Interpreters

Interpreters and translators are essential in communicating with patients who do not speak the same language as the physician. They help translate one language into another to help facilitate the doctor-patient relationship and help in the care of the patient. By enabling this cross-cultural communication they translate not only words but also relay concepts and ideas between languages. They not only have an understanding of the two languages they are translating, but they also have an understanding of the two cultures.

Introduction and Question
I'm not sure how it is in Richmond but I've run into this situation a bunch in Fairfax. The Hispanic population is booming up here and during my pediatric rotation I must have used the translation service a dozen times. To start the discussion off, '''I just want to know if you all have personally experienced the doctor/patient/interpreter scenario yet and how you dealt with it. Also, please comment on the before and after scenarios on the video. Personally, I think the after video (which was supposed to show improvement) could have been a little better.'''

Discussion
In response to the last question about the doctor's comment to continue applying oil to the belly but to stop the tea, I think you are right in that this is an important aspect of the interview. I believe that by doing this, it increases the trust in the physician and allows the mother to feel that the doctor understands her, meanwhile helping to form a "therapeutic relationship. It also acknowledges and affirms the patient's beliefs about what is causing the problem and empowers her to help heal her child, thereby potentially increasing compliance.

My question after watching the video is if at any point it would be reasonable to explain the medical cause of Miguel's symptoms in addition to the doctor's affirmation that this is a bad case of empacho. Or do we simply defer to the mother's reasoning and not explain the diagnosis?

First of all, I just wanted to share a situation that I experienced during my peds rotation that relates to this topic. A 1 week old baby girl was admitted to the hospital for hyperbilirubinemia. Since I know zero Spanish, I had to use the interpreter line every time I assessed the baby. I was under the impression that the mother understood what was going on but on about day 3 she asked me if her baby was going to be brain dead forever because of what was in her blood. I had no idea that the entire hospital stay she was thinking that her baby was brain dead! How terrible for that mother! Also, during one conversation I had, the interpreter, who was supposed to remain an objective 3rd party, continued to interject his own perspective about the mother. I am almost positive that the things I was saying were not getting translated word for word to the mother in this situation.

Another situation that I encountered this week actually made me realize the value of an interpreter. I went to see a patient who spoke no English but whose daughter did. The woman, who was about 68 wanted a Pap smear and during the interview which included a sexual history, the daughter answered every question without asking the mother! In this particular situation I felt it was inappropriate to use the daughter because an accurate history could not have been obtained.

These two situations made me realize that in one case, I would have wanted a family member to interpret and convey to me the mother’s feelings. However in the second situation it would be of benefit to have an interpreter. Does anyone else have thoughts about any situation when it would be beneficial to have an interpreter over a family member or vice versa (or if a family member should ever be used)?

Another question is what to do when a patient is adamant to use a remedy that will jeopardize their health? What if the patient is under 18 and the parents are putting the child in this situation? What should be done to keep the parents from putting their children in harm's way?

At Hayes E Willis in South Richmond a large percentage of the patients are Spanish speaking. It is difficult to communicate effectively with these patients unless one knows Spanish. The language line is the next best thing but can still be challenging to use in some cases. It seems that the end result is that one must spend more time with the patient trying to overcome the language/cultural barrier, and hope that nothing was lost in translation. From what I've seen, if the patient doesn't understand one of two reactions occur. Either they become frustrated or they simply act like they're understanding when in fact they don't. The latter of the two I feel is most common. This is unfortunate because their condition may get worse or they may be deterred from seeking medical treatment in the future. As a physician, it is important that when the patient doesn't understand, or vice versa, that one have patience and work with the situation. Has anyone had encounters with a scenario where it didn't seem as if the language/cultural barrier was being overcome?

The ability to accurately and sensitively communicate is critical to the physician-patient relationship. According to the reading in the case, if both parties speak different languages, a multilingual clinician is preferred to a remote professional interpreter, such as the blue phone. Indeed, if I were in Germany and sick, I would prefer a doctor that speaks English. However, if we defer patients to other clinicians that speak the same language, how are we to improve our skills? Has anyone witnessed a language/culture barrier have a bad outcome or be overcome by an astute clinician? Finally, does anyone have any insight into how the demographics of an area might affect the training we receive as student and resident doctors either here in Richmond or other areas of the US such as the southwest? http://www.healingtherapies.info/Curanderismo1.htm This website explains the different specialty areas within curanderismo, which is a mind-body-spirit healing approach as mentioned in the case.

