UO > Feature > The Many Languages of Medicine

According to the National Health Law Program, a public interest law firm that works to improve health care for the nation’s disadvantaged citizens, nearly 47 million people — that’s 18 percent of the U.S. population — speak a language other than English at home. In California, that percentage rises to 40 percent; it’s 37 percent in New Mexico, 31 percent in Texas and more than 23 percent in Arizona, Hawaii, Nevada, New Jersey, and New York.

The “good” news: The numbers of those who speak English “not well” or “not at all” is less at 11 million, says the Washington, D.C.-based organization. But that’s only for today. From 1990 to 2000, the Hispanic population alone increased by 58 percent, so experts expect a proportional rise in limited English proficiency (LEP) people. While California, Nevada, Arizona, New Mexico, Texas, New York, New Jersey, and Florida lay claim to the greatest proportion of these LEP patients, Georgia and North Carolina saw their LEP residents grow by more than 200 percent in the last decade. Arkansas, Colorado, Nebraska, Oregon, Tennessee, Utah, and Minnesota aren’t far behind, according to Census Bureau figures.

Physicians who try to accommodate these patients often find that learning a new language as an adult isn’t easy, or even practical. Take Elizabeth Jacobs, MD, for example. The internist and assistant professor of medicine at Cook County Hospital and Rush University Medical Center in Chicago ventured off to Guatemala for an intensive Spanish training program for two months, then practiced another two months in Chile. “And I’m still not fluent,” she confesses.

The same is true for internist Alice Chen, MD, a staff physician at Asian Health Services in Oakland, California. Although she grew up speaking Mandarin, that doesn’t mean she can communicate with the patients pouring through the doors who speak Cantonese, Vietnamese, Korean, Cambodian, and Mien languages.

Gary Kaufman, MD, who is double-boarded in internal medicine and pediatrics, staffed his Chicago-area clinic with Russian and Bosnian speakers and still found himself drawing pictures to a mother from Liberia to explain treatment for scabies and iron deficiency. “I drew the sun coming up over the horizon and in the sky and then stars and the moon for times of day. Then I showed a number of spoons to communicate the medicine doses.

“I hate practicing medicine that way,” he says.

Welcome to the next tool designed to help physicians provide good service and health care to their patients: an interpreter.

Title VI of the Civil Rights Act of 1964 states that any entity receiving federal financial assistance can’t discriminate against anyone based on their national origin or religion. Some courts have ruled that failing to provide language services equals discrimination under these terms, says Jacobs, who co-authored a study on the impact of interpreter services in health care published in the July 2001 Journal of General Internal Medicine.

While the political powers-that-be wrangle over whether this wording constitutes an unfunded mandate (for updates on current guidelines, visit www.hhs.gov/ocr/lep/guide.html), doctors at the practicing level emotionally embrace the excuse to bring in help. After all, in today’s litigious society, non-communication issues leave physicians vulnerable to punishing lawsuits.

On the other hand, having an interpreter only lessens the exposure —it doesn’t let the doctor off the hook completely, experts agree. “We don’t record anything in medical interpreting, so it’s very hard to prove somebody misinterpreted,” says Cynthia Roat, the co-chair of the National Council on Interpreting and Health Care (NCIHC) board in Seattle. While interpreters contracted with service firms often carry errors and omission insurance, lawyers love to add doctors with their perceived deep pockets to the court papers.

Such troublesome issues are front of mind for Chen when she works with LEP patients. “I worry about not getting a clear picture of the patient’s real complaints,” she says. “It’s frustrating because as a physician I should be focusing on symptoms, differential diagnosis, and treatment options. Not ‘Did that person say everything I said accurately?’” Nor is she an advocate of some colleagues’ knee-jerk reaction: Order tests to find the answers. For starters, many LEP residents won’t show up at the facility.

Then there’s Kaufman’s nightmare story: Using his American Sign Language (ASL) skills, the physician took a history from a deaf hospital patient that indicated the man’s physical activities the day before caused his chest pains, which were clearly unrelated to his heart. The intern on duty later, however, shunned an interpreter, opting to write back and forth in a notebook instead. Based on incomplete information, he scheduled an invasive cardiac catheterization for the next morning. Luckily, Kaufman stopped the procedure in time.
“I still get chills,” he says. “Our patients are at our mercy.”

The solution lies in part with establishing a standard set of ethics for medical interpretation. Roat’s NCIHC is currently working out the details to these basic tenets:

Confidentiality — Everything discussed in the medical exam remains hush-hush. It seems rudimentary, but many interpreters know the patients in their close-knit cultural communities and find themselves torn between social standing and job expectations.

