order to improve the
patients’ care and make them feel comfortable. As seen with the previous case, physicians have a lack of in-house
resources when foreign languages are faced in communication with patients and relatives. When they know they will
face an interview like that, it is often too late to search for additional help and support. Hence a complete tool kit of
resources should be provided in every hospital consultation and get the doctors familiarized with its use, as long as
this specialized language gap is being fulfilled with proper language training.
It would be advisable to make use of the already existing teleinterpreting services (often ignored), in-place
interpreters and basic diagram charts -often provided by pharmaceuticals, fact that depends entirely on the hospital
and specific doctor. We could consider the benefits of inserting a handful of new resources, which may catch the
attention of the doctors, resulting in a higher usage rate. Following the upcoming trend of electronic communications
and devices, the idea of multi-platform apps containing interactive dialogue resources including anamnesis
terminology, images, description of diagnostic tests and results and treatments, would be the best option such as
Tradassan. Another app is also being developed by the EC+ project, focused on patients suffering from perceptive or
mental disabilities, both previous or consequence of their current disease.
In our previous case, communication may have reached a higher point of understanding if our doctor had some test
reports or diagrams in order to show them to the family. If they are not available, resources like the aforementioned
996 Alberto Pino-Postigo / Procedia - Social and Behavioral Sciences 237 (2017) 992 – 997

apps may have come in handy to elucidate some aspects like the protocols to follow when the two options were given
or in different situations, those resources may provide support to locate patients’ injuries.
Gestures and body language also imply a point of conflict in an intercultural interview. Therefore, doctors should
be careful in the way they proceed to physical examination, paying some extra attention to some specific ethnic groups.
These contents could also be included in a briefing text on the app, checking it quickly before meeting the patient.
As Bührig (2004) stated, diagrams sat the medical relationship to a new dimension named multimodality. This
whole new level must continue on his expansion by integrating new tools in everyday devices such as smartphones or
tablets, featuring apps focused on the better understanding of medical terms and processes, enhancing the healthcare
quality. In order to accomplish this purpose, the use of such mentioned tools ought to be taught and introduced at
predoctoral levels during the academic training so that the future doctors can get accustomed to it as soon as possible,
taken them into account as a first hand tool.

5. Conclusions

Linguistic barriers pose huge challenges for healthcare workers especially in multicultural settings like the city of
Malaga. Humanistic approaches (Weisman, 2006) and Communication Accommodation Theory (Watson et al, 2015)
advocate promoting humanistic strategies in doctors’ training and the dynamic nature of communication, that is, each
party bringing their own motivation to the meetings. These approaches undoubtedly will enhance healthcare
communication. There is not a well-established structure of professional interpreting services or they are not available
in critical situations (Angelelli, 2015). Therefore doctors need resources for effective communication with foreign
patients. Multimodal support (Pascuandrea, 2011), (Bührig, 2004) and electronic applications are available (Verdugo,
2014). However, a standardized use of these aids should be established as a protocol in institutions with multicultural
population.

Acknowledgements

I would like to thank all the hospitals and doctors in which I spent my training period, for all their teaching, both
in technical and humanistic fields; and, of course, for providing me the cases and experiences in which this essay is
based. I am very grateful to Dr. Postigo-Pinazo E. for giving me the notions I currently have about linguistics and
communication theories.
The research has been carried out in the framework of the Erasmus+project: Enhancing communication: research
to improve communication for people with special needs and development of ICT resources and tools. as an AEMMA
student member. Reference number: 2015-1-ES01-KA203-015625

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