Patients with Language Barriers: Getting the Message Across

by Lubna Kousa Pharm.D., PGY1 Community Pharmacy Practice Resident, Johns Hopkins Home Care Group

The United States is notorious for its diversity. Over the past several decades the use of a language other than English at home has increased by 148 percent.¹  The number of non-English speakers increased from 23.1 million in the 1980’s to 57.1 million in 2009.  This rapid change can be seen throughout the country, whether it’s a Chinese language television station or a road sign in Spanish, the linguistic diversity continues to evolve.

Language barriers are becoming progressively more challenging for the delivery of health care services. Given the heterogeneity of ethnic origins and the primary languages among these groups, individuals who have limited English proficiency have significant challenges when communicating with health care providers. Patients with poor communication skills have difficulty accessing care and conveying their health concerns to practitioners.  In many health care settings, there is a lack of interpreters. This often results in misdiagnosis, inappropriate treatments, and the delivery of suboptimal care.²  Moreover, patients with limited English proficiency report being less satisfied, less likely to understand medication instructions, and more likely to have problems adhering to their medication regimens.

But why should this be? It shouldn’t. We invest billions of dollars in systems and programs for providing medical care and finding cures for diseases.  Why can’t we invest resources in systems and programs for patients with language barriers?

As pharmacists, we are responsible for providing excellent care in order to achieve optimal outcomes for our patients and enhance their quality of care.  It is our mission to provide our patients with a level of comfort and an opportunity to be understood.  And we should communicate clearly with our patients so that we can arrive at the best decisions together.  Being a pharmacist isn’t about filling prescriptions for our patients, but creating a bond that enables us to ensure a positive outcome, regardless of any barriers. Whether the patient is in a hospital, outpatient clinic, or a community pharmacy, this process requires excellent communication between the patient and the pharmacist to ensure the quality and safety of drug therapy.³  Patients who don’t fully understand their treatments are less likely to follow-up, which in turn puts them at greater risk of being hospitalized or experiencing drug complications.  For example, patients with asthma are at greater risk of intubation if they fail to properly use their treatments.⁴

Using visual methods can help. Going to the drawing board, showing pictures, and drawing examples can paint a clearer picture for our patients.  If nothing else, it demonstrates the effort put forth to help them. Using plain language and avoiding technical jargon is a strategy for making written and oral information easier to understand.  Written materials can be referred to at a later time.  Printed instructions for patients that contain pictographs and photographs that demonstrate medication-use techniques can be very useful in this patient population.² However, a better long-term solution to this problem is for our healthcare system to invest in a powerful interpreter service that is consistently available in order to facilitate optimal communication between providers and patients.  This will, in turn, improve patient satisfaction and safety.^5,6

Despite ongoing efforts to increase awareness of communication difficulties in patients with limited English proficiency, health disparities continue to exist.  Our challenge as pharmacists involved in the direct care of patients is not only to provide medications, but create a welcoming environment that encourages them to seek care even when language barriers exist.  Our job is to build a system that can mitigate communicate problems and deliver the best possible care to diverse patient populations.

References

1.    Ortman JM. Language Projections: 2010 to 2020. Population Division, U.S. Census Bureau.  Accessed on January 28, 2013.

2.    Diamond LC and Jacobs EA. Let's not contribute to disparities: the best methods for teaching clinicians how to overcome language barriers to health care. J Gen Intern Med 2010;25 Suppl 2:S189-93. Accessed on January 28, 2013.

3.    Bubalo J, Clark R, Jiing S et al. Medication adherence:Pharmacist perspective.  J Am Pharm Assoc 2010;50: 394-406.  Accessed on January 30, 2013.

4.    Flores G, Laws MB, Mayo SJ, et al. Errors in medicalinterpretation and their potential clinical consequences in pediatric encounters. Pediatrics 2003;111:6-14.  Accessed on January 30, 2013.

