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  • Medical Translation in a City of Immigrants

    Submitted by joseph on Wed, 03/31/2010 - 12:56

    One out of four New Yorkers doesn't speak or understand complex sentences in English. But at some point in their lives, every one of them will need to see a doctor. Language barriers can result in misdiagnoses, medication errors, and potentially fatal mistakes that are costly for both patients and providers. For this reason, hospitals in New York are required to provide “meaningful language access” to all patients. But in a city where more than 140 different languages are spoken, this is no easy task.

    When Inocencia Nolasco landed in the Wycoff Hospital room with phlebitis, an inflammation of the veins, she knew exactly how she felt, but couldn’t explain it to anyone there.

    “When I arrived the doctor didn’t know Spanish. We didn’t understand each other, and finally I called a friend who could come and be my interpreter,” Nolasco says.

    Nolasco was lucky that she had a bilingual friend who could come to the hospital, but excruciating hours were wasted. “Time was passing and I was in pain. It was really horrible,” she says.

    Nolasco was in the ER a decade ago. Until quite recently it was common that patients had to wait for hours for language interpreters at hospitals. Dr. Danielle Ofri, an internist at Bellevue hospital in Manhattan, says it was a confidentiality nightmare ripe for miscommunication and error.

    “We rely on whoever is available, whether it’s a clerk who’s bilingual, a cousin, a six-year-old kid, an uncle in a taxi cab calling from their cell phone. There are so many things that are highly inappropriate, but we would do that,” Ofri remembers.

    In 2003, with immigration levels rising, health advocates began filing complaints against hospitals in the state attorney general’s office. They argued that without language services, immigrants couldn’t get equal medical care.

    Nisha Agarwal, an attorney with New York Lawyers for the Public Interest, says, “When language access isn’t provided, it’s like doing veterinary medicine, just guessing randomly what they needed to do instead of having a conversation with the patient.”

    In 2006, New York State passed regulations requiring all hospitals to provide free interpretation for patients within 10 minutes of arriving in the ER, and 20 minutes elsewhere in the hospital. The city has taken additional steps -- in 2008, Mayor Michael Bloomberg ordered all public hospitals to have a language access plan. This fall, major pharmacy chains were required to translate prescriptions into the top seven languages spoken in the city.

    Many hospitals now rely on telephone interpreters to be the crucial link between patients and doctors. By dialing a central number, within a minute doctors can be connected to someone who speaks one of 180 languages. Each room at Bellevue now has one of these special phones installed.

    One day recently, Dr. Ofri visits Tong Woo Lee, a Korean American patient who is isolated in a room at Bellevue. They speak to each other while holding telephones to their ears. Dr. Ofri wears a mask and she tries to maintain eye contact, but it’s difficult.

    “Can you tell me a little bit about when you first started to feel sick?” Ofri says into the phone, while looking at Lee. There’s a slight pause. Lee listens to the interpreter’s voice, and looks away. He responds in Korean. Line-by-line, their sentences are translated. The conversation takes twice as long as it would if they were speaking the same language.

    Through the telephone interpreter, Lee tells his doctor that he called an ambulance because his back hurt so much he couldn’t walk. He assumed it was because he had lifted something heavy. But Ofri tells him that he has a more serious problem -- an infection in his spine.

    On this day, Ofri has 20 patients to see, and can only spend a few minutes with each one. She tells Lee -- through the interpreter -- that he may have tuberculosis, which is why he’s in isolation with an IV in his arm, being subjected to tests.

    According to Ofri, the interpretation phone is much better than the old ad-hoc system of hoping there’s a native speaker nearby. But she still finds it a frustrating and awkward tool. Her bedside manner goes by the wayside because there’s no possibility of chitchat, and the interpreters speak in neutral voices that don’t always transmit her tone. Ofri is always worried that details about her patients are lost in translation.

    “I don’t always know what they’re saying and I think vice versa. It’s like speaking underwater; everything’s a little bit blurry. It’s the sensation that we’re doing pretty well, but I can’t be completely confident, and it’s frustrating and it’s frightening. I imagine it’s frightening for the patient. I’m nervous I’m going to miss something or do something wrong, but it’s also the best we can do,” she says.

