At Saint Louis University, medical residents think—and learn—globally
By Katherine Lahey Horrigan
Photograph by Frank Di Piazza
I've heard patients tell me that they’ve walked across a country with their child on their back,” says Dr. Elizabeth Montgomery, assistant professor of pediatrics at Saint Louis University School of Medicine. “That is unfathomable to residents here. But once they’ve gone to third-world countries and they see patients walking 20 miles to visit their clinics, they understand a lot more.”
As co-director of Saint Louis University’s Medicine Abroad Program, Montgomery is partly responsible for this shift in perspective. Co-directed by Montgomery and Dr. Donna Halloran since 2005, MAP sends SLU residents abroad to learn how to better serve needy communities and how to medically care for people from other cultures. When they return to St. Louis, the residents are better equipped to work their pediatric rounds at Cardinal Glennon Children’s Medical Center, where their patients include immigrants from Liberia, Ethiopia and Somalia.
Since its founding, MAP has sent five residents abroad each year and will do the same this coming year. After returning from a trip to Botswana, third-year resident
Dr. Maria Carrillo explained to other residents and faculty the serious challenges of working in a country where 30 percent of children are HIV-positive and resources are sometimes very basic. “You see these kids come in just skin and bones,” she said, “and then the ones who have had a few months’ treatment—they’ve gained weight, they are interested in what’s going on around them.” Carrillo also spoke of her efforts at connecting with the community. “I tried to learn a Botswanan language so I could speak a little to the patients,” she said. “At first they couldn’t understand me, but when they finally realized what I was trying to say, they laughed so hard.”
Dr. Shana Vore, who completed her residency in June, spent a month late last year at a clinic in southwestern Uganda, near the Congo border. The clinic was founded to serve the health needs of the Batwa, hunter-gatherers indigenous to the Bwindi Impenetrable Forest. When the Ugandan government established a national park in the forest to protect the mountain gorillas that live there, “they kicked the Batwa out,” Vore explains. The clinic subsequently expanded to serve the entire community.
“It really was a life-changing experience,” she says. “I have a better appreciation for differences in culture. There’s more than just a difference in language—it’s really a difference in ways of life, a difference in value systems, a difference in morals.”
Vore noticed one central cultural distinction. “They have a very different view on illness and death than we do,” she says. “I think that’s important to keep in the back of our minds when we work with people from other cultures. In a country in Africa—any country, really—death is more a way of life than a huge tragedy. They’re sad—they’ve lost a loved one. But in our culture, you do everything you possibly can to avoid death, even if it means that a person may be permanently disabled. Many times, they will turn down measures to prolong life. They’ll say, ‘No, this is
the end.’”
Vore’s time in Africa also taught her to be a better doctor in other ways.
“I was learning how to practice a purer form of medicine,” she says. “In our hospital, if we want to diagnose a kid with something, we order a bunch of lab tests. Over half of them are normal, and one of them gives us our answer. But in a country where you have fewer resources, you have to rely a lot more on your exam skills and your history-taking skills. From that standpoint it’s an absolutely valuable educational experience. And then you add in the cultural awareness, the experiences that you’re going to carry with you for your life. I just think it’s the most incredible thing I’ve ever done.”
Two years into the program, Montgomery is proud of the work done by these young people and of how MAP is strengthening the field and the university. “There’s an increased awareness about international hospital work,” she says. “When students come here to interview about residency, the current residents are proud to talk about the program. First-year residents hear lectures and stories, and they’re excited to go. For the first time this year, we had more applicants than we could send.”
Interpreters Bridge The Language Gap
A 2005 U.S. Census estimate put the number of foreign-born residents living in the St. Louis Metropolitan Statistical Area at 109,000—a nearly 35 percent increase from 2000. St. Louis’ International Institute reports that in 2005, the city welcomed new immigrants—many of them refugees—from Bosnia, Afghanistan, Russia, Liberia, Turkey, Uzbekistan, Ethiopia, Eritrea, Vietnam and the Congo. Compassionate medical care for these new St. Louis residents is a priority for several hospitals and clinics in St. Louis—and one of the most important elements of that care is effective communication.
Barnes-Jewish Hospital, in partnership with Children’s Hospital and Washington University Medical Center, is a leader in providing interpretation services as an integral part of their medical care. When Jewish Hospital was founded in 1902, one of its four basic missions was to serve refugees and immigrants, says Barbara Bogomolov, director of Refugee Health and Interpreter Services for the hospital and medical center.
That commitment has been extended to all hospitals and clinics that are part of the Washington University Medical Center, so that everyone served there receives the same standard of care.
The 32 interpreters at the medical center support an average of 100 events a day—everything from a 15-minute three-way phone conversation in which a doctor reports results of a lab test through an interpreter to six hours of neurosurgery with a patient who needs to be semiconscious. “The interpreter is scrubbed into the OR with the rest of the team,” Bogomolov says, “making sure that the patient can in fact lift his left baby finger when the doc tells him to.”
Interpretation requires not just language skills but extraordinary cultural sensitivity. Some patients burst into tears of relief when they see an interpreter who can explain what’s happening. But Bogomolov also remembers an elderly Chinese-speaking woman whose daughter wanted to send the interpreter away and do the interpreting herself, as she had at the referring community hospital. Taking her aside, the interpreter and a cross-cultural specialist discovered that the patient was unaware of the seriousness of her illness; the daughter had filtered out the cancer diagnosis when she translated for her mother at the community hospital. The daughter feared that Western medicine’s blunt candor would be devastating to her mother—and actually endanger her health. So the physician was brought into the discussion, and it was decided that, to ensure informed consent, the patient would be told that her impending surgery would result in a stay of some days in the intensive care unit, given details about what to expect and offered the chance to discuss her condition more fully. When she shook her head and requested that her daughter continue to handle all such matters, nothing more was said. And she recovered beautifully.
Since 1996, the number of annual healthcare encounters supported by interpreters within the Washington University Medical Center has grown from 7,300 to more than 32,000. The number of languages supported has grown from 13 to 73. And that’s still not always enough.
“The International Institute of St. Louis has an interpreter service,” Bogomolov says, “and I use them when a patient has a language that I just plain can’t pull off on campus. I most recently used them for Swahili. They’re very good.”
Another major interpreter service for the community, as well as other area medical clinics and hospitals, is the Language Access Metro Project. LAMP grew out of the interpretation service Bogomolov directs into a stand-alone program that trains bilingual people in health and social-service systems.
With an increasing number of resources and professionals focused on language barriers in healthcare, St. Louis is strengthening its capacity for serving its foreign-born residents. As Bogomolov explains, this is a winning scenario all around.
“It’s often an ‘Aha!’ moment for all the players,” she says, “when you suddenly have a real interpreter there at the medical center and information gets exchanged in a way that turns up what people weren’t getting before.”