I agree. The fact that the doctor agrees with a patient's cultural beliefs probably means a whole lot to the patient. It helps build rapport and in the long run helps with compliance.

I think that it's a physician’s obligation to at least try to explain the real dx. But at the same time, relate it to Empacho for the same reasons above. You don't want to say that this is not a case of empacho but a case of intussusception.

I agree that leaving bias aside, a caring physician can come close to overcoming cultural barriers. However, I feel that a patient can probably relate more to you as a physician if you are aware of their background, where they come from etc. Thus, no matter how caring and nonjudgemental you are, a patient will have a hard time not to judge you.

I saw a patient today that did not speak English and the language line was utilized. I kept wondering what the person doing the translating was saying.

The patient was a pregnant lady in for a checkup that had previously been placed on an antibiotic for a UTI. She thought she was taking the prescription to treat chronic pain. I was lucky in that she had only been prescribed one medication at the previous visit. Somewhere at her previous visit there was a breakdown in communication, and I can't help but think it was the translator.

What I took away from this was, if on the language line, the importance of speaking slowly and clearly to the translator and ensuring that the patient understands, and remember that the language line translator is not a doctor.

In my own experiences with pediatrics in Fairfax, I found that about 90% of my inpatient experience involved a language barrier. However, I will say that the Inova system is well-prepared for this since there are ~70 different languages spoken in Fairfax/Arlington counties. So my problem didn't involve obtaining pertinent information or worrying about if what I said was being accurately relayed...my issue was relationships. I believe the patients acute concerns were well assessed and treated--but I still feel they received substandard "care." To my 10% English speakers, I could bounce in the room throughout the day and talk about cartoons or football. But to do this with my other 90% would require grabbing a phone or calling up an interpreter, which honestly seemed like a hassle, and thus, I did not do it. This was especially difficult when waking patients during pre-rounds--I felt myself just wanting to get in and out with the information I needed and I didn't feel I had the time to use the language line for every single patient. So in summary, while I think that interpreter services are invaluable for obtaining information, I feel that medicine is also about relationships, and it is this aspect that I feel is the unspoken casualty of language barriers.

In my 3 weeks of Family Medicine I have only dealt with one non-English speaking Hispanic patient, whose daughter did the translating during the encounter. I too wondered what was actually being relayed from me to him. He was seen by me for a suspicious lesion on his gum, which had led to his dentist referring him to us. I had no way of knowing whether his daughter conveyed to him that we had a high suspicion of oral cancer and that he needed to see surgeon for potentially radical treatment.

i have a story thats funny but only bc my pt understood some english. i was giving a mom the "mom talk" in the newborn nursery when i said the part about not smoking around the baby and not letting others smoke around the baby. the interpreter instead said "dont let the baby smoke." the mom started laughing and i asked her why she was laughing and she told me. i mean hopefully most parents would understand the misinterpretation but the point is that they obviously do occur even when explaining what we think are "easy" to translate.

I also think that as long as we are understanding of our pts diverse cultures and do not be judgmental and assume that there is only one way to look at something, we can always learn from others and better be able to treat our pts at the end of the day because we understand where they are coming from and why they believe what they do.

Today I had yet another interesting encounter with cultural barriers. A sister brought in her brother who was in pain. They were from Afghanistan. Her English wasn't bad and the patient didn't speak English at all. What made it worse is that it seemed that the patient had mild cognitive delays. I too ran into the problem of the sister answering all my questions without translating them to the patient. To solve this I asked politely yet firmly, "would you please ask him the questions?" She acquiesced to my request.

With regard to the latest question, to a degree I feel that non-English speaking patients do delay seeking medical treatment because of lack of familiarity with Western culture and intimidation. In these instances, their best motivators are family/friends that speak English as a second language.

One of my professors a few years ago taught me a trick with using translators who were in the room, was to focus your eyes and attention on patient with your side to the translator. It doesn't eliminate the problem completely but it encourages the translator that the focus is on the patient and not him/her.

