Inclusive Communication and Services for Diverse Communities with Alejandra Ullauri, AuD

Brian Taylor 0:10
Hi, everybody, and welcome to another edition of This Week in Hearing. I am Brian Taylor. And our topic today is inclusive communication skills and serving diverse communities. And we’re going to talk about how you can bring those two things to life in your practice. And speaking of diversity and diverse backgrounds, our guest today is audiologist Alejandra Ullauri. And she has a great new book out. It’s entitled Audiology Services and Diverse Communities: A Tool to Help Clinicians Working with Spanish Speaking Patients and Families. So that’s a long title. The main title is Audiology Services in Diverse Communities. And I want to welcome to the broadcast Alejandra.

Alejandra Ullauri 0:53
Hi. Hi, Brian. Thank you for having me.

Brian Taylor 0:56
Yeah. Thanks for being with us. I appreciate you taking time out of your busy schedule. And I thought a good place to start our conversation today would be for you to kind of share with our viewers, your diverse background.

Alejandra Ullauri 1:08
Thank you so much. So I’m, I’m an audiologist. I was born and raised in Ecuador. So you can imagine Spanish is my first language. I trained in audiology in the US and in Australia. I’ve been practicing Audiology for about 20 years. And early my training, I learned about the impact that audiologists can have in public health. So hearing loss is a public health problem in an ever since I’ve been interested in supporting and leading initiatives that can bring services to more people, especially underserved communities. You know, in audiology, we have a wide scope of practice, from prevention and promotion of healthy hearing, to early detection and diagnosis of hearing and balance problems to rehabilitation of these problems, you know, including amazing technologies, such as cochlear implants. But if you think about all those areas, all of those areas are of public health interest. So I’m always thinking, What can I do to create a bigger impact? You know, I mean, there is only so many patients that you can see in my private practice. I’m a solo provider practice. So I’m always thinking like, How can I What can I do to expand access in service delivery. So a little bit more about me, I’ve been very fortunate to be able to work in different countries and see different health systems. So I trained in Australia, and I did you know, a lot of my clinical placements over there. I worked a couple of years in the United Kingdom in the NHS system. And a couple of, I worked more years in in Ecuador in a very different health care system in Latin America. And I’ve been in the US for the last 10 years. So when I moved here, initially, I managed the audiology department at University of Chicago. And then later on, I went on to open my private practice. And that’s where I am now.

Brian Taylor 3:10
Well, I want I want to ask you about that. First, I want to mention that I think you’re the first guest we’ve had on This Week in Hearing that as a degree from three different continents. Right, South America, North America, and Australia. So talk about a diverse background. And that’s let’s, let’s talk a little bit about your practice in Chicago that you opened a few years back. What’s your mission in the practice? What what are the typical patients that you see there? I’m really curious about the private practice that you have in Chicago.

Alejandra Ullauri 3:41
Yeah. Thank you. Thank you, Brian. Um, so, as many of your listeners, you know, we all wear different hats. I have two major hats right now. One is my private practice. And in the private practice, we see mostly adult patients with hearing disorders would concentrate on hearing disorders and do diagnostics, amplification, and cochlear implants. When I set up the private practice, I wanted to, I wanted to target a niche of need, I guess, a gap in a service gap that I thought existed, and that was cochlear implant patients accessing services in a private practice, you know, an established adult cochlear implant patient, it’s no longer in need. It’s no longer or always in need of hospital setting services. So I figured if I if I can expand those services and be in haven’t in medical model, but still more accessible to people and just an offer cochlear implant assessment in cochlear implant mappings, so I can be maybe the link of the hearing aid patient in a private practice link that patient and cochlear implant program in a major hospital. So that was my initial idea when I said I set up the practice. Recently, I found it in a new entity, which is called Audiology en Espanol. And this is a learning platform that teaches medical Spanish for audiologists, and its vision is to advance audiological care for the Hispanic-Latino community. So basically, that’s where I spent most of my time between the the private practice and Audiology en Espanol.

Brian Taylor 5:35
Gotcha. So you must have found found some time to write a book, what prompted you to write the book that I mentioned?

