Caring for Hispanic patients who speak little or no English can be a challenge. Practices must rely ideally on either professional interpreters, whose services can be costly, or bilingual staff members, who can be difficult to find but effective if trained to fill that role.
Last year, we practiced in separate community health centers in an inner city neighborhood with a rapidly growing Hispanic patient population. While our clinics belonged to different health care delivery systems, we both encountered the same challenge: finding and training bilingual staff members who could help us create a welcoming environment in which non-English-speaking patients would feel comfortable disclosing their personal information. Based on our experience, we offer the following suggestions for making the most effective use of bilingual staff interpreters. Keep in mind, however, that some states have laws about who can perform medical interpretation. Before you ask a bilingual staff member for help, check with your state health officials.
Bilingual staff members can be taught to provide interpretation services when professional interpreters are not feasible.
To enhance communication, the staff member should use the universal form of the language being interpreted whenever possible and avoid regional words or dialects.
The interpreting staff member should refrain from participating in the conversation and instead encourage discussion between the patient and physician.
Eight rules for interpreters
Most bilingual staff members have not been trained to provide interpretation services. To help them fulfill this role, you should encourage them to seek training in this area and to follow these general rules:
1. Use the universal form of the language whenever possible. Regional words and meanings may be confusing or misleading to patients, regardless of what language they speak. Many languages have a universal or “high” form of the language that is free of regional words and dialects and can be understood by native speakers from all regions. We found that using universal Spanish with our non-English-speaking Hispanic patients minimized confusion and increased comprehension. Using the universal form of the language is especially important when patients are from a different region or country than the staff member doing the interpreting.
2. Refrain from assuming the role of interviewer or decision maker. Instead, the staff member should encourage and help maintain conversation between the physician and patient. In our clinic neighborhood, a significant part of the population speaks only a rare dialect of Burmese. When a member of that community needed health care, there was only one person in our area who spoke both that dialect and English. He would come with the patient to translate. It was evident, however, that this man was making decisions and filtering information that he translated. For example, a patient was asked, “Do you smoke?” and the interpreter answered, “No,” without saying a word to the patient.
However, the patient obviously understood some English and began moving his hand back and forth to his mouth, nodding “yes” to the contrary.
3. Let the patient lead the discussion. In general, it is best to let the patient direct the flow of conversation. The staff member doing the interpreting should refrain from interrupting the patient, other than asking him or her to slow down or pause for a moment for the interpreter to bring the physician into the conversation. The interpreter should encourage the patient to bring up topics of concern in the order the patient chooses. By allowing the patient to start the encounter with the topic of his or her choice, the interpreter helps to center the encounter around the patient’s needs. If during the encounter the patient changes the topic, the interpreter should be careful not to ignore the patient’s comments. Additionally, at the end of each segment of the history, the interpreter should ask the patient if there is anything else he or she would like to discuss with the physician.
If the patient expresses his or her opinion, the interpreter should translate it exactly to the physician, even if the interpreter doesn’t agree with it. If the physician asks the patient to make a decision about something, the interpreter shouldn’t try to influence that decision.
4. Translate everything. Extra conversation between the interpreting staff member and the patient or physician that is not interpreted to the other party can lead to miscommunication and subsequent errors. The interpreter may need to ask the patient or physician to clarify what he or she is saying so that the interpreter understands the context of the conversation. Conveying the content of what was said does not necessarily require word-for-word translation. However, if the interpreter doesn’t relay all of the information from the patient to the physician and vice versa, then the lost information can lead to medical errors. The interpreter needs to convey everything that was said without additions, deletions or changes to the meaning.
5. Be aware of culturally significant issues that affect patient care, and translate in a way that conveys the cultural framework. The staff member doing the interpreting should try to explain things to the patient and the physician in a way that communicates the cultural context of the conversation. For example, a patient from a matriarchal culture might not want to take a certain medication because it would be costly and would not please his or her mother. Rather than assume that the physician understands the cultural context, the interpreter should translate that concern in such a way that the physician understands why the mother is a such an important figure to the patient.
