One night on a lonely stretch of Mexican highway, Dr. Haywood Hall stumbled on a car accident and a man who was unconscious. For 30 minutes Hall, a vacationing emergency physician, waited for the ambulance to arrive. When it did come, it was with shoddy equipment, expired Valium and an undertrained staff. Although Dr. Hall didn’t have a license to practice medicine in Mexico, he got police permission to help.
The patient survived, but Hall, who was raised in Mexico, realized the Mexican emergency response team could use some training help. Fourteen years after that car accident on the road to Chihuahua, Hall has developed a training program that not only trains Mexican emergency physicians but also trains American physicians in language skills.
MedSpanish, the language portion, takes American emergency physicians into San Miguel, Mexico, for three weeks of general language skills (worth up to 50 CME credits). Hall describes it as “general Spanish in a healthcare setting.”
Although more than 21 million United States residents have problems speaking or understanding English, medical instruction hasn’t quite kept pace. A May 2007 survey of over 2,000 physicians found that most reported receiving little or no instruction in cross-cultural skills beyond what they learned in medical school. Emergency physicians were more likely to say they were ill-prepared to treat cross-cultural patients and more likely to say they had very little cross-cultural training outside of medical school.
This cultural gap can negatively impact patient care. A 2007 study by University of California Irvine researchers also found that language barriers can lead to longer hospital stays, medical errors and lower patient satisfaction. Patients who didn’t speak their doctor’s language were 61 percent more likely to rate their health care providers as fair or poor – and the presence of an interpreter actually exacerbated this effect instead of mitigating it.
Cristina Gonzalez, who developed and teaches the medical Spanish program at University of Texas-Southwestern, was a medical interpreter as a child, when she accompanied her mother to doctor’s visits. It was awkward, and she now sees that she sometimes tacked on irrelevant information that sidetracked the doctor from her mom’s true ailments. She says relying on interpreters has its downsides: “We wouldn’t want a third party in the room with us, especially if it’s a delicate exam or a delicate issue we’re talking about, and we especially wouldn’t want it to be a different person every time.” This lack of rapport can affect patient compliance, said Gonzalez, and the patient may not come back.
MedSpanish, and programs like Gonzalez’, try to close this gap. Gonzalez is developing her own curriculum after noticing deficiencies in the available textbooks. One textbook showed a physician talking to a young Hispanic girl about having an abortion without taking into account the fact that many Hispanics are Catholics and against abortion. The book presented it as though the girl was simply “taking an antibiotic” – a culturally inaccurate portrayal, Gonzalez said.
Gonzalez’ program began with classroom instruction, then evolved to include Spanish-speaking simulated patients who follow a script to teach students how to do the exam and also counsel the patient. “Each step gets more real world,” she said.
The MedSpanish program takes the next “real world” step by sending participants to Mexico where they participate in actual clinical rotations. Like Gonzalez, Hall has lived the cross-cultural life. The child of a mixed-race couple, Hall was born in New York City, moved to Mexico as a baby and lived there until age 8. He spoke Spanish as a first language and found life in the US difficult. “I wasn’t white enough. I wasn’t black enough. I wasn’t Hispanic enough. I wasn’t Indian enough,” says Hall. He finally dropped out of high school to join a band and drive a cab in New York City, until he became interested in health care and emergency medicine.
Hall says that the program opens physicians’ eyes to Mexican culture: “We tend to think of Mexicans as poor, as economic refugees, and maybe illegal, and kind of the most marginalized people. People are actually shocked that there’s a major civilization in Mexico.”
MedSpanish is part of a larger program, called PACE, that trains and certifies 11 percent of Mexican doctors. Because of this, the Mexican government lets MedSpanish students come and learn in their hospitals. MedSpanish provides individualized instruction, matching an instructor with each student for two to three hours of focused teaching per day.
Bill Ewen, a third-year emergency medicine resident who participated in MedSpanish, liked that the program is primarily a medical organization that also offers cultural and language training. He had to score at least 25 percent on his baseline language proficiency exam to participate in clinical rotations. (Those who score too low, MedSpanish assigns to mobile health units and ambulances while they work on their language skills.) Since Ewen wasn’t licensed to practice medicine in Mexico, he acted as a consultant—observing, advising and demonstrating techniques if needed, with the patients’ informed consent. He and the other students got two hours of individualized language instruction each day and participated in up to five hours of clinical rotations.
“Some people back home were shocked to learn that I worked in an actual emergency department with X-ray, CT scan, ultrasound capabilities, and not in some kind of makeshift medical hovel,” Ewen said. He knew to expect sophisticated medical practices there, but he was impressed to see San Miguel emergency physicians using bedside ultrasound to diagnose trauma patients. This technological training is what Mexican doctors gain from PACEMD and MedSpanish involvement.
But Ewen said he learned from them, too: Every day, American emergency medicine doctors use such sophisticated technology—CT scanners, MRIs, ultrasounds, lab testing—that they sometimes forget to do an examination the old-fashioned way. “I noticed that in San Miguel, physicians in the developing world still rely on their hands, eyes, ears, nose and intuition to diagnose and treat many disorders,” Ewen said.
“What I gained from observing their practice was the simple reminder to trust what I learned in, and sometimes haven’t practiced since med school.”
And that includes Spanish.