5.    Flores G. Language Barriers toHealth Care in the United States. N Engl J Med 2006; 355:229-231. Accessed on January 30, 2013.

6.    Phokeo V and Hyman I. Provision of pharmaceutical care to patientswith limited English proficiency. Am J Health-Syst Pharm 2007; 64: 423-429.  Accessed on January 30, 2013.

Preceptor, Mentor, or Both?

by Carmen Nobre, Pharm.D., PGY2 Oncology Resident, University of Maryland

Lines between being a preceptor and mentor often blur.  To be a preceptor is to participate in a prearranged role where one assumes the responsibly of fostering and building the core professional skills of a trainee.  As outlined by American Society of Health-System Pharmacists for pharmacy post-graduate residency programs¹, a preceptor is one that models, coaches, and facilitates a trainee's performance as a professional. 

To be a mentor is to function as a role model within your given profession.  Research on mentoring indicates that a mentor should:²

·      be nurturing

·      be a role model

·      function as teacher, sponsor, encourager, counselor and friend

·      focus on the professional development of the mentee

·      sustain a caring relationship over time

This type of relationship is traditionally freely entered by both parties (i.e. not as a requirement of a curriculum or program).  The mentor and mentee build a closer, more personal relationship than that of a preceptor and student.  Of no surprise, this often means that the two parties share similar interests and characteristics.  A mentor may participate in professional activities with the trainee, and may also engage in discussions relating to the trainee as an individual and not solely as a member of a larger group of professionals.  Topics of discussion often include families, hobbies, frustrations, and ambitions.³

Despite their differences, the terms preceptor and mentor are often interchanged.  This may be due to their shared goal of fostering the development of a young professional.  Yes, both roles have the common goal of guiding a trainee in their professional development, and coaching them through their journey.  Each role may also serve to challenge the trainee, evaluate their performance, or offer advice.  However, there exists a different tone between these relationship.  Most obvious are the differences in the goals and benefits of these relationships, their duration, the socialization process, the support for learning and feedback given.⁴  Simply put, a preceptor is more of an authoritative figure while a mentor acts more like an older sibling.

Can these lines ever be blurred?  Should they be blurred?  If so, when is it appropriate to play this dual role?  Furthermore, how do you juggle between the two?  Playing this dual role can be tricky.  As a preceptor there is a responsibility to evaluate the trainee, and provide constructive feedback to further their growth.  But as a mentor there is an expectation that you offer support and advice in how to handle even the worst of situations.  Is it possible to provide necessary criticism while being supportive?

In my experience, it can be difficult for both the preceptor / mentor to have this overlapping relationship.  From the trainee's perspective, it is difficult to maintain a goal-oriented working relationship with a preceptor, and then switch modes and disclose personal thoughts and feelings to that person.  In addition to identifying when it is appropriate to have a mentoring discussion, it is also difficult to reveal your weaknesses and frustrations (or even pleasant feelings) to a person who will be evaluating your performance.  From the preceptor’s perspective, it must be difficult to transition between nonjudgmental casual conversations and to formal discussions and evaluations of the trainee's performance.  Although it may be possible to carry this dual role, it requires a certain degree of balance.

Nonetheless, the benefit of having a mentoring relationship with a resident outweighs the risk of blurring the line between being a preceptor or a mentor.  There is much to gain.  There are opportunities to exchange ideas, improve job satisfaction, and build networking relationship.  Many institutions have developed formal mentoring programs where the mentor and mentee are paired and given guidance about how to develop an effective relationship.⁵   

Creating a formal mentoring program is one way of incorporating this fundamental practice into a resident's experience.  Another way is to purposely integrate it into the objectives of the residency curriculum.  By including instruction about mentoring, it will clarify the intent and expectations of the mentor-mentee relationship, and would also ensure that important professional development topics are addressed during the year.  This would serve to establish goals and clarify expectations (such as frequency of meetings).  An example: mentors should set aside time to discuss potential career opportunities after residency.  It is important to keep in mind the fundamental distinction between being a preceptor and a mentor, and that any relationship requires effort from both parties to be successful.⁶

Learning to be an effective preceptor and mentor requires training for a successful and positive experience.  As a recent graduate and having precepted my first student, I commend those who are able to fulfill these dual roles.  However, I would encourage new preceptors and mentors to have an open exchange with their trainees about expectations, and even seek advice from more experienced mentors (i.e. become a mentee yourself).

