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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Although human communication is our main means of organizing a society&#44; it also presents us with major problems today&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Physician-to-patient communication is one of the most important skills health professionals must acquire during training&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> yet doctors have been shown to be very poor communicators&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Net population growth in Spain in recent years has mainly been due to immigration&#44; which has risen gradually to maintain a positive net migration rate &#40;immigrants &#8211; emigrants&#41;&#46; Meanwhile&#44; the vegetative balance &#40;between births and deaths&#41; continues to be negative&#46; The Spanish Statistical Office &#40;Institute Nacional de Estad&#237;stica&#41; reported that as of January 1&#44; 2020&#44; 11&#46;06&#37; of residents were noncitizens&#46; The proportion is notably higher in some areas&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">One consequence is an increased demand for health care from patients from cultures other than Spain&#8217;s&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> A patient&#8217;s culture affects lifestyle&#44; perception of disease&#44; and what is expected and required of a health care system&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">It is important to remember that health care for migrants is not equivalent to medicine centered on rare parasitic and viral diseases&#46; Rather&#44; it is medical care for men and women who have left one health system behind without abandoning it entirely&#44; migrants who have acquired a new system they do not yet understand&#59; the 2 systems differ in how they express suffering and how they conceptualize disease&#44; pain&#44; death&#44; and the medical act&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">When physician and patient fail to communicate&#44; quality of care can be seriously harmed&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> making it difficult to comply with the principles of medical ethics&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">One study carried out in a Spanish primary care setting showed that although language is the first obstacle to overcome when communicating with migrant patients &#8211; and is one that often interferes with identifying symptoms &#8211; additional problems can be introduced by &#8220;mediators&#8221; &#40;family&#44; friends&#44; neighbors&#44; etc&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> because of the varying notions of disease at work in different ethnic groups&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">For use in such contexts&#44; the figure of &#8220;intercultural mediator&#8221; was developed&#46; This figure belongs to the patient&#8217;s culture&#44; is recognized as such&#44; and is able to negotiate between the 2 cultures&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> We must not forget&#44; however&#44; that the mediator is a third party who may also potentially interpret and transmit information incorrectly&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Thus&#44; we agree with other authors that language is not the sole problem in communication&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Several others are in play&#46; Some are patient-related&#46; Examples are marginalization&#44; an uncertain legal status&#44; the migratory duel between cultures&#44; lack of understanding of how the health system works&#44; less continuity of care due to family or socioeconomic problems&#44; and lower awareness of health campaigns carried out in a language different from the patient&#8217;s native one&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We also believe there are health care staff-related factors&#46; Staff&#44; who are under pressure from high caseloads&#44; must make an extra effort with migrant patients in the short time that is available&#44; sometimes making verbal communication more difficult and diminishing nonverbal communication&#46; In this situation&#44; patients can become victims of prejudice or disrespect if they are labeled &#8220;difficult&#46;&#8221; The health caregiver may fail to perceive the feedback required to confirm whether professional and affective acts are effective or not&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A literal translation of what the patient explains seems to be inadequate for overcoming communication obstacles&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">One reason lies in the difficulty of establishing equivalents between languages&#44; or failing to appreciate subtle differences in meaning whereby concepts can become lost in translation&#46; Another lies in the additive effect of grammatical artifacts that occur when each of the interlocutors uses a language with structural differences&#44; or when they communicate in a shared language they may speak and understand only imperfectly&#46; Morphology and syntax that are transferred may then introduce confusion&#46; An example is the statement&#47;question &#8220;You haven&#8217;t been taking your tablets&#63;&#8221; &#40;&#191;<span class="elsevierStyleItalic">No ha tomado las pastillas</span>&#63;&#41; &#8212; to which an English speaker wishing to confirm that this negative construction is correct&#44; would answer &#8220;no&#44;&#8221; whereas the Spanish speaker would reply <span class="elsevierStyleItalic">s&#237;</span>&#44; and so there develops a situation in which &#8220;no&#8221; can convey &#8220;yes&#8221; &#40;and vice versa&#41; to a listener&#46; In addition to telephone or in-person interpretation services and the previously mentioned intercultural mediators&#44; graphic communication tools have been developed to depict concepts&#44; accompanied by labels in different languages&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Finally&#44; we summarize some of the recommendations to bear in mind when communicating with migrant patients<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0070" class="elsevierStylePara elsevierViewall">Acquire knowledge of features of the patient&#8217;s culture &#40;transcultural medicine&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0075" class="elsevierStylePara elsevierViewall">Avoid obstacles such as interruptions&#44; noise&#44; parallel conversations&#44; or the use of specialized terminology&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0080" class="elsevierStylePara elsevierViewall">Facilitate communication&#58; recognize the presence of the interpreter and maintain a triangular position with respect to him or her and the patient&#46; Address the patient&#44; speak slowly and clearly to express a concrete message&#44; and reinforce the patient&#8217;s understanding&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0085" class="elsevierStylePara elsevierViewall">Use multilingual pictograms and graphic aids in different languages&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0090" class="elsevierStylePara elsevierViewall">Express empathy throughout the communication process&#46;</p></li></ul></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This paper received no type of funding&#46;</p></span></span>"
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Opinion Article
Communicating With Migrant Patients: An Unsolved Problem?
La comunicación con el paciente migrante: ¿asignatura pendiente?
R.M. Díaz-Díaza,
Autor para correspondencia
rmaria.diaz@salud.madrid.org

Corresponding author.
