Speaking the Same Language: Medical Providers Struggle to Communicate With Immigrant Patients

Tue Apr 21 17:05:46 UTC 2009

Speaking the Same Language: Medical Providers Struggle to Communicate
With Immigrant Patients

By Eliza Barclay
Kaiser Health News
Tuesday, April 21, 2009

"Devil, devil," the man muttered.  Sabyasachi Kar, a doctor at
Washington Adventist Hospital in Takoma Park, shook his head in
bewilderment. He was examining a Spanish-speaking patient with the
help of a colleague who barely spoke the language, and he was getting
nowhere. "It was frustrating. I couldn't do my job," Kar recalled.
Only the next day, when he returned with a bilingual colleague, did
Kar learn the man had been saying he felt "debil," or weak. As
immigrant communities swell around the country, hospitals, clinics and
health-care providers are increasingly confronted with language and
cultural challenges that can discourage people from seeking care and
lead to calamitous errors in diagnoses and treatment regimens.

In the Washington area, a sharp rise of the foreign-born population in
the past two decades has been met by a patchwork response in the
medical field. Many area hospitals have taken steps such as installing
phones to connect patients and staff members to interpreters, hiring
interpreters or training employees to do the job, and recruiting
bilingual staff. But some large physician practices and small primary
and specialty care services have not added language or cultural
services.

"All providers in this area should . . . have a mechanism to deal with
language barriers," said Isabel van Isschot, director of
interpretation services at La Clinica del Pueblo in Washington, which
supplies interpreters to health facilities. When patients don't have
access to an interpreter, she said, "I think that's a form of
discrimination."

Hospitals and doctors, however, are wary of the cost of interpretation
services, which can run up to $190 an hour; they say the government,
not them, should pay these costs.

"Appropriate funding for these services is needed so that patients
don't lose access to care," said Joseph M. Heyman, chair of the board
of trustees of the American Medical Association, which has asserted in
policy statements that "physicians cannot be expected to provide and
fund . . . translation services for their patients."

A 45-year-old federal civil rights law requires hospitals and doctors
who accept federal funds to offer language services. Some federal
funding for interpretation services is available through Medicaid and
the Children's Health Insurance Program, state-run programs that serve
the poor and children, respectively. But to obtain the money, states
have to pitch in some of their own. The District and Virginia have
done so; Maryland has not.

California alone has put the funding burden on private insurers for
patients who have that coverage. Some other states are considering
similar legislation, but the issue is not a political priority in the
Washington area, advocates say, even though about 20 percent of
residents in the region are foreign-born, according to the Urban
Institute, a nonpartisan think tank. Some 110 languages are spoken
here, an analysis of 2000 Census data by the U.S. English Foundation
found, making the Washington area the sixth most linguistically
diverse urban area in the United States.

Though many immigrants speak enough English to get by in their
workplace, that may not be sufficient in the doctor's office, where
medical jargon and emotional reactions can cloud their ability to
communicate.

Norma Chinchilla, 26, a Honduran immigrant living in Silver Spring,
has been in the United States for four years but has not learned
English. Last year, she ran smack into the language barrier while
trying to make an appointment over the phone for her 2-year-old son.
When she reached an English-only operator at Children's National
Medical Center, the few English words she knew seemed to vaporize as
the impatience on the other end of the line grew. She hung up,
defeated and without an appointment.

"It has been very hard to get medical care for my son without speaking
English," Chinchilla said.

Paula Darte, public relations director for the center, says it does
have a language services office. "It's troubling that this person
didn't get through the right channels, because there's usually someone
around who speaks Spanish," she said.

Patients with limited or no English who do manage to obtain care can
still fall prey to miscommunication. In a 2006 study published in the
New England Journal of Medicine, Glenn Flores, now a professor of
pediatrics at the University of Texas Southwestern Medical Center at
Dallas, detailed several such cases. In one, a mother misunderstood
instructions and put oral antibiotics in a child's ears. In another, a
doctor not fluent in Spanish interpreted "she hit herself" as "I hit
her," resulting in a mother's losing custody of her children.

Some interpreters say medical staff sometimes are unsympathetic to
immigrants' needs. "There is a lot of prejudice and animosity," said
Rosemary Rodriguez, an interpreter in Richmond. "Nurses say to me,
'Why don't they learn English?' or 'I know she speaks English.' "

To address the language barrier, many area hospitals have installed an
array of options. Adventist HealthCare, the parent of Washington
Adventist Hospital, has provided medical interpretation and cultural
competency training to 150 of its bilingual nurses, janitors,
technicians and other staff members.

Kar, the physician who once found it frustrating trying to communicate
with Spanish-speakers, says he can now call in a trained bilingual
colleague for assistance. And if he has a patient who speaks a rare
language, such as Bulgarian, he uses a special phone to reach
professional interpreters.

Howard University Hospital has two full-time Spanish interpreters; one
full-time Amharic, Tigrinya and French interpreter for the Ethiopian,
Eritrean and French West African communities; and one full-time
Chinese interpreter.

They also interpret cultural differences. Azeb Abraham, Howard's
Amharic, Tigrinya and French interpreter, says some Ethiopian and
Eritrean women feel uncomfortable undressed in the presence of male
doctors, so she helps the doctors figure out how to examine the women
in a way that does not offend them.

Inova Fairfax Hospital in Falls Church has several full-time
interpreters and 700 staff members trained to interpret on the fly in
some 35 languages.

Alicia Ellis, one of Inova Fairfax's full-time medical interpreters,
recently got a call for help with a pregnant Nicaraguan woman
complaining of vaginal bleeding.

Ellis hurried into a labor and delivery ward to find Juana Varela, 36,
lying on her back, her ample belly protruding between the top and
bottom of her hospital gown. Ellis explained she was there to
interpret for Colleen Pineda, the nurse who would perform the
preliminary examination. Ellis began to speak for Varela: "I woke up
in the morning with pain and bleeding, and now I'm worried this birth
won't be normal."

"When did the pain begin?" Pineda asked in English. Ellis repeated the
question to Varela in Spanish, her eyes cast down to deflect attention
from herself and create a seamless link between doctor and patient.

Other health-care organizations have been slower to invest in
interpretation services. George Washington University Medical Faculty
Associates, a practice that sees about 4,600 patients per day (more
than five times the number treated at Inova Fairfax), has no full-time
staff interpreters but a few bilingual staff members. According to the
group's chief executive, Stephen Badger, "The cost of interpreters is
expensive and usually is greater than the payment we receive [from
Medicaid] for the health care actually provided."

Montgomery County provides professional medical interpreters to
clinics at no cost, according to Sonia Mora, manager of the Latino
Health Initiative at the county's Department of Health and Human
Services.

Mora says that there is still a tremendous need in immigrant
communities that is not being met and that providers who do have
capacity have a huge burden thrust on them. But, she says, she has
seen language services improve significantly in the last five years.
"Now we're starting to see that it's going to save us money, because
people are going to be healthier," she said.

This article was produced through a collaboration between The Post and
Kaiser Health News. KHN is a service of the Kaiser Family Foundation,
a nonpartisan health-care-policy research organization unaffiliated
with Kaiser Permanente. Comments: health at washpost.com.

http://www.washingtonpost.com/wp-dyn/content/article/2009/04/20/AR2009042002466.html

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