Canada is multicultural and multilingual in the same way as your average British emergency room. Both work better when we listen as much as we talk
In 1972 Peter Gzowski, a beloved presenter from the Canadian Broadcasting Corporation, hosted a national competition. The goal was to find the Canuck equivalent to “as American as apple pie.” After weeks of anodyne answers—such as “as Canadian as ice hockey” and “as Canadian as maple syrup”—a winner was announced: “As Canadian as can be expected under the circumstances.” This mot juste beautifully summarises a nation built on compromise, saddled with an identity problem, and simultaneously marvellous and mediocre. With the utmost Canadian politeness, perhaps the mighty National Health Service shares a thing or two with little Canada.
The lesson for the NHS—or whatever three letter acronym you work for—is that diversity can be your weakness, or it can be your strength. In Canada it is often simultaneously both. Regardless, in a multicultural and multilingual place like Canada, just as in the practice of modern medicine, diversity and plurality are inevitable: like it or lump it. Personally, I am a big fan.
My experience is that we do best when we simply roll up our metaphorical sleeves and make the extra effort. It is how we turn lemons into citron pressé. It is also how we build a country and a health system that are the envy of others. I would also hazard a guess that Canada is multicultural and multilingual in the same way as your average chaotic British emergency room. Both work better when we sacrifice our egos, and when we listen as much as we talk.
At its worst, Canada can also be fractured and confused. This most often occurs along its English, French, and Native divide. To bring them closer has required—and will always require—extra patience, sensitivity, and reflection. I find travelling in French Canada as exciting as it is humbling. It has taught me that it takes courage to speak up even if I don’t have the vocabulary, even though I undoubtedly sound like a fool, and even though it exhausts me. Presumably the same fears exist for our patients and their families. They know the medical language basics but work hard to understand the nuances, and especially the unwritten customs. I think more attention to communication might bring together two other circles, namely clinicians and patients. You can easily be miles apart while using a common language.
Despite the highfalutin promises of the Canada Health Act, unilingual English speaking medical practitioners treat many unilingual French speaking patients and vice versa. Using translators and family members can be helpful. However, patients who require translators are often less satisfied with their care, may be less informed when providing consent, and may demonstrate less outpatient compliance. If I haven’t communicated explicitly enough then let me try again: you can be lost in translation in the same language. Ask yourself how many times your patients are unable to repeat what you just said.
Obviously, within Canada, bilateral bilingualism would be ideal. In the medical world the corollary is to have patients who understand medicine and doctors who truly understand patients: their needs, hopes, and fears. When faced with obvious language discordance we call a translator: one who converts each word and maintains meaning. My experience is that we often get interpreters instead: people who change the message in subtle but important ways.
Even though I will likely never be bilingual, my experience is that the ability to communicate francophone phrases goes some way towards building a therapeutic alliance. It is a palpable way to demonstrate effort, and an empathetic way to show that I can be vulnerable too. It is also why I have little time for people who offer a robotic “bonjour” but nothing else. After all it only takes 10% more effort to appear 50% better.
Data from Canada and elsewhere suggest that physicians may treat language discordant patients differently. We are less likely to discuss psychosocial issues or to provide lifestyle counseling, even when using competent translation services. Nobody cares how much you know until they know how much you care, you might say. Alternatively, the data suggest that you might not say anything at all through fear of embarrassment or misguided sensitivity. My point is that you really cannot NOT communicate. Silence is just as likely to be interpreted as disinterest or aloofness. Accordingly, do not be surprised if those patients or colleagues find it harder to trust you in return.
The proudly bilingual Royal College of Physicians and Surgeon of Canada, has prioritised medical communication. Using the CanMEDS framework, this same Collège royal des médecins et chirurgiens du Canada has also emphasised that communication requires more that just the words that are said. It includes how words are said, and how they are interpreted. Medical practitioners in Canada and worldwide are expected to be more than just factual or procedural experts. This is because inadequate communication has been shown to be a major cause of preventable medical error. Expressed another way, the best doctors will have communication skills that match their procedural dexterity and factual know-how.
When it comes to communication, as in medicine, competence and excellence requires practice and immersion. My French was described accurately by a dear francophone friend as “enthusiastic but modest.” At times that would have been an apt description of my medical abilities. Regardless, in both, I intend to be persistent despite any embarrassment. This is because I know that my words can hurt as much as they heal and because effort matters along with results.
In the meantime, I would like to extend an invitation to come and visit my wonderful country. Much like your NHS, Canada strives to be welcoming and works hard to please. It is, like your NHS, one of the finest compromises in the world. We both have much to teach and much to learn: let’s ensure a meaningful conversation.
Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb
Competing interests: None declared.
 Brindley PG, Smith KE, Cardinal P, Leblanc F. Improving Medical Communication: Skills for a complex (and multilingual) world. Can Respir J 2014; 21:89-91
 Smith KE, Cardinal P, Leblanc F, Brindley PG. Medical French and Medical English: General Language Skills for a Bilingual Country/Langage médical francophone et anglophone: habiletés de communication médicales attendues dans un pays bilingue. CJGIM 2014. 9;1:26-31