Talking to the doctor; listening to the patient Part II

The Open Mind
Host: Richard D. Heffner
Guest: Dr. Mack Lipkin, Jr.
Title: Part II
VTR: 12/03/02

I’m Richard Heffner, your host on The Open Mind. And this is the second of two programs about doctor/patient communications; about your and my ability and willingness as patients to tell our medical providers what they must know to care for us well enough and with our physicians’ ability and willingness to listen, hear and then act effectively.

My guest again today is Dr. Mack Lipkin, Jr., Professor of Medicine and Director of the Division of Primary Care Internal Medicine at New York University’s distinguished School of Medicine. And a leading international researcher in doctor/patient communication.

Now I want to ask him first today about the research that is being conducted at NYU to deal with an aspect of doctor/patient communication that I suspect most of us never dream of, that there are millions of foreign born U.S. residents who do not speak English or have limited English proficiency and yet need as much as, if not more than the rest of us to make themselves understood to their doctors and understand them in turn.

Tell us about this project. I know that the Commonwealth Fund is involved with it and others, too.

Lipkin: Yes. You know in New York City there are 178 languages spoken according to the Census Bureau.

Heffner: Incredible.

Lipkin: In an average year, Bellevue, where I work … there are over 80 languages spoken. And in my Division, in a typical practice there are about 40 languages spoken. In New York City 40% of the people living here were born somewhere else, outside of the United States. And a high percentage of them prefer to speak not in English. Some of them can’t speak in English and it’s a tragedy in the United States currently that many of those patients are not provided an interpreter who’s trained to interpret in a medical situation. So that they can really communicate effectively with their medical practitioner. It seems that, at least until a current Administration … we’re not sure now … but historically this right of having an opportunity to speak in your own language is covered under the Civil Rights Act. And in the courts, of course, it’s obvious. In the courts there’s been governmental support for interpreters so that a defendant can understand the proceedings and participate.

But across the United States interpretation has been very, very deficient. So the patients sometimes have to bring a family member which can be a problem if they want to talk about … if it’s a child or an adolescent, they want to talk about their spouses drinking, or their own intimate issues … that they really couldn’t talk about in front of a child. It’s a problem if they bring in a family friend for the same kinds of reasons, there’s a big loss of confidentiality.

But on the other hand, hospitals have been unable and unwilling to have an interpreter bank of peoples waiting to be available.

Heffner: How could they?

Lipkin: Well, that’s part of the point of what my colleague Dr. Francesca Gany has been working on and developing. Dr. Gany was a resident at Bellevue and stayed on the faculty and now runs our Center for Immigrant Health Studies. And she felt, correctly, that we’d never be able to … you know we might be able to do Spanish, Chinese and Russian, Creole … those are probably the most common languages in this part of New York. But we’re not going to cover Wallaf, which is the Senegalese language or dozens of other languages.

The idea that she sort of found, because it wasn’t her invention, but she really has revitalized it was to adapt remote simultaneous interpretation to the medical setting. So that you don’t have to wait for the interpreter’s body to get in the room with the other people.

Heffner: You say “remote”.

Lipkin: Yes. I’ll explain how it works in a second. Well, let me explain. A doctor or the practitioner and the patient each wear a headset. They are the same kind that football coaches wear so that they can …

Heffner: Right.

Lipkin: … be heard in a noisy place. Very good fidelity. That transmits to a base in the corner of the room, which then generates a digital signal like a digital phone signal or it could be a computer signal. Whatever. And that goes to where the interpreter is sitting. When we first piloted this down at Gouverneur Diagnostic and Treatment Center, a huge wonderful clinic on the lower East Side, the doctors were on the fourth floor and the patients … the interpreters were on the 12th floor. And Dr. Gany had the wonderful idea to try to recruit visually and otherwise handicapped persons who were not able to get into the job market, but this really allowed them to do a job they could do. Which is … highly intelligent, fluent people. So that if you’re the doctor and I was the patient, I was speaking Spanish, you would be hearing the translation of what I was saying. But the patient, I wouldn’t be. And then when you spoke in English, the patient would be hearing in Spanish. It’s almost simultaneous.

