A Failure to Communicate: Caring for Patients with Limited English Proficiency

If modern connective technology is changing the face of contemporary medicine in the United States, then the nation’s shifting demographics are changing its voice as well. In 1990, approximately 31.8 million Americans spoke something other than English as their primary language; around 14 million had what is called limited English proficiency (LEP; defined as a limited ability to listen to, speak, read, and/or write in English). By the year 2000, the number of US residents with LEP had increased by 50%, to 21 million; 45% of turn-of-the-millennium Americans spoke one of more than 150 non-English languages at home.

Given that the percentage of healthcare providers who are fluent in 150+ languages is rather small, the result of these demographic changes is a constantly increasing proportion of patients who are unable to communicate clearly with their physicians, with consequent difficulties including reduced or nonexistent access to healthcare benefits and services (including

Medicare/Medicaid), the complication of the diagnostic process, reduced subjective satisfaction for all parties, and—potentially—the violation of the patient’s civil rights.

One solution for overcoming these challenges is to employ interpreters in the healthcare setting. However, haphazardly assigning interpreters with no medical training or knowledge apart from fluency in a particular language carries its own hazards. An interpreter who knows the language and dialect of a patient but isn’t comfortable or familiar with medical terminology in either English or the patient’s language may struggle to communicate key diagnostic questions or treatment instructions. An interpreter who doesn’t understand the patient’s cultural background may be unable to appropriately communicate the true meaning

behind the words spoken by either party.

Title VI

According to the American Academy of Family Practitioners, “addressing language barriers can influence medical outcomes by improving access and the quality of services provided, reducing medical errors, and increasing patient adherence with care regimens.” In many cases, it can also be a legal necessity, with roots dating back to the 1964 Civil Rights Act. From the Act’s Title VI, Section 601: No person in the United States shall, on the ground of race, color, or national origin, be excluded

from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.

Four decades of case law have confirmed an interpretation of this statute, under which providers receiving federal funds must make accommodations for patients with LEP. At minimum, says the US Office of Civil Rights (OCR), providers must make available language services at no cost; these services must be sufficient to “ensure that the LEP person is given adequate information, is able to understand the services and benefits available, and is able to receive those for which he or she is eligible.”

Programs attempting to comply with this provision—and violating Civil Rights legislation passed in 1964 is generally bad business and bad medicine whether or not one is receiving federal funds—are encouraged to conduct a thorough self-assessment, develop a written policy, and train staff on its execution. The OCR’s guidance on complying with Title VI offers advice on specific approaches to this problem, including the hiring of bilingual staff members, the use of contract interpreters or community volunteers, and the use of telephone interpreter lines like Language Line or CTS Language Link. The latter alternative may be particularly useful in providing rapid response. However, a telephone-based interpreter may not always be available (in case of equipment failure, for example) or may be unfamiliar with the terminology specific to a given practice; such services should never be relied upon as the only language-assistance option.

Also required under Title VI: the translation of written materials routinely provided to patients in English into all languages commonly encountered in regular practice. Specifically, compliant practices should translate all materials into languages spoken by 10% or 3,000 members of the likely patient population, translate vital materials (such as consent or benefit enrollment forms) into languages spoken by 5% or 1,000 members of the likely patient population,\ and provide notice in other languages of the right to receive competent oral translations.

From the Very Long Acronym Department On December 22, 2000, the Federal Register published a new set of national standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS), created by the US Department of Health and

Human Services’ Office of Minority Health (HHSOMH).

The HHS-OMH CLAS Standards (www.omhrc.

gov/assets/pdf/checked/executive.pdf) include three types of

standard: (1) Mandates, which are required for all recipients

of federal funds; (2) Guidelines, which accrediting

agencies are encouraged to adopt as standards; and (3)

Recommendations, which are considered strictly voluntary.

Of the CLAS Standards, four deal directly with the issue

of patients with LEP; all are mandates. These standards

(numbers 4-7) are quoted in the box below. The first

CLAS Standard summarizes the philosophy underlying the

entire group: Healthcare organizations should ensure that

patients/consumers receive from all staff members effective,

understandable, and respectful care that is provided

in a manner compatible with their cultural health beliefs

and practices and preferred language.

The OMH offers a practical guide to compliance with

the CLAS Standards, located online at www.omhrc.gov/

assets/pdf/checked/CLAS_a2z.pdf. Key recommendations are

summarized on the next page; readers are encouraged to

download the full guide for more.

