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By Dr. David Scales
When I met Mr. Y., he was sitting up in bed, sweating and breathing quickly. An elderly, Russian-speaking man, he was admitted to the cardiology ward at a large hospital where I was working. His blood pressure was dangerously high and he struggled to breathe. His fear was instantly apparent in his wide blue eyes. Panting, he told us that he had liver pain, pointing to just below the ribs on his right side.
It’s unusual for patients to complain about liver pain. In broken English, Mr. Y. explained that it began after starting new blood pressure medications a few months ago. But his chest X-ray told a different story. His lungs were drowning in fluid — the likely reason why he was so out of breath — and that couldn’t have been caused by the medications he was so worried about. Having already perused his laboratory results, his condition seemed like a straightforward case of heart failure, but I quickly realized admitting Mr. Y. would be linguistically and culturally complex.
I needed to understand what made him so short of breath, and why he thought his medications caused the problem. But no in-person interpreter was available for another hour and a half. The telephone interpreting service at this hospital was designed to be accessible — the interpreter can be paged from any hospital telephone and should call back. Yet, no one had called back after my two attempts. I imagined they were busy interpreting for other patients. In the meantime, Mr. Y. continued to pant and sweat, leaning forward in bed to help his breathing.
Reluctantly, I asked his adult daughter if she would interpret for me. She agreed, but was clearly reticent; her hesitance and discomfort apparent as she stumbled over questions about her father’s recent urinary and bowel habits. While I speak no Russian, I became suspicious of misunderstandings when she interpreted my question about previous “heart failure” as “infarkt,” which sounds like a medical term for a heart attack.
"Family members may struggle to interpret accurately when family or cultural expectations are upset by medically routine, but personally embarrassing questions."
I know of studies showing patients suffer when clinicians do not use interpreters or use untrained, informal interpreters like family members. I learned this during medical interpreter training and in my own experience volunteering as an Arabic interpreter with Iraqi refugees in New Haven and Syrian refugees in Jordan. As was the case with Mr. Y.’s daughter, family members may struggle to interpret accurately when family or cultural expectations are upset by medically routine, but personally embarrassing questions.
As a trained interpreter myself, it is painful and frustrating when good interpreter services are not available. But it isn't just a dearth of interpreters — it's also a lack of time that presents challenges to providing good care to non-English speakers. If I had a leisurely day I could have waited or returned, but on an adrenaline-fueled day on call, waiting for the interpreter was not possible. I had to balance my limited time with Mr. Y. against preparing for the three other patients I expected to be admitted at any minute. Worried this would be my only chance to hear his story, I put my interpreter training aside.
Long waits for in-person interpreters, an unreliable telephone interpreting system and the pressure of three other sick patients waiting to be admitted put both my resident and me in the uncomfortable position of just “getting by.” I had enough information to treat his illness but not enough time to understand how he connected his liver pain to his new medications.
Interpreters are easier to obtain with better technology. One analysis points out that physicians tend not to use interpreters much in the system I was using. It's where the patient speaks to the interpreter over the phone then passes the phone to the physician for interpretation. Advancements in technology to two handsets and videophones now bring the telephone interpreter into the room with my patients and me. Some studies show these technological improvements have increased the use of interpreters by physicians. In one small study, placing a dual-handset phone at every patient’s bedside led to a fourfold increase in the use of telephone interpreter services without a decline in demand for in-person services.
In my case, better technology would have helped. But the busy day with high patient numbers also contributed to my rush. On any given day, I divide my time between different patients, prioritizing to care for the sickest among them. On admitting days, I have more patients who tend to be sicker, raising the stakes as I divide my time. Non-English-speaking patients force what feels like an “unfair” reprioritization — regardless of how sick they are a non-English speaking patient often requires significantly more of my time.
In a setting with such competing demands on time, I wonder if our hospitals are really set up to support high-quality of care for people with low English-speaking ability?
I have a colleague who recently relocated to a New Hampshire hospital, and recounted a particularly egregious example. An outside company determined that a doctor there should be able to see 1.8 patients per hour, meaning 24 patients a day. Even the basics of good care — talking to the patient, examining them, discussing the plan with them, coordinating care with nurses and specialists, writing notes, having a discussion with a family member — will take much longer than the allotted 33 minutes per patient. Add interpreting to the list, which often doubles the time it takes to see a patient, and it's no wonder patients with limited English proficiency receive worse care.
"I wonder if our hospitals are really set up to support high-quality of care for people with low English-speaking ability?"
At the small community hospital where I am usually based, I typically have a handful of patients. Rather than admit a wave of sick patients every fourth day, we admit a small number each day. As a result, I can usually find enough time to meet the linguistic needs of all my patients.
This is no accident. The administration of my community hospital has designed the hospital to cater to those of different cultures. Patient loads tend to be lower to allow more time, and there are portable videophones available on each floor and in the emergency room, making it easy to speak to the many patients who are Portuguese- or Haitian Creole-speaking immigrants. This helps explain how, despite being one of the smallest hospitals in the state, we have some of the highest numbers of interpretation sessions in Massachusetts (at least when the study was done in 2008). Our hospital recently received an award for treating high proportions of underserved patients. Perhaps there should be awards for institutions that go the extra mile (and provide commensurate funds) to free up nurses’ and doctors’ time to provide patient-centered care.
Of course, patient-centered care is expensive, as my hospital also has some of the highest cost-per-patient ratios in the state (and recently one of the largest budget deficits, too). Allowing doctors and nurses to see fewer patients and hiring interpreters is costly, putting an additional strain on hospital budgets even as they face the usual shortfalls.
Still, there are low-cost steps every hospital can take to make physicians more likely to access interpreters. One study found five key factors, including institutional commitment, investing in relatively inexpensive remote interpreter technologies like videophones, training clinicians in how to access interpreters, and supporting and certifying bilingual staff to function as interpreters.
We gave Mr. Y. medications to help him urinate out extra fluid and also drained the fluid around his lungs. He started to breathe more easily. The following day, my resident was able to obtain an in-person interpreter. We found out that Mr. Y. thought his new blood pressure medications were damaging his liver so he only took them intermittently. We reassured him that his liver tests were normal, explained his new symptoms of heart failure and emphasized the importance of his new medications in keeping fluid out of his lungs and helping him breathe.
A care transition team with a Russian-speaking pharmacist planned to follow him for 30 days outside the hospital. Ultimately, with a clearer understanding of his perspective and a good care plan for discharge, we were all able to breathe a little easier.
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