Excuse me, could you repeat that?

Doctor-patient communication has been the subject of jokes for years. But if a physician’s accent is so strong that patients or colleagues can’t understand his or her instructions, it’s hardly a laughing matter.

Lynda Katz Wilner, a speech pathologist in Owings Mills, Md., first observed this 25 years ago, when a foreign-born neurologist in a Philadelphia hospital was delivering a grand rounds lecture, ostensibly to demonstrate a patient’s inability to comprehend directions after a stroke.

There was only one problem: The audience couldn’t understand the doctor’s instructions either. “His whole presentation was sabotaged because of his accent,” Wilner says.

Today, Wilner runs a home-based business called Successfully Speaking that helps foreign-born doctors and other professionals modify their accents to make themselves easier to understand. So far, she says, she has trained about 100 clients.

With the number of foreign-born doctors increasing, programs such as Wilner’s are on the rise nationwide. In 2004, a quarter of the 884,974 physicians practicing in the United States were graduates of foreign medical schools. Last year, 22,931 foreign-schooled doctors registered to take the U.S. Medical Licensing Examination, an increase of 9% from 2004, according to the Educational Commission for Foreign Medical Graduates.

Since 1998, the commission has tested doctors’ command of English as part of overall doctor-patient communication during a mock physical exam in which actors portray patients. Doctors must take a medical history, ask and answer questions, write a note on the patient’s chart and list what tests they would order.

“Accent per se is not a problem,” says Dr. Gerry Whelan, the commission’s vice president for assessment services. “It has to do with intelligibility and the quality of language exchange.”

Although foreign-born physicians may have excellent medical training and comprehension of English, patients and co-workers can struggle to understand their speech and are often reluctant to call attention to the problem. For example, the numbers 15 and 50 can sound similar in some accents, as can the words “breathing” and “bleeding.” This increases the potential for medical errors, Wilner says.

“People are frustrated when they get in this situation,” she says. “Others, especially elderly patients, may be intimidated and not want to ask questions.”

The biggest issues, she adds, are rhythms and intonations that don’t match American English. Doctors from Latin America may speak very quickly, for example, or have difficulty pronouncing the American “v” sound, saying “berry” instead of “very.” Other problematic sounds for some foreigners are “l,” “th” and “r.”

To deal with such issues, Wilner developed a training manual with exercises that target intonation and pronunciation. She also goes over common medical terms as well as slang that doctors won’t find in a dictionary, such as, “The patient kicked the bucket” or “Catch 40 winks.”

Wilner uses mirrors, video and audiotapes so clients can see and hear themselves, and provides CDs for practice at home. An evaluation and 12 to 16 sessions averages $2,500, which is sometimes covered by a doctor’s employer.

After finishing her coursework, Wilner says, clients “usually feel much more confident, and that people are understanding them better.”

One satisfied client is Dr. Gabriel Soudry, director of nuclear medicine at Baltimore’s Franklin Square Hospital Center. He signed up for individual sessions with Wilner after hearing her speak at a medical convention.

“I thought I had to improve my accent,” says Soudry, who grew up in Marseilles, France. “In general, people understand most of what I say but occasionally they would ask me to repeat a word, or when I would dictate reports, the transcriptionist would occasionally miss a word. Also, because I give a lot of conferences, I didn’t want people to be distracted by my accent.”

Soudry says working with Wilner taught him which syllables to stress. Now “the transcriptionist makes less mistakes, and usually not due to my accent,” he says.

As the number of foreign-born physicians has increased, so has the demand for accent modification programs nationwide. For example, over the last three years, the American Speech-Language-Hearing Assn. has fielded an increasing number of calls from speech therapists looking for training in this area, according to Claudia Saad, the organization’s director of multicultural education.

And Lorna Sikorski, a California speech therapist who has trained more than 500 colleagues in accent modification techniques, says she has “a continually expanding group” of students. There have been no published studies looking at the effect of healthcare providers’ accents, so Wilner and two speech therapist colleagues last year started an online survey to investigate communication breakdowns faced by international medical graduates.

Of the 160 respondents so far, 36% of nonnative English speakers said they had been perceived or treated differently by patients, colleagues or others because of language, accent or cultural differences.

Fifty-nine percent reported difficulties building rapport with patients and colleagues, while 35% reported difficulties with dictation and communicating with colleagues.

Some 23% said they had problems with trust and credibility, providing test results and recommendations, and communicating with patients and family members.

Thomas LaVeist, director of the Center for Health Disparities Solutions at the Johns Hopkins Bloomberg School of Public Health, has conducted studies that examine the “health encounter” between patients and doctors of different races.

Though the work hasn’t specifically looked at physicians’ accents, he says, anecdotal evidence shows that “some patients felt like the doctors were practicing medicine in a second language.”

“It’s an issue, especially in the inner city,” LaVeist says, noting that these patients didn’t understand the doctor’s recommendations. “We need to do something.”