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Learning to communicate with all your patients

Hiring interpreters—and other tips—to work with patients who are deaf or don't speak English

From the November 1997 ACP Observer, copyright Š 1997 by the American College of Physicians.

By Christine Kuehn Kelly

As medicine becomes more complex, communication skills are critical. Yet in today's polyglot society, it's becoming increasingly likely that you'll have patients who can't understand your questions or can't hear your instructions.

Consider the statistics. Ethnic minorities account for nearly 25% of the U.S. population, with the Spanish-speaking population growing most quickly. In addition, more than 350,000 people described themselves as deaf in the latest research on the topic. Include varying degrees of hearing impairment, and the deaf community easily reaches 20 million.

For physicians, these figures add up to one thing: To properly care for patients who can't communicate with you, you'll need to learn to use interpreters and other methods of communication. While you are not legally required to communicate with patients who don't speak English, working with the deaf is a different story. The Americans with Disabilities Act (ADA) requires physicians to provide auxiliary aids and services so they can effectively communicate with deaf and hearing-impaired people, as well as the deaf family members of patients.

Advocates for the hearing impaired, however, say that health care is doing only a mediocre job of complying with the law. "The ADA was enacted seven years ago, and there still are problems," said Laura Rovner, staff attorney for The National Association of the Deaf Law Center. In one egregious instance, she recalled, a deaf patient wasn't told that his leg had been amputated until four days after the surgery. While many instances of neglect occur in a hospital setting, Ms. Rovner noted, private practitioners have also been sued and settled for monetary damages over their treatment of hearing-impaired patients.

One solution to better communicate with both hearing-impaired and non-English speaking patients is to use professional interpreters. Experts point out that family members or friends of the patient willing to interpret may not be qualified to interpret medical concepts and terminology; they are also unlikely to meet ADA requirements that information be interpreted competently.

Family and friends who serve as interpreters, for example, may shield patients from important information or may add their own comments. In addition, patients may be reluctant to communicate sensitive medical information in the presence of a non-professional interpreter, particularly if the person is a daughter or son. Patients may also have concerns about confidentiality if the interpreter is a friend or volunteer from the community.

What about deaf patients who can read lips? Experts say it's still best to bring in a professional and not rely on the patient's lip-reading skills. "Only 30% of English sounds are visible on the lips," said Steve Barnett, MD, clinical sciences instructor, University of Rochester School of Medicine. In addition, patients who were born bilaterally deaf are likely to have learned sign language—usually American Sign Language—which is not based on English and uses a different sentence structure, grammar and syntax.

Working with the deaf poses other challenges. "There's an important issue at stake when doctors use interpreters for the deaf," said Bonnie Weikel, executive director of the of El Paso Medical Society. She noted that while interpreters in her area charge $25 an hour, price is not the main issue. "Most doctors have been seeing patients all these years without a problem, but now deaf patients demand interpreters," she said. "The doctors feel like someone is intruding on their relationship with the patient."

One way to avoid the "triangular relationship" that can develop between doctor, patient and interpreter is to become competent in the languages of your patients, whether hearing impaired or non-English speaking. "The better you communicate with your minority patients, the better their outcomes," said Eliseo J. Perez-Stable, ACP Member, professor of medicine at University of California, San Francisco (UCSF). "Studies have shown that when the doctors of Hispanic patients communicated in Spanish, patients remembered more, followed advice better and adhered to medicine schedules."

Even if you don't speak other languages, you can still communicate effectively with your hearing-impaired and non-English speaking patients. Here are some ways to better serve these patients:

Formulate a plan. Contact a local ethnic group or organization for the deaf to find someone knowledgeable about patient communication. Use this person as a resource to develop a plan that includes office procedures to accommodate the hearing impaired and patients who don't speak English. This person can also help you come up with a list of interpreters.

Use a competent interpreter. The gold standard for interpreters for the deaf is certification by the Registry of Interpreters for the Deaf. Interpreters can also be trained by universities or organizations for the deaf.

Expect all interpreters—whether for hearing-impaired or non-English speaking patients—to follow these principles of interpreting: faithful rendering of the message, confidentiality and discretion in their ability to interpret in individual situations. While interpreters represent the patient, not the physician, you can still expect to have a comfortable working relationship.

According to Dr. Perez-Stable from UCSF, language interpreters also act as cultural interpreters and "may give added interpretation to what the patient reports." For example, when a Chinese patient reports he "has no fire," the interpreter should be able explain that the patient is saying that he lacks "energy."

Advertise your accommodations. "Put a sign in the waiting room to advise patients to contact the receptionist for interpreting services," said Ms. Rovner from The National Association of the Deaf Law Center. Stock the reception area with health care brochures and magazines in other languages. Get a special teletype phone—known as a TTY phone—so deaf patients can call your office and list your practice in the national directory of TTY numbers.

Learn the nuances of other cultures. "In general, the U.S. culture is more casual," according to Elaine Barron, MD, who practices in El Paso, Texas. "In the Latin culture, it rubs elderly patients the wrong way if you don't address them as 'doņa' or 'seņor.' " Great respect for the elderly also applies to many Asian cultures.

