PT, Healthcare, and Language Diversity

Healthcare struggles to meet demands of an expanding multi-lingual population

There are approximately 6,703 living languages in the world today, according to a University of Pennsylvania linguistics department website. And likely every one of them has a way to say, "I'm sick." Check off the ones you recognize:

Estoy harto  -- Spanish

Ik ben ziek  -- Dutch

Jsem nemocnĂ˝ - Czech

Mimi na mgonjwa  -- Swahili

Ako sakit - Filipino

Jeg er syg  -- Danish

Je suis malade - French

Sto male - Italian

Mwen malad - Haitian Creole

Making the point is easy. But solving the problem of an ever-growing linguistic diversity throughout American healthcare is tough, particularly in a society where most inhabitants are mono-lingual.

Nevertheless, when a non-English speaking patient requires medical attention, language services must be provided by the medical provider. It's the law.  

"Virtually every healthcare facility is subject to Title VI of the Civil Rights Act of 1964," says Mara Youdelman, managing attorney of the National Health Law Program (NHeLP), Washington, DC, office. "Any provider taking federal funds - and therefore any hospital that participates in Medicaid or Medicare or takes research dollars from NIH or CDC - must comply and provide language services. Precisely what types of language services is determined by the hospital/providers."

Legal Linguistics

The law is clarified in HHS Office of Minority Health's National Standards on Culturally and Linguistically Appropriate Services. Some of those standards explain legal language service requirements for healthcare organizations. They include:

  • Interpreter services must be offered and provided to all patients with limited English proficiency during normal hours of operation, in a timely manner, and at no cost to them.
  • The availability of language services must be explained to patients in their language.
  • Professional interpreters and bilingual staff must be used to assure competenceHealthcare organizations must offer patient materials - consent forms or treatment instructions, for example -in languages most commonly encountered, and they must post signage in those languages.

Even with such clarifications, the best intentions of the law and providers do not always intersect. "We still hear lots of anecdotal information about patients being asked to bring their own - medically untrained -- individuals to interpret in hospitals," said Youdelman. "We hear about a janitorial or housekeeping staff being asked to step in and interpret. There are very specific skills needed to interpret that encompass more than being able to translate a few words. And then there are even clinicians who may be sufficiently bilingual for simple conversations, but not competent to provide services in a non-English language, often because they don't know medical terminology in a non-English language or have sufficient language proficiency for clinical encounters."

According to What's In a Word, a report from  the National Council on Interpreting in Healthcare, NHeLP and the  American Translators Association,  both translators and interpreters require advanced language proficiency, and must have the ability to capture nuances and idioms, as well as understand medical terminology.  But interpreters work primarily " in the moment ," with oral communication [as opposed to translators who work primarily from written text] "analyzing a spoken or signed message, and re-expressing that message faithfully, accurately and objectively in another language, taking the cultural and social context into account," according to the report.

Languages in the Field

Yolanda Cuevas, MAED, RN, RCP, is a Los Angeles Unified School District (LAUSD) Asthma Program lead. The LAUSD program, funded by the Merck Childhood Asthma Network, provides a comprehensive asthma program to students at risk for negative health and academic outcomes.

"It has been my experience that non-English speakers struggle to comprehend or benefit from information given to them by a healthcare provider," said Cuevas. "About a year ago a student was referred to us after frequent absences and frequent office visits to the school nurse, complaining of asthma symptoms. The student's parent was from the state of Oaxaca, Mexico, and spoke a dialect specific to that area. I realized during a home visit how difficult it was for this parent to understand what was being communicated to her in Spanish - which was her second language, and very limited."

LAUSD serves to provide a snapshot of the healthcare diversity within a single school district. The student population there, according to Cuevas, is 10% African American, .o4% American Indian, 3.9% Asian, 2.2% Filipino, 73.4% Latino, .4% Pacific Islander and 8.8% Caucasian. While the LAUSD Asthma Program recruits diverse asthma educators (approximately 71% Latinos, 22% African American) and covers the majority of their student population's ethnicity, some students will remain unrepresented.

Costs of Language Barriers

"NHeLP did a report on the high costs of language barriers on healthcare," said Youdelman. "We worked with a researcher at Berkeley and who in turn worked with a

malpractice carrier. The researcher investigated closed claims in which language was one of the issues. We found that about 2 ½%  of this carrier's claims involved language issues, and they resulted in $5 million in either settlements, legal fees or damages awards.

"Five patients lost their lives," detailed Youdelman, "and other patients have severe lifelong disabilities because of poor communication.  Some of that communication was the result of either not using an interpreter, or using providers who thought they had sufficient language knowledge -- and didn't. The result? Errors that led to significant clinical consequences and death."

While there is "no one size fits all solution" for medical interpretation, Youdelman also said," There is a variety of services available to healthcare facilities, for example  in-person interpreters on staff or from outside contractors who come in as needed, or telephonic or video interpreting offered by various companies. Usually they can provide 150 languages within a 30-second connection time."

Improve the Experience

Whichever language service you or your facility select, remember there are things you can do to make the experience more successful. The following tips are excerpted from "Using Medical Interpreters" by D. Hart, MD; J. Bowen, MD; R. DeJesus, PhD; A. Maldonado; and F. Jiwa, MD, and published by minnesotamedicine.com, April 2010. The authors suggest that you:

  • Allow enough time for the session. Allow for before- and after-session time with the interpreter.
  • Meet briefly with the interpreter before meeting with the patient. Go over any documents that will be used, discuss goals of the session.
  • Use appropriate seating arrangement. Sometimes it is best to place the interpreter to the side or slightly behind the patient so that you can maintain eye contact with the patient.
  • Speak to the patient, not to the interpreter.
  • Speak slowly and clearly in short sentences with appropriate pauses to allow for interpretation. 
  • Avoid jargon and technical terms
  • Confirm the patient's understanding by asking him to repeat key information back to you.

Valerie Neff Newitt is on staff at ADVANCE. Contact: vnewitt@advanceweb.com.


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