Friday, January 17, 2014

Non-English-speaking patients. Lost in translation?

What is one of the rules that medical people comply with the least?

My vote goes to "translation." The rule is that you must use a qualified medical interpreter for any interview or discussion with a patient who does not understand English.

How is lack of understanding defined? It is usually fairly obvious. If you aren't sure whether the patient gets it, he probably doesn't.

Why can't family members act as translators?

There is no guarantee that they will understand what is said or transmit it accurately to the patient.

What are the options?

You can summon a translator from the list of hospital personnel who have volunteered to translate. This works if the language in question is Spanish or maybe French. It's not often useful for Bengali or for most of the 13 or so national languages spoken in Mali.

The Joint Commission says if hospital employees are used, they must be qualified as translators and suggests ways that they can become qualified such as language proficiency testing, training in the practice of interpreting, interpreting experience in a health care setting and knowledge of medical terminology.

One website I found while researching this subject claims that the Joint Commission says all on-site interpreters must undergo an FBI background check. I could not verify this with the JC because its standards are only available if you pay. [Digression: If this is true, it is very interesting since doctors and nurses do not have to undergo FBI background checks.]

Many hospitals do not have formal training for interpreters nor are interpreters always available around the clock.

Sometimes hospital administrators take things too literally. In one hospital I know of, a fully bilingual surgeon was told he could not obtain an operative consent in Spanish (his native language) because he had not been trained as an interpreter.

There also are times when the hospital employee is not up to the task either because of education or attitude.

A hospital can contract with a service to provide interpreters via telephone. The advantages are that the interpreters are qualified and speak many different languages, far more than you might find among hospital personnel.

Among the disadvantages is the awkward nature of these conversations. If you use only one handset, you have to keep passing the phone back and forth and you can't hear what the interpreter is saying.

A two-handset phone set-up is somewhat better, but you have to find it. It is always stored in a different place on each floor of the hospital.

Accessing the service can be time-consuming. You must make an 800 call, log in, wait for the interpreter to join and so on.

Either in person or by telephone, the conversation can be frustrating.

I have had occasion to say something to the interpreter that took 2 minutes only to have the interpreter talk to the patient for 10 seconds. Here's a video example.

But the real problem is lack of true physician-patient interaction. You are both talking to someone else. Telling a patient she has cancer or what the risks and benefits of a procedure are is often accompanied by stunned silence from the patient. You really can't tell how much has been understood.

Also worth noting is that whatever the language, most of the time we then have the patient sign a consent form that is written in English.

You may have figured this out by now—many hospitals don't do any of this very well.

What do you do with a patient who speaks a language that even the telephone interpreter service doesn't provide?

We simply do the best we can. I'm not sure that any interpreter, phone or in person, can really communicate with some of these patients. 

Now that I think of it, I'm not sure how many English-speaking patients understand us either.


Anonymous said...

Despite all rules and regulations, in most places we still use:

1) family

2) nurses and aides on the ward

3) hospital-employed and certified on-site interpreters (they are the best but not readily available and not after-hours).

4) non-clinical personnel

5) phone interpreters: great in theory but horrible in practice.

Skeptical Scalpel said...

I agree. Don't forget housekeeping under #2.

Anonymous said...

At our institution. we have cracked down on the use of "impromptu interpreters" across services with a possible exception of emergency surgery/trauma (procurement time is an issue but this is being addressed.) It's rare that a patient will be consented to a procedure or seen in clinic through non-clinical personnel. It certainly helps that a large contingent of staff here are fluent in Spanish.

I've noted that after we adopted mobile video-interpreter units (TV on a cart with a microphone and camera, on speakerphone, connected to a certified interpreter) staff feel much more at ease communicating with their patients in depth.

Personally, I find that my Spanish-speaking patients tend to understand treatment plans and verbalize a good knowledge of their condition(s) - more so on average than English-speaking patients of similar socioeconomic status. I don't know if this is because the terminology is inherently more precise in Spanish versus English, or if I'm explaining concepts in simpler terms in Spanish. My experience is probably not the norm, however.

Skeptical Scalpel said...

You are fortunate to have so many resources and so many staff fluent in Spanish. I could be wrong, but I think your entire situation is not the norm. Your patients are lucky too. Congrats.

Anonymous said...

I'm in a CERT group. CERT = Community Emergency Response Team. When there is a crisis and the fire/police/etc. are overwhelmed (as in a hurricane, floods), we do basic triage and helping out until the real medical people get here. We do have nurse volunteers, doctor volunteers. That being said, one of the things I'm putting together here are some phrases that we can use to get a dialogue going to help us out. The local university has a lot of foreign students. We have a few other resources, and I'm going to use that to put together something so that if we are "activated" we can do some sort of speaking with people and alert the medical personnel that we have someone who doesn't speak English (or very well).

Has any one tried working with a hospital for their resources so we can point them in the right direction? If they have German at one hospital and not another, that's something we need to know, so we can send that patient to that particular hospital. Treatment would be delayed if we can't communicate.

Skeptical Scalpel said...

Sound like what you are doing is a great idea. I have no personal experience with trying to see if a hospital would cooperate with your efforts. I suggest you call their public affair or public relations departments. Good luck.

Anonymous said...

The hospital where I work will not allow physicians to act as interpreters, even in their native languages. I have seen instances where docs have had to wait for 30 minutes or more to be connected with a medical interpreter on the phone when they could simply be obtaining a consent. It is a silly waste of time and valuable resources. Isn't there an easy way to certify mutlilingual staff who are medically trained?

