Language Barriers

One of the most important aspects of the doctor-patient relationship is communication - the ability for the patient to communicate his/her symptoms and the ability for the physician to communicate diagnosis and treatment as well as prevention and education. Most of the time, we are able to still communicate effectively despite cultural differences. However, there are times when the doctor and patient do not speak the same language. In those cases, the language barrier can impair the doctor-patient relationship and make communication so much more difficult unless steps are taken to break down the barrier.

Introduction and Question
On several occasions, I have found myself in situations in which I am asked by a resident to do "a quick physical exam" on a Spanish-speaking only patient. While I have picked up a few phrases along the way, I have never felt comfortable examining a patient with whom I have only a very limited ability to communicate. Often, he/she will try to tell me something and I can only look at them with a blank face and say "Lo siento." ("I'm sorry.") While I will try to find someone who speaks Spanish to help me, often there is no one immediately available. The "blue phone" is an option but usually, in an in-patient setting, there is some pressure to move rounds along quickly. I do my best to perform a brief physical exam but often will never actually speak to the patient. I often walk away from the encounter hoping that I did not miss anything important and wondering if that patient is getting the same quality of care as the English-speaking patients.

While healthcare delivery is certainly not a perfect system, are there any thoughts on how we could improve delivery to those patients who do not speak English?

Discussion
Perhaps designating time to use translation phones during / immediately following rounds, attempting to match bilingual nurses / physicians to non-English speaking patients, etc.

I feel that it is impossible to provide patient care if you cannot communicate with the patient! The first video clip was very irritating to watch. How can a doctor provide recommendations for treatment without even knowing what is wrong with the patient? I realize that it is a challenging problem to obtain adequate translation for patients who do not speak English, however feel it is absolutely necessary. The last video with proper translation was drastically different than the first one with poor translation.

One solution is, of course, more translators with better availability. I recently finished an away rotation at a hospital that had translators for most major languages in-house until midnight every night. The translators would be present finitely much more diverse than my current hospital in rural which is basically a homogeneous population). I was wondering if anyone knew if there was any data out there about how large target populations need to be to make more comprehensive translation services cost-effective?

Most hospitals cannot afford live translators in all major languages. But I have worked in small clinics where they had a Spanish translator, because they were in an area with a large Spanish-speaking population. I think that it depends on the population and the specific needs for translation services. In many settings, one must make do with a translator available by phone.

I should start by saying that the feeling that non-English speaking patients getting the same quality of care as others is shared by a lot of people, especially students. I sincerely hope that “a quick physical exam” asked by a resident was not initial H&P. In order to balance personal lives in the 80-hours-work-week AND multicultural patient population era, it may not be easy for house-staff to give the care as they may wish. (Don’t get me wrong: I think 80 hours is great idea, but we just have to get better at communication when we sign off – but that’s another topic).

Being said all that, I don’t think it is not acceptable to sacrifice the proper care because of the pressure to move rounds along quickly. Have I been in similar situation as described? Absolutely. I’ll share what worked for me with non-English speaking patients. During the initial H&P, if the team is extremely busy, using the blue phone, we try to get the pertinent information. Usually, as students, we can ask to stay behind and get the full H&P. Otherwise I just go back and spend time with the patient using the blue phone. (even in surgery rotation). What I found is that like with any patient, when you build a great rapport in the beginning, the rest got a lot easier.

So, when it was a follow-up morning exams, the patient knows you. If you have already talked about what your concerns were and what your physical exam is about, you would have found a way to communicate quickly and effectively on the stable patients. For example, when I pressed on abdomen, patient would say “yes” and point to the area and say “7”. But always ready to reach for the phone. Don’t get me wrong; when I have non-English speaking patients, I try to get there extra early and make sure I have time to do adequate pre-round before the round. I make sure other patients are seen first so that I can manage my time effectively with non-English speaking patients.

As for using nurses, they are over-worked due to shortage. You may find that even if they can speak the language, they cannot dedicate their time to one patient as a translator for all the medical team members. And many patients do try to find physicians who speak and understand the culture if they are able.