Satinder Swaroop, MD, a cardiologist who practices in Fountain Valley, Calif., sees patients of many ethnicities including Chinese, Japanese and Indonesians. "Generally speaking, most immigrant Asians are afraid of surgical procedures and wait until they are really sick [to get medical attention]," he said. "They also are likely to be using herbal or hot oil treatments, including those that increase the heart rate. It's important to inquire about alternative medicines, and to tell patients to stop taking medications that have the potential for drug interactions." Also, in recognition of the modesty of his female Muslim patients, Dr. Swaroop has a female staff member in the examination room with him during exams with those patients.

Communicating with the deaf has its own cultural nuances, according to the University of Rochester's Dr. Barnett. "Communication is vital to the deaf, so they don't want to miss any information," he said. "Many deaf people prefer the physician be up front with information. Whereas you might tell a hearing patient there is a 'spot' on his lungs, the deaf person usually prefers to be told it's adenocarcinoma."

Be actively involved. When working with patients who are either deaf or don't speak English, the primary rule is to look at the patient when communicating, experts stress. The translator is only a conduit through whom you address your questions and responses. Acquaint yourself with the interpreter before you see the patient and provide a list of questions you are likely to ask, or provide a medical history questionnaire to facilitate communication.

Translate frequently used materials into other languages. Dr. Barron, for example, had a Spanish-speaking neurologist translate the mental state exam her practice uses for Alzheimer's into Spanish. Patient instructions, as well as history and physical questionnaires, can also be translated. This saves time and helps ensure accuracy. Dr. Swaroop has special cards prepared for his non-English speaking hospitalized patients that list 15 common phrases like "I'm thirsty" or "Call my family" in the patient's language and in English.

Hire bilingual staff members. Hiring receptionists or nursing assistants who speak American Sign Language or a second language is a convenient way to have translating services readily available, but you need to know that they are competent. Try having potential employees interviewed by a native speaker of the language they claim to speak. While certification of proficiency from training programs shows a basic level of competence, you may also want to follow that up with your own written or oral exam. Expect to pay those who qualify more for their skills, Dr. Perez-Stable said.

Note on your charts if the patient is deaf or non-English speaking. This quickly advises staff to establish a contact person, because non-English speakers and the deaf may not read mailings written in English. "The patient usually doesn't volunteer this information," said Donna Walters, RN, deaf services program manager for the Baltimore Medical System. "You must ask for it."

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.


Six tips

Providing interpretation services without breaking the bank

When it comes to providing interpretation services, the financial burden is usually on physicians. But experts say that there are ways to lighten the load of improving communication with your patients.

1. Take advantage of tax credits. Tax credits are available for expenses you incur when accommodating your deaf or non-English speaking patients, according to the National Association of the Deaf. The Disabled Access Credit (Form 8826) provides annual tax credits equal to half the cost of interpreters, as long as total interpreting expenses exceed $250 per tax year. Interpreter expenses are also deductible as ordinary business expenses. Check with your accountant for more details.

2. Use interpreters from your local hospital. Douglas Smith, MD, president of the Alaska Medical Association, recalled that several years ago, a local organization for the deaf insisted that he use their interpreters at $100 an hour, more than the physician would be paid for the visit. Dr. Smith resolved the situation by arranging for local physicians to take patients to two local hospitals, which agreed to provide interpretation services at no charge.

3. Pick up the phone. For limited translating needs, AT&T language line services provide 24-hour phone interpretation in 140 languages. Charges start at $4.15 a minute.

4. Organize patient schedules. Interpreters certified by the Registry of Interpreters for the Deaf are paid for a minimum of two hours, so try to schedule your deaf patients in a single morning or afternoon to make better use of the interpreter's time—and your money.

5. Anticipate translation needs. "If a patient is going for a sigmoidoscopy, you need an interpreter," said David A. Ebert, ACP Member, assistant professor of clinical medicine at the University of Illinois Medical Center. "If the patient will be returning for a blood work-up, take the time to explain the second procedure with the interpreter present. When the patient comes back for the phlebotomy, you won't need to provide the interpreter service again."

6. Get HMOs to help pay for the service. For example, Columbine Medical Group in Denver is a 2,200 member independent practice association (IPA) that provides free interpretive services to all physicians in the area, not just IPA members. The IPA and area HMOs split the costs to make the services available to any physician who needs the services. The project was developed with the support of a local organization for the deaf.


Interpreters: a resource list

Here are some resources for working with hearing-impaired and non-English speaking patients:

  • "Cross Cultural Communication" is a video that demonstrates how to work with translators. The video is produced by the University of Arizona, Tucson, and available by calling Matilda Sandefur at 520-626-7343.
  • AT&T language interpretation services start at $4.15 a minute. Information: 800-628-8486.
  • The National Association of the Deaf Law Center offers details on physician's legal responsibilities for providing interpreters. Information: 301-587-7730.
  • The Registry of Interpreters for the Deaf Inc. educates, certifies and provides continuing education for interpreters. Information: 301-608-0050.
  • Self Help for Hard of Hearing People Inc. offers a medical staff training video, "I Only Hear You When I See Your Face," a brochure titled "Patients with Hearing Loss" and tips for staff. Information: 7910 Woodmont Ave., Suite 1200, Bethesda, Md. 20814.

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