Completeness — Interpreters shouldn’t edit out, add in, soften, or overdramatize the message. “The interpreter is not a filter for what is being said—just the means by which what it is being said,” Roat says.

Accuracy — not to the words, but to the meaning of what is said. Roat sometimes refers to interpreters as “cultural brokers” who need to convert the doctor’s message into a scenario the patient understands and vice versa. So if a Southeast Asian gentleman refers to hot not as a temperature but a state of being, the interpreter informs the doctor of that context.

Or, says Natasha Robage, an interpretation manager for Houston-based TransTech, an interpreter contracting service, ask the doctor’s permission to rephrase questions should his original wording violate a cultural norm.

Most physicians agree the optimal route is to hire a dedicated, in-house interpreter or contract with a third-party, professional language service. But because medical interpretation is in a state of evolution today, physicians must approach the hiring process aggressively.

Shiva Bidar-Sielaff, the manager of interpreter services and minority community relations for the University of Wisconsin Hospital and Clinics in Madison, follows three steps before officially hiring interpreters to serve the 10 facilities under her direction.

Number one, make sure the candidate is truly bilingual. “Right now many places take someone who just knocks on the door and says, ‘I know Spanish. Can I be an interpreter?’” she says. “That’s just a recipe for disaster.” Asking someone you know is bilingual to converse with the candidate in both languages for a while is a simple solution. Bidar-Sielaff also recommends honing your questions on the candidate’s background: Where did he learn two languages? How long has she been exposed to the two? “High school French does not make someone bilingual,” she says.

For $139, the American Council for the Teaching of Foreign Languages headquartered in Yonkers, New York, will conduct an interactive telephone interview with candidates to grade their functional speaking skills from superior to novice.

Second, check for basic training in medical interpreting. “Health vocabulary is learned—it doesn’t come naturally to anybody,” says Bidar-Sielaff. Indeed, Chen admits she faced a steep learning curve to put words like appendix, mammogram, and hysterectomy into her Mandarin knowledge base.

“They weren’t common words we used at the dinner table,” she says.

Ideally, the medical interpreter holds an MD in his country, but that’s a rare find. American doctors usually have to settle for bilingual speakers who have passed a 40-hour training program like NCIHC’s “Bridging the Gap,” which includes medical terminology. Washington State’s Department of Social and Health Services certifies its medical and social service interpreters; Massachusetts and California are studying the results of a similar pilot before jumping on board.

Such training usually involves covering sticky ethical issues, but Bidar-Sielaff asks candidates to complete a written, scenario-based evaluation anyhow. For instance: the interpreter is in the waiting area with a woman who confides her husband is abusing her, which is why she has bruises. Yet when the patient is in the doctor’s office, she denies abuse. What does the interpreter do? The right answer is tell, says Bidar-Sielaff, because the interpreter is part of the medical team under the same obligation as a nurse or medical assistant.

The upside is that when a professional interpreter is in the room, the conversation often runs smoothly. In fact, Chen says, one of her Cantonese patients stopped the doctor on the street one day, chatting away happily. “She forgot we needed a go-between to communicate,” the internist says.

For smaller offices like Richard Keller, MD’s HealthReach clinic in Waukegan, Illinois, it pays to hire staff proficient in two or more languages. But remember—bilingual doesn’t naturally translate to interpreter. That’s why the Asian Health Service sends its multilingual staffers for the specialized 40-hour training, and builds interpretation duties into the job description.

Keller saves still more money by writing his own Spanish training manual to steer his Puerto Rico-born staff toward communicating efficiently with Mexican immigrants. “Most of the materials I found were written at a college level, which is not at all what we need for our patients. We wanted street jargon and help with dialects,” he says.

Kaufman found a hidden gem when he began practicing at a refugee clinic that used native Russian and Bosniain staff that could back up his need for Russian and Bosnian interpretation. These native speakers gave him credibility within the community his clinic serves. “They bond with the patients—it’s an attitude of ‘10 years ago we were where you are’ that makes cooperation better. I don’t fight the same battles I did two years ago. My staff fights them for me,” he says.

On the other hand, always pulling in an LPN to translate quickly crashes the rest of the office system. Chen advises doctors to balance between professional interpreters and trained back-ups by constantly monitoring patient records to determine the primary languages streaming through the office. Community-based organizations in larger cities are willing to chip in as an additional resource as well. (However, as Keller learned, “Volunteers are lovely people, but it’s hard to count on them when you really need them. If they’re an employee, it’s easier to hold their job over their head to make sure they arrive at a given time.”)

“It’s about structuring your practice so people don’t always feel at a disadvantage,” Chen says.