    When a person walks into one of the city’s public hospitals now, they are greeted by signs with directions in 12 different languages. In fact, so many immigrants rely on Bellevue that it has become a leader in the interpretation field. Bellevue has built a remote simultaneous medical interpreting center for the hospital's top eight languages right on site, similar to the system used at the United Nations. On the fifth floor of Bellevue, 28 people are sitting at stations waiting for their phones to ring. They’re grouped by language. There’s an area for Spanish, Mandarin, Cantonese, Russian, Polish, Bengali, French, and Haitian Creole.

    Simultaneous interpretation means the workers translate each word as they hear it, so the two ends of the conversation don’t have to wait for each sentence to be repeated. The workers were trained to create the illusion that doctor and patient are speaking directly to each other.

    On average, this in-house system, called TEMIS (Technology Enhanced Medical Interpreting System) receives almost 6,500 calls a month, and more than half of them are for Spanish speakers.

    Walking through the cubicles, the eight languages mingle together, creating a cacophonic soundscape that mirrors the city’s diverse population.

    Evens Jean, a French and Haitian Creole interpreter who has language maps taped to the walls of his cubicle, says the stakes are high -- patients are essentially trusting their lives to his voice. And even using this innovative system, he knows there are communication gaps.

    "Not every single patient is going to see things from the American perspective, they come from their own culture with their own baggage, they have a way of seeing and understanding health care,” Jean says.

    In many cases -- for both doctors and patients -- cultural interpretation is equally important as word-for-word translation. Many interpreters report they hear patients saying yes, even when they don't really understand.

    Dr. Ofri, the internist at Bellevue, has seen this many times.

    “It's a different cultural experience to be at a doctor’s at other countries. So many of my patients are extremely respectful, they say yes to whatever I say no matter what. So I don’t know if they know what I’m saying and agree, or they have no idea what I’m saying and say yes because that’s what they’re supposed to say and be polite. So, yes can mean any one of a hundred things,” she says.

    That's why Ofri says it would be ideal if every immigrant patient could have a bilingual and a bicultural interpreter at the hospital. But she says that’s not realistic given the hospital’s budget. For her, the true connection often begins after she and her patient hang up the interpreter phones and the physical exam begins. It’s the age-old non-verbal conversation between a sick person and their healer.

    “When you touch someone, it’s an intimacy, an unromantic intimacy, but an intimacy nonetheless, and sometimes in that setting the patients can really tell you what’s going,” Ofri says. “So that’s when our connection is formed.”

    Bellevue hospital alone spends $2.5 million a year on interpreting. And Maribel Castillo, the hospital’s language access coordinator, says she sees the need rise each month. But Castillo maintains that even though the service costs the hospital a lot of money, it’s a necessity.

    “This kind of service helps the patient adhere to treatment and for them to get better, and that’s what ultimately matters the most,” Castillo says.

    But even with the hospital’s efforts, a 2008 survey by the New York Immigration Coalition and Make the Road New York showed that one out of five limited English proficiency patients in the city felt their medical care had been compromised by language barriers. Almost half said they wanted to ask a question but couldn’t.

    Theo Oshiro, director of health advocacy at Make the Road, says even if hospital administrators may understand the regulations, information about language services doesn’t always trickle down to caregivers, like nurses, aides, and receptionists with whom patients interact.

    “A lot of front-line staff have not been trained. [They] don’t know how to access the system of the hospital to get an interpreter quickly. Just a couple of years ago I was talking to a hospital resident, he was saying, ‘I can’t understand a lot of people at my hospital, I don’t know what they’re saying, I don’t know what their complaints are,’” Oshiro says.

    Advocates agree the 2006 language access regulations have had a big impact, like ending the practice of using bilingual children to interpret sensitive topics for their parents. But patients say the quality of interpretation still varies widely across the city. In September, the New York State Department of Health issued a citation to St. Barnabas in the Bronx because of its failure to provide an interpreter to a Spanish speaking patient.

    Nisha Agarwal, the attorney with New York Lawyers for the Public Interest, represented that patient in court. “She did not get an interpreter at all, and when she did get interpreters, in the hospital, it was usually somebody who had been pulled in from somewhere else who was actually not trained to be an interpreter. So half the time they couldn’t even do a good job,” Agarwal says.

