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Language Barriers Hamper Health Care Follow Law On Translation
Language Barriers Hamper Health Care
Non-English speakers find lack of fluency can hurt their ability to obtain quality treatment.
By Michelle Keller | Sentinel Staff Writer
July 16, 2005
Trying to speak above the cacophony of children playing and weary parents chatting, the receptionist at the Eastside Clinic calls out a name. José C. Cruz's face perks up.
Oh, no, the receptionist says to a frustrated Cruz, I didn't say your daughter's name yet.
Cruz, 37, who recently moved from Puerto Rico, often finds people in the States speak too quickly for him to catch every word with his limited English. Sometimes it's just an annoyance, but if the misunderstanding involves health care, the consequences can be serious.
When Dayanara, 12, finally is called and receives the shot she will need to attend school, Cruz's wife, Magaly, 31, wants to ask about side effects. But the nurse speaks no Spanish, so they walk away.
"Sometimes you get the feeling that they just don't care," José Cruz said in Spanish. "I've felt that with some Americans, if you don't speak English, they close up."
Limited English can be a barrier to getting medical care, researchers say.
"If you don't speak English well or at all, you are less likely to receive access to care or adequate communication when you actually enter into care," said Dr. Elizabeth Jacobs, assistant professor of medicine at Cook County Hospital and Rush Medical College in Chicago, who studies health disparities among minority groups.
Research by Jacobs and others has found that when people speak little or no English, they are less likely to receive screening tests or to be offered a follow-up visit -- and they are more likely to leave dissatisfied with their experience than those who speak English proficiently.
With more than 50 million American citizens and residents speaking a language other than English at home, regulators and health-care administrators are increasingly aware that language-assistance services are a necessity.
A series of federal laws and regulations requires hospitals and clinics participating in Medicare or Medicaid to provide language assistance to patients with limited English proficiency. Additionally, the U.S. Office of Civil Rights interprets lack of language-assistance services as a violation of civil-rights laws, which prohibit discrimination on the basis of race, color or national origin for any program receiving federal funds.
The laws are not specific, however, and medical-interpreting services can vary widely. Some hospitals and clinics use trained, certified interpreters or telephone language-assistance services, while others rely on bilingual or trilingual staff members -- anyone from a doctor to a receptionist -- to interpret for patients.
The Florida Hospital Group, which includes seven hospitals and 14 Centra Care walk-in clinics, uses outside agencies for medical-interpreter services, which include in-person interpreters and language-assistance services over the phone. Using staff members for interpretation is not encouraged, said Jean Aldridge, who coordinates interpreter services at the hospitals.
"I'm not saying that it never happens," Aldridge said. "We're working on educating all of our staff to know their limits."
Florida Hospital also is experimenting with video-conference equipment for interpretation use. When patients need immediate language assistance, they stand in front of a screen with a small telescoping camera attached, with a doctor at their side.
A trained medical interpreter receiving the image from another location appears on the screen and interprets for the doctor and patient. The service, called Deaf-Talk because it was developed for sign-language interpretation, is available only at the emergency department at the Orlando Hospital location.
Interpreters can be costly
Although trained medical interpreters are ideal, contracting independent agencies or having full-time interpreters on staff can be expensive. Services range from $25 to $60 per hour for an in-person interpreter service and up to $125 per hour for telephone language-assistance services, according to a report issued by the National Conference of State Legislatures.
Instead, many health providers opt for the next best thing: using staff members who speak the patient's language.
The Veterans Affairs Healthcare Center in Orlando maintains a list of bilingual staff members for use when an interpreter is needed, according to Barry Stanley, an administrative officer at the center.
"We have a very diverse staff at the VA," Stanley explained. "We have a Hispanic person on every primary-care team, so interpretation in Spanish has never been an issue."
While using a bilingual nurse, clerk or physician can often suffice, some researchers and medical professionals think that not using trained medical interpreters can be detrimental to patients and staff members.
"Interpreting is a highly cognitive task," Jacobs said. "You have no idea if someone tells you they speak a language, if they are fluent in both languages."
A study published in 2001 by researchers at the University of California at Irvine found that when bilingual nurses without medical-interpretation training served as interpreters for Spanish-speaking patients and their doctors, about half of the encounters resulted in serious miscommunication. The study, which video-recorded 21 medical encounters, found that bilingual nurses misstated information that affected the physician's understanding of the patient's symptoms or misrepresented the patient's concerns.
Staff can't help all
Clinics, such as the Eastside Clinic, run by the Orange County Health Department, also rely on bilingual or trilingual staff members to interpret. When language assistance is not immediately available, patients might have to wait or use their limited English skills during the appointment.
As one of the two Spanish-speaking nurses in the immunization clinic at the Central Clinic, Julia Brignoni, who recently moved from Puerto Rico, often helps patients who cannot speak English. Yet she cannot help every family that comes in -- there are simply too many patients who speak only Spanish.
"Sometimes the other nurses try to help out the patients [who need language assistance]," Brignoni said in Spanish. "But often their kids end up doing the interpreting. The kids help out so much because they learn English at school."
Others call upon family members who have been in the United States longer and have a better command of the language.
For example, Bertha Rueda, who recently moved to the United States from Nicaragua, sometimes relies on her sister-in-law Rosa Flores.
Flores, also from Nicaragua, has lived in the United States for 10 years and knows how to handle the mountains of paperwork. One rainy Tuesday afternoon, Flores, 29, accompanied Rueda, 28, to Central Clinic to get Rueda's daughter Madeline, 12, immunized for the school year. With Flores by her side, Rueda didn't need a bilingual nurse on this occasion.
But when Rueda comes to the clinic alone, she often has to wait until someone becomes available. On some days, Rueda said she has to return at another time if no bilingual nurses are present.
The worst came a few years ago, when her daughter Rosa, now 4, contracted meningitis when she was 3 months old. Rueda remembers feeling overwhelmed by the language barrier.
"I couldn't understand anything the doctors were saying," Rueda said in Spanish. "We would always have to wait for someone to finally arrive, someone who would speak Spanish. It was a very hard time."
Follow Law On Translation
Our position: Courts are a good model for hospitals and clinics in providing interpreters.
July 21, 2005
When it comes to health care, no patient's question should remain unanswered, no detail should be left to doubt. Yet, this is the case for thousands of elderly and low-income Central Floridians, many of them minorities, for whom English is a second language.
Many hospitals and clinics that accept Medicare and Medicaid patients do not provide adequate translation services, as required by federal law. Health professionals often grab the nearest bilingual employee to help translate without knowing that person's language proficiency, to say nothing of medical knowledge.
What patients understand is open to broad interpretation. And this can result in bad health care. Health providers need to comply conscientiously with the law.
They should follow the lead of Florida courts, which use language interpreters who must pass one of the toughest oral and written language exams around. That's as it should be, because defendants have a lot at stake in criminal proceedings, for instance. So, too, do patients.
The Florida Hospital Group gets it right by hiring an oustide firm for either in-person or telephone interpreter services for its network of seven hospitals and 14 walk-in clinics. And they correctly discourage using staff for translation purposes.
Translation services are expensive, but it's the best course to follow. Available staff may be a cheap alternative, but it also leaves hospitals and clinics legally vulnerable. To improve health care to minority poor and elderly, providers need to employ qualified language interpreters.