I would like to share a situation that arose this past week with me. A spanish speaking couple brought their sick child in. Looking at his records, it was obvious that he was way behind on his immunizations. When asked it was because he got sick from the shots he had taken. The language barrier between provider and patient had caused this little boy to fall way behind schedule. In rural areas, spanish translation and documentation is not always available. If you are not fluent in someone's language and a translation service is not available, literature is the best way of communicating potential outcomes.

Working down at MCV, I found the blue language lines to be great. I see a bunch of you posting about using them in the newborn nursery. I don't think I'm exaggerating when I say I used them with 50% or more of the patients during those two weeks. It did not seem to interfere with the task at hand, however, I do think that a language barrier can significantly reduce the quality of care in a continuing care atmosphere. My experience at the family medicine clinic that I work at is that all Spanish speaking patients are sent to the one Spanish speaking resident at the office. If he is not there, then we have to have a translator come in. The real difficulty I find is in the patients who speak just enough English to not warrant a translator, but cannot express when they are not understanding the treatment plan. The other day we had a child with a viral cold and we told the mother that he would just need supportive care. She smiled and said yes. When she went to the front desk she was outraged that we did not give her an antibiotic, and it wasn't until then that we had a Spanish speaking nurse clear up the misunderstanding.

I have, admittedly, limited experience using the translator phones. However, the experiences I have had have been far more effective when facing the patient, maintaining eye contact and non-verbal forms of communication. This may not help in conveying the results of lab tests, but it is certainly essential in establishing a rapport with a patient fluent in a language other than English. I never realized how much the nonverbal component adds to an interaction until I watched someone take a patient's history through a translator phone while staring at a wall and not at the patient - there was absolutely no dynamic or rapport established during their interaction.

I think the barriers that exist are much more than cross-cultural and language...Although these are certainly obstacles and can interfere with proper understanding and treatment, they are part of a much bigger problem. I can think of dozens of patients with no language barrier that believe that the flu shot can give someone the flu or that an antibiotic is the cure for a cold. Despite education, there are old tales and beliefs that often interfere with healthcare. I've seen a lot of patients these past few weeks who have a similar culture system to me and yet convincing them that the flu shot was a good idea or that taking an antidepressant was not being weak was a difficult task. Beliefs can come from articles on the internet or from tales friends have told, and access to information is a great thing, but healthcare providers have to do a better job of informing the public of the truth and demystifying the myths of healthcare.

As far as language barriers, I used to be a volunteer translator as part of a volunteer language bank at a hospital. Although this probably only works for hospitals in big cities or academic centers, this was a great asset. There was a bank of people with hundreds of languages covered who were trained in confidentiality and being non-judgmental with health issues. Scheduled appts. who needed translators were done in advance and then there were lists to call for emergency translators. It worked well because you didn't lose the connection to the patient and you could see the translator and the non-verbal communication.

I also used the blue phone quite a bit during peds and maybe I just needed more time with it, but I had a really hard time telling what was being conveyed by reading the patient's or mother's face. It often seemed that it took a very long time to translate something fairly simple that I said, which worried me. I did often ask the patient a question to see if they understood, but still, no guarantees that the question I asked was the one being asked. Most of the translators on the phone seemed really good, but a couple of times, the translator had difficulty with words like "jaundice" and relaying the difference between potential side effects and what was actually happening to the baby. Also, we had an issue of finding a translator on the blue phone for one patient who spoke a very rare dialect from Mexico that was not a version of Spanish. We ended up using a translator who spoke Spanish, the mother's husband who spoke a little Spanish and the mother's dialect and a lot of gestures. I felt like it was a disservice to the newborn, but there were no options as so few people in the world speak that particular language and she had no other family members who spoke good Spanish or English. It amazed me that they could survive day to day with such language barriers. I know this is fairly rare to have no one speak a language, but it's also very frustrating for everyone. I don't know how this kind of situation can be overcome except through translated handouts or other written translation.

Recommended Resources
http://www.healingtherapies.info/Curanderismo1.htm

http://www.bls.gov/oco/ocos175.htm

Links to Cases
Back to Miguel or Case studies.