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The Many Languages of Medicine (continued)

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Legal implications

The rules on using family members to interpret are clear in the deaf world today [although they’re not always honored.]: The Americans with Disabilities Act forbids medical personnel to use family to interpret in medical situations. If only Kaufman’s colleagues had that same cut-and-dried luxury. “It’s inevitable that at times you will be using untrained interpreters,” Chen says. Sometimes the patient insists. Other times, the family member is the only available solution for hours. Under any circumstances, the pitfalls are numerous:

• Family members may lack the necessary memory skills so they repeat only the first and last sentence of your message.

• They don’t want to tell the patient everything you are saying because it’s (pick one) shameful, upsetting, embarrassing, confusing, or shocking. Kaufman learned ASL because a deaf friend at college mentioned he relied on his mother to interpret at the doctor’s office. “As a teenager, I immediately thought about pregnancy, sexually transmitted diseases—you don’t want your Mom sitting in on that conversation,” Kaufman points out.

• Family members think they know more than they do. Ask Kaufman, who caught one mother mangling his message when signing it to her daughter. Bidar-Sielaff, too, has stories of untrained interpreters inserting themselves to prescribe treatments and dispense medical advice.

With the physician ultimately responsible for what transpires in the exam room, such bungled communication is a nightmare. Then, too, are the HIPAA implications: What about patients’ privacy rights when they bring friends or family members to act as interpreters?

According to Darice McNelis, a partner with the health-care law group at Buchanan Ingersoll in Pittsburgh, a patient who brings an interpreter into the exam room has waived his HIPAA rights with regards to that visit, because a health-care provider can reasonably infer from the circumstances that the patient does not object to a disclosure. However, the physician should not assume the patient waives privacy rights for all future communication. Further, if the visit pertains to sensitive matters such as sexually transmitted diseases, mental health, drugs, alcohol, or HIV, it would be wise to obtain additional clarification, if necessary, involving an unrelated interpreter.

Working with a family member as an interpreter can pose dangers, Chen admits, but once aware of them, a physician can mitigate them, she says. Her safety precautions include reminding the family member that he must say everything the doctor says, repeat everything the patient replies, and interrupt the doctor if he needs clarification or time to catch up. She also tosses all medical terminology out the window for this conversation—appendectomy becomes a series of drill-down questions that start with “have you had surgery on your abdomen?” Pause after every sentence to allow the family member to interpret.

And allot twice as much time as you would normally set aside for this patient visit. “They’re a lot more challenging,” Chen admits.

Manners win the day

Of course, physicians agree, any LEP patient encounter takes 50 percent longer than the same visit with an English-speaking patient—and that’s if you develop a smooth protocol. Start by spending a minute outside the exam room with the interpreter, filling this person in on the nature of the visit so that he can prepare his vocabulary. Mention if you expect to ask sensitive questions, and inquire whether the interpreter is aware of any cultural no-no’s you could stumble into, Robage suggests.

Once you open the door, greet the patient first, then introduce the interpreter by name to the patient. If the interpreter is already in the room, it may be difficult to distinguish who’s who. Say hello to the person not wearing a badge, TransTech’s Robage tells physicians. Kaufman finds it helpful to shake hands or make other appropriate physical contact with the patient at the onset when he needs to establish a cooperative, one-on-one atmosphere.

Opinions on where to have the interpreter stand vary, but Roat advises her interpreter students stand next to and slightly behind the patient. This plan gets the interpreter out of the middle, so the patient and physician speak directly to each other. It also gives the patient a sense of support to have someone next to them, as opposed to being confronted with the doctor and interpreter in her face. “This patient is probably already nervous and scared,” Roat says. Finally, it keeps the interpreter out of the doctor’s way so he can grab a stethoscope, flip through files, scoot around the room on a stool—normal movements for a patient visit.

“Think of the interpreter as clear glass. All the information gets transferred, but we are just the medium,” Robage reminds. So speak in first person, directly to the patient. Sentence structures that start with “Tell her I want her to turn around” often are interpreted exactly that way, making the patient feel like an object rather than a person. Present one thought at a time; but don’t feel you have to speak in an unnatural one-sentence cadence. Just don’t cram several directions into one exchange.

