We're in!

He ended up quadriplegic... because something was lost in translation.

The patient came to the emergency room complaining about feeling sick to his stomach, but was treated for drug abuse due to the misinterpretation of a single word. This led to the patient's delayed care, preventable quadriplegia and a $71 million malpractice settlement. The delay in treatment resulted in rupture of a brain aneurysm.

An ad hoc interpreter told the mother of a seven-year old girl to put an oral antibiotic in the girl's ear to treat her middle ear infection.

A resident physician who interpreted a Spanish speaking mother's explanation that her daughter had "hit herself" when she fell off her tricycle assumed the fracture had resulted from abuse, and called the social services department who had the mother sign over custody of her two children.

These are just three of the many stories Dr. Glenn Flores, an expert on the issue of multicultural health care communication in the U.S., encountered in his research for an article published last July in the New England Journal of Medicine.

"No American should suffer from medical mistakes, preventable hospitalizations, and substandard medical care just because he or she doesn't speak English," says Dr. Flores, professor of pediatrics, epidemiology and health policy at the Medical College of Wisconsin, and director of the Center for Advancement of Underserved Children at the Medical College and Children's Hospital of Wisconsin.

Dr. Flores’ article highlights the many deleterious and sometimes tragic effects of language barriers on health and health care for these patients and emphasizes that the lack of effective communication also contributes to the high cost of healthcare.

Dr. Flores and other experts believe that the language barrier negatively impacts health care for many of the 50 million (19%) U.S. residents who do not speak English at home and the 22 million (8%) with limited English proficiency, according to U.S. Census data.

Video Medical Interpretation

A UCLA study shows that more than one third (34%) of HMO enrollees in California communicate at home in a language other than English or solely in another language. The same study found that in California, 4% of HMO members have limited English proficiency (LEP).

Since interpretation for LEP patients is mandatory based on Title VI of the Civil Rights Act, health care centers have solved this in many different ways, but as Dr. Flores study shows, ad hoc interpreters can do more harm than good.

Dr. Judith Wolfsy, Physician Director of the Highland Adult Medicine Clinic, part of Alamo County Medical Center (ACMC), in California, explained "our interpreters not only interpret the words. They interpret concepts allowing patients and providers to bridge gaps in communication and work as a team to improve our patients’ health and well-being. They are a key part of our rich diversity."

Until recently, interpreters used telephone interpretation and, when needed, they had to travel from one health care institution to another to be able to conduct face to face interpretations.

In recent years however, the need for interpretation, particularly for Spanish, has skyrocketed and become difficult to manage. Felicity Russell, who manages the Language Interpretation Services at Alameda County Medical Center (ACMC), which offers interpretation in 27 languages, says that "in the recent decade keeping up with the Spanish is a challenge."

Its solution, Video Medical Interpretation (VMI), allows patients, providers and interpreters to communicate through a screen. It has reduced the time needed for each interpretation and its cost. The system, pioneered among others by the UC Davis School of Medicine at University of California, is offered now to LEP patients whose native language is Spanish, Chinese, and Vietnamese among others. At ACMC, two thirds (65%) of all VMI interpretations are conducted between English and Spanish.

Targeting Health Disparities through Communication

The Office of Minority Health (OMH) has also played a pioneering role in the development of VMI. A $765,000 grant from OMH to the Alameda County Medical Center funded both a pilot program in telemedicine and the first stages of a project to provide interpretation services via video conferencing. Currently, VMI is offered in all ACMC clinics. The initial success led to expansion of the video conferencing medical interpretation program thanks to grants, from other sources, including the California Endowment.

Russell, from ACMC, says that OMH played a key role in initiating development of this project and she estimates that the amount granted by OMH has covered about 30% of the costs associated with the implementation of VMI services in the Alameda County’s health network.

Russell adds that "before video interpretation was available, the ACMC interpreters were tied up longer with each patient, and could not interpret for each and every visit."

Language is more than words, and we all can relate to the image of someone pointing to some part of her body to indicate where the pain is or how the pains travels down a leg. So, Russell emphasizes the benefit of the video interpretation system that allows the interpreter to actually see the gestures a patient uses to express his symptoms... saving the money and time of traveling from site to site.

In essence, Russell concludes, the availability of the VMI system allows for a faster service to the patient and a shorter visit; more accurate diagnosis and treatment in a cost effective way; and lower costs and multiplied benefits to entire health care networks by sharing interpretation resources.

San Joaquin Hospital and San Mateo Medical Center are two of the California hospitals that have implemented the VMI based partially on the ACMC project. Video Medical Interpretation is also used these days in other states. The Central Nebraska Area Health Education Center promotes the use of VMI through its website, informing of its availability in at least four hospitals in the area.

VMI’s benefis for the patients

A study by Cisco Systems, which provides video conferencing products, together with Tandberg, provider of video communications systems, found that at ACMC, the average request time for interpretation has been reduced from 37 minutes to 17 minutes with the use of the video translation stations and software. Russell of ACMC says that VMI "makes interpretation instantly available right when you need it."

Financial benefits

The statistics made available by Cisco Systems show that "using VMI technology could save approximately 40 hours per day, 2.6 hours per interpreter, and 14,500 hours per year." All this is equivalent to "seven full-time interpreters at a cost of more than $420,000."

Nevertheless, Russell asserts that experience shows "VMI is not always the preferred method. There is a large portion of interpretations done by phone in cases such as patients filling or renewing prescriptions or when the doctor and the patient know each other and need just a short interview."

Language Barriers Can Be Hazardous to Your Health

A Broken Heart Can’t Be Treated at the ER

"When this elderly woman was asked how she felt," Chu said, "she hit her chest and said ‘somtong’" which in Chinese literally means heartache. Chu explained that "faced with a patient with extreme high blood pressure who was hitting herself on the chest and looking very unhappy, doctors called a code and the patient was rushed to the Emergency Room."
At the ER, the patient was able to get an interpreter, where the patient explained that her physical heart did not hurt at all. She had a broken heart and was severely depressed. She had been describing feeling unwell and sad. "With VMI" Chu said, "the interpreter would be able to see and understand the culturally emotive gesture and appropriately interpret its meaning" which would have saved a lot of time and efforts to the health team in charge.

Dizzy or Paralyzed?

A 12-year-old Latino boy arrived at a Boston emergency department with dizziness and a headache. The patient, whom I'll call Raul, had limited proficiency in English; his mother spoke no English, and the attending physician spoke little Spanish. No medical interpreter was available, so Raul acted as his own interpreter. His mother described his symptoms:

"La semana pasada a el le dio mucho mareo y no tenía fiebre ni nada, y la familia por parte de papá todos padecen de diabetