What's That You Said?

July-August 2010


On hospital rounds, a foreign-born physician introduces a patient whom he considers noncompliant. The doctor asks the patient to perform some simple tasks. The patient sits quietly. A young American speech therapist in the room realizes that the doctor's heavy accent makes his orders incomprehensible to the patient — and to everyone else in the room.

That was 30 years ago. Today, Lynda Katz Wilner, the speech pathologist who recalls the incident, is in the accent-reduction business. Accent reduction (also known as accent modification, accent neutralization and speech intelligibility) helps modify sounds and speech patterns in foreign-born individuals so Americans may more easily understand them. The American Speech-Language Hearing Association experienced a 15 percent increase from 2005 to 2006 in the number of inquiries about such programs, and a recent article in the Los Angeles Times reported, "An increasingly multilingual workforce is prompting a surge in enrollments."

Wilner heads Successfully Speaking (www.successfully-speaking.com), a communication skills consulting company based in Baltimore that offers customized accent-reduction programs for native and nonnative English speakers in the medical professions, the clergy and other fields. She emphasizes that accent modification is different from speech therapy, which implies a disorder. Accent modification is used to enhance communication skills.

Some experts question the effectiveness of the programs. Dennis Baron, a linguistics professor at the University of Illinois at Urbana-Champaign, told the Los Angeles Times that "eliminating an accent is difficult" and may require years of interaction with native English speakers.

However, Nancy Hiser, the director of American Speechsounds (www. americanspeechsounds.com), based in Portland, Ore., said some studies show the programs result in a reduction in communication errors by 50 to 90 percent. Hiser is also the author of a CD-Rom program called "American SpeechSounds for Healthcare Professionals."

From 1983 through 2007, Hiser and her staff provided accent-reduction training in hospitals in southern California. "We dealt with foreign-born doctors, nurses, social workers, chaplains, custodial staff, lab staff and pharmaceutical staff," said Hiser. "Anecdotally, you might have an Egyptian doctor talking to a Korean nurse who is talking to a Vietnamese phlebotomist who is talking to a hard-of-hearing or confused patient. You can't imagine the communication issues that erupt in that situation."

Communication issues in hospitals across the nation are unlikely to end anytime soon. According to the American Medical Association, doctors born and trained elsewhere in the world account for more than one-quarter of the physician population, and U.S. hospital patients have a 1-in-4 chance of seeing a foreign-born physician.

Foreign-born doctors are not the only professionals in America who may benefit from accent-reduction programs. David Lichter, executive director of the National Association of Catholic Chaplains, noted that "about 30 percent of our 450 priests have surnames that point to Africa and India as countries of origin." A study conducted 10 years ago by the Center for Applied Research in the Apostolate reported that 16 percent of all Catholic clergy in the United States are foreign-born. Now that figure is said to be closer to 25 percent.

"In some nursing schools, Africans account for about 40 percent of the student body," said Hiser, and many others come here from India and Pakistan. Because most foreign-born medical professionals and clergy have studied English as a second language in their countries, they arrive here with varying levels of English competency. "Still," said Hiser, "their pronunciation is unique, their cadences unusual. All this causes stress and prohibits clear communication."

The quality of patient care at every level depends on clear communication. According to a study conducted in 2002 by The Joint Commission accrediting organization, more than 65 percent of hospital deaths and injuries and 55 percent of medication errors were due to communication factors.

Some hospitals provide accent-reduction programs, and some foreign-born doctors, nurses, hospital chaplains and other staff seek them out. "For motivated individuals, it's like learning a sport — you have to practice," said Wilner, who conducts distance-learning sessions and holds accent-reduction "webinars" (on-line seminars) for health care professionals (see www.successfully-speaking.com). She lists the benefits of such training:

  • Improved patient care outcomes
  • Greater comprehension by patients, families, colleagues
  • Improved image of the hospital/clinic/practice
  • Minimized patient attrition
  • Diminished risk exposure
  • Career growth opportunities

An accent-reduction program helped the Rev. Philip Boateng Brembah, a priest who serves as a hospital chaplain in the Diocese of Fort Worth, Texas. A native of Ghana, in 2008 Fr. Brembah took part in the International Priest Internship program at St. Mary's Oblate School of Theology in San Antonio. An acculturation program, the internship emphasizes accent reduction. Now in its seventh year, the program has served priests from India, Nigeria, Indonesia, Madagascar, Mexico, Ghana and Panama.

"I learned a lot from the program," said Fr. Brembah, 42. "When you come to a foreign land, you may presume you know the language and the culture, but you do not. Ghana was a British colony, and people there talk differently from the way Americans talk. Also, Americans use words in different contexts." For instance, early on, Fr. Brembah was mystified when people spoke about "trunks" in relation to cars. In Great Britain, what Americans call a trunk is known as a boot. Fr. Brembah discovered that he spoke too quickly for some people to understand him. "I learned to slow down," he said. "Also, after some time here, my ears got adjusted to the way Americans talk. The course was very helpful."

To date, the internship program has served between 75 and 100 priests. Most of them are in their early 30s, and most learned of the program from bishops in their home countries. The internship consists of two on-campus workshops of three weeks each. In between the two workshops, participants spend four months at their individual jobs. Staff members from the program conduct site visits.