6. Meet the patient prior to the medical encounter. Frequently patients don’t recognize that the staff member doing the interpreting is an integral part of their health care and they are uncomfortable sharing information with the interpreter. Gender differences can compound this discomfort. For example, we cared for a 39-year-old Hispanic man with painful lesions on his buttocks. He stated at the initial visit that the lesions had been hurting for three weeks and had worsened to the point of intolerable pain when sitting or lying down. When questioned at the follow-up visit, the patient admitted that the lesions had been present intermittently for approximately nine years, with two exacerbations of symptoms in the last four years. He was subsequently diagnosed with perianal fistulas and referred for surgical evaluation and treatment. When asked what kept him from sharing this information initially, he answered that he was uncomfortable disclosing this information to a female interpreter. Instead of volunteering information, he answered only the exact questions asked. In hindsight, having the patient meet the staff person prior to the medical encounter would have given the staff member an opportunity to formalize his or her role in the patient’s health care and might may have made him more comfortable.
The patient handout, "Do I need an interpreter?", will help explain to your Spanish-speaking patients what they can expect when using an interpreter (an English translation is also included).
7. Develop interpreter-physician work plans for each patient. While the patient should be allowed to direct the topics of conversation, the physician and the staff member doing the interpreting should agree on the structure of the interaction prior to the visit. Having an individualized work plan increases your ability to identify and meet the needs and expectations of each patient. Developing these plans requires only a few minutes of discussion prior to entering the exam room. Take, for example, a patient with diabetes. Prior to the visit, a physician might tell the interpreter that he plans to begin by having the patient share any recent concerns related to her diabetes. Once those are addressed, he will then provide some counseling. However, the patient has a history of noncompliance because she often doesn’t have enough money to purchase her medication. If this is the case today, the physician explains that they will drop the planned visit structure and will instead spend the rest of the visit on getting her social assistance.
8. Seek continuing education. Even without formal interpretation training, bilingual staff members can learn to do many of the things mentioned in this article. To improve their interpretation skills, however, they should participate in educational programs, and physicians should encourage this. The Cross Cultural Health Care Program (http://www.xculture.org/index.cfm) offers a variety of educational resources. For a list of resources by state, visit the National Council on Interpreting in Health Care’s Web site at http://www.ncihc.org/hciaus.aspx. Ongoing training is important not only for increasing job satisfaction but also for improving quality of care and service within your practice.
WHAT IF YOU DON’T HAVE A BILINGUAL STAFF MEMBER?
A variety of resources are available to practices that don’t have bilingual staff. For example, community organizations sometimes have interpreters who can come to your clinic on an as-needed basis. Or, if you have a large non-English-speaking patient population, you may want to consider contracting with an outside interpreter service. (See “Getting the Most Out of Trained Language Interpreters,” FPM, June 2004, page 37.) Companies such as the ones listed below offer over-the-phone translator services for a per-minute fee. Many are available 24 hours a day, seven days a week.
Language Line Services (http://www.languageline.com) uses certified medical interpreters and offers telephone interpreter services in 150 languages for a per-minute fee. Telephone service is available 24 hours a day, seven days a week.
Langua Tutor (http://www.languatutor.com) offers telephone and on-site interpreter services and document translation in 25 languages.
1-800-Translate (http://www.1-800-translate.com/medical.html) offers fee-for-service telephone, online interpreting and document translation services in 148 languages. Translators are trained in clinical terminology. Telephone service is available 24 hours a day, seven days a week.
The above services are preferable to using a patient’s family member or friend as an interpreter because they remain more objective. When friends or family members are used as interpreters, the patient may not be as forthcoming about his or her behavior, symptoms or concerns.
In addition, we don’t recommend that patients use their child to interpret for them. Children often don’t understand medical terminology and will substitute these terms with words that they are more familiar with but that might not be correct. Children can also become fearful for their parents and may filter information to try to protect them.