Heffner: Like the United Nations, that sort of thing.

Lipkin: Like the United Nations. Not quite as quick. That takes a lot of expense to train those folks. And it’s also very high stress. But it’s quicker, at least in our pilot study, than having someone in the room. Because when there’s someone in the room, you speak English to that person … that person then speaks Spanish and it goes like that. And there’s also the experience that with untrained people, you might ask a question like “do you have a headache?” Expecting “yes” or “no” and the translator speaks for five minutes to the patient, the patient speaks five minutes to the translator, who says … sometimes … “so by having” …

Heffner: You don’t know what has really been asked and what has really been answered.

Lipkin: That’s right. So part of training people, and this doesn’t happen with an ad hoc interpretator like a family member or a staff member who’s not trained … is people .. The interpreters are trained, not only in the language … how do you say “asthma” and “depression”, but also not to … just to say what was said … then if there’s a cultural issue … well what does that mean? You know, say the person said, “The winds were unfavorable.” You know, you might not understand that and there’s a chance the person from …the interpreter does and you can ask them. But they don’t interpret it for you until you hear it.

Patients love it, doctors love it. A lot of people thought, “Well, there’s a loss of connection because the interpretator is not there.” Actually we’ve all struggled with this for a long time and that the doctor feels like the third wheel. There’s so much going on between the patient and the translator …

Heffner: In the usual setting.

Lipkin: … in the, in the room. And second of translation, say …

Heffner: Right.

Lipkin: So, we found the person who holds the patent on this in medicine. We’ve formed a partnership with that person. We did pilot studies that showed it’s quicker, more satisfying to both parties and probably leads to more complete and accurate diagnosis. And now with the Commonwealth Foundation’s help, we’re doing a high volume, really rigorous research level study to look at this method.

Our hope is that, and our belief is that once that study’s done and we demonstrate how much better it is … which might not happen … it’s a controlled study … we’d then be able to add more languages and more interpretators so that, you know, people who are … languages 10 through 178 can actually expect that there will be an interpretator available because we’ll have those people on call and we can reach them.

Heffner: Do you find this being criticized as one of those “soft” things that you get yourself involved with?

Lipkin: Well, there’s a good percentage of our faculty that probably think that characterizing the crystalline structure of an enzyme is more important. But there’s also a lot of people who we work with at Bellevue and in the city hospitals and across country … and you know, something that surprised us when we go … started to learn about this … you wouldn’t think there would be a problem of interpretation in rural North Carolina. But it turns out that a lot of Hmong people from Vietnam, mountain people from Vietnam moved there. Or that there would be a problem with translating Vietnamese in southern rural coastal Texas. But they’re there fishing.

This problem is everywhere. And a doctor practicing alone in their office just can’t have an interpreter sitting there. But now they can.

Heffner: Is there any realization … obviously that’s a ridiculous question; of course there’s some realization. Is there enough realization that if we don’t handle this problem of so many of hundreds and hundreds and hundreds of thousands of people …

Lipkin: Millions.

Heffner: Who … millions … who can be a danger to our public health. Is there the realization that this isn’t just “do-good”, softheaded project, but we’re protecting our own health.

Lipkin: Well, I think that the Commonwealth Foundation, also the California Endowment that are funding Dr. Gany’s study believe that … foremost, this will improve the health of underserved populations like you mentioned. But there’s no question that it will also help protect the public. But you know we’ve neglected our public health infrastructure. We’re in an era of … my view … of somewhat public mean spiritedness toward those less fortunate. And people don’t stop to think that if a person doesn’t get care, they might spread tuberculosis or some other illness that otherwise was preventable.