    A good medical interpreter is much more than just bilingual. The interpreter must know medical terminology, and never insert her own opinions into the translation. But one problem is it’s up to the hospitals to train their own staff -- and to figure out how to pay the interpretation bills. Language access is an unfunded mandate in New York.

    “New York has been quite good in terms of language access issues. Our state regulations are very strong. Some of the ways New York has not been as much of a leader has been in terms of funding language services,” Agarwal says.

    The language of medicine is difficult to understand, even for native English speakers. The names of diseases, medication instructions, and general hospital systems are confusing, especially when people are worried about their health. When these issues are compounded by language and cultural barriers, many immigrants are lost and can't make informed health decisions. There's no question that language access in hospitals has improved since Inocencia Nolasco landed in an emergency room where no staff spoke Spanish. But hospital administrators across the city say the need for trained interpreters outweighs the supply. And with an ever-growing immigrant population, the need is getting acute.

    By: Sarah Kate Kramer (WNYC)

    To read more and to listen to this story visit: www.wnyc.org/news/articles/152532

  • Patient Interpreters Save Money, But Who Pays?

    Submitted by joseph on Wed, 03/31/2010 - 12:48

    At a Northern Virginia pediatric clinic, 1-year-old Katy is getting a checkup.

    As Dr. Hoda Bastani peers into her throat and eyes, Katy's mother, Myrna Mejia, looks on. Standing just behind her is Barbara Perez, one of 16 full-time medical interpreters for Inova Hospital, which runs this clinic.

    Under civil rights laws, health care providers who accept federal money must provide interpretation for patients who can't speak English. But the law doesn't compel the government or insurers to pay for that. As Congress debates a health care overhaul, medical providers are hoping that will change.

    Inova also has a contract with a company that offers phone interpretation in 176 languages. And it has trained hundreds of its own bilingual staff to help out as needed. Inova spends more than $1 million a year on medical interpretation and is something of a model.

    When You Have To Wait

    But this is by no means standard. Mejia found that out a few years ago. Her older son had an asthma attack, and Mejia took him to another hospital late one night.

    The hospital didn't have any interpreters on the overnight shift, she says. She had to wait four hours until someone who spoke Spanish showed up and could explain what was happening.

    "Every day there are thousands of patients whose English is not very good who have a faltering ability to talk to their doctor or nurse," says Leighton Ku, who teaches health policy at George Washington University.

    Ku says most insurance companies do not pay for medical interpreters, so many health care providers don't have them.

    "There's no serious monitoring or enforcement of the law," he says. "Clearly it's the nature of the health care system that health care providers work in response to payment."

    Horror Stories

    Often family members or friends are left to interpret. Ku says studies show that leads to confusion and medical error. Doctors order unnecessary tests, wasting money. Children can be scared when they have to interpret things like a parent's cancer diagnosis or the consent form for surgery. And then there is the list of horror stories kept by patient advocates like Mara Youdelman of the National Health Law Program.

    "There's one case that came out of Florida where an 18-year-old young man collapsed into a coma, and unfortunately paramedics and personnel in the emergency department never got an interpreter to speak with the man's girlfriend or mother," she says.

    They had told medical workers the man had been "intoxicado" — Spanish for nauseated. But emergency room staff took the word to mean "high on drugs." For 36 hours they treated him for suspected overdose.

    "And it was only after the 36 hours when there was no recovery that they started to do a neurological examination," she says. "In the meantime the young man suffered a severe subdural hematoma and was left quadriplegic."

    Response From The Federal Government

    A $71 million malpractice settlement in that case among others has prompted a push for more interpreters. But progress has been slow. Some federal matching funds are available to pay for interpretation through Medicaid and the Children's Health Insurance Program. But states have to put up their own money first, and Youdelman says only 14 states and Washington, D.C., have done so. Starting this year, California became the only state to require private insurers to pay for interpretation.

    One stumbling block may be that insurers often don't know who qualifies as a legitimate medical interpreter.

    "We want to make it convenient and accessible for all the interpreters everywhere in the United States to be tested, and in essence allow for us to have one single certification process that will recognize individuals as a CMI — certified medical interpreter — designation," says Louis Provenzano, who heads Language Line, one of the country's largest interpretation providers.