Some physicians give in to the temptation to have chatty side conversations with interpreters they know—they intend to foster goodwill in the room. Instead, such rudeness creates anxiety. “The patient imagines every stray word is something you’re not sharing about his condition,” says Bidar-Sielaff. And never ask the interpreter’s opinion—both Robage and Bidar-Sielaff say it makes them extremely uncomfortable and insecure. “I don’t know if the patient is depressed,” Robage says. “You’re the doctor.”

As the physician, you bear the responsibility of making sure the patient ultimately understands the conversation—even if it is in a language you can’t identify. “I know physicians wish we came with subtitles,” Bidar-Sielaff says. So don’t ask if the patient understands your instructions—the deaf, in particular, will nod yes as a habit, not a communication tool, Kaufman says. Optimally, you should ask the patient to describe in her own words what you said.

“But you don’t want to offend the translator by implying she misinterpreted, either,” he warns. His lingo: “This is a hard concept—I want to make sure you understand it. Would you mind explaining it to me?” Doctors say it’s best to apply this technique after each major discovery or instruction. But Kaufman doesn’t stop there. To make sure patients are understanding medication regimens, he requests they bring in their bottles and he actually counts pills on the follow-up visit.

Jacobs watches body language to clue her into whether the answers match her questions. For instance, if the patient appears in pain but the interpreter’s response is that everything is fine, she smells a disconnect. And it doesn’t take a rocket scientist to figure out that if the patient’s response rattles on for a minute and a half but the interpreter only says “no” that you have a problem. Don’t be shy about getting a second interpreter any time you feel doubt, Robage urges.

“Believe me, I’m horrified of going to another country where I don’t speak the language now,” Kaufman confesses. “I’ve seen how frustrating it is, but I hope that understanding makes me a better doctor for this group of people who need me.” g

Can You Hear Me Now?

Many physicians rely on telephone interpretation 24/7. Some companies even provide the telephone with dual handsets to make the process easier. Rates are falling, too. According to independent consultant and interpretation trainer Cynthia Roat in Seattle, Washington, it’s not unusual to pay as little as $1.30 a minute.

But that doesn’t make it a cheap way out for doctors. “I hate them,” Alice Chen, MD, a staff physician at Asian Health Services in Oakland, California, says bluntly. Phones don’t work for hard-of-hearing patients or those who are disoriented or confused. They don’t invite good patient-physician relationships. Many exam rooms aren’t equipped with phone jacks in the first place. So save this
option for times when you can’t identify a patient’s language or the medical emergency makes it
impossible to wait for an interpreter to arrive, Roat advises. g

Back to the Classroom

Did you know that over praising a child—a statement as well-meaning as “This is the most beautiful child”—to people of many cultures invites additional illness? They call it the evil eye and it’s certainly not a great beginning for American doctors hoping to communicate effectively on complicated medical issues.

So while it’s impractical to expect busy physicians to acquire a second language in their spare time, brushing up on cultural competency is reasonable and painless. Shiva Bidar-Sielaff, the manager of interpreter services and minority community relations for the University of Wisconsin Hospital and Clinics in Madison recommends these on-line resources:

• The Office of Minority Health’s recommended standards for all physicians and institutions to provide culturally and linguistically appropriate services. www.omhrc.gov/clas/index.htm

• Cross Cultural Health Care Program, www.xculture.org

• Resources for Cross Cultural Health Care, www.diversityrx.org

• EthnoMed, www.ethnomed.org g

Say it Right

Physicians often interchange interpreter and translator, a substitution that makes industry professionals cringe.

An interpreter converts spoken or signed speech to another language. A translator converts written text to another language. Each requires a different skill; translators, for instance, work meticulously and with more time to consult their dictionaries for a precise explanation of each word.

“We panic when someone says, ‘Oh the translator’s here!’ because we instantly assume the physician needs a document explained. Many of us don’t do that well,” reveals Cynthia Roat, a consultant and trainer in Seattle, Washington. g

Julie Sturgeon is a regular contributor to Unique Opportunities.

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