Published in the March 2010 issue of Today’s Hospitalist
It’s a common scene in both big-city hospitals and community facilities: The patient speaks little or no English, but has supportive family members who are happy to translate. No one working in the hospital speaks that language, so you handle the situation as best as you can. But there are always lingering doubts. Are you getting the straight story, and are your comments to the patient being fully and correctly translated?
Most health care regulations and guidelines either encourage or insist on non-family translators. And the Department of Health and Human Services (HHS) treats “limited English proficiency” (LEP) as a disability that requires the same level of accommodation as limited mobility or visual deficits. Providers who receive federal assistance ” and that’s just about all of us “are required to “take reasonable steps to ensure meaningful access to their programs and activities by LEP persons,” according to HHS policy.
While the HHS makes allowances for small offices with limited resources, any medium to large size hospital is expected to provide translation services and written materials 24/7. Patients can file complaints with the HHS’ Office for Civil Rights, which was exactly what happened to one large Southwestern hospital. Because of that complaint, the hospital has gone to considerable effort and expense to improve the availability of interpreters, ensure that bilingual employees are truly functional in both languages, and inform LEP patients about their options.
The lack of a common language is not just a social or legal problem; it can also produce bad clinical outcomes. A 2007 Joint Commission study found that inpatients with limited English experience more frequent adverse events, and that the events they have are far more serious than those of English-speaking patients.
These patients are also less likely to have regular medical care and more likely to be hospitalized, with treatment compliance directly proportional to how well they understand its importance. Patient satisfaction tends to be lower, both for hospitals and doctors, and patients’ level of health literacy is generally lower than for people who understand English.
Working with family members
You know the downsides of using informal translators, but it’s 3 a.m. and the patient’s family is really helpful about translating for Mama. (One of her daughters, who seems bright and responsible, is being particularly helpful.) It seems like a lot of trouble to call in an interpreter. Can’t you let the daughter at least help explain the diagnosis?
Most medical groups and hospitals wisely discourage using children for this type of adult job, although some allow it if the child is over 16. I suggest using common sense: You’ve known this kid how long? Unless you’ve spent days or weeks getting to know the patient and family, give minor children a pass on translation duty. And if you have that much experience with the family, you should have already been able to find a non-family interpreter.
Patients may feel more comfortable with a friend or relative translating, and most of the time that seems to go OK. But the neighbor who seems so helpful may have a fifth-grade education, be carrying on with the patient’s spouse, or may just not know the patient’s language as well as she claims to. And family members the world over tend to be reluctant to give bad news or to discuss sensitive subjects with Grandma, so you may not get reliable information or have your explanations relayed the way you want.
Or you may not be alerted to what’s really going on within a family. We had one terminally ill patient a few years ago whose spouse spoke no English, so one of the patient’s adult children who was a medical professional offered to serve as family spokesperson when we discussed end-of-life care. Because I was uncomfortable with the family’s insistence on care that seemed futile, I called in a pulmonologist who also spoke the language.
That’s when the real story came out. Everybody wanted comfort care except a relative in another state, who was threatening to expel the spokesperson from the family unless the patient received every possible form of life support. The pulmonologist and spouse worked out a DNR order, the spokesperson was hugely relieved, and the patient expired peacefully with loved ones at the bedside.
What about hospital staffers?
In a city with a large immigrant population, it’s not uncommon to have hospital employees who speak Tagalog, Hindi or Russian. Many hospitals keep a roster of these employees in the administrative office and will tell you that they have a pharmacy assistant or respiratory therapist who is just what you need.
But be careful. These folks may not only lack certification as medical interpreters, but they may not be as fluent as they think. Many volunteer interpreters, however well-intentioned, were educated in the U.S. They speak English most of the time and use their second language mostly around the house and on family visits, never developing a large vocabulary.
I listened one day to a hospital employee explain a neurosurgical patient’s postop problems in a language that I didn’t speak. After a few minutes, I realized that I understood everything that he was saying. If you replaced the patient’s native language with ellipses, here’s what the conversation sounded like: “… hemorrhage … craniotomy … infection … spinal fluid … resistant … PICC line … antibiotics.”