, M.M. Alcalde Alonsob
a Sección de Dermatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
b UGC de Dermatología Médico-Quirúrgica y Venereología, Complejo Hospitalario Torrecárdenas, Almería, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Although human communication is our main means of organizing a society&#44; it also presents us with major problems today&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Physician-to-patient communication is one of the most important skills health professionals must acquire during training&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> yet doctors have been shown to be very poor communicators&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Net population growth in Spain in recent years has mainly been due to immigration&#44; which has risen gradually to maintain a positive net migration rate &#40;immigrants &#8211; emigrants&#41;&#46; Meanwhile&#44; the vegetative balance &#40;between births and deaths&#41; continues to be negative&#46; The Spanish Statistical Office &#40;Institute Nacional de Estad&#237;stica&#41; reported that as of January 1&#44; 2020&#44; 11&#46;06&#37; of residents were noncitizens&#46; The proportion is notably higher in some areas&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">One consequence is an increased demand for health care from patients from cultures other than Spain&#8217;s&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> A patient&#8217;s culture affects lifestyle&#44; perception of disease&#44; and what is expected and required of a health care system&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">It is important to remember that health care for migrants is not equivalent to medicine centered on rare parasitic and viral diseases&#46; Rather&#44; it is medical care for men and women who have left one health system behind without abandoning it entirely&#44; migrants who have acquired a new system they do not yet understand&#59; the 2 systems differ in how they express suffering and how they conceptualize disease&#44; pain&#44; death&#44; and the medical act&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">When physician and patient fail to communicate&#44; quality of care can be seriously harmed&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> making it difficult to comply with the principles of medical ethics&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">One study carried out in a Spanish primary care setting showed that although language is the first obstacle to overcome when communicating with migrant patients &#8211; and is one that often interferes with identifying symptoms &#8211; additional problems can be introduced by &#8220;mediators&#8221; &#40;family&#44; friends&#44; neighbors&#44; etc&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> because of the varying notions of disease at work in different ethnic groups&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">For use in such contexts&#44; the figure of &#8220;intercultural mediator&#8221; was developed&#46; This figure belongs to the patient&#8217;s culture&#44; is recognized as such&#44; and is able to negotiate between the 2 cultures&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> We must not forget&#44; however&#44; that the mediator is a third party who may also potentially interpret and transmit information incorrectly&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Thus&#44; we agree with other authors that language is not the sole problem in communication&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Several others are in play&#46; Some are patient-related&#46; Examples are marginalization&#44; an uncertain legal status&#44; the migratory duel between cultures&#44; lack of understanding of how the health system works&#44; less continuity of care due to family or socioeconomic problems&#44; and lower awareness of health campaigns carried out in a language different from the patient&#8217;s native one&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We also believe there are health care staff-related factors&#46; Staff&#44; who are under pressure from high caseloads&#44; must make an extra effort with migrant patients in the short time that is available&#44; sometimes making verbal communication more difficult and diminishing nonverbal communication&#46; In this situation&#44; patients can become victims of prejudice or disrespect if they are labeled &#8220;difficult&#46;&#8221; The health caregiver may fail to perceive the feedback required to confirm whether professional and affective acts are effective or not&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A literal translation of what the patient explains seems to be inadequate for overcoming communication obstacles&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">One reason lies in the difficulty of establishing equivalents between languages&#44; or failing to appreciate subtle differences in meaning whereby concepts can become lost in translation&#46; Another lies in the additive effect of grammatical artifacts that occur when each of the interlocutors uses a language with structural differences&#44; or when they communicate in a shared language they may speak and understand only imperfectly&#46; Morphology and syntax that are transferred may then introduce confusion&#46; An example is the statement&#47;question &#8220;You haven&#8217;t been taking your tablets&#63;&#8221; &#40;&#191;<span class="elsevierStyleItalic">No ha tomado las pastillas</span>&#63;&#41; &#8212; to which an English speaker wishing to confirm that this negative construction is correct&#44; would answer &#8220;no&#44;&#8221; whereas the Spanish speaker would reply <span class="elsevierStyleItalic">s&#237;</span>&#44; and so there develops a situation in which &#8220;no&#8221; can convey &#8220;yes&#8221; &#40;and vice versa&#41; to a listener&#46; In addition to telephone or in-person interpretation services and the previously mentioned intercultural mediators&#44; graphic communication tools have been developed to depict concepts&#44; accompanied by labels in different languages&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Finally&#44; we summarize some of the recommendations to bear in mind when communicating with migrant patients<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0070" class="elsevierStylePara elsevierViewall">Acquire knowledge of features of the patient&#8217;s culture &#40;transcultural medicine&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0075" class="elsevierStylePara elsevierViewall">Avoid obstacles such as interruptions&#44; noise&#44; parallel conversations&#44; or the use of specialized terminology&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0080" class="elsevierStylePara elsevierViewall">Facilitate communication&#58; recognize the presence of the interpreter and maintain a triangular position with respect to him or her and the patient&#46; Address the patient&#44; speak slowly and clearly to express a concrete message&#44; and reinforce the patient&#8217;s understanding&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0085" class="elsevierStylePara elsevierViewall">Use multilingual pictograms and graphic aids in different languages&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0090" class="elsevierStylePara elsevierViewall">Express empathy throughout the communication process&#46;</p></li></ul></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This paper received no type of funding&#46;</p></span></span>"
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