    The International Medical Interpreters Association estimates that right now, fewer than one-third of patients who need an interpreter get one. And with the country's changing demographics, that overwhelming demand is only expected to grow.

    By Jennifer Ludden (NPR)
    To read more and to listen to this story visit: www.npr.org/templates/story/story.php?storyId=111066555

  • Post Traumatic Stress Mess (Article from the ATA Chronicle)

    Submitted by joseph on Wed, 01/27/2010 - 10:49

    Featured Article from The ATA Chronicle (January 2010)

    Post Traumatic Stress Mess Or How I Learned to Stop Worrying and Love Medical Interpreters
    By Michael King

    The tricky thing about drawing a line in the sand is knowing how to respond when people start to test it. At least, this has been my experience recently when dealing with the complex issue of medical interpreters.

    About a year ago, I was hired to manage the behavioral health department of a system of clinics. Many of our patients speak Spanish, and until I arrived, the modus operandi had been for staff to ask family members or friends to accompany patients to interpret. If no such resource was available, the providers would request that a bilingual staff member facilitate communication. This was one of the first clinic practices I set out to change, but I never expected that the effort would take so long or that a final resolution of the issue would prove so challenging.

    Client Education Starts at Home:
    What I quickly realized as I began my work was that our clinic was far from the only one in our organization that approached medical interpreting in a less-than-ideal fashion. All clinics either used family members or, more often, enlisted the aide of a bilingual staff member, usually a medical assistant or nurse. Unfortunately, our behavioral health department had no medical assistants or nurses. Left with only front desk staff, those asked to interpret were persons who had no training in professional interpreting and no background in medical concepts or terminology.

    Coupled with the task of finding another source of medical interpreting was my obsessive desire to train staff to understand the difference between translation and interpreting. This is not as easy as you might think, and the resistance I encountered as I gently corrected people was nothing if not comical. Some psychiatrists resisted the distinction out of hand, not stopping to think that if a layperson confused him or her with a psychologist, we could all rest assured that the offending party would receive a prompt and thorough reeducation.
    I persisted in my pedantic ways and achieved mitigated success. For example, my supervisor at the time, who was bilingual, gave an interview last winter to the local affiliate of the Spanish television network Univision about the services we provide. The issue of interpreting came up briefly and she fumbled on the word, later telling me that this was the only time in the interview that her delivery was not pitch perfect. I smiled broadly. That’s one battle won, I thought to myself.

    Quality Versus Economics:
    In short shrift, I forbade front desk staff from interpreting and hired a local professional interpreter for all patients requiring language services in Spanish. The interpreter was extraordinarily gifted and maintained a mode of professionalism I admired. From my organization’s perspective, she was also quite expensive, charging a two-hour minimum that stood even if patients did not show for their appointments. I understood that this was justifiable—interpreters are paid for their time and our clinic is located some 20 miles from a large city center. I defended my decision by explaining this reality and pointing out that the needs of a behavioral health clinic are different from those of medical clinics. Given that our appointments last anywhere from 30 to 90 minutes, we could not reasonably pull support staff from their other duties and still manage workflow. I was allowed to continue hiring the interpreter, with the mutual understanding that this was a temporary measure and that we would work toward finding a more financially viable long-term solution.

    In the ensuing months, there were a few occasions I was called to interpret. Clinic staff would unwittingly schedule two patients who required interpreting services at the same time but with different providers, or they would forget to contact the interpreter. We had no contract for telephone interpreting and some of our providers were booked out as far as a month. Rather than tell patients who arrived for their appointments as expected and on time that they would have to reschedule, I offered my services with the disclaimer that I was not the interpreter we normally use, but would help facilitate communication.

    In the back of my head, I heard the voice of the famous doctor of the original Star Trek series: I’m a translator, damn it, not an interpreter!

