Patient Lost in Translation

[Harold F. Schiffman]

>>From the New York Times, April 8, 2003

	When a Patient Is Lost in the Translation

By ERIN N. MARCUS, M.D.

     MIAMI, April 7 One afternoon, I was paged to see a man who had passed
out while waiting for an appointment. When I arrived, he was lying on his
back, awake and looking at the nurses and medical staff bustling around
him. "Are you having chest pains?" I asked. He looked at me directly but
did not say anything. I repeated my question in Spanish and French and
tapped my hands on my chest to illustrate. Still no answer.

"I speak Creole!" said a well-dressed woman who jumped up from her seat.
She said something to the man, who answered her immediately. Over the next
five minutes, this woman, a fellow patient who had never met the man
before, proceeded to help us extract vital information that guided our
treatment. We found out that the man was 54, was feeling chest pressure
and palpitations, and had not taken his heart medicines or diabetes pills
for a week because he could not afford them.  Several minutes later,
paramedics arrived and took the man to an emergency room.

In the public clinics of Miami, where I often work, many patients speak
Spanish or Haitian Creole. Though many doctors and nurses here speak
Spanish (though not always fluently), very few know Creole, a language
with French, African and Spanish influences. Communication problems
between doctors and patients who speak different languages occur
nationwide. According to the 2000 United States census, 19 million people
have limited proficiency in English.

As a medical student in Massachusetts a dozen years ago, I remember
pediatricians who struggled to explain an emergency procedure to a young
Spanish-speaking mother and waited an interminably long time for an
interpreter to show up. Many hospitals and clinics hire interpreters. But
because of their workloads, physicians often resort to having family
members or hospital workers translate, instead of waiting the 30 or 40
minutes it may take for an official interpreter to arrive.

A recent study in the journal Pediatrics says that translation errors are
common and can be dangerous. Dr. Glenn Flores and colleagues at the
Medical College of Wisconsin and Boston University examined the
transcripts of 13 audiotaped visits of Spanish speaking patients to a
pediatrics clinic. Six encounters involved an official hospital
interpreter; seven involved an "ad hoc" interpreter like a nurse, social
worker, or, in one case, an 11-year-old sibling.

The official interpreters made 231 errors; 53 percent of them were judged
to have the potential to cause clinical problems. The ad hoc interpreters
made 165 errors, and 77 percent of them were potentially dangerous. Some
errors included the interpreters' omitting questions about drug allergies,
telling a parent to put a steroid cream on an infant's entire body
(instead of just the face), telling a mother to give an antibiotic for two
days instead of 10, telling a mother to put an oral antibiotic into her
child's ears (instead of his mouth) for a middle-ear infection, and using
a Puerto Rican slang word for mumps, which a Central American mother could
not understand.

Interpreters sometimes also added comments, like telling a mother not to
answer the doctor's questions about sexually transmitted diseases or drug
use. Although the hospital interpreters' errors were significantly less
likely to cause problems than those of the ad hoc interpreters, the
authors wrote, "these findings support the conclusion that most hospital
interpreters do not receive adequate training."

Interpreter errors can also put hospitals and physicians in legal
jeopardy. In 1984, a 22-year-old man won a $71 million settlement after he
asserted that a group of paramedics, doctors and emergency room workers at
a South Florida hospital had misdiagnosed a brain clot. The patients'
relatives used the Spanish word "intoxicado" to describe his ailment. They
meant that he was nauseated, but the medical staff interpreted the word to
mean intoxicated, a valid meaning in some cultures, and treated him for a
drug overdose.

When an unofficial interpreter translates, patient confidentiality can be
a problem, and this month patient privacy laws become even stricter. More
money to train and hire interpreters may help. So will requiring medical
and nursing students to take Spanish, or the foreign language prevalent in
their regions. (Even though my adult-education Spanish is painful on the
ears, I can at least understand enough to make sure an interpreter is
giving the correct instructions.) The number of non-English-speaking
patients is not likely to drop anytime soon, and if we do not take steps
to improve the way we communicate, we are likely to continue to make
mistakes and to put our patients and ourselves at risk.