Unfortunately, since we do not have the resources to have a translator for all of the non-English speaking individuals, we have to do the best we can with what we have. It's true that on rounds you don't have much time to interview patients. The fact that you can't communicate effectively can compound this problem. Since time is an issue, maybe coming back to the patient when you have a free minute and using the blue phone to be sure that all of the patient's concerns have been addressed would be a good idea. If time is too constrained for that, using the blue phone initially with more direct questioning could speed things along. I would advise use of the blue phone if you are attempting any significant exchange of information, like a H&P, so that no info is lost with lack of knowledge of their native language. Without a thorough H&P we really can't effectively treat the patient. This is why I feel the blue phone is really the only way to go if no translator is available.

I'm sure that we'd all agree that ideally a Spanish speaking patient would have a trained medical interpreter by their bedside, but the resources for this are not available at every hospital/medical practice.

I think that the blue phone is the best alternative to not having an in-house translator. I am not sure if doctor's offices also have translator services, but I believe that all general practitioners (Family Medicine, IM, pediatrics) should have these phones available in their office/exam rooms. The reason for this is at times, you may get urgent cases (appendicitis, AMI, etc) that present to the GP's office.

Another idea that I thought would be helpful is if there was some way that an internet based translation service could be set up where the doctor and patient type back and forth to each other. The efficacy of this probably would be the same as the blue phones, but laptops are portable and not all "blue phones" are. The downfall to this is not everyone knows how to type and it seems somewhat impersonal to “type” something to your doctor.

I agree as others have said, that without good communication it is extremely difficult to establish a rapport/relationship with patients and come to a diagnosis and treatment plan that is satisfying to both patient and doctor. Probably the best thing to do is to have an impartial, official translator at hand. I know this is not always possible, and sometimes family members or friends need to translate. One caveat to this is that in some cultures, a translating family member may deliberately keep information from the sick patient--for instance, sometimes grown-up children feel that it is their duty to protect their elderly parents from serious news such as newly diagnosed cancer or other terminal disease. If they are translating for their parent, how would the physician know if they gave the correct dx and prognosis, or changed it in order to fulfill their duty of protecting their loved one from devastating news? Or consider the opposite situation--a patient does not wish anyone in their family to know what is going on with them medically, but needs a family member to translate because of lack of official translators, translator phones, etc. Remember that in accordance to HIPPA, we cannot let family members know a patient's medical status without their permission. But here, a patient may feel forced to use a family member for translation, whether they feel comfortable or not, in order to have proper medical treatment.

Also, in our country, the patient has the right to make the final decision on their treatment after a doctor has given them treatment options, with pros and cons to each. If a doctor cannot communicate with a patient, how can he give them this information? And how can the patient make an informed, educated decision? It is not possible.

In some community offices I have worked at, we have had access to translation phones/translation lines, which was very helpful. I think that if some clinics/offices cannot have physical translators present, that subscribing to a translation line is a good alternative.

Finally, even if a physician cannot speak the same language as the patient, and is relying on an interpreter, the physician is still capable of establishing good rapport and a positive environment with non-verbal communication, such as: smiling at the patient and shaking their hand when entering the room, sitting down across from the patient, maintaining eye contact with the patient (NOT the translator) when asking questions and also keep eye contact when the patient is talking. These gestures show respect towards the patients and let them know that the doctor cares about their medical problems.

I can definitely relate to the general frustration in being unable to speak with our patients personally. I have been fortunate to work with many residents and attendings that were fluent in other languages and I have noticed a certain ease these patient have when they are in the presence of these health professionals verses the interaction that occurs between patients who must use the blue phone. Although the blue phone is often a much needed resource, I definitely feel that something gets lost in the whisper down the lane. With the growing population of non-english speaking people in our country, I feel that this should prompt many of the health professionals in our country to make the extra effort and become fluent in the languages that are prevalent in their own patient population.

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