We were supposed to be getting informed consent for a central line to treat a MRSA wound infection long-term. The interpreter was familiar with medical terminology, all right, as long as it was in the language he trained in. We never did find out if he was able to explain even basic terms like “spinal fluid” or “pneumothorax” in words a layperson could understand.
Two organizations offer certificates for interpreters in hospitals. The American Council on the Teaching of Foreign Languages (www.actfl.org) offers testing in 64 languages and gives rankings that go from “novice” to “superior.”
The Council does not, however, offer a specialized test in medical terminology. The National Board of Certification for Medical Interpreters (www.certifiedmedicalinterpreters.org), however, requires applicants to pass both written and oral exams, and tests not only medical terminology, but ethics and cultural competence.
Training in all three areas is now mandatory for interpreters in California, where health care interpreting standards are set by a state-wide nonprofit organization (www.chiaonline.org). The Registry of Interpreters for the Deaf is setting up similar rules, and efforts are underway to set a national standard for medical interpreters in Canada. And in October 2009, the National Board of Certification for Medical Interpreters in the U.S. announced that credentialing will begin this year for certified medical interpreters, starting with Spanish and adding other languages with time.
What if your hospital has only 12 bilingual employees and four of them are in housekeeping? Or a patient just arrived from another country and speaks only Greek or Yoruba. Where can you turn for help?
The best emergency resource I know is Language Line, which is operated by AT&T and offers telephone interpretation 24/7 in more than 170 languages at $3.95 a minute. You can set up an account by dialing 800-528-5888 or via the Web at www.languageline.com/webpi.
If your hospital doesn’t want to pay for Language Line, it’s worth asking why not. If the administrator you wake at 2 a.m. is less than helpful, you may have to be more creative in finding interpreters. You can turn to mosques or community organizations; shell out your own money to call Language Line; or use family members until the administrative office opens in the morning and authorizes payment for a professional translator.
One thing is clear: You shouldn’t wait until you’re called to the ED to take a history from a patient who is new to the country “and the hospital. Talk to your administrators now, offer them the Language Line number and some Web resources, and ask what translation resources are already in place.
If that doesn’t elicit a response, you may need to explain that the Joint Commission and the HHS view problems caused by inadequate translation as serious. In the end, this is about patients’ safety and how to help them. Preventing bad outcomes is always our job “and now, occasionally, the job of an interpreter as well.
Stella Fitzgibbons, MD, is a board-certified internist who has been a hospitalist since 2002. She has practiced in several Houston hospitals and is fluent in Spanish and Russian. Her patients, however, speak far more languages than she could ever hope to learn.
Getting the most out of interpreters’ services
- Lay the groundwork. Spend a few minutes telling the interpreter what’s going on and what you need to ask or tell the patient and/or family. Once interpreters are aware of the problem, they may be able to anticipate some of the patient’s or family’s questions. Interpreters also need to understand the severity of the problem and which issues are most urgent.
- One sentence at a time. Don’t expect interpreters to memorize an entire paragraph of medical problems and translate it perfectly. Human memory is limited, and shorter items allow family members to link what you’re saying to your expression and tone.
- Listen whether you understand or not. Expressions and other nonverbal communication can be priceless in understanding the family situation and recognizing what the patient finds most troublesome. Body language varies between cultures, but some things are the same, especially when it come to strong feelings provoked by a serious illness or injury. Listening to interpreters will clue you in to whether they are adding side comments or asking questions beyond what you need to know. You may also be able to pick up on whether the interpreter is competent.
- Do what you can to help when interpreters aren’t available. Ask bilingual family members to make “point and talk” sheets with common words and phrases in both languages. Staff members can use these sheets to ask questions about everything from pain levels to urine output. If the language is Spanish, odds are you at least know enough to say “Buenos dias,” maybe more. And while learning Arabic may sound hard, a simple phrase like “Salaam aleikum” (“Peace be with you”) will make points with folks from Morocco to Indonesia.