    All in all, I performed much better than expected given my lack of formal training. But my brief interludes as an interpreter were not without incident. One day, the topic of post traumatic stress disorder arose. I interpreted the expression as desorden de estrés postraumático. Curious as to whether I had gotten it right, I consulted my Spanish dictionary when I returned to my office. Not bad, except that in Spanish trastorno is the word usually used for disorders of a medical nature, while desorden is more often used to connote the disorder as a mess or disarray. Post Traumatic Stress Mess…great! I shuddered internally, but consoled myself with the perspective that the error did not obscure the meaning of the communication. My foible, I told myself, was akin to the extraneous indefinite article that John F. Kennedy notoriously added to his 1963 Ich bin ein Berliner speech in West Berlin. Nonetheless, after this I doubled my efforts to ensure that the professional interpreter was always scheduled properly.

    One Small Step:
    As time passed, the pressure to find less costly methods of procuring interpreting services grew. I identified a local nonprofit organization that would train our bilingual staff to serve dual roles and would give them a base level of knowledge in interpreting methods, ethics, and legal issues. Although from an experiential standpoint this was not preferable to a professional interpreter, at least I could get the staff some measure of training. Alas, I was told that the course would be too expensive, especially in light of employee turnover and the certain need to train new staff continually.

    I consulted the organization that provides the instruction and was told that they could also provide staff members—presumably the more stable, long-term ones—with the training they would need to teach future interpreting classes internally. In response, I learned that dual-role interpreters, even untrained ones, presented a workflow challenge for my company. It appeared that our other service lines, which had continued to use their bilingual medical assistants and nurses, had been experiencing severe challenges in their ability to see patients promptly. Every time a medical assistant or nurse had to interpret for a doctor, that was one less member of the support staff available to take vitals or perform other essential duties. Every time a front desk staff member was pulled, one less person was available to check patients in or out or answer phone calls. The resources of the clinics were particularly strained when three or four patients required interpreting services at the same time. Something, I was told, had to give.

    Many good minds contributed their ideas on the issue and attempted to find a solution that was both appropriate for the standard of care and sustainable from a business perspective. That a solution was not readily apparent only underscored the enormous logistical challenge the issue presented.

    After performing a number of interpreting appointment time studies and pro forma financial analyses, clinic administrators focused on telephone interpreting as a potential answer. Several concerns with this approach were raised and answered, and our company resolved to conduct a pilot project in a small sample of clinics. I requested that behavioral health be included in this initial phase.

    Not long afterward, in a meeting with our behavioral health administrator and medical director, I was told that some of the physicians in other clinics were expressing resistance to the idea of using telephones to contact interpreters. Apparently, they were more than content to continue using their medical assistants and nurses. At word of this, the medical director chimed in. “Well, I’ve been practicing psychiatry for 20 years,” he declared, “and I’ve never had a problem with asking front desk staff to translate.” He paused, glanced in my direction, and amended, “…interpret.” Well, I thought, at least that’s progress.

    Tips on Advocating for Medical Interpreting:
    Are you unsure of how to approach your employer about the need for professional interpreting services where you work? Perhaps the following tips can help:

    Be persistent yet patient. Efforts to change institutional practices are long-term endeavors. Aim to educate first, and then work on practical solutions.

    Focus on practicality. In order to advocate successfully for a change in business practices, you have to demonstrate how your approach makes sense from the perspective of your organization’s business model. Provide clear and convincing evidence that the status quo is unacceptable.

    Understand the relationship between quality and cost. Or, as economists might say—there is no such thing as a free lunch. You can argue that all interpreters should be contracted from an organization that is ISO certified, but given the cost for this level of quality, what is the likelihood that your appeal will be taken seriously?

    Be willing to compromise and offer options. The quickest way to shut down a discussion is to insist that there is only one right way to resolve a challenge. Come to the table with options.

    Accept small victories. All progress is meaningful. If your organization began by asking the family members of patients to interpret and subsequently agreed to use only bilingual staff—even if untrained—treat this as a success.

    Maintain open dialogue. It is not always a bad sign if your organization does not act immediately on your suggestions. The most important goal is to keep avenues of communication open.

    Remember that both you and your organization want the same thing. In the final analysis, both you and your company want to provide high-quality care to patients. If your company disagrees with your proposed solutions to the issue of medical interpreting, investigate its concerns and work to resolve them.

    About the Author:
    Michael King translates from Spanish and Italian into English, specializing in the fields of business and law. He has worked in education, health care, and state government.