Misunderstandings: a qualitative study of primary care consultations in multilingual settings, and educational implications

BACKGROUND Patients in inner-city areas come from increasingly diverse language and cultural backgrounds. Neither communications training modelled on local English speakers nor the provision of interpreters offer adequate solutions. AIM To identify how patients with limited English and culturally different communication styles consult with general practitioners (GPs) in English, and to develop training strategies from both good practice and observed misunderstandings. METHODS Randomly selected routine and emergency surgeries in 19 inner London general practices were video-recorded. The videos were viewed independently by 2 discourse analysts. Key consultations, across a wide range of English language ability, were selected and transcribed to analyse misunderstandings resulting from language/cultural differences. RESULTS Of the 232 video recordings that were made, 20% were with patients with limited English and contained major and often extended misunderstandings. QUALITATIVE ANALYSIS Four main categories of patient 'talk' contributing to misunderstandings are identified: (1) pronunciation and word stress; (2) intonation and speech delivery; (3) grammar, vocabulary and lack of contextual information; and (4) style of presentation. The importance of different styles of self-presentation by patients as the reason for misunderstandings is highlighted. On only 3 occasions were culturally specific health beliefs raised. CONCLUSION It is routine for GPs in inner London practices to manage consultations with patients with culturally different communicative styles from their own. Specific training in identifying these problems and preventing/repairing them in the consultation is essential. This level of awareness-raising is more crucial than general discussions of culturally different health belief models.