Heffner: You know, Dr. Lipkin, I …this is what puzzles me … I know as a historian that at the turn of the last century, moving from the 19th into the 20th century in terms of the problems of the cities, there was an increasing understanding that if we didn’t deal with the social problems of the immigrants; that if we didn’t deal with what they were bringing with them, or what they found here, we were endangering ourselves. I don’t have the feeling that there is much of a crusade among doctors, among professionals generally to help Americans understand how self-protective these measures … you’re researching now … would be.

Lipkin: I think that’s true. You know it’s not the kind of issue that gets high enough on the political agenda to balance it …overbalance security considerations, where the strong, well-publicized fears of drug addicts, for example, or it might be somewhat over-publicized pursuit of certain cancers, which are less common than others, where there’s no money going into them as leading causes of death. There’s not a whole lot of rationality of funding in health care, although people keep trying to work on it.

Heffner: In the issue that we discussed in our first program together, the question of doctor/patient relationship … I indicated at the beginning because I know that it’s true that you have a reputation around the world in this area. What about other people? Are they more, shall I say, “enlightened” when it comes to fostering a wiser, more humanistic approach to doctor/patient communications? Are they wiser when it comes to this matter of protecting themselves by having people who do not speak the native tongue have the means of being interpreted in terms of the experiment that you’re working on now?

Lipkin: Well you know there’s nobody else who’s using this remote …

Heffner: Really?

Lipkin: Yeah.

Heffner: Is that because of the copyright.

Lipkin: Ah … patent …

Heffner: Patent.

Lipkin: No, there are some similar systems that are somewhat coming in. There is a way to do it on the phone. The problem with that is that the interpreters are generally not well trained, it may take a long time to access them, and you have to pass the phone back and forth. It doesn’t feel natural.

Heffner: Hardly achieving what you want in the doctor/patient …

Lipkin: Right.

Heffner: … communication.

Lipkin: Right. You know, the United States in particular has lead in setting priorities worldwide in terms of health expenditures for a long time now.

In 1979 Carl White, who I was working with … was one of my mentors then … and I looked at the case of Thailand, where in 1979 they bought four head CT machines, head CAT scanners … one sixth of the capital budget of the whole country. Which the calculations suggested would save about 600 lives, while there were 6 million people in Thailand with malaria. This kind of gross distortion toward high tech, toward things that company’s could promote; toward if you will, sort of pot latch(?????) difference that institutions seek in order to distinguish themselves from their competitors, has lead to quite systematic distortion of, of spending. And that’s not what it does.

You know in the 1950’s, in Beijing, a tertiary modern hospital was build. Also with American money for leadership. And I have to say that they did invest in some public health … back then. They really … you know, they did this amazing thing of eradicating schistosomiasis. Only place in the world; they got every village to got down to the water and eliminate the places where the parasite could breed. But that’s gone now in China, too, with the new Administration and the, sort of, more capitalist orientation.

Heffner: Talking about capital orientation; talking about dollars and health, is it unfair for me to ask what your “fix” is on the question of the commercials we read, the adverting we see constantly about medical matters, drugs and the like. How do you feel about that?

Lipkin: I think that when a commercial is informative and destigmatizing … I’ll give you an example … Pfizer has … I think it’s Pfizer … has created a symbol that they call the “dot” or “spot”, or the people call … that is depressed … it’s a black and white drawing, cartoon; but the message is … many people are depressed, it’s not a matter of character or shame … shouldn’t be shameful, but instead is really a combination of bio-chemistry and stress in one’s life and grief and things like that all mixed up and affecting the brain itself. And it can be treated.

That’s the message. That is a really constructive thing, I think. I think it’s not a bad message to men who previously would have been too ashamed to discuss it, to see that a leading baseball player uses Viagra. Those kinds of messages that say “You might have a problem, it’s okay. Get help.”

Those are good messages. Where I stop is when the messages are science fiction, strange image laden, but unclear simple attempts to establish a brand or to get people to ask their doctor to give them something in an unclear way that doesn’t inform them. Those I’m opposed to.

Heffner: What about the impact upon … about the use of medications, of the constant selling, selling, selling.

