Born and raised in India, Dr. Sandeep Grewal speaks four languages fluently, including English. Even so, he was often asked to repeat himself as he spoke with patients at Novant Health Presbyterian Medical Center in Charlotte.

"There were certain words that I would say and my patients would not understand," said Grewal, a hospitalist, a physician who specializes in treating hospitalized patients. "Since the U.S. is my adopted country, I should be able to speak in the way people in the U.S. speak."

So when a nationally recognized specialist, Dr. Amee Shah, was invited to offer one-on-one coaching to help Novant Health’s foreign-born team members hone their communication skills, Grewal eagerly took advantage of it.

The coaching isn’t intended to change or erase anyone’s accent. Instead, speech pathologist Shah pinpoints what’s getting in the way of clear communication and then shows each of her clients what to do about it. The aim is to improve patient satisfaction, promote inclusion and teamwork in a diverse workplace, and ensure safe and effective care.

With a workforce of nearly 40,000, Novant Health has workers from around the world — a third of whom are people of color. Since the program began, 45 languages and 52 dialects have been represented in the communications program, including Spanish, French, Vietnamese, Swahili, Russian, Hindi, Gujarati and Mandarin Chinese.

The far-reaching diversity is by design: When patients see and hear themselves reflected in the health care workers they encounter, it builds comfort and trust. That's why Novant Health recognizes the extraordinary value multilingual, foreign-born doctors, nurses, nurse assistants, and other members of the team bring to the organization and to health care.

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Foreign-born health workers

From Charlotte to California, the communication needs are significant.

Immigrants, including refugees, made up 17% of the nation’s health care workforce in 2018, according to the latest federal data cited in a report by the Migration Policy Institute — including 28% of physicians and surgeons; nearly 16% of registered nurses; and more than 22% of support workers, including nursing assistants and aides.

Dr. Amee Shah
Dr. Amee Shah

But study after study has found that some patients are wary of foreign-born health care workers, according to Shah, founder and director of the Cross Cultural Speech, Language and Acoustics Lab at Stockton University in New Jersey and the Evidence-based Accent Management (EBAM) Institute in Philadelphia.

"Patients may see them as an outsider, as not competent," she said. "They may not trust the veracity or truth of the physicians or nurses, they may not trust in their competence, they may not trust in their underlying interest in them."

And yet, Shah said, many of those same patients feel intimidated to ask a foreign-born doctor or nurse to speak more clearly or clarify their instructions — risking serious misunderstandings.

"Clear communication is one of our safety behaviors," said Denise Mihal, executive vice president, chief nursing and clinical operations officer. Without it, there is increased risk for medication errors and that patients or their families may misinterpret doctors’ instructions after leaving the hospital, with potentially serious results.

So Shah’s online classes are a healthy dose of preventive medicine. Since 2018, 95 Novant Health team members have received one-on-one lessons tailored to their individual communication needs. No one is required to attend. But most team members who are recommended for the coaching decide to give it a go. Each one gets a detailed communication evaluation and personal set of objectives.

For all, the emphasis is on mastering the peculiar pronunciations, rhythms and inflections of U.S. English.

For many, it is also getting comfortable with expressions like "his head is buried in the sand" and the sports-world jargon that peppers everyday American speech. (Think: touching base, hitting a homerun or going back to square one.)

Sometimes, medical staff get a crash course in the pitfalls of what’s known as "false friends" — words that sound similar in two languages but have different meanings that can cause confusion or even insult. (For example, the Spanish word embarazada means pregnant, not embarrassed.)

For many, the focus is on more subtle, yet significant forms of communication — understanding cultural nuances like when and how to interject and ask probing questions without seeming overbearing or learning to read facial expressions and body language.

More natural exchanges for all

It’s all intended to make exchanges between team members, patients and families easier and more natural.

If you’ve ever traveled overseas, you know how stressful and tiring it is to listen to someone speaking another language, translate it in your head, consider your response and then say it in the other language. Imagine doing it over and over and over again, every day, as you work.

Denise Mihal

Mihal recalled one nurse with a heavy accent whose patients often described her as "cold and uncaring." Supervisors wondered why. The nurse had a ready explanation: "When I go into the room," she said, "People say: 'Do you speak English?' And they make assumptions about me, and I’ve got an accent, so I’ve gotten really shy about speaking and I try to speak as little as possible. I try to say yes or no or whatever I think is really easy to say."

After her turn in the program, that nurse is more comfortable with the everyday back-and-forth and is now drawing consistently higher patient satisfaction scores, Mihal said.

But the benefit of communication training goes beyond patient praise to sheer safety, she added.

When a health care provider is able to slow down and worry less about the next words they will say, they can pay closer attention to what patients are saying and to their body language — which often provides subtle yet important clues about pain or illness.

"They’re able to see the whole person," Mihal said.

One doctor’s story

Grewal, the hospitalist, isn’t Shah’s typical Novant Health coaching client. Unlike most, who enroll in one 15-week session, he’s had two and is gearing up for a third. "Anything that you can learn adds value," he explained.

Dr. Sandeep Grewal

The first time around, Shah helped him with his pronunciation. Grewal’s "v’s" and "w’s" weren’t distinct, so words like "vase" and "was" were indistinguishable to some.

Shah showed him how to position his lips and tongue to create different sounds — skills he practiced while driving and making rounds.

"I didn’t realize it but those mechanics are very important in how the word sounds to you and to the other person," Grewal said. "I do notice that when I’m talking to the patients now, I’m not repeating my words again and again."

The second time around, Grewal asked for help with his presentation skills.

As head of a push to put artificial intelligence to work at Novant Health, he’s seeking buy-in from partners, leaders and potential donors. But Grewal felt cultural differences were holding him back. In India, casual banter and humor are considered rude during a formal presentation.

"My biggest trouble with presentations is becoming monotonous," Grewal said. "I did not know how to break that monotony, so she gave me a lot of tools."

He learned how to emphasize key words, pause, vary his pitch, stress specific sounds, and weave in anecdotes and humor to keep American audiences engaged. The strategies quickly paid dividends. Grewal was recently elected to a Novant Health advisory board — a role in which his ability to communicate clearly and bridge cultural differences will be more important than ever.

Though he concedes that it hasn’t always been easy to acknowledge his communication struggles Grewal is grateful for the gentle and specific correction provided by Shah, a fellow Indian immigrant.

"That’s how I know what I need to improve," he said. "In my birth country, we have a saying that you should keep the person who criticizes you closer than the person who praises you because the person who criticizes you will actually help you improve. The more smoothly we can communicate, the better it is."