Alejandra Ullauri 5:43
Thank you, Brian, so… It’s a long story, and I’m gonna make it short. When I moved. When I moved to the US, I worked in a hospital setting. So I was a fluent Spanish speaking audiologist in a hospital in Chicago. So quickly, I realized I saw the difference I made every time I interacted in provided care to a monolingual Spanish speaking patient and their families, I saw the struggles they faced to navigate, you know, a complex system such as the healthcare system, I saw that professional interpreting services, were not always available, despite, you know, best efforts. Any of your listeners, who are my colleagues in audiology and have covered an ENT clinic, they know what I’m talking about, they know how, how busy and in changing clinics, these type of clinics are, you know, the last minute patient that was added to the clinic, because of a sudden hearing loss and you know, things that you can not always prepare for, even when you are in a major hospital setting where you have interpreting services on site. So even in those situations, I saw that professional interpreters were not always available. And I also saw that there is, you know, some, some, the, I also saw, like a, some issues with the quality of the integrity of the interpretation. So that was my first experience, you know, my first I guess, overview of what was surrounding me and then, so the more I read about it, then I realized that this is not an issue related to what audiology really related it to a hospital, this is an issue related to, you know, healthcare in, in a bigger spectrum. Um, so if you think about it, there are not many Latino Hispanic audiologists, right, so ASHA reports that about 8% of its members represent minority communities or ethnic racial groups 8%. In all, minorities smaller,

Brian Taylor 7:55
yeah, relative to the number of Spanish speaking people in the entire country. It’s a very small number, right?

Alejandra Ullauri 8:00
Exactly. And this is a percent represent all minorities, it’s not even 8 percent Latino. And then if you think about it, you know, in the medical field is not very different. 5% of physicians identify that as Latino Hispanics. There was one thing then the next thing I learned is that professional interpreters are underused. So studies have shown that between 30 and 40% of physicians don’t use professional interpreters. So they’re relying either on their own language, Spanish language skills, or they’re relying on untrained staff or maybe family members, sometimes even children are used, you know, for interpreting and accuracy during the interpretation. You know, when you use untrained staff or family members, there is about 50%. So they they make about 50% of errors during the clinical encounter. You imagine it Can you imagine 50% of the clinic out there read, interpreted incorrectly, I guess. But professional interpreters also make about 25% of errors. There is a recent study that I find that shocking because it’s it goes to the core of our profession. So they were going off so they were analyzing if every time a clinician, an English speaking clinician attempts to build rapport with the patient, right. That’s essential for building trust for your patients that asking questions and also for your patience, trust in the recommendations you’re making. So when they were when they were analyzed if the researchers were analyzing the data, they found that clinicians attempted to build rapport and how do you build rapport? Maybe you say a compliment, maybe you say you use inclusive pronouns, such as, let’s say, I would say, Mrs. Smith, I think we are gonna make progress. If I increase the gain in your hearing aids, I’m not wearing hearing aids, but I use we to imply that, you know, we are in this together, you know, we are going to make progress. So all those, so they coded all these attempts, right. And they, in one day, what they found out is that 82% of those attempts were not translated.

Brian Taylor 10:41
Wow.

Alejandra Ullauri 10:42
Can you imagine, every time they in those attempts, I mean, keep building clinical rapport with the patient is essential. I mean, it’s it’s everything is that connection with the patient is, is your patient trusting trusting the diagnosis you’re giving in the recommendations?

Brian Taylor 11:01
Exactly.

Alejandra Ullauri 11:02
So it shows you that, you know, it’s some, I mean, it goes beyond interpreting some. I also, going back to the question, what prompted me to write the book. I also, you know, I was working and always getting phone calls, emails from my colleagues saying, like, oh, by the way, what kind of speech perception test battery do you use with Spanish speaking patients? What kind of Speech audiometry? And so on. So I thought, What about if I create a one stop tool that my English speaking colleagues can go to? Then if you if you’re wondering what kind of speech perception tests are available in Spanish, this is what we have. And this is where you can get it. What about if you if you’re wondering, all I need is help to, I need to instruct the patient describe a test to the patient giving instructions on how to perform the task to a patient? What about if everything is housed in one place? I mean, if you think about it, like I want to have more Hispanic, Latina people access and benefit from the services they access, right? And what better way to help my colleagues who are serving this population. So that’s how kind of how the idea started.