"We like to see them at work in their environments," said Fr. Ron Carignan, OMI, former head of the program. "During the program, we spend a lot of time on accent reduction. For many international priests, their accent is their weakness, and that is the biggest liability. Our program provides 12 CDs on accent reduction and sessions with a speech therapist."

That speech therapist is Cindy Dellenback, whose 15-year-old company, Communication Associates (www.communicationassociate.com.), is based in San Antonio.

"These men know their native language is a wonderful language and an important part of who they are, and many of these priests are bilingual, trilingual or more," said Dellenback. "They also understand how critical it is for their parishioners to understand the priests' homilies, the scriptures and what they want to convey in one-on-one conversations."

Dellenback's training focuses on four aspects:

  • Articulation
  • Volume/loudness
  • Pitch inflections
  • Rate of speech

"The most important component to focus on is volume, as so much of the other components are lost when their loudness is not adequate," said Dellenback. "Once they understand we have at least five different levels of volume in the United States, we work on the best volume to use when reading Scripture. We work on pitch inflections after they understand the different intonation for statements and yes/no questions. Articulation is another key area," especially with pronunciation of vowels.

Dellenback asks priests in the program to read aloud for her, and she provides them written feedback with suggestions on what to practice. She also uses videotaping so the men can see if they are opening their mouths wide enough and positioning the tongue to the correct position for each sound. She noted that words with the "r" sound — such as "war," "world," "girl," "Mother" and "Mary" — are particularly difficult.

"They all work hard, and we laugh a lot," said Dellenback. "It is an honor to work with these men and hear their stories about their lives. So many of them have had quite a few hardships, and yet they still want to help others, and are doing that through their work. Over time, many report the satisfaction of being able to be understood more clearly when they give their homilies or when they read Scripture."

Fr. Brembah worked with Dellenback. "She is a wonderful woman, very patient," he said, laughing. He is pleased to report that at this point, hospital patients he visits do not have any trouble understanding him. "With Cindy Dellenback's help, and with conscious effort, I became aware of myself, of my speech. Now I don't hear anyone asking me to repeat what I say."

Fr. Carignan praised Fr. Brembah and the other internship participants. "They are brave individuals, strong individuals, who came here because of their faith and because their bishops are trying to promote missionary outreach," he said. Fr. Carignan stepped down as director to work in related research. "We're building a database to try to understand the needs and challenges of international priests. We need to coordinate better where they go from here, so we can keep getting feedback."

Other research in related fields is also underway. Eileen Van Schaik, Ph.D. — a senior research scientist at Talaria Inc. and clinical assistant professor of biobehavioral nursing and health systems at the University of Washington in Seattle — is the principal investigator on a grant from the National Institutes of Health to determine the effectiveness of a program designed to improve pronunciation and communication skills. Van Schaik works with speech pathologist Lorna Sikorski of LDS & Associates, Orange County, Calif. Sikorski is author of the "Mastering Effective English Communication" training program.

With the grant, Van Schaik and her team developed an intercultural communication workshop, a multimedia, Internet-based educational tool designed to improve the communicative competence of foreign-born nurses. To date, reactions to the workshop have been uniformly positive. Evaluations from participating nurses include "I have a greater awareness of my pronunciation and different nuances in the U.S. English language" to "Oh my! I had no idea how different I sound from what we call American English." Phase II of the grant work begins in September. Van Schaik's goals include:

  • Refining the course based on the results of the field test and expert reviews
  • Expanding the number of intelligibility lessons to meet the needs of native speakers of additional languages
  • Developing interactive instructional content in health care vocabulary, communication practices and culture in U.S. health care
  • Using a multi-method, multi-measure, two-group randomized controlled trial to evaluate the educational effectiveness of the workshop

In Las Vegas, Yu (Philip) Xu, Ph.D., is completing a two-year research project on the effectiveness of accent-reduction programs among foreign-born nurses. Xu is a tenured full professor and coordinator for the doctorate in nursing program at the University of Las Vegas School of Nursing. Xu also is a certified nurse educator and a certified transcultural nurse. His research is funded by the National Council of State Boards of Nursing.

"The focus of my research program is transition and adaptation, the integration of foreign-educated nurses in the U.S. health care system," said Xu. "In order to integrate successfully, communication and language are essential issues. We are testing the effectiveness of comprehensive communication training programs."

By almost every account, the benefits of accent-modification programs are many. "Foreign-born individuals who take advantage of accent-modification programs will never sound like they were born in Nebraska," said Hiser, head of American Speechsounds, "but the programs can provide the tools to help them communicate more clearly."

Clearer communication means that patients would be more likely to hear a foreign-born individual's message, not just the accent. That's not all. Wilner — the speech pathologist whose experience with the foreign-born physician on hospital rounds evolved into a satisfying career at Successfully Speaking — summed up: "When patients who are already overwhelmed cannot understand what a medical professional tells them, you have more than a breakdown in communication. You have a crucial situation."

PATRICIA CORRIGAN is a freelance writer in San Francisco.


Copyright © 2010 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

What's That You Said

Copyright © 2010 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.