References:

1.  American Society of Health-System Pharmacists. Education and training.   Accessed 2012 Oct 22

2.  Kerry T, Mayes AS.  Issues in Mentoring,   Routledge Publishing Company in association with The Open University; New York, New York: 1995.

3.  Wensel TM. New Practitioners Forum:  Mentor or preceptor: What is the difference? Am J Health Syst Pharm 2006; 63:1597.

4.   University of Medicine & Dentistry of New Jersy (UMDNJ) Center for Teaching Excellence. Teaching Portfolio: Precepting and Mentoring [Web page]. Accessed 2012 Oct 22

5.  Johnson MO, Subak LL, Brown JS, et al. An Innovative Program to Train Health Sciences Researchers to be Effective Clinical and Translational-Research Mentors.  Acad Med. 2010; 85: 484–9.

6.  Sambunjak D, Straus SE, Marusic A. A Systematic Review of Qualitative Research on the Meaning and Characteristics of Mentoring in Academic Medicine  J Gen Intern Med 2009; 25: 72–8.

Interprofessional Team Teaching, What’s It All About?

by Taemi Cho, Pharm.D., PGY1 Community Pharmacy Practice Resident, University of Maryland School of Pharmacy

When you were a pharmacy student, did you ever experience interprofessional team teaching? Many will probably answer without hesitation, “Yes of course. On rounds during my acute care rotation.”  But consider these questions: What exactly is an interprofessional team? How does an interprofessional team differ from a multidisciplinary team?

Although the terms multidisciplinary and interprofessional are frequently used interchangeably, multidisciplinary teams differ from interprofessional teams. Multidisciplinary and interprofessional teams differ based on the degree of interaction and sharing of responsibilities.¹ In patient care, multidisciplinary teams are described as being led by the highest ranking team member which is usually the physician.¹  Each member works independently but in parallel.  The medical record serves as the primary tool for information sharing.¹

In contrast, interprofessional healthcare teams include members with different professional training coming together to interdependently develop goals.^1,2 In an interprofessional team, leadership is shared, members engage each other and learn from one another.¹ An interprofessional team approach involves the collaboration of people with diverse perspectives to devise a unified approach.² The aim of the interprofessional team is to provide more comprehensive patient care than what is typically achieved today.

Are there real benefits to adopting interprofessional team teaching in healthcare education?  Unlike instruction received from people from a single professional background, interprofessional teaching introduces multiple (two or more) perspectives in a teaching-learning process that enhances each profession.³  Interprofessional teaching challenges students to integrate alternative views and helps them to understand complex issues that must be considered when providing optimal patient care.²  This approach also educates students about conflict resolution and group dynamics, important skills that must be learned in order to be an effective member of a high-functioning team.⁴

A recent paper described interprofessional education at the Rosalind Franklin University of Medicine and Science, the University of Florida, and the University of Washington.⁵   Each of these interprofessional education programs included didactic instruction, a community-based experience, and an interprofessional-simulation exercise.⁵ The didactic instruction taught principles of collaborative patient centered care and clinical concepts.⁵ The community service component included interprofessional teams working with community partners on a community service project.⁵ And the simulation activity had students from different disciplines working together on a skills assessment. All three interprofessional education programs felt they had achieved their programmatic goals.  Students were reported to comprehend their professional roles and understood the contribution of other professional’s roles on the team.⁵    

One pilot study assessed an interprofessional team reasoning framework

(IPTRF) utilized to teach and learn cases studies among student of different health professions.⁶ The following flowchart is the framework used in the study:

Figure from:  Packard K et.al.  Interprofessional team reasoning framework as a tool for case study analysis with health professions students: A randomized study. 
JRIPE Vol 2.3  August 2012.