Lipkin: Yeah. Well I think that we’ve gotten out of balance. We’ve … the best predictor of what a doctor will prescribe for depression or for high blood pressure or diabetes is what was being advertised in the medical journals the year they finished their training.

Heffner: Wow. What a statement.

Lipkin: Yeah. So, people who trained when I did use the old treatments. They’re cheaper, as good … but the specialists … might see it … this happens … one of my patients will go see somebody who’s a high blood pressure specialist and he’ll say, “He gave you that? That went out, you know, with the Stone Age.” When actually it’s just as good and a tenth the cost.

Heffner: So, is it a plus or a minus, overall? Your judgment.

Lipkin: Ahmm … “it” being … promotion?

Heffner: Promotion. Advertising. Of over-the-counter drugs.

Lipkin: Overall, I’d say it’s a plus.

Heffner: That’s interesting.

Lipkin: I think the public has a right to hear things. You know, I also think that we have a problem with journalism, which is that …

Heffner: Problem with journalism?

Lipkin: Yeah. That, you know, we get the same stories written over and over about medical miracles …

Heffner: MmmmHmmm.

Lipkin: So that the public expects … “doesn’t Dr. Lipkin know best?”. The public doesn’t expect to have side effects and have problems with their treatment and not to get better. And they feel cheated. That’s a new change in our culture, and it’s an unwise change.

Heffner: How do you relate this to journalism?

Lipkin: Because the kinds of … journalists don’t think it’s news unless it’s really dramatic or something that could be promoted as really brand new. But if you look at most journalistic medical stories, they’re just re-hashes, they’re not news. And they promote this attitude of expecting miracles that don’t have a down side.

Heffner: Now, we’ve got just a couple of minutes left. This is our second and last program, though I hope not forever. I would imagine that you could still be characterized … not “still be”, but you could be characterized as quite optimistic about the future, the medical future. Is that a fair assumption?

Lipkin: Well, I think we’re making a lot of progress. If that’s what you mean.

Heffner: Yeah. What’s the downside?

Lipkin: Well, I think these are scary times. We have emerging infections, we have a global village now so that a mosquito can bite a chicken in Israel and people die in New Orleans two years later. We have … one of the things we’ve been working on quite a lot since September 11th is really genuine threats to the health of the public through terrorist acts. So those are scary things. You know AIDS emerged from the jungle quite unexpectedly. We think there are probably other viruses that will emerge that will also be …

So, you know, one of the good things is probably like what you do … one of the wonderful things about medicine is it keeps changing. We’re, we’re not go to lick it all. And so we’re going to be needed and useful. Hopefully, as that happens we can help each patient get the best for themselves based on what they feel they need and want.

Heffner: Well, that brings me back, of course, to that statement I made, taken from you about how many doctors are now refusing to recommend to their children that they become doctors. Your father was the best doctor I ever had in my life. Are you going to recommend to you daughter that she do it or not do it … go into medicine?

Lipkin: You know my daughter’s got a strong mind of her own, she’s going to make up her mind. I’m going to tell her all about it, which I do. And she’ll decide. Just like it would be with a patient.

Heffner: That’s a cop-out.

Lipkin: Are you saying … am I happy in my career and can I tell her that? Yes.

Heffner: I would think you are.

Lipkin: Yeah. Yeah. What could be better. You know I do … I love working my patients, I’m in a scholarly field where I have to keep up and fascinating changes are occurring. I get to contribute to knowledge, I really get to impact. I think your figure is a little out of date now in terms of how many patients a general physician will see. It’s now up to about a quarter of a million …

Heffner: A quarter of a million.

Lipkin: In a professional lifetime. So I feel, if I can make both the doctor and the patient a little more satisfied, effective, then I impact a generation or two of doctors … you know, I’ll have done something. And I hope my daughter finds something like that, too.

Heffner: That’s a nice way to end our program. Dr. Mack Lipkin, Jr., thanks so much for joining me again today.

Lipkin: Thank you.

Heffner: And thanks, too, to you in the audience. I hope you join us again next time on The Open Mind, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.