Brian Taylor 12:30
I know exactly what you mean, having practice myself in a busy ENT office back in the 90s. I know exactly what you mean. And that was, you know, more than 20 years ago now. And I can only imagine the level of diversity, how it’s gotten even more diverse over the last couple of decades. So I think that your your book is just an outstanding tool for any clinician out there that works with Spanish speaking individuals, which I think just about everybody these days, encounters, at least once in a while, if not every day. There’s a couple things I wanted to just kind of explore a little bit more in your book that kind of caught my attention. One is this notion of cultural competence. You talked about in your book, kind of early on, if you can kind of share with our viewers what this term cultural competence means and how you relate that to clinical practice and audiology.

Alejandra Ullauri 13:27
Thank you, Brian. Some cultural competence means the system’s ability to work effectively with multicultural groups within their communities. So the National Center for Cultural Competence at Georgetown University, defines cultural competence organizations as those that value diversity, conduct self assessment, acquire and promote cultural knowledge and those that adapt to diversity in the cultural context of the communities they serve. And I think these efforts is what allows them to work effectively with these multicultural groups within their communities. But I think the the, the word that I want to highlight is adapting, because cultural competence, it’s it’s a journey, you’re always adapting, because you always have to identify the needs of the specific populations that you’re serving. So what do you just mentioned right now about your experience 20 years ago, working in an ENT clinic. So, if you think about it, the US Census has a great graph that shows that in the 1960s, the biggest immigration migration wave into the United States came from Europe. In 2010, the biggest migration wave comes from Latin America, and Latin American people are not the first people migrating are not going to be the last ones. So we always have to be adjusting our services to the population and to the communities we serve your department, your hospital can be in a location where right now is a moat. I mean, it’s mostly, I don’t know, a Hispanic community. And then in 10 years, it’s mostly a Portuguese community. So, so you have to constantly adjust to to to address the specific needs of those populations. Some. So how do you bring that to your audiology practice? And I think we have to, we have to understand that it, it, this doesn’t only apply to big departments in big hospital settings, it applies to all of us, because we’re all because they they are, our communities are becoming more multicultural. So we’re all all going to come across these patients. And we all have to prepare to serve and provide quality of services, in this case, in this point in time, to the fastest growing group, which is the Latino Hispanic community, some. So basically, if you’re in a silo provider, small private practice, like mine, or if you are in a major clinical hospital department, we all have to have strategies and tools in place so we can serve these communities. And it might be something as simple as having the paperwork in the language of the communities you serve, having testing materials available in those languages, having information material, so I guess it’s, it’s ident, first of all, is identifying the communities that you serve, the where your patients are coming from, and then tailoring the services you provide to those needs.

Brian Taylor 17:00
Yeah, that’s great advice. I mean, I think that what what speaks to me is the fact that you’re promoting that yeah, need to be what need to be aware of what’s going on within your own community, and then providing the language or the tools that they need, so that they can feel comfortable being in your office. And I think, you know, in this, in this day and age, which is a good thing, you hear a lot about patient centered care and patient centered communication. And to me, given the diversity within the United States, a big part of patient centered communication is making sure that you have the, the forms, the right tools that are in the person’s language. So your book, I think, really goes a long way in helping people recognize that they need to do that. What I wanted to do next, Alejandra was asking you want you to maybe put your public health hat on because I know in your book, you talked a lot or a little bit, at least in the beginning of the book, if I remember correctly around about health care barriers and disparities. You don’t hear those terms a lot in audiology textbooks. So it’s really refreshing that you mentioned it in yours. If you could tell us a little bit more about what you mean by healthcare barriers and disparities.

