AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. October 2002, Volume 4, Number 10.

Health in the Public Interest

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Cultural Impasse

Patients with limited English proficiency may suffer in the health care setting in the absence of clinical interpreters.

Akshara Meran

Name of patient: Lee, Lia
Ethnic group: Hmong
Principal language: Hmong
Western diagnosis: Severe epilepsy
Hmong diagnosis: Soul loss
Cause of death: CULTURAL IMPASSE

By now the tale told in The Spirit Catches You and You Fall Down by Anne Fadiman [1] is familiar to many students of cultural competence in medical schools and residency programs. The novel captures the tragic story of Hmong immigrant parents, Foua Yang and Nao Kao, and their clash with Merced Community Medical Center over the care of their daughter Lia Lee. Fadiman demonstrates how profound cultural differences and linguistic miscommunication cause an increasing rift between Lia's loving parents and her well-intentioned doctors, eventually resulting in her death.

The novel is remarkable in that it does not seek to blame either Lia's parents or the medical professionals for Lia's death, but rather advocates that the medical establishment overcome linguistic barriers and bridge the cultural gap with its immigrant patients. As one review said, "It has no heroes or villains, but it has an abundance of innocent suffering, and it most certainly does have a moral" [2].

A reflection of the colliding worlds of Western medicine and Hmong culture, Lia's story represents the situation faced by immigrants who do not speak English and hold different cultural values about health care.

In addressing the culture gap present in the health care setting, Fadiman presents an approach put forward by Arthur Kleinman, which entails colloquy between the patient and health care professionals. Kleinman proposes a model of mediation and urges physicians and other health professionals to recognize that biomedicine has its own cultural biases that also influence each medical case.

Apart from cultural differences, language is a problem for immigrants trying to communicate with nurses and physicians. Foua, the mother in the novel, cannot read English. Yet, she is asked for her signature so many times that she masters writing her name. Foua signs forms she does not comprehend, which is the case for many immigrants who do so to satisfy the abhorrent unfilled blanks.

America is a land of diverse people, and, as the number of minority communities increases, some ask whether we need to impose a multilingual requirement on our health care professionals in addition to our expectations of medical competence. At the same time, they know it is unreasonable to expect every doctor to be proficient in Wolof, Tswana, Hmong, and Queche, in the off chance that one of their many patients speaks one of these languages. The need for translators/interpreters to bridge the language gulf between immigrant patients and their doctors is evident. While health care professionals accept this solution, it is now a matter of who should pay for translation services.

In August 2000, the Department of Health and Human Services' Office of Civil Rights issued a mandate that all physicians who receive federal financial assistance, including payments under the Medicaid program, should provide, at their own expense, a trained clinical interpreter for all their limited English proficiency (LEP) patients [3]. This has caused heated debate. Many physicians claim that the financial burden of providing written and oral translation services to LEP patients would cause them great economic loss. The cost of hiring an interpreter ranges from $30-$400 per patient visit, significantly higher than the $30 to $50 Medicaid reimbursement for an office visit [3]. To reduce the financial burden on physicians, several options have been promoted and even adopted in some states, such as "I speak" cards that list the languages a patient speaks and provide the phone number of interpreters [4]. The idea of telephone interpretation services, allowing physicians to access state-funded, trained clinical interpreters also has appeal. Others argue that if the federal government is serious in its mandate for interpretation services for LEP patients, it should increase its funding so as to cover the costs.

While payment issues need to be resolved, it is necessary that interpretation services are made available to LEP patients as a first step in dealing with cultural differences in health care like the ones that resulted in Lia's death. Then, Anne Fadiman's wish will come true; the voices of immigrants and voices of American doctors will be heard on the same tape, speaking a common language.


  1. Fadiman A. The Spirit Catches You And You Fall Down: A Hmong Child, Her American Doctors, And The Collision Of Two Cultures. NY: Farrar, Straus and Giroux. 1997.
  2. Konner M. The New York Times Book Review. Excerpted in: Fadiman A. The Spirit Catches You And You Fall Down: A Hmong Child, Her American Doctors, And The Collision Of Two Cultures. NY: Farrar, Straus and Giroux. 1997.
  3. AMA Report of the Board of Trustees. Availability and payment for medical interpreter services in medical practices. Chicago: AMA. 2001. (unpublished).
  4. Hawryluk M. AMA: doctors shouldn't pay for translators. AMNews. January 14, 2002.

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