Eighteen students from dentistry, medicine, nursing, occupational therapy, pharmacy, and physical therapy were randomized into 3 teams of six members.⁶ The first team received only the case; the second received the case and framework; and the third received the case, framework, and a videotaped example of interprofessional interactions. The primary end point evaluated students’ perceptions and the secondary endpoint evaluated students’ performances.⁶ The results found that students’ perception of team skills improved when they were given the IPTRF tool (second and third teams). Moreover, team three’s students’ performance was significantly better when compared to students on the other two teams.⁶

The success of an interprofessoinal education lies in developing a curriculum that prepares students to collaborate in an interprofessional manner. One cannot expect recently graduated pharmacists to successfully work within an interprofessional team without instruction, both didactic and experiential. Many barriers exist in implementing interdisciplinary team education including a lack of administrative/faculty support, insufficient faculty with interdisciplinary training, limited financial resources, entrenched power dispositions/territorial imperatives, logistics, scheduling, and reimbursement.³

To progress, these barriers need to be addressed. Collaborators from successful schools that have implemented interprofessional education indicated that their success relied on resolving conflicts in the initial stages of developing an interprofessional course.⁷   Collaborators need to understand each other’s pedagogical views and negotiate those differences.⁷ Integral to an interprofessional education are the core competencies identified by the Interprofessional Education Collaborative Expert Panel.⁸

You may be wondering if I have experienced interprofessional team teaching.  I can honestly say, “Yes!”  I took a class as a pharmacy student that had interdisciplinary components. My Geriatric Imperative class had a geriatric dementia team consisting of a physician, nurse, pharmacist, psychologist, and social worker from the Veterans Affairs (VA).  The team members discussed how they met with their patients and shared their perspectives to optimize each patient’s care. Later, as a P4 student, I rotated through the Dementia clinic at the VA.   For 3 months, I worked in this interdisciplinary team where we made assessments based on our various perspectives, integrated the information, and together developed a patient care plan.

References

1.   Cooper BS, Fishman E. The interdisciplinary team in the management of chronic conditions: has its time come? Partnerships for Solutions Better Lives for People with Chronic Conditions [Internet]. New York: Mount Sinai School of Medicine; 2003 June: 2-4.

2.   Goldsmith AH, Hamilton D, Hornsby K, Wells D. Interdisciplinary Approaches to Teaching. Lexington (VA): Washington and Lee University; [updated 2012 May 29; cited 2012 Nov 17].

3.   Page RL, Hume AL, Trujillo JM, & Leader WG. ACCP White Paper Interprofessional Education: Principles and Application. A Framework for Clinical Pharmacy. Pharmacotherapy 2009; 29: 145e-164e.

4.   Allen DD, Penn MA, Nora LM. Interdisciplinary Healthcare Education: Fact or Fiction? Am J Pharm Educ 2006 April 15;70(2): Article 39.

5.   Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online 2011 April 8;16:6035.

6.   Packard K, Hardeep C, Maio A, Doll J, Furze J, Huggett K, Jensen G, Jorgensen D, Wilken M, Qi Yongyue. Interprofessional Team Reasoning Framework as a Tool for Case Study Analysis with Health Professions Students: A Randomized Study. JRIPE 2012; 23: 251-263.

7.   Shibley I. Interdisciplinary Team Teaching Negotiating Pedagogical Differences. College Teaching. 2006; 54(3): 271-274.

8.   Interprofessional Education Collaborative Report of an Expert Panel. Core Competencies for Interprofessional Collaborative Practice [Internet]. 2011: 1-47.