• An initial self-audit is critical; providers are advised

to study the evolution of their own patient demographics

and attempt to forecast future changes.

Practices should assess whether they can handle

incoming telephone calls, whether diverse reading

materials in the waiting room are available, whether

signage describing office policy is translated, and

so forth. The AAFP website links to “I-Speak” language

flashcards, which allow quick identification of

the primary language of a patient.

• Institutions are advised to employ an on-staff interpreter

for each language group from which they see

10+ patients per day.

• Other language groups may be handled via medical

interpreters hired on an “as needed” basis, bilingual

staff members who are certified and have completed

specific training, or telephone services.

Issues and Solutions

The National Council on Interpretation in Health

Care (www.ncihc.org) is a multidisciplinary organization

whose mission is to “promote culturally competent

professional healthcare interpreting as a means to support

equal access to healthcare for individuals with

[LEP].” The Council addresses unresolved issues surrounding

the use of interpreters in a healthcare setting

in a series of working papers accessible through its

site. According to the paper “The Role of the Health

Care Interpreter,” by Maria-Paz Beltran Avery, PhD,

the most critical of these issues concerns the definition

and limitations of the interpreter’s role (www.ncihc.org/

NCIHC_PDF/TheRoleoftheHealthCareInterpreterAnEvolving

DialogueApril2001.pdf).

“If meaning rather than literal conversion is the

goal,” asks Avery, “should the interpreter also convey

the emotional tone and affective content of the message?”

Historically, the interpreter has focused on being a

mechanical operator, and providing straightforward interpretation

without editorializing; should the contemporary

interpreter instead serve as an advocate for patient rights?

Should the interpreter be considered a full member of the

healthcare team? “When I arrive and find that the family

is waiting and the doctor is not yet ready, I visit with [the

family] in the waiting room,” one community interpreter

told Avery. “This way I can learn many things about them...

it helps me do a better job when we meet with the doctor.”

Developing a relationship like this with the patient and

his/her family can enable the interpreter to provide true

“cultural translation,” assisting the doctor in understanding

the patient more clearly, as opposed to pure linguistic translation.

However, says Avery, this sort of assertive “cultural

brokering” can reduce the quality of the translation and

increase complications if not handled carefully.

Related problems are associated with the use of friends,

family, and minor children as interpreters in a pinch. The

OCR notes that the use of such persons could constitute a

breach of confidentiality. Moreover, “such untrained individuals

often [have] little or no understanding of medical

concepts or terminology,” says Avery. Meanwhile, many

patients may be uncomfortable discussing sensitive medical

matters around close family and be less than perfectly open

and honest as a result.

In the end, opines Avery, “the interpreter cannot

remain a passive, uninvolved party. There are times when,

because of the cultural distance between the parties, the

interpreter may have to serve as a cultural bridge. Fidelity

to meaning may require the use of metaphors as well as

negotiated explanations of concepts that do not necessarily

have matching referents in the other language.” At

the same time, interpreters must be carefully trained to

remain professional and provide effective translation first

and foremost.

Whatever the system’s final form, technology will certainly

play a key role in healthcare interpretation in the

years and decades to come. Already, some providers are

utilizing the dramatically increased document storage

capacity associated with electronic record-keeping and file

management to archive versions of key documents that

have been translated into a variety of languages.

Other groups are currently experimenting with a system

called Remote Simultaneous Medical Interpreting (RSMI).

Under RSMI, both patients and providers are equipped

with a wireless headset, which broadcasts the conversation

between the parties in real time to an offsite, well-trained

interpreter. The interpreter then provides simultaneous

translation of both ends of the conversation; since the

interpreter is not required to travel to each participating

facility, this practice speeds the transaction considerably

and allows multi-facility providers to offer translation

services to all facilities from a central interpreter bank. To

read about an ongoing New York University study assessing

the value of RSMI in clinical practice, visit www.med.

nyu.edu/cih/language/index.html.

No diagnostic or treatment tool can achieve maximum

utility if all parties, provider and patient, fail to communicate.

Most estimates suggest that the US patient population

will only become more diverse in years to come, with

LEP individuals representing an ever-larger proportion of

most practice’s client bases. The establishment of a systematic

approach to interpretation/translation, according to

the guidelines described in this article, is a key component

in the provision of compliant and effective care. â– 

Frank Ferrara is a freelance healthcare journalist and

former MDNG editor.