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Healing Words: SLUCare Staffers Bridge Communications Gap Between Patients, Physicians

by Amelia Flood on 03/21/2018

When it comes to accessing health care, language can be just one of the challenges faced by St. Louis’s large Bosnian community, especially its older members. Guided by their deep understanding of Bosnian culture, interpreters from SLUCare Physician Group, the academic medical practice of Saint Louis University, bridge the communications gap between physicians and patients, helping them to make informed medical decisions.

Elly Avdic and Andrea Zimmerman

SLUCare interpreter Elly Avdic (left) and Andrea Zimmerman, SLUCare physician liaison, both have deep roots in St. Louis's Bosnian and Croatian communities. Inspired by those roots and the University's Jesuit mission, both women have made careers at Saint Louis University that allow them to bridge the cultural and linguistic gaps between patients and physicians. Photo by Ellen Hutti

SLUCare Bosnian interpreter Elly Avdic understands firsthand the difficulty that many Bosnian patients face when it comes to living the healthiest lives possible. She and Andrea Zimmerman, SLUCare physician liaison manager, are passionate about connecting members of their community with the University’s resources.

“To work with people, you have to understand them,” Avdic said. “You have to empathize with them.”

Becoming an Advocate

Avdic came to the United States with her family at age 16 from Bosnia and Herzegovina. She spent her teen years adjusting to a new language, new school and new city. As her own English skills improved, she acted as a medical translator for her parents. Like many Bosnians who had come of age prior to the 1990s, she explained, her parents resisted talking about many health issues or seeking medical help.

During the 1990s, about 300,000 Bosnians resettled in the United States as refugees during and after the war in Bosnia and Herzegovina. About 70,000 settled in St. Louis, which is now home to the largest Bosnian community in the world outside of Bosnia. The horror of war, she said, left its mark physically, psychologically and culturally on many in the community.

“They built a wall around them,” Avdic said. “My people have been through a lot of traumatic events. My people come from war. They are survivors but the aftermath of war continues to haunt them and I know what it is like because I am a survivor myself.”

"I was forced to grow up prematurely because I had to think about survival," she continued. "On the one hand I can see that some of us have become a lot more serious and responsible because of this, but on the other hand, some always feel as if something is lacking because we did not group up at a normal pace."

When an opportunity in 2016 arose to join SLUCare as a medical interpreter working with Bosnian patients, Avdic jumped at the chance.

“My goal is to build a relationship with Bosnian patients, to understand their needs and to advocate for them,” Avdic said. “I am their voice. I want them to feel welcome and understood.”

Like Avdic, Zimmerman, whose full name was originally Andrja Stavljenic before her marriage, is Croatian. Unlike Avdic, Zimmerman was born in the United States to immigrant parents from the former Yugoslavia. Ties to her heritage run deep and led her directly to SLU. After growing up in St. Joseph’s Croatian Catholic Church in Soulard, a parish member gave Zimmerman the financial support to pursue her undergraduate education at SLU. She received her bachelor’s degree in 1995 and her MBA, also from SLU, 1999. She was married at St. Francis Xavier College Church.

Zimmerman connects community physicians and their patients to the right SLUCare physicians and specialists. Her desire to help members of the Bosnian-Croatian community access SLU’s programs also comes from her own experience. Her father, she said, worked hard to support his family after coming to the U.S. but suffered a devastating stroke at a young age. Taking care of him inspired her to help others in her community, and  SLU’s mission, she said, ties directly to that passion.

“If I could save one person from having a stroke or having an outcome which resulted in no quality of life like my dad did, that would be enough,” Zimmerman said. “There’s a huge need in the community. Health care is already difficult to navigate, much less with a language barrier.”

Reaching Out to Patients

As SLUCare’s interpreters assist patients, SLUCare physicians also are reaching out to the Bosnian community through programs that promote wellness. They also conduct research to find the best practices to improve health.

The Bosnian community in St. Louis faces several health challenges, including heart disease and mental health concerns stemming from historic trauma. Researchers, physicians and community leaders acknowledge the need for continued work to address those issues.

SLUCare physicians Dawn Hui, M.D. , and Robert Morgan, M.D., are initiating interactions to draw members of the community into SLU’s wider range of programs geared to the area’s Bosnian residents.

“In the United States, health is something that you can manage, health care is a right,” Hui, a cardiothoracic surgeon, said, “whereas other countries look at health differently, more as ‘this is the thing that will kill you.’ You tough it out because you’ve gone through some tougher things.”

Hui learned about the Bosnian community after moving to St. Louis. The Texas native said that in talking with Zimmerman, she saw the need to reach out to the community and realized building trust would be critical so people could make informed choices as patients. Hui applied for and won funding from the Greater St. Louis Health Foundation in 2014 for a community outreach program focused on cardiovascular health.

While the screenings were a first step, she also saw a need for data and more on-the-ground research. In collaboration with Zimmerman, Avdic and other members of the community, Hui approached Bosnian groups and leaders for help. Bosnian students at SLU assisted with screenings and collected data. A partnership with SSM Health Saint Louis University Hospital was also critical to the project’s success.

“We could not have done it without that support,” she said.

The team’s research, published in 2017 in The Journal of Immigrant and Minority Health, found that of the 128 people who participated in the study, about two-thirds were overweight or obese. While many displayed other risk factors for developing heart disease including lack of physical exercise and high smoking rates, over 80 percent had medical insurance that they could use to seek medical help to manage their risk.