Alejandra Ullauri 18:13
Thank you, Brian. So, of course, I’m really passionate about this topic. So the CDC defines disparities as those preventable differences in the burden of disease, violence, injury, or just the difference in the opportunity to achieve optimal optimal health. So these differences are experienced mostly by disadvantaged populations. So when it comes to hearing in hearing and balance problems, so this is our area of expertise. It turns out that this population group, the Latino Hispanic population is experiencing health care, health and healthcare disparities, that put them at a higher risk of hearing and balance problems. And I think that’s the urgency for all of us to prepare to, to provide quality of services to this population. So just to name a few- diabetes. Now, we know that diabetes before we used to think of diabetes are a comorbidity, but now we know that diabetes can cause hearing loss can aggravate hear existing hearing loss. Some the Latino population is twice more common. It’s gonna it’s more like it’s twice. I’m sorry, diabetes is twice more common in the Latino population. If we think about cardiovascular disease, the Latino population has a high prevalence of those risk factors for cardiovascular disease, such as high cholesterol, high cholesterol, high blood pressure, and so on. So about 45% of the Latino population has high blood pressure. Latino Hispanic men have a high blood level of high cholesterol in the blood compared to other racial or ethnic groups. Some, if we go out into dementia, you know, a whole, a whole new on its own. It’s a major issue in the Latino population. So all your listeners, everybody, we are all familiar with the Lancet publication and how dementia is. Some risk factors for dementia is less education, early life, diabetes, high blood pressure and cardiovascular disease in midlife and so on. There, CDC goes on into adding ethnicity as a risk factor, because the Latino Hispanic population has a 1.5 higher probability of developing dementia. So it means that this this part, this healthcare and health disparities that we see in the Latino population, are also so related to what we do and the services we provide, because this population group is going to face hearing imbalance issues, because of these health care disparities. Some when when we talk about barriers, we’re talking about those challenges that socially disadvantaged groups experience, to access services, and also to receive quality of care, because you might make it to the appointment. But if nobody speaks your language, can you really benefit from that from those services? Right? Some. So when we’re talking about barriers, barriers can be you know, lack of transportation, lack of cultural competence training within the workforce. And one of those big barriers is lack of language concordance during the clinical encounter. So language becomes a barrier, you can add health literacy, and so on. So that’s kind of just to give you just a name a few samples of barriers that our patients face.

Brian Taylor 22:13
Well, I had a question and kind of curious about the use of technology. Are we in a situation now where you could use, like Google Translate, or some other service like that, you know, sort of an automated, so if you don’t have an interpreter, and you’re trying to connect better with somebody that speaks another language? Is there tools out there available today that are viable? Or are we still a ways away from that?

Alejandra Ullauri 22:42
Um, so I think that accuracy has to be, you know, at the top, because we want to make sure that we’re not only translating, but it goes within the context. So I would say that a great tool that has come up in the, in the recent years is remote professional interpreting services. So we know that the quality of the interpretation is as good as in person. There are some studies that show some slight difference, like what we were talking before about making errors, but it’s not significantly worse, then you know, it in any in person interpreting service delivery or something like that.

Brian Taylor 23:29
Right. So it’s good to know that if you don’t have a professional interpreter in person, but there are services that provide that remotely.

Alejandra Ullauri 23:37
Yes, absolutely.

Brian Taylor 23:39
Yeah, it’s good to put that on people’s radar for those that may not know that somewhere that that’s available. So back to your book, that was a small diversion, I wanted to talk more about your book, because one of the things I love about it is that basically, for every different kinds of appointments, different kinds of clinical encounters, you have a chapter kind of devoted to each part of the patient journey, or each kind of type of appointment. Maybe take us through a couple of chapters and highlight what I mean by that. And how you can use that in daily practice. If you’re an audiologist.

Alejandra Ullauri 24:11
Thank you. Um, so the book is split into parts, right? So part one reviews, reviews those barriers that we were just talking about those challenges that patients face. In chapter three, things become a little bit more brighter, not as sad as just barriers. So in chapter three, we introduced this concept of design thinking. So in Design Thinking you you’re always trying to find the pain points that your patients experience. And then you do some brainstorming about what are the possible solutions. You connect with all the stakeholders, the direct and indirect stakeholders, and hopefully you can move on to implement the solutions. So in the third chapter, We go over those barriers that you that patients clinicians that we all experienced when we’re trying to provide better care to these patients. And, and then we, we highlight positive, successful experiences in many of those areas that we’ve seen in audiology, or, or that we’ve seen in other specialties. So for instance, in cancer treatment, there is been some improvement in how minority communities access early screening, and also follow up, you know, in the following years after treatment, and it’s in, they were talking about the use of patient navigators. So you have a patient navigator in place, that helps the patient to, you know, identify the challenges they’re facing, whether it’s related to insurance, transportation, and so on, and they help them overcome those challenges. Another thing that they had been using was, like a simple card, that, you know, you’re gonna, you’re gonna be on, let’s say, surveillance for so many years. So you have a card where it says, where your last, I’m just going to be mammography was and so every time you go somewhere you have, you have a record of what was done, when was done were the results. And some, some in this in this third chapter, we just review successful experience. And the idea is just to create an a discussion, to get the reader to think about, okay, these are the things I’m seeing my clinic, because, you know, challenges may differ from place to place, if you are in a big urban community, your patients might have different challenges that if you are in a more rural community, and so on, some, so it invites the reader to think about what are those pain points? What can I do? And what have what others have done that have worked that has worked in, you know, and what can I implement and so on. And then the second part of the book is the language tool. So in the language tool, one, it’s a place where you can find your own audiologist and you’re providing services, we were wondering, are there any questionnaires in Spanish, it’s not only that you want the questionnaire in Spanish, you want the questionnaire that was validated in population, some questionnaires are there, you also have description of the different tests and instructions for the patient. So if you are a bilingual clinician, but you’re unsure about terminology, you know, in audiology, this is a great reference place. If you’re working with a new interpreter, that interpreter that it’s not maybe familiar, same thing with the terminology, great place there. If for some reason, you ended up not having an interpreter, but you can you can have the patient read the description, the interpretation, the instructions, and so on. And if you open the book, English is on the left hand side, Spanish is on the right hand side. So right here, thank you. And the idea was that, you know, the court I guess what I was envisioning was that, you know, patient provider are on the same page kind of thing.

