Hispanic Patients: The Communication Challenge

You're a new amputee, about to be fitted for your first prosthesis. You're a bit nervous and apprehensive, even though some of your family has accompanied you to the prosthetic facility. Spanish is your first language, and the English you know seems to be rapidly deserting your mind as you face this somewhat intimidating experience. The prosthetist comes through the door--and speaks to you in fluent Spanish. How reassuring! At once, you're relaxed and much more confident.

This is the experience of many Spanish-speaking patients as prosthetic and orthotic providers, who are mostly non-Hispanic, increase their efforts to serve this growing segment of the US population.

The nation's Hispanic population has been growing much faster than the population as a whole, increasing from 35.3 million on April 1, 2000, to 38.8 million on July 1, 2002, according to US Census Bureau estimates. "The official population estimates now indicate that the Hispanic community is the nation's largest minority community," said Census Bureau Director Louis Kincannon in an address to the League of United Latin American Citizens (LULAC) convention in Lake Buena Vista, Florida, in June. "This is an important event in this country--an event that we know is the result of the growth of a vibrant and diverse population that is vital to America's future."

New Census Bureau population estimates show that the Hispanic population grew 9.8 percent between April 1, 2000, and July 1, 2002. The rate of growth of the population as a whole was 2.5 percent.

Cultural Immersion Helps Texan

Caring for a Spanish-speaking patient population has come easily to John W. Fain II, CPO, chief executive officer, Medical Center Brace & Limb Inc., Houston, Texas. Fain has had almost a lifelong passion for Spanish culture and the Spanish language. "I even dream in Spanish," he says. Fain studied Spanish in junior high and high school, including several years at an East Coast prep school, and throughout his four years at Southern Methodist University (SMU), Dallas. Two of Fain's sisters had lived with a non-English-speaking family in Spain for awhile, and Fain, the youngest of eight children, later did likewise. Immersing himself in the language that way helped make it second nature for him. One of his college majors was Ibero-American studies, which deepened his understanding and appreciation for Hispanic peoples and culture.

In his work, "I use my Spanish every day," Fain says. He frequently is asked to translate for physicians and therapists. "I'm a 6'4" blond gringo," he continues, "and when I walk in and surprise people by speaking Spanish, I'm usually met with smiles and warm expressions of thanks." Patients and families relax and "open up" when they hear their own language, he notes. Sometimes he doesn't reveal immediately that he understands Spanish, so when a patient or family member makes comments, such as "He won't have the leg ready in time," or "He's really tall," he elicits surprise and giggles when he suddenly chimes into the conversation in Spanish. Spanish-speaking friends often call him "Juanito" or "Rubio" ("Blond").

Houston has a large Spanish-speaking population, and the staff at Fain's company all speak Spanish at some level; several are fluent. Printed informational materials are available in both Spanish and English. Fain also treats patients at the renowned TIRR rehabilitation hospital and a prison population in two state clinics and a large federal prison in the Houston area, and has found that his language skills are useful in these settings too.

As far as cultural differences, Fain sees more differences in "haves" and "have-nots," such as low-income families in the Houston area and wealthy Latin Americans who fly to the States for medical care--money no object--than between various countries of origin.

Shriners Hospitals

The Orthotics and Prosthetics Department at Shriners Hospital in St. Louis, Missouri, also sees many children from Spanish-speaking families, according to Eddy Leopoldo Fuentes, CPO. The hospital covers areas of Missouri, Illinois, Kentucky, Tennessee, Arkansas, Iowa, Kansas, and Oklahoma. The number of Spanish-speaking patients has been increasing, especially from Kansas, Fuentes says.

Although many of the children speak English well, most of the consent forms must be signed by the parents, Fuentes notes. "Explanations of surgical procedures, post-op care, orthotics, prosthetics, and other relevant information have to be given to the person who is responsible for the child," Fuentes explains. "And many of them speak very little English, or none at all."

Fuentes, who is bilingual, assists the medical staff and other coworkers with translations when needed. Also, non-English-speaking patients are encouraged to bring a translator with them, he notes. "If they cannot provide one, the hospital, through the Family Services department, makes arrangements to help." A 12-week course, "Medical Spanish for Healthcare Providers," is also offered. The course, which involves two hours a week, is an intermediate-level course requiring students to have taken Spanish classes in high school or college. Instructional documents and forms for patients are available in Spanish.

Steve Baxter, CO, LO, director, Orthotics Department, Shriners Hospital, Houston, finds the language barrier more formidable. Originally from Cleveland, Ohio, Baxter, like many others, took two years of Spanish in high school--25 years ago. "That apparently did not help me when I came here five and a half years ago," he says. Rescue has come in the form of a bilingual Hispanic office manager who "over the years has tried to teach myself and two other practitioners enough Spanish to be able to communicate somewhat with our patients. Mostly she will translate--but with three practitioners, the phone, and handling our reception desk, she can't be everywhere--so we've had to learn some Spanish!"