Skeptical Scalpel said...

Anon, thanks. You would think that common sense would prevail, but when it comes to hospital administrators, that is not always the case. I wish I could tell you how to solve this problem, but it is beyond me.

Anonymous said...

Let me be politically incorrect here:

I lived and worked in CA, but am now semi-retired.

We should and do try our best to get interpreters. In many instances, it is logistically convoluted.

The major non-English language in CA is Spanish. But, even in large Hispanic communities, few of the doctors and nurses can speak Spanish outside of cursory greetings. "Do you have pain?" is answered with long replies which lead us to a loss.

I've had several patients (in a county hospital) who asked me why I don't speak Spanish. Since they were 30-40 year olds who had been in the US for years, I wondered why they can't speak English.

I've treated a patient (injured at work) who spoke only a dialect used in rural Myanmar. Fortunately, he was accompanied by the only guy in the entire county who speaks both English (not well) and the Burmese dialect. Did I call ATT? No.

If a patient does not understand English well and does not speak the native language of his physician/nurse, he will be at a disadvantage. That is just the way it is.

artiger said...

I try to view this realistically, as Anon above stated very well, but I have noticed that the Spanish-speaking patients in my rural area (Mid South) will almost always bring along an interpreter to their office visit. And they do so happily. It is often a family member, sometimes a friend, but occasionally someone they didn't know but were referred to by a friend or relative.

I know that doesn't satisfy Joint Commission and all the other busybodies, but it's effective and efficient for us. I can't see it changing around these parts.

Skeptical Scalpel said...

Anon, very true and thanks. It's handy to know how to speak English.

Artiger, thanks for the reality check. I'm sure what happens at your hospital takes place thousands of times per day across the US.

Anonymous said...

Just a side note as an RN, at least in the state of MD, we are subjected to background checks. Whether it is FBI, state police or what I don't know but when I graduated nursing school in 2007 we were the first class to have to do this and they were phasing in all RN's over the next several years. Just FYI.

Skeptical Scalpel said...

Thank you for that information. I have worked in 3 states and unless it was done without my knowledge, I have never undergone such a check. I don't know of any other physicians who have either.

Anonymous said...

In the 2 states I have worked recently (West Coast) as a locums, it is becoming common to have a background check prior to medical staff credentialing. For the last one, I was curious and asked what exactly was checked.

The employment screening company used had several tiers of services, and this hospital opted for a mid-level one. It checks for state criminal records, individual county criminal records for your counties of residence for the past 7 years, and national sex-offender databases. But, the hospital consent form I signed also authorize credit checks and was basically open-ended.

I got a copy of this check, and although I was clean they did list all my previous addresses.

Several other hospitals also ran background checks, although their details. These screening agencies are big business these days, and for high fees they can really find out everything about you.

As far as I know, the hospitals run the same checks on their permanent staff applicants.

This is of course in addition to the usual inquiries into medical and previous hospital credentials.

Skeptical Scalpel said...

Very interesting. Thank you for commenting. I wonder how widespread the practice is?

Anonymous said...

This prob. may make for an interesting separate thread, but...

I know that in CA, MD's and RN's get a background check on initial license application. Many hospitals (?percentage) also run them before hiring/granting privileges.

The LA Times in the past year or so ran a bunch of articles about criminals maintaining their RN licenses. In response, I think the Nursing Board may start to run background checks upon renewals. The Medical Board already gets notice of arrests and convictions of doctors.

When I applied for a Washington State MD license 4-5 years ago, I had to submit fingerprints for a state and FBI check.

With the ease of collating data, it is just a matter of time before everyone's past is publicly available.

artiger said...

I applied for a TN license last year, and a background check and fingerprinting was part of it. I don't have a problem with it, but of course my record was clean.

Skeptical Scalpel said...

Thank you both for contributing to the discussion. I see no reason not to do detailed background checks on doctors and nurses.

Henry Woo said...

Sometimes and in spite of your best efforts, resources cannot provide you with an interpreter in a timely manner. Google translate on the iPad it iPod has been a 'life saver' on these occasions

Skeptical Scalpel said...

Yes, Google translate is pretty good, but far from perfect. Isn't it a bit awkward to type on the iPad and then have the patient read it and vice versa? It also assumes the patient can read.

I guess it's better than nothing.

Pepe said...

As a med student I had the opportunity to make a couple of clerkships in the US and had no trouble translating for the spanish-speaking patients. It was a great experience and accounted for a different patient-doctor relashionship.

As for the comment from anon I don't think it's fair to compare why the reasons why an immigrant with low education and economic background to someone who has spent more that years getting grad education.

Jose, surgical resident from Mexico

Skeptical Scalpel said...

Pepe (Jose) thanks for commenting. Good luck with your career.

Allen said...

I went to an Insurance Company closed-case event several years ago, so as not to re-create errors the insurance company has paid for once.

As it was related, the doctor was trying to relate something complicated, but had trouble with the interpretation, so they got the housekeeper to translate.

The found out in the depositions that after the first couple of rounds of interpretations the housekeeper started telling the patient and family 'you need to get a lawyer and sue'. So, housekeepers are out...

We use double handset phones, and they're okay but not as good as in-person interpreters.

Skeptical Scalpel said...

Allen, thanks for the comment. Great story. I've used the double handset. As I said in the post, it's OK, but far inferior to a person-to-person conversation.

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