Levering Code-Switching to Improve Information Delivery for Surgical Patients

You may be saying to yourself, what exactly is code-switching and why should a surgeon care? Code-switching is a linguistic term that applies when a speaker, who is multilingual, switches between two or more languages or dialects within the context of a single conversation.¹ Code –switching can happen without the cognitive awareness of the user who is employing this technique. More commonly, we see code switching happening when a person switches between different cultural styles, for example, using clinical examples that are in line with the cultural background of a patient who you are counseling.  Code switching, therefore, is not just a natural phenomenon that happens among those who speak multiple languages—it can also be used intentionally as a way to enhance the way surgeons talk to their patients.

When I was getting a master’s in public health degree, one of the most important lessons I received was about the importance of the town hall meeting and effective public health communication. A town hall meeting is a venue that invites members of a community from all walks of life to receive and discuss important health information. Extending this example to a surgical setting, such as a preoperative clinic visit demonstrates the relevance of this type of communication to our most vulnerable patient populations. Using language that your patients understand, either based on their education level or their level of health literacy is essential to ensure that they not only understand and follow the plan of care but become invested in that plan, which has been shown to be associated with certain health outcomes in surgery.² Although code-switching has sometimes been criticized as being inauthentic, the ability to understand the cultural background of your patients and use this information to better connect with them can be a major advantage to providing culturally appropriate health information delivery for your patients.

I was recently talking with my co-resident who is a native Spanish speaker. In his everyday speech, he does not have a detectable accent when he speaks English. He reflected that he occasionally adopts a slight Southern accent when speaking with patients, but he did not recognize this behavior until a colleague pointed it out to him. This is likely a subconscious way of mirroring his patients’ speech patterns. It likely puts his patients at ease, in the same way that studies have demonstrated that patients and providers pairs that are gender mismatched or dissimilar ethnicity have decreased satisfaction with their healthcare.³ Conversely, my colleague was a bit self-conscious about the realization and expressed that he would never want a patient to think he was poking fun of their accent or looking down on the in anyway. His thoughtfulness regarding the matter makes it seem unlikely that this would be the case, but it does remind us of the dangers of code-switching. A small note of caution is appropriate when discussing its impact on our surgical patients. Physicians, and surgeons in particular, are incredibly powerful and the potential to alienate our patients or bring them closer based on very brief interactions and clinical encounters.

It is easy to overlook the fact that most health information is written with a bias towards white, upper/middle class, educated, primary English-speaking individuals. On the other hand, for most surgeons, our patient population represents a diverse swath of the United States (US) population representing many racial and ethnic groups, socioeconomic classes, and varying levels of English proficiency. Although health materials are supposed to be written in and communicated at a fifth-grade reading level, according to most experts, this has been shown to happen at alarmingly low rates.⁴ It is our responsibility as surgeons to ensure that we are always utilizing language that keeps it simple. Most of us believe that we are communicating well with our patients and have excellent intentions; however, in reality, we are often failing to meet our patients where they are. Have you ever used the phrase “your family member is septic”? If so, did you translate that discussion into words that the patient would be able to easily comprehend? Would your daughter who is in middle school understand the phrase “hemodynamically unstable”? If not, consider providing the information you would like to communicate and then utilizing a teach back method to ensure comprehension.⁵

Code-switching can be a powerful tool for both communicating and connecting with our patients. It should remind us of the importance of language precision and considering the background of the patients and families who you are communicating with. Striving for simple and direct communication will only serve to enhance relationships with your patients and decrease the chance that a patient consents for an operation for which they do not fully understand the indication or risk involved. It is ultimately up to the surgeon to take the lead in ensuring that our communication with patients is both safe, effective, and culturally appropriate.

Note: The topic of this blog was inspired by my desire for improved cultural competency in physician-patient interactions and my love of NPR’s Code Switch podcast.

References:

1. Nilep C. ‘Code switching’in sociocultural linguistics. 2006.
2. Wright JP, Edwards GC, Goggins K, et al. Association of Health Literacy With Postoperative Outcomes in Patients Undergoing Major Abdominal Surgery. JAMA Surg. 2018;153(2):137-142.
3. Saha S, Arbelaez JJ, Cooper LA. Patient-physician relationships and racial disparities in the quality of health care. Am J Public Health. 2003;93(10):1713-1719.
4. Paasche-Orlow MK, Taylor HA, Brancati FL. Readability standards for informed-consent forms as compared with actual readability. N Engl J Med. 2003;348(8):721-726.
5. Use the Teach-Back Method: Tool #5. Rockville, MD: Agency for Healthcare Research and Quality; February 2015.