Clinical:Case Study: Speaking through Translation

Original materials created in October 2000 by Francesca Taylor, M.D.

History

AB is a 56 year old married Latina woman, who presents for follow up and well-woman care. She has limited English proficiency (LEP) and has brought her sister-in-law to help translate.

Dr. CD is the resident physician seeing AB, and speaks limited Spanish. Dr. CD has requested interpretation services from me to conduct the interview.

We both enter the exam room where AB is seated next to her sister-in-law. I seat myself midway between the doctor and AB, and introductions are made. Dr. CD begins by stating: “Please ask if she has any particular problems she wants to discuss today,” and looks at me while speaking.

I remind Dr. CD to speak directly to the patient and talk as though she were speaking without any need for translation, and that I will translate in consecutive fashion. This acknowledged, she begins again, facing and addressing AB. AB responds, stating that she is somewhat concerned about the results of a recent mammogram, but otherwise has no current complaints.

Dr. CD asks several standard OB/GYN history questions: How many pregnancies have you had? How many living children? Have you ever had an abortion or a miscarriage? and others. I translate each question and answer, and I notice that as I translate the term “aborto” (Spanish for “abortion”), AB’s facial expression changes, looking vaguely distressed. She replies no, and the interview continues.

Her concerns regarding the mammogram stem from a letter she received from the clinic advising her to have a breast ultrasound. The letter was written in Spanish but she desires a more full explanation. Dr. CD explains that the mammogram result was a Category 0, which meant that a final result was pending. An ultrasound was being recommended because a mass was seen in the right breast on the mammogram, and it was felt that an ultrasound study would be the next best step to figure out what the mass is.

Dr. CD pauses to flip through AB’s chart, and notes that a mammogram done a year ago had been read as Category III, i.e., for a six –month interval follow up, and then asked the patient whether she had kept the appointment given her. At this point AB and her sister-in-law begin speaking to one another in Spanish. I understand this conversation, which contains information about AB’s beliefs regarding breast cancer, and stop them, indicating to Dr. CD to proceed. With further questioning by Dr. CD, AB reveals that she did not get the repeat mammogram because, even though she could feel a lump herself, she thought that it had to be painful to be cancer. This last passage of the conversation was arduous as AB’s sister-in-law interrupted repeatedly, in both languages, making the communication confusing

Dr. CD gently and respectfully requested that AB’s sister-in-law leave the exam room and wait for AB in the waiting room. AB echoed the same to her sister-in-law, noting that the interpretation being provided was adequate.

After the sister-in-law left, Dr. CD performed a partial physical exam for AB, beginning with a breast exam. During the exam, AB looked at me worriedly and asked if she could “tell something to the doctor”. I indicated yes, and instructed her to speak directly to the doctor. AB told the doctor then that she actually had had an abortion years ago, but hesitated to reveal this in front of her sister-in-law. Dr. CD assured her that it was understandable that she might wish to keep such information confidential, that a patient’s medical history is generally confidential and expressed regret that she hadn’t established that in the beginning.

After the exam was concluded, plans for ultrasonography and follow up were made and clarified. Both Dr. CD and AB were grateful for the translation service I provided

Discussion

Relationship between patient and physician/provider

The medical literature is replete with affirmations for enhanced doctor-patient communication and patient confidentiality as well as appropriate inclusion of family/significant others. Lack of translation services is a threat to these values. As women continue to be greater users of health services, and frequently seek care for highly personal concerns, sensitive and accurate translation is becoming recognized as critical in women’s health care.

Ad Hoc Translators

As in the case of AB, many patients with LEP bring family/friends as translators, and often these ad hoc assistants are quite valuable in a system that does not guarantee qualified interpretation services. They are usually not trained formally however, and may engage in disorderly cross conversations, as well as make outright errors (1). Problems of confidentiality exist also, as seen above.

How Physicians/Providers Actually Utilize Interpreters

Providers themselves often need instruction in the use of interpreters. The physician should develop a seating pattern that keeps the conversation between the physician and the patient. Physicians should speak to patients directly rather that “telling” the translator to “tell” the patient something. The patient should be similarly oriented at the outset. Physicians also must never expect translators to “explain” items the patient doesn’t understand. The interpreter’s responsibility is to translate any explanations the physician gives to the patient.

Because translation services are lacking, many providers speaking with limited proficiency in the patient’s native language. The danger of error is high as providers often grasp at cognate terms that may not always be accurate. While it is desirable for providers to be bilingual, a qualified interpreter is often better than a partially proficient provider

Translating perceptions as well as language

Clarifying patients’ perceptions is always important, particularly when speaking through translation. It has been show that patients with LEP are less likely to understand their diagnoses, special instructions and plans for follow-up care (2). In AB’s case, it was not clear that she had received adequately translated instructions regarding her first mammogram.

In Summary

Many challenges arise in medical interpretation. These include preserving the patientprovider relationship, avoiding ad hoc translation, assuring efficacious use of translators by providers, and more. More complex problems occur with interpretation of non-verbal communication, translation of consent forms and other written materials for patients with limited literacy in any language, and group translation such as for family conferences. The highest pressure situations call for the best possible translation: interpreting emergency decisions and translating instructions/ expressing sympathy in situations such as a labor room and others.

As women are greater consumers of health care, they more frequently need and utilize interpretation services. It will behoove our society to make a more firm commitment to providing quality interpretation more reliably.

References

1. Woloshin S, Bickell N, “Language Barriers Medicine in the United States”, Journal of the American Medical Association, March 1, 1995,Vol 273, No. 9 pp.724-728.
2. Betancourt J, Jacobs E. “Language Barriers to Informed Consent and Confidentiality: The Impact on Women’s Health” Journal of the American Medical Women’s Association, Fall, 2000, Vol 55, No. 5, pp.294-295.