More help arrived when an orthotist, who is originally from Mexico but received his orthotic training in Minnesota, joined the staff. "He has been a great asset in battling the language barrier," says Baxter.

Spanish fluency has been vital to the Shriners Orthotics Department, since a large percentage of the hospital's child patients are Hispanic. They come from the Houston area, other parts of Texas, plus northern and central Mexico. An outreach clinic is held several times a year in La Feria, Texas, about four miles from the Mexican border. "Very few of these 250 patients speak any English," Baxter says.

Practitioners Share Experience, Insight

"Our staff was primarily Spanish-speaking because our patient base was also primarily Spanish," says Robert A "Bob" Bangham, CO, LO, who was working at Park Prosthetics & Orthotics Inc., Corpus Christi, Texas, at the time this article was researched. "Our city's Spanish population is the majority; we Anglos' are the minority."

Bangham started a new program for the company, "Diabetic Shoes," since he learned that the south Texas population has twice the rate of diabetes as the rest of the US. "We were experiencing so many diabetic patients that we could hardly begin to keep up with them," Bangham says. Since the majority were Hispanic and many did not speak English, Bangham was training a Spanish-speaking pedorthic staff to help handle the volume of work.

Ellie Boomer, an orthotic resident at Mary Free Bed Rehabilitation Center Orthotics and Prosthetics, Grand Rapids, Michigan, at the time this article was being researched (she's now staff orthotist), found to her surprise that the facility sees quite a few Hispanic patients. "I am always thankful for my four years of high-school Spanish that I suffered through," she says. Another aid is a small English-to-Spanish electronic translator that she bought at a local store.

"I have seen an increase in the number of Hispanic patients here, primarily due to our location in southwest Florida," says Steven Fries, CPO, Cardinal Prosthetics & Orthotics, Fort Myers. "There are a lot of migrant workers and immigrants employed in unskilled labor positions who have proven themselves to be quite dependable and industrious."

The two biggest challenges his firm faces in caring for Hispanic patients, according to Fries, are 1) most are uninsured, and 2) many speak little or no English. Fries has found a new tool: "Franklin makes an electronic English-Spanish dictionary-translator which actually speaks," he notes. "These are available at most Radio Shacks at a very reasonable cost and serve well in communicating with Hispanic patients who no habla Inglés.'" Fries also comments on a helpful website, AltaVista's Babel Fish, which converts words, phrases, and more extensive material into other languages (www.world.altavista.com). When this reporter tested it, longer translations can be somewhat garbled--but the general meaning is usually clear.

There is a strong need in the O&P field for an English/Spanish lexicon with prosthetic, orthotic, and other rehabilitation/medical terminology included, several practitioners have noted. An online lexicon/dictionary is now available on the Canada member society of the International Society for Prosthetics & Orthotics (ISPO) website (www.ispo.ca/lexicon). A Spanish addition to the lexicon/dictionary is underway, according to Wieland Kaphingst, Dipl-Ing, BMT, CPO, one of the authors. In some areas, continuing education courses in Spanish are available.

Josh Ryder, CO, Island Coast Orthopedics, Cape Coral, Florida, does not speak much Spanish, he says, although he learned to read and converse a little when he lived in Miami several years ago. One way Ryder has adapted his practice to the needs of his Hispanic patients is to have a translator on staff: his office manager is fluent in both Spanish and English. "You should see the joy they have," says Ryder, when he thus meets their communication needs and "shows their culture respect."

Lane Ferrin, CP, Northwest Orthotics Prosthetics Inc., Provo, Utah, says, "I speak Portuguese and grew up in a Latino neighborhood of Phoenix, so my Spanish is coming along." His language skills have helped him in his practice, since he says he has seen a great increase in the Hispanic population in the last two-three years, "being a general trend in our area."

Eric Schwelke, CPO, has treated patients of many nationalities in his 19 years of practicing in the New York City area. Since quite a few have been Spanish-speaking, Schwelke says he wishes he had studied Spanish in high school and college. "Out of necessity, I have picked up a rudimentary vocabulary to help communication." His company supplies manuals and patient instructions in Spanish: "This has helped tremendously in educating them about their new devices we provide."

Another help has been a bilingual employee to assist with translations when needed. "It has been a challenge trying to make appointments and such when not one of the family members speaks English," Schwelke says. "I have often thought of taking a Spanish course, but finding the time is hard."

