Posted by: sbilingual | December 7, 2011

Doctoring Across The Language Divide

Trained medical interpreters can be the key to communication between physicians and patients.

b y Al i c e Ch e n

The first time i met Mrs. Haddad, I

was running late. She was sitting on the

exam room’s metal folding chair, covered

head to toe in the black hijabworn by some Muslim

women. Her face was exposed but expressionless

and didn’t change when I walked into

the room. A man seated beside her stood up immediately.

Because most of my patients don’t speak much

English, my usual routine is to walk into the

room, introduce myself, and ask what language

the patient speaks. In addition to English, I speak

Mandarin and Spanish, but as often as not, I leave

to find an interpreter. Fortunately, this community

health center has professional interpreters

who speak Cantonese, Korean, Toisanese, and

Vietnamese, as well as bilingual staff members

who have been trained to serve as medical interpreters

for Cambodian, Lao, Mien, and Tagalog.

“Hi, I’m Dr. Chen. I’m sorry to have kept you

waiting. What language do you speak?” Mrs.

Haddad said nothing. Theman—her husband, as

it turned out—answered instead, “She speaks

Arabic. But I speak English.” Mr. Haddad was

slender with an open, animated face, wearing a

dark blue T-shirt and dark pants and holding a

cell phone.

PREFACE: It’s fortuitous that “patients” and

“patience” are pronounced the same. Their link

as homophones continually reminds us that

physicians’ communicating with their patients—

and the patience it involves—is essential

to good doctoring. When one factors in different

languages and different cultures,

communicating becomes an even more layered

process requiring additional patience—and

perseverance. California physician Alice Chen

speaks three languages; nonetheless, she found

herself one language short with a patient who

spoke only Arabic. As Chen details in her essay,

the only communication with her patient that

she could trust was provided by a trainedmedical

interpreter; she finds it inexplicable that despite

the growing need for this important specialized

service and its proven effectiveness, the

need for trained medical interpreters is often

swept under the carpet by policymakers. Then,

too, although people from two different cultures

ostensibly speak the same language, it doesn’t

mean that they truly understand one another. In

his essay, physician-professor Jack Coulehan

looks back on a summer almost forty years ago

when he and his wife worked on a public health

project in Jamaica—and realizes that with

time and patience, he has finally understood

what was said to him.

I looked at Mrs. Haddad. She looked at me, silent. I looked back at her husband.

He launched into the reasons his wife was here to see me: “She has leg pains and

stomach problems. She recently had breast surgery.” She was still looking at me,

without expectation. None of the clinic staff spoke Arabic.With no other interpreter

available, I sat down reluctantly, pen in hand.

“How long have you had these symptoms?” I glanced at Mrs. Haddad. She

looked down, and Mr. Haddad began to describe hiswife’s aches and pains. I tried

to multitask: noting her birth date (she was forty-nine); listening to her husband

and nodding; thumbing through her chart for something that could anchor the litany

of problems swirling around me; and, out of the corner of my eye, keeping an

eye on my patient. She watched us stoically. This went on for a few minutes. I began

to feel inundated as I registered lab results (normal blood counts, normal

chemistries, normal thyroid) and x-ray reports (all normal) while trying to focus

on what Mr. Haddad was saying.

Then I stopped. I didn’t have any sense ofwho Mrs. Haddadwas; Iwasn’t able to

hear her intonation, watch her facial expressions, or read her body language. All I

had so far was a long list of symptoms filtered through her husband.

I turned to him and asked, “Can we start over?” He looked surprised. I took a

deep breath. “Because I can’t speak Arabic, I need you to bemy voice andmy ears. I

need you to say everything I say, exactly the way I say it. I need you to tell me exactly

what your wife says, exactly as she says it. If you want to add something, or

have an opinion, that’s great, but I need you to let me know that it’s your opinion,

not your wife’s. OK?” He looked dubious. “Sure.”

Mr. Haddad proved to be a fair interpreter. I spoke in short, simple sentences,

and, generally, he interpreted rather than answered for hiswife. Iwas able to begin

focusing more on my patient, and I soon realized she seemed unhappy. We discussed

her symptoms, when they started, what made them better, what made

them worse, and what treatments she had received before. We talked about her

surgeries and her medications. I commented, “You seem sad.” Her husband responded,

“She has a lot of stress.” I asked him to interpret my words to her. Mrs.

Haddad nodded slightly, then tears started rolling down her face.Her husband explained

tersely that their whole family was under a lot of stress because their son

was being harassed by U.S. authorities. I handed her a tissue.

She wiped away her tears, and we moved on to other subjects. I recommended

some changes in her diet and sent her for some blood tests. After she left, I felt uneasy,

wondering if I had missed something important because Iwasn’t comfortable

asking sensitive questions with her husband serving as our interpreter. What if

she was crying because her husband or someone else was abusing her, or what if

she was feeling suicidal?

