Cristina Romagnoli

Cultural & Linguistic Competence

We didn't need Walt Disney to tell us it was a "small world after all" ... indeed it is easy to see in our culturally diverse communities the need to begin to think outside our anglocentric world view. As children, we learn in grade school that The United States is a “melting pot.” This mix of cultures provides for the rich tapestry that makes our country unique but can also prove to be a challenging hurdle for health care professionals who wish to provide consistent quality care across cultures. My German and Italian background have been helpful for communication in very limited situations but it was clear after the first day I volunteered at the pro-bono clinic that I would need to learn Spanish. The Office of Minority Health, the OMH describes that the demographic changes anticipated in the next decade will magnify the importance of addressing these cultural and ethnic disparities in health and health care. Indeed, the OMH reports that 76% of Hispanics who reside within the mainland US speak a language other than English at home. The Spanish language barrier is one of the most tangible hurdles that I have encountered on my path to become a Physical Therapist: from treating patients at the Little Workers of the Sacred Heart Pro-bono clinic to my most recent internship in Lutheran Hospital. When realizing that my deficit in communication was impeding my ability to connect with my patients and give consistently good care, I joined “Salud” the Latino Health Interest Group at George Washington. At their monthly Spanish nights, I learned the foundation for the basic review of systems and exams in Spanish. This past October, I also received a scholarship to attend the Del Norte Spanish Seminar for Health Care Professionals where I was further able to develop my language skills. 

I believe it is no longer simply an option for health care professionals to consider cultural competence in their treatment but a vital imperative for quality care. 

During my clinical rotation at Lutheran Medical Center, I was also able to develop a Home Exercise Program for Total Knee Replacement Patients to improve compliance and outcomes for Spanish speaking patients, please feel free to use in your practice: Total Knee HEP

_______________________________________________________

Critical Thinking

As discussed above, communication can be tricky business even when speaking in the same language. Below is an essay that describes two such challenging situations:

A Tale of Two Strategies
Stories of Communication and lack thereof 

    Often, the ability to communicate goes beyond the use of words. We take for granted the ease with which language assists us on a day-to-day basis and forget that affective communication involves more than just stringing coherent words together. Sometimes, sharing a knowing glance with someone or a smile can communicate more than any essay, the use of pictures or symbols can be fairly close to universal, and consideration of whom you want to communicate with can be integral to having a conversation. When language is a problem, someone can’t speak or perhaps it is just a different language than your native tongue, you have to resort to non-verbal methods of communication to express yourself or understand what someone wishes to tell you. From a young age I was introduced to the art of communication across language barriers from the moment my family landed on Okinawa, Japan. I was in first grade and while I found the toilets to be rather foreign, the international “I’ve really got to go to the bathroom” dance was quite successful in getting me there. From that day on my family moved throughout the Far East and then into Europe. By the time I was in high school, I considered myself to be rather astute at the art of cross-cultural communication. In this essay, I would like to share two short stories: first, exploring how my overconfidence in my abilities leads to ineffective communication and secondly, how patience and perseverance can make all the difference in a successful conversation. 

Parlez-vous anglais?!
Riding head long into language barriers 

“We’re lost” Dan grumbled frustratingly, “and no one speaks English!”
“Or Spanish…” Geoff chimed in, his voice horse from the cold he was fighting.
“Or German.” I added, beginning to feel the gravity of the situation as a streak of lightning clapped in the ominous sky and the sun started to set behind us. 

    So, there we were, straddling our bicycles, maps seemingly sprawled about every which way and the citizens of the small town of Barcelonnette rushing into their homes. We had three languages between us and none of them were working; of course, we were in a small town in the middle of France. In the bigger cities like Paris, Versailles or Orleans we were able to get by with broken French or find someone who spoke German, Spanish or English, but now we found ourselves dozens of miles from any big city, not a youth hostel in sight and a large storm only moments away. 

Geoff looked back at the tent strapped to the back of his bike and coughed; I knew spending a night camping in the cold and rain would surely exacerbate the bug he was fighting. However, no one would stop or listen to our frantic shouts: “Parlez-vous anglais!?”

    At the time, we were stressed and worried about spending a night in the cold and rain. We were tired from a long day of cycling and concerned about our friend’s health. However, I did not consider that shouting at the passing citizens in my frazzled state was not an effective means of communication. If I had considered the situation more carefully, I would have realized that we were strangers and outsiders in this town and should have approached the situation with a lot more discretion. I should have dismounted my bicycle, cleaned myself up a little bit and approached people individually with my map and French guidebook. It was very difficult at the time to think about how I was being perceived by the inhabitants of the town because I was too concerned about my immediate well-being. This situation showed me that even in a perceived sate of emergency, it is always better to relax and consider the most effective way getting where I need to go. When Geoff, Dan and I were standing there in the rain, we didn’t think about the best way to communicate with the people of Barcelonnette. Of course, I did have a lot of time to consider my actions that night shivering in my wet sleeping bag. 

More Ice Chips Please
There is a method to the scribbles…

“I really don’t know what I would have done with out you,” my father said about 10 minutes after the doctors removed his breathing tube and then squeezed my hand three times in succession. 

I smiled, “I love you too,” I said. 

    The first 10 days my father was in the Cardiac ICU after his heart transplant were a few of the hardest days of my life. About 3 hours after his surgery they pulled out his breathing tube and aside from a slightly horse voice he was speaking just fine. However, by that evening, my father’s condition had deteriorated and he couldn’t stop coughing. His cardiologist ordered a chest x-ray and then quickly decided to put his breathing tube back in when they saw how much fluid was building up in his lungs. Dr. Beaver explained that my dad had pretty severe case of pneumonia and because of his delicate situation after surgery, it was safest to leave the tube in until he improved. 

    I was scared, alone and just wanted to be able to take care of my dad and make him comfortable. So, I started to ask him questions. It was such a simple thing but at first I didn’t realize that the questions I asked him had to be answered by just a simple nod of the head “yes” or shake of the head “no.” Due to the various tubes and wires, he often had a hard time writing what was on his mind but could still hold a pen and point. I could see the frustration in my dad’s eyes when I didn’t understand what he wanted and occasionally he would tap the pen angrily on the paper when he couldn’t write. That gave me an idea! On the paper I wrote and drew a few things he repeatedly needed or wanted. The top left was for ice chips, since his lips got very dry I was able to dab them with a swab. The top right was for eye drops. The center was to call the nurse. On the bottom there was a part to change TV channels and a few other essentials. He would squeeze my hand and I would bring the paper over to him and he could just point to what he needed. A couple of days after we devised this system, he squeezed my hand and when I brought the paper over he started to try and write something. I couldn’t make it out so I started going through the list of things he might want or need but he kept shaking his head. There were several lines but it mostly looked like scribbles, he squeezed my hand three times and stared at me. I kept trying to guess what he wanted but he would shake his head, start writing and squeeze my hand: once, twice and again. Then I saw it; he was drawing a heart:

“I. Love. You.” a squeeze for each word.