Introduction
In today’s uncertain world, from both economic and life security perspectives, tens of thousands of people are moving from unsafe places, mostly in the Middle East, to safer regions, primarily in European countries. This issue contributes to many clinical encounters across different languages and cultures in resettlement countries. Cross-cultural clinical encounters involve interactions between healthcare providers and patients from diverse linguistic and cultural backgrounds. These encounters can present unique challenges and opportunities for both parties, especially when a third person acts as an interpreter (1).
In cross-cultural clinical consultations with an interpreter as the language link, not only is language competency important, but cultural competency is also essential. Cultural competence refers to the interpreter’s ability to understand the resettlement country’s culture and the norms that guide healthcare providers and organizations, ensuring that healthcare services meet the cultural and social needs of patients from different backgrounds (2).
To prevent misunderstandings, healthcare professionals must have knowledge of the main factors that influence the consultation process through an interpreter. In this context, patient-centered communication and awareness of cultural diversity between the patient and healthcare provider are crucial (3). Additionally, healthcare professionals’ awareness of socio-economic and psychosocial factors that may influence the consultation process is essential (4). People typically express pain and joy through language, and it is well known that language and culture are two interconnected components of human verbal expression (5, 6). Caregivers’ knowledge of cross-cultural understandings of concepts related to psychological disease symptoms is critical in today’s multicultural society.
According to previous studies, there is a lack of knowledge about cultural concepts in the field of psychiatric illnesses (7). Research and experience have shown that without successful cross-cultural clinical communication, delivering adequate healthcare to patients from different cultures is difficult. Furthermore, patients who speak a language different from that of the healthcare provider may have limited knowledge of health literacy and the healthcare system in resettlement countries (8).
Case report: A mistake I will never forget
He looked like a restless person in the waiting room of the medical center, moving from chair to chair and glancing at the door. Suddenly, a middle-aged man with a book in his hand appeared. He asked him, "Are you my interpreter?"
"No, I'm a patient. What language do you speak? Maybe I can help you?"
Before he could answer, I, a new interpreter who had been asked to interpret for a compatriot in room 9, went up to him and introduced myself as his interpreter.
He sat next to me and asked, "Do you speak Kurdish?"
"No, I speak Persian."
"Okay, I speak Persian. Although it was seven years ago, I spoke Persian with no problem. I have to tell you how I was last night; it was terrible, I couldn't sleep."
"Wait until we go in to the doctor, where you can tell me everything, and I will interpret it. I hope it's only five minutes to go—take it easy, my friend."
"To speak two words with me is not forbidden, is it?"
He mumbled to himself and said, "I'm a new interpreter and have so much stress. Anyway, he wanted to burden me with unnecessary and unpaid work."
"Okay, at least look at this blank sheet I got from the tax office. I don't understand why they sent it to me."
"Hang on, we have to go in soon. You have to see the doctor today, right?"
We were called in to see the doctor, and I began to introduce myself in both Persian and Swedish. The patient was a Kurdish speaker, but as Persian is the official language in Iran, he could also speak Persian.
Doctor: "Why are you here today?"
Interpreter to patient: "Why are you here today?"
Patient: "Tell him I might have come to have fun. Say he's sick, sick, and sick."
Doctor: "What is your problem?"
The patient mumbled to himself and said, "Strangely, doctor, if I knew what my problem was, why did I seek a doctor? Tell the doctor I have a lot of air in my Riye (lungs)." In fact, he had air in his intestines (rode). because the pronunciation of the words of lung and intestine is very close in Persian, he said Riye (lungs) instead of Rode (intestines).
Doctor: "We must have air in our lungs; otherwise, we could not continue to live. That's good."
Interpreter to patient: "We must have air in our lungs. It is good."
Patient: "It is troublesome to have air in the lungs" (he meant intestines).
The doctor wanted to examine the lungs to see why the patient found it difficult to have air in his lungs. The patient muttered to himself and used a Kurdish expression: "The dog's arm is broken, and they are wagging its tail." He pointed at his stomach and added, "I have problems in my stomach, not in my chest."
At that point, I realized there had been a misunderstanding between the patient and me at the beginning. I told the doctor, "Excuse me, it's his intestines (Rode) that have air in them, not his lungs (Riye)."
It was an event I will never forget.
Discussion
Although we strive for a world where people can live in a satisfying and peaceful physical and psychological environment, factors still force tens of thousands of people to leave their homelands every day (9). Many of these individuals cross cultural and linguistic borders and settle in foreign countries, bringing with them significant differences in language and culture. Without caregivers' understanding of language and cultural barriers, it is difficult to find appropriate strategies to overcome such obstacles and provide effective care to patients facing language barriers in any clinical setting or healthcare system (10). Two prominent factors contributing to this issue are natural disasters and wars around the world (1). Misunderstandings in clinical communication through interpreters can result in higher costs for healthcare systems and increased patient suffering. Minimizing misunderstandings is crucial for achieving positive healthcare outcomes (11). Previous studies have shown that misunderstandings in medical interpretation are common, occurring an average of 31 times per clinical encounter.
Ensuring the competence of interpreters and using trained, professional interpreters is essential for providing adequate healthcare to patients with language barriers (12). According to my studies, a potential source of misunderstanding arises from the use of three-linguistic clinic consultations instead of two-linguistic encounters. This occurs when an interpreter who shares a common language with the patient is not used, as seen in the case report. The interpreter in this case was a Persian speaker, while the patient’s mother tongue was Kurdish. If the interpreter had been assigned based on the patient's mother tongue, only Swedish and Kurdish would have been involved in the communication, significantly reducing the risk of misunderstanding. In the case report, if a Kurdish interpreter had acted as the language bridge, they could have distinguished between what the patient meant by lungs (Riye) and intestines (Rode), which was the source of the misunderstanding (1).
The Kurdish words for lungs and intestines differ completely from their Persian equivalents. The patient, lacking sufficient knowledge of Persian, confused the two terms, as "Riye" (lungs) and "Rode" (intestines) are having close pronunciation in Persian. However, in Kurdish, the words are "Sipelk" for lungs and "Rekholle" for intestines. In multi-ethnic countries like Iran, where Persian is the only official language used in education, a significant portion of the population remains illiterate. To prevent misunderstandings in clinical encounters, interpreters should be assigned based on the patient's mother tongue rather than patient’s nationality. At least five different ethnic groups live in Iran—Persians, Kurds, Baluchs, Turks, and Arabs (13).
Conclusion
When I began my research on clinical consultations through an interpreter in the 1990s, there were few studies on communication via interpreters. Furthermore, the importance of the mother tongue in consultations through interpreters had not been studied in Sweden. After more than a quarter of a century of research in this area, I am now convinced that trilingual consultations (where the patient and interpreter have different native languages) are a potential source of misunderstanding. If interpreters are assigned based on the patient's mother tongue, resulting in bilingual consultations (where the patient and interpreter share the same native language), misunderstandings will be significantly minimized.
Conflict of Interest
No Conflict of Interest to declare.