A month later, when Mrs. Haddad came for follow-up, her husband again

served as our interpreter. With some prompting and occasional redirecting, we

again fell into a rhythm: talk, pause, interpret, pause. He stopped me once to ask,

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“What does ‘irritated’ mean?” I had thought I was doing a good job by avoiding

specialized medical terminology but had forgotten that English was his second

language. “It means upset, feels bad.”

While examining her, I looked carefully for signs of bruises, asked casually

about any episodes of trauma. I found out that she was from Yemen; had been in

the United States for about six years; spoke and understood almost no English;

had four children and five grandchildren; lived in a household of fourteen people;

and spent her days cooking, cleaning, and looking after her extended family. With

these facts I felt I had a quick sketch ofMrs. Haddad, but no real understanding of

her as a person or how her neck, shoulder, back, hip, and knee pain related to her

activities or stressors or her expectations ofmedical care.Her interactionwith her

husband seemed reasonable, and her labs were reassuring except for a mild anemia,

but I still felt troubled. I sent her for more blood tests and some x-rays.

I also looked into how we could get a trained medical interpreter for our visits.

Mrs. Haddad was insured through aMedicaid health plan that has a simple process

to request and obtain an in-person interpreter for medical visits. This was, indeed,

fortunate. Although allMedicaid managed care plans across the country are

required by federal regulation to provide language-assistance services for enrolleeswho

speak limited English,many have not yet developed this service. Some

have created daunting administrative hurdles to accessing interpreters,while others

provide only telephone interpreters, which requires a clinician to have a telephone—

and, ideally, a high-quality speakerphone—in the exam room.

Suddenly, Seamless Communication

At mr s . haddad’s next appointment we had a professional female interpreter

with us. One of Mrs. Haddad’s sons had brought her to the appointment,

but once he found out we had an interpreter, he was happy to

stay in thewaiting room. I started off by reviewing Mrs. Haddad’s symptoms, then

gingerly edged toward asking about the source of her stress and about her relationship

with her husband. Thanks to our interpreter, our exchanges were quick

and seamless. Her spontaneous smile—the first I had seen—and immediate shake

of her head when asked about problems with her husband were all the answer I

needed. Although I still had all her aches and pains to deal with, I didn’t have to

worry about domestic violence, too.

From there I developed a fuller understanding of my patient. She made a face as

she relatedwhy she hadn’t gotten the hip x-ray I had ordered to assess for arthritis:

The x-ray technician was a man, and he had wanted to lift up her hijab so that he

could properly position the equipment. (I referred her to a different facility with a

notation that she needed a female technician.) In discussing her anemia and recommendations

for further evaluation, I discovered that she was still having heavy

monthly periods. Although she didn’t know her exact age, working backward

8 1 0 May/ Ju n e 2 0 0 6

N a r r a t i v e M a t t e r s

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from the age of her oldest child, we calculated that she was roughly thirty-nine

years old, not forty-nine as her official birth date suggested. I relaxed a bit; at her

age, a mild iron-deficiency anemia was likely due to heavy periods and less likely

due to colon cancer.

She told me about how several months before, the police had broken down her

door. One of them had thrown her to the ground and held her down with his foot

on her back; she had experienced nagging back pain ever since. She said that a policeman

had put a gun to her son’s head and that the family van had been impounded.

She cried about how her son had been accused of financing terrorism because

he owned a currency exchange, a common business practice in immigrant

communities. Her exam unremarkable, I was able to reassure her that she didn’t

have any permanent physical damage from her encounter with the police.

At the end of that visit, along with a prescription for iron supplements, I gave

her the telephone number of a legal advocacy organization. She clasped my hands

in thanks. I, in turn, thanked our interpreter, who had helped us connect, at least

for now, across the no-man’s land between English and Arabic. And I silently

thankedMrs. Haddad’s health plan.

Needed: Trained Medical Interpreters

According to the most recent u. s . census, the number of limited-

English speakers in the country increased by 50 percent during the past decade,

with one in five residents in my home state of California considered

limited-English speakers. This burgeoning linguistic diversity has been accompanied

by a number of policy initiatives addressing language barriers in health care

settings. For example, in 2001 the federal government issued national standards

for Culturally and Linguistically Appropriate Services in health care (CLAS standards),

which served as a catalyst formany organizations to develop or refine their

interpreter services. Unfortunately, for the most part, these national standards

have been treated as voluntary guidelines without the force of law.

Depending on a facility’s number of limited-English-speaking patients and organizational

resources, it might not be feasible—or necessary—to hire trained

medical interpreters for a given language. At the same time, too many hospitals,

clinics, and health plans leave it to the individual clinician and patient to muddle

through with an untrained interpreter or to try to make do with English. Neither

of these options should be acceptable to clinicians or their patients.

Communication between a clinician and a patient is always a delicate transaction.

Even in the best of circumstances, with both being native English speakers

and with a well-educated, well-informed patient, the opportunities for miscommunication

are plentiful—and the consequences potentially profound.Add in differences

in language and culture, lack of acculturation, and sometimes low literacy,

and it’s a wonder that we connect at all.

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In the ideal world, we would have bilingual, bicultural clinicians who could

communicate with their patients directly without the assistance of a third party.