Brian Taylor 28:36
Yeah, no, I can see how it would work fantastically for that it’s just a great tool to have with somebody that speaks Spanish, and you want to be able to communicate more effectively with them.

Alejandra Ullauri 28:46
So thank you, Brian.

Brian Taylor 28:47
Well, I know that your time is precious. So I don’t want to hold you up too much longer. I was wondering, any other insights that you wanted to share about your practice about your book?

Alejandra Ullauri 28:59
Absolutely.

Brian Taylor 29:00
The readers with

Alejandra Ullauri 29:01
Yeah, absolutely. So I think that so far, we’ve talked about the importance of language in the clinical encounter. And we know some studies have shown that when there is language concordance between the provider and the patient, the patient is more likely to ask questions, and therefore, you know, the patient is more likely to understand their condition, understand the recommendations, hopefully, you know, adhere to those recommendations and so on. So I think there is so much room for all of us to work on and improve services and, you know, we need to increase diversity in our study in our student body. So later on, we can hire more Hispanic Latino audiologists, but we also but we can also help our English speaking clinicians who have high intermediate- advanced level of Spanish. So these are great bilingual clinicians that if we help them to get their Spanish language skills to a clinical level so they can use the language appropriately in a clinical setting. We know we have more providers out there, and more chances that patients will encounter a clinician that speaks their language. And obviously, with all the benefits that that can bring,

Brian Taylor 30:29
all the more reason why young clinicians, hopefully took Spanish when you were in high school or, or college, and you can put those skills to use with a little bit of extra training.

Alejandra Ullauri 30:39
Yeah, absolutely. So yeah, if you’re a bilingual audiologist, you know, we need you, but we need you to take those skills to clinical level, we want you to provide, you know, high quality of care. So, yeah,

Brian Taylor 30:52
is that what you’re the you mentioned, the other business that you have, besides your practice, is that

Alejandra Ullauri 31:00
that’s exactly what Audiology en Espanol is doing. And it’s teaching medical Spanish to audiologists who are practicing the profession who have a high an intermediate or advanced level. So we’re helping them transition those Spanish language skills to a clinical level. So

Brian Taylor 31:19
excellent.

Alejandra Ullauri 31:20
Yeah. So I’m excited about that project, too.

Brian Taylor 31:23
So if, if our viewers wanted to know more about that, do you have a website or a place they can learn more about it?

Alejandra Ullauri 31:30
Yeah thank you, Brian. So you can visit Audiology en Espanol. So audiologyenespanol.com. And you’ll learn more about you know, medical Spanish for audiologists, the courses, what we envision and so on

Brian Taylor 31:48
Well, be sure to put that in the notes so that people have a link. If they go to the website, they can click on the notes of summary of what we did today, so they can see that get that easily. So thank you again, here’s the book, Audiology Services in Diverse Communities. Plural is the publisher, so you go to the Plural website and find this book would be a great addition to anyone’s library, especially if you’re in clinical practice just about anywhere in the United States. Probably other places in the world, too. So, Alejandra Ullauri. Thanks for your time, and for your expertise. It was great to have you on this weekend hearing and we look forward to catching up with you sometime in the future.

Alejandra Ullauri 32:30
Thank you so much, Brian. It was a pleasure being with you today.