Interpreting Language and Culture in Primary Care

MCL Backstory

By Chris Koenig

Words matter. Speech acts. Utterances you may not even understand nevertheless can be powerful and cause harm due to misunderstanding. Yet, communication does not end with words alone. Bodies silently speak, inflecting a word in one way or another. Usage and situation cue cultural meanings that make sense of speech and make words meaningful. When barriers exist in communication, particularly due to speaking different languages, communication can break down even in the best of intentions and situations.

Chris Koenig wanted to help with that precise challenge. Koenig is an early MCL member and Associate Professor of Communication Studies at San Francisco State University where his focus is health communication, an interdisciplinary field that intersects public health, social science, and communication science. He has conducted research in both academic institutions and large health systems, including the San Francisco and Palo Alto Veterans Affairs Health Care System and Palo Alto Medical Foundation Research Institute. However, his interest in language and culture reach back to his childhood in Central Oklahoma where he grew up. 

When he went with his mother to the public junior high school where she taught in the late 1970’s, he heard Spanish, Spanglish, and Black English more than what he heard on the 5 o’clock news. His parents used Spanish to communicate when they did not want him to know what they were saying, so he had a “love-hate” relationship with the language for a long time. However, after spending two years living in rural Spain, Koenig found a new love of the language and hoped to “be a professional where I used Spanish everyday.”

Working towards this goal, Koenig studied Spanish Linguistics and Literature and specialized in translation and interpretation as an undergraduate. He aimed for a career as a medical interpreter and translator. For over three years, he volunteered as a medical interpreter at two local community primary care clinics in Austin, Texas. “It was the first time I had a front and center seat in medical interactions, and I was fascinated by the work being done in the middle (of those interactions) and the roles and responsibilities a cultural interpreter has,” says Koenig. It was here that Koenig recognized that he was not only translating words but also acting as a knowledge and cultural broker mediating the patients and clinicians he served.

After graduation, he joined a community clinic as a staff Spanish-English interpreter where he worked in general medicine, women’s, and pediatric clinics while pursuing a Master’s degree full-time. Being both witness and participant in medical interaction, he noticed differences with how different communities oriented to common-place medications, like antibiotics. Clients who came from Mexico oriented to antibiotics as prized because they were difficult to obtain in the US. When receiving a prescription, some clients treated antibiotics as precious, and they disregarded physician’s instructions to “take them until they are gone.” 

Day to day work in the clinic was engaging, but Koenig found medical interpretation and translation work lonely. At the same time, his interest in research on language and culture were growing. When he mentioned this to a mentor, he learned that communication and health research could itself be a viable career field. “I had no idea you could make a career out of that,” Koenig said, “so I started to explore.”

Initially, Koenig focused his health communication research on clinical encounters between Spanish-speaking patients and English-speaking providers. Drawing on his own experience, he was interested in discussions of medication and treatment. Over time, his focus expanded to encompass other language communities and their experiences of complementary and integrative health, oncology, diabetes, and rheumatology. Uses of language remains his passion. 

One long-term project focuses on how clinicians refer to medications during primary care visits; this is known linguistically as a “medical formulation.” Koenig explains there is typically a moment in primary care appointments where the physician will make a recommendation for a medication or another form of treatment. “Clinicians have a range of formulations available – from specialist terms, like ‘hydrochlorothiazide,’ that clients will likely not understand, to something more generalized, like ‘water pill,’ or even something vague, such as ‘something for your problem.’ The main insight is how a clinician refers to a treatment affects how clients might understand the recommendation overall,” says Koenig.

Koenig uses a specialized methodology. He records actual clinical encounters using digital video and then transcribes the recording in fine-grained detail. Using video and transcript together, he then examines how communication choices influence the trajectory of the encounter. Koenig observed how conversations about medicine formulations can be used for different functions. “For example, a clinician might use an opaque scientific name to encourage a patient to accept the recommendation and move on to the next matter,” said Koenig. “Analyzing the conversations is a puzzle where the form of the formulation may, or may not, match its apparent function. Sometimes a clinician uses a scientific drug name, which can be intimidating for some clients, but recognizable to others. Formulations are dynamic because clinician and client navigate who knows how much about what. Clients can be experts, intermediate, or novice in their understanding. And clinicians are surprised about who knows about which treatments, as clients’ health literacies are variable across the economic, geographical, racial, and ethnic spectrum.”

This approach helps us understand the culture of medicine by showing how individual words can be used in different ways and for different effects. Koenig said. “The culture of medicine works at multiple levels, from how the visit is organized, who speaks first, and even which topics are or are not legitimated, such as many complementary treatments that are not recognized by medicine, but used by many people in the US and worldwide.”

Koenig sees new energy infusing this long-term project because of its potential to improve health equity. Basic premises of health equity include Diversity, Equity, and Inclusion. Medical formulations of treatment have the potential to foster inclusivity across populations in clinical and everyday cultures. He commented, “clinicians can tailor how they refer to treatments by blending clinical and everyday cultures to make their recommendations more inclusive for a variety of people.”

Koenig recommends that clinicians stack formulations to make them more understandable. “For example, a clinician might say, ‘I’m recommending hydrochlorothiazide. It’s a medication that helps push water out of your body, and some people call it a ‘water pill.’ That gives much more helpful information and presents it in a way that is understandable and helps raise health literacy.”

Communication links language and culture in everyday situations. “Medical cultures infuse every aspect of clinical interactions but are often overlooked. Communication science helps to ask questions with a fresh perspective that helps see what others may not,” Koenig mused. He aspires this research to show how medical culture influences people’s ability to participate and to be more inclusive and accessible to a diverse population during primary care encounters.