My goal is to build a relationship with Bosnian patients, to understand their needs and to advocate for them. I am their voice. I want them to feel welcome and understood.

Eldina "Elly" Avdic, SLUCare interpreter

With the findings in mind, Hui said that translating better health practices into action for the community is about understanding the Bosnian culture.

Hui herself started exploring Bosnian culture to discover why some advice about diet and other risk factors for cardiovascular disease seemed to fall flat. Eating at Bosnian restaurants, she recalled, led her to one epiphany.

“Cheerios for breakfast wouldn’t resonate,” she explained. While Americans might conceive of the cereal as nutrition, Hui said, traditional Bosnian cooking emphasizes different ingredients, other meal staples and people grow up attuned to other tastes to start their days.

Adapting American health care practices and advice to suit the patient, she said, is the key to improving a patient’s overall health while also supporting the person as a whole.

“When I encounter a patient, I try to be sensitive to how I counsel them,” Hui said. “Asking and probing to find the barriers is how we find a solution and compromise. You have to approach your patients differently.”

Navigating Family Dynamics

Morgan, who came to SLU a year ago from the University of Minnesota-Twin Cities, sees forming partnerships with patients as one of the reasons SLUCare’s commitment to the Bosnian community has been a success for both patients and health care providers.

“Care is not a technical exercise, it’s a human enterprise,” said Morgan, who is an orthopedic surgeon who specializes in spinal reconstruction. “For the really complicated things, I really need a human person for a human interaction.”

Morgan remembered one Bosnian patient who was suffering from increasing paralysis. While the man’s family was there to support him, they were also withholding information in an attempt to protect him. Bringing in SLUCare’s Bosnian interpreters, with their language skills and sensitivities to Bosnian family life, helped Morgan and his patient connect.

“The interpreters helped me to navigate the language and the family dynamics to have a conversation with my patient so he could make an informed decision,” Morgan said. Based on that conversation, the patient was able to take control of his health care and has since recovered.

That kind of service, at the heart of SLU and SLUCare’s mission, drew Morgan to Saint Louis University.

“To practice informed medicine, to actually engage the patient in their care, you can’t just cross the language chasm,” Morgan noted. “You have to cross the cultural chasm and you need human interpreters to do that. And sometimes you just need someone to hold a hand. An iPad can do many things, but it can’t hold a hand or wipe a brow.”

Caring for the Whole Patient

Ajlina Karamehic-Muratovic, Ph.D., assistant professor of sociology and anthropology at SLU, agreed that bridging cultural gaps between the Bosnian community and the health care system is challenging. She has studied health interventions in Bosnian communities, most recently collaborating with Yale University on a nationwide look at Bosnian health outcomes. She has a new research project underway with the University of Missouri-St. Louis that is examining bicultural identity in second-generation Bosnian Americans.

To practice informed medicine, to actually engage the patient in their care, you can’t just cross the language chasm. You have to cross the cultural chasm and you need human interpreters to do that."

Robert Morgan, Ph.D.

“Usually the physician is focused on a specific body part, the diagnosis and the treatment,” Karamehic-Muratovic explained. “Sometimes the physician cannot care for the whole, the mind of the patient,” which is what many Bosnians seek and need. Karamehic-Muratovic, who left Bosnia in 1988 and settled in St. Louis more than a decade ago, said that understanding Bosnian attitudes toward health, particularly as influenced by their war and relocation experiences, is crucial.

For many Bosnian patients, she continued, addressing psychological issues like post-traumatic stress disorder, isolation and stress is stigmatized culturally, but still influences how they approach working with a physician.

“They have the upmost respect for their doctors,” Karamehic-Muratovic said. “But they want to be heard and listened to. They don’t want to be treated as a collection of body parts, but rather as a whole.”

Expanding the SLU-Bosnian Connection

Akif Cogo, SLU’s assistant director of custodial services, came to St. Louis from Bosnia and Herzegovina 17 years ago. Drawn to SLU by its mission, he said, in his five years working at the University, he’s watched the connections between SLU and his community expand, from the health fairs SLU faculty, physicians and staff members have undertaken, to the growth of SLU’s Bosnian student population. “I think we’ve just scratched the surface,” said Cogo, who is president of St. Louis Bosnians Inc., a nonprofit organization that advocates on behalf of St. Louis’s Bosnian community through educational, cultural and relief programs. “I think the studies and research being done at SLU really shines a light on something that we knew before but it wasn’t communicated well before and now gives evidence to solidify approaches to help the community.

SLU’s willingness to reach across language and cultural barriers, he said, has been a key factor to grow its relationship with the Bosnian community.

“SLU is so embedded in our community and it shows the great diversity that Saint Louis University is known for,” Cogo said.


About Saint Louis University

Founded in 1818, Saint Louis University is one of the nation’s oldest and most prestigious Catholic institutions. Rooted in Jesuit values and its pioneering history as the first university west of the Mississippi River, SLU offers nearly 13,000 students a rigorous, transformative education of the whole person. At the core of the University’s diverse community of scholars is SLU’s service-focused mission, which challenges and prepares students to make the world a better, more just place. For more information, visit slu.edu.

About SLUCare Physician Group

SLUCare Physician Group is the academic medical practice of Saint Louis University, with more than 500 health care providers and 1,200 staff members in hospitals and medical offices throughout the St. Louis region. SLUCare physicians are among the most highly trained in their fields — more than 50 specialties in all — and are national and international experts, renowned for research and innovations in medicine. For more information, visit www.slucare.edu.