What the doctor ordered and what the patient heard

It had been a long night in the ER. The family sat stiffly on the rickety plastic chairs as their toddler whimpered and squirmed in his mother’s lap. In bits and pieces of broken English, the father tried to communicate why they had come.

“No good. Ear no good.”

Lacking an interpreter, I struggled to piece together his story using gestures and the few words of the family’s language I remembered from my travels. Apparently, the little boy had been seen in a local clinic and diagnosed with a middle-ear infection. He had been treated with a common oral antibiotic, “the pink one,” so familiar to generations of parents. My examination of his ear confirmed the parents’ fears -- the infection was still active and acute. The medicine should have worked. What could have gone wrong?

One possibility was a viral infection that wasn’t responding to antibiotics. Or, more specifically, perhaps the infecting bacteria were resistant to the prescribed antibiotic. Did I need to change the prescription or was there a simpler solution: Was the youngster truly getting his full treatment? Even when parents are diligent about offering each dose, little ones sometimes spit out more of the liquid than they swallow.

I asked the family how often they were administering the antibiotic. The answer: like they were supposed to, three times a day. How much medicine? Again, right on target: a 5-cc dropperful each time. Were they having any trouble administering the medicine? They hesitated. Sometimes it was difficult, they admitted, especially when the sticky pink liquid would leak back out of the ear.

I did a double take. Apparently, the family had misunderstood their doctor’s instructions. Instead of giving their child a teaspoonful of the medicine by mouth, they were carefully inserting the medicine into the ear canal. The antibiotic could not get past the eardrum to treat the infected area in the middle ear, so the infection had grown worse.

This family’s situation was not unique. Studies have shown that up to 80% of patients don’t fully comply with recommended therapy -- even when the instructions are clear. But the problem is compounded when language and cultural barriers prevent adequate understanding and communication.

Patients who are confused by their doctors’ recommendations may hesitate to question a perceived figure of authority or may be unable to speak English well enough to do so. They may leave the office with multiple prescriptions, unsure how to take their medications, what to expect from treatment, what side effects to look out for and when to return for follow-up. In many cases, the outcome is a partially treated or untreated illness. Sometimes an even greater tragedy can be the result -- death or disability.

A risk can also arise from a custom common in some cultures: seeking additional care from alternative health-care providers who may give treatments or medications that can interact with or interfere with medications a doctor prescribes.

Traditionally trained physicians may be unaware of these treatments and medications and how they are being used by patients. Some of these practices may even seem alarming or dangerous to traditionally schooled eyes. I recall having to inform a colleague that the numerous red, circular bruises on a teenager’s back were not due to intentional abuse, but to “cupping” -- heating a cup over a small flame then briefly vacuum-sealing it onto the skin in an attempt to draw out the illness.

Acknowledging the role that alternative practitioners have in the care of patients, many medical schools, healthcare organizations and hospitals are beginning to provide training to doctors and medical students in cultural competency -- briefly, the knowledge, understanding, attitudes and skills needed to identify, respect and support the health needs of a diverse patient population.

To promote effective communication between doctors and patients, new federal and state laws encourage and, in certain settings, require health-care providers to have interpreters available. Many health centers are compiling lists of staff members who speak different languages and can serve as ad hoc interpreters when needed. Others are now hiring phone-based interpretation services that encompass a global list of languages and guarantee patient privacy and confidentiality.

Unfortunately, I didn’t have access to an interpreter in the ER that night. It took more than half an hour, but working word by word with a dictionary, I was able to explain to the worried parents why the antibiotic had not yet helped their child.

Once the family restarted the medicine, this time orally, their youngster quickly improved. I didn’t need to translate the relieved smiles on the couple’s faces during a follow-up visit a few days later as we watched their laughing son scamper around my exam room.

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Dr. Linda Reid Chassiakos is director of the Klotz Student Health Center at Cal State Northridge and a clinical assistant professor of pediatrics at UCLA.