Marita Dorsch-Carozza, CP, FAAOP, now of Klemmt Orthopaedic Services, Vestal, New York, notes that in her former Manhattan practice, Dorsch Prosthetics & Orthotics, Spanish-speaking patients were the largest non-English-speaking population in her practice, followed by Italian, Russian, and Chinese-speaking clients. Dorsch-Carozza, who studied four years of Castilian Spanish in school, says, "I speak enough Spanish to work with patients." At hospitals, a social worker often helps with translations when needed, but "pain is easy to pick up," she says, as patients point to areas of pressure and pain.

Forms, instructions, and other printed materials in Spanish have helped in communicating with patients, plus Dorsch-Carozza had Spanish-speaking office staff for over 28 years. She also had Spanish questionnaires that the non-Spanish-speaking staff could use in order to communicate properly with her patients. "It is imperative for patients to be able to express their prosthetic or orthotic issues clearly to their practitioner," she says. "One can never underestimate the comfort level of speaking with someone in your native tongue."

Communication among Staff Members

Of course, not all communication difficulties and linguistic barriers involve patients. Many patient-care centers and other O&P-related companies have staff members whose first language may not be English. How do business owners meet this challenge?

A problem can arise when many staff members speak the same language, but not all. The ones not speaking the language may feel like excluded outsiders. They may even feel that they are being spoken about in a derogatory way--and this could actually be happening. A recent newspaper article described a situation in a fast-food restaurant in which workers who could speak a Native American language were insulting workers who did not speak the language "behind their back," as well as the English-speaking-only owners of the business. A legal case arose.

One business in another industry solves the problem by requiring all workers present in an area to speak a language--not necessarily English--that everyone present understands. In other words, if the majority speaks a non-English language and everyone understands it, they may use it, but if someone comes in who doesn't understand the language, they must speak in a language that person understands also.

Hersco Orthotic Labs, Long Island City, New York, a pedorthic central fabrication facility, has ten employees, mostly of Hispanic and Eastern bloc origin. "We're diverse--just like New York City," says Séamus Kennedy, CPed, who with his brother Cathal, bought the 65-year-old business a few years ago. "Out of the 12 people who work here, including my brother and myself, only two were born in America." The Kennedy brothers came to the States from Ireland.

"I've learned a little bit of Spanish and Russian," says Kennedy, "and it helps a feeling of goodwill and reaching out when I try to speak it with our staff." The Kennedys make it plain to the staff that, although communication can be a problem, "there is no room for confusion or animosity," Séamus says. "If anyone has a problem, they are to bring it to my brother or myself, and we can clear it up."

Culture per se has never been a problem, Kennedy notes. "People generally come to New York to get ahead, and they understand that the rules' may be different here." Hersco Labs keeps rules clear and simple: "no smoking, no drinking on the job, no fighting." The drinking issue came up because some cultures accept it and also some US companies accept it. "Some of our guys came from another shoe manufacturer, who allowed them to drink on the job," Kennedy says. "However, they understand that here it is different."

Kennedy also lets the staff know that if they fit in and do well, they can have a secure future with the company. He points to two staff members of Puerto Rican origin, who have been employed for over 35 years.

Ways To Overcome Linguistic Barriers

So, how have non-Hispanic O&P practitioners been meeting the challenge of communicating with Hispanic patients? Here are some ways:

1) learning Spanish;
2) employing bilingual office and clinical/technical staff;
3) using bilingual or Spanish patient instructions, manuals, brochures, and other forms;
4) using electronic translators, the Internet, or printed translation guides to help; and
5) having a sincere respect for their language and culture, an attitude which comes through to Hispanic patients.

Meet the Challenge: Learn the Language!

And, of course, if you are not a fluent Spanish speaker, or fluent in another language widely used in your area, there's always the challenge and adventure of learning a new language. Even though adults do not usually learn a language as fast as children, and research shows that adults actually use a different part of their brain in learning a language than children do, it's certainly possible. Sometimes adults, unlike most children, are self-conscious about their grammar and pronunciation.

But go ahead--go for it! Many who have tried to learn and use another language have found that native speakers appreciate their efforts.

Note: The federal government treats Hispanic origin and race as separate and distinct concepts; thus Hispanics (who reported themselves as Hispanic, Latino, or Spanish to the Census Bureau) can be of any race. Specific Spanish, Hispanic, or Latino categories listed on the Census 2000 questionnaire included Mexican, Mexican Am., Chicano, Puerto Rican, or Cuban, as well those who indicated there are other Spanish/Hispanic/Latino. Persons in the other category include those whose origins are from Spain, the Spanish-speaking countries of Central and South America, and the Dominican Republic, as well as people generally identifying themselves as Spanish, Spanish-American, Hispanic, Hispano, etc.