But truly bilingual clinicians who understand the nuances of more than one culture

are few and far between. No one can speak all the languages needed in our increasingly

polyglot society; my clinic, for instance, had professional interpreters

and bilingual staffmembers for ten languages—not one ofwhichwas the right one

forMrs.Haddad. Even ifwe began to require second-language fluency as a prerequisite

to medical school admission, it would take years for this to affect clinical

care, and we would still be lacking numerous languages. So we are left with relying

on a third person to help us communicate: an interpreter.

Trying to communicate through an untrained interpreter is like playing the

children’s game of telephone: Startwith a sentence, pass it along a chain of people,

and laugh when it emerges altered and garbled at the end of the chain. Except in a

clinic situation with an untrained interpreter, you are left wondering whether

what you askedwas what the patient heard. And that’s not funny.

Study after study has shown that untrained interpreters in medical settings—

such as husbands, friends, secretaries, and janitors who have some bilingual skills

and happen to be available—are reliably unreliable. They typically lack fluency in

English, the linguistic skills to convert from one language into the other, and

knowledge of the medical terminology that’s needed to provide an accurate and

complete interpretation. They might have their own agendas or opinions and, in

the worst cases, might intentionally cover up their own abuse of the patient.

Children used as interpreters are a special problem. Although their English

might be accentless, their command of their parents’ native language is often

shaky, their vocabulary is usually sparse, and their understanding of medical concepts

tends to be simplistic at best. They often feel a tremendous burden of responsibility,

even guilt, for the information they convey, and just as often parents

can be embarrassed or reluctant to disclose important

symptoms and details to their child.

And there can be far-reaching consequences.

One of my patients never finished high school

because, as a child, when her baby sister was

chronically ill, her parents routinely pulled her

out of school to interpret for them.

Bilingual medical staff members, such as

medical assistants, are a better alternative;

however, few organizations actually test their staff members’ bilingual fluency in

medical terminology, let alone their interpreting skills. Anyone who can speak a

second language knows that it is one thing to be able to speak in the second language,

another to be able to interpret into that language, and yet still another to be

able to interpret from that language into English. In addition to quality assurance,

asking bilingual staff members to serve as interpreters requires that organizations

8 1 2 May/ Ju n e 2 0 0 6

N a r r a t i v e M a t t e r s

“Our professional

interpreter was arguably a

better diagnostic test than

all the labs and x-rays I had

ordered.”

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explicitly acknowledge and structure this responsibility. Otherwise, such staff

members are likely to resent and avoid interpreting as a burden that distracts from

their primary obligations.

Clearly there are many challenges. There are an estimated 311 languages spoken

in the United States. The health care workforce is diversifying, but at a glacial

pace. Few clinicians have training or experience workingwith trained medical interpreters.

Telephone interpreter services, such as the prototypical AT&T Language

Line, are increasing, but they can be prohibitively costly depending on how

often they are used and the languages involved, and they are frustratingly inadequate

when difficult cultural or interpersonal issues arise.

The U.S. Department of Health and Human Services’ Office for Civil Rights has

the authority to enforce federal requirements mandating medical interpreter services.

However, it suffers from chronic underfunding and understaffing and, in recent

years, has been additionally tasked with the enormous responsibility of enforcing

theHealth Insurance Portability and Accountability Act (HIPAA) of 1996.

On the policy front, there have been legislative attempts to ban the use of children

as medical interpreters, as well as laws passed in New Jersey and California

mandating that cultural competency (including issues of language access) be part

of continuing medical education for physicians. Although important, these efforts

sidestep the central question: Who pays for trained medical interpreters? The federal

government has indicated that medical interpreters are an allowable covered

service under fee-for-service Medicaid, but each state has to decide whether to

pay for this service; so far, only eight states exercise this option. Outside the

Medicaid arena, the issue has been a hot potato,with insurers, health plans, hospitals,

and physicians each looking to the others to devise a solution.

We need increased support for using trained medical interpreters, through either

centralized, direct reimbursement for medical interpretation (similar to how

our federal judiciary pays for qualified courtroom interpreters) or increased payment

to providers that care for patients with language barriers. Another model

would be to establish a national system of telephone interpreters, similar to the

one operated by the Australian government, which provides interpreting services

formedical practitioners throughout the country—twenty-four hours a day, seven

days a week, in one hundred languages—for the cost of a local phone call.

For Mrs. Haddad, just as the legal advocacy organization’s telephone number

might have been more therapeutic than all the various antidepressants and pain

medicationswe had tried, our professional interpreterwas arguably a better diagnostic

test than all the labs and x-rays I had ordered during the preceding months.

Caring for patients who speak limited English can be a challenge for both linguistic

and cultural reasons; using a trained medical interpreter is the right medicine.

Aportion of this essaywaswrittenwith support from theMedicine as a Profession initiative at theOpen Society Institute.

To find out how Bilingual Resources Group can support your interpretation, translation and bilingual staffing needs, please call 504-253-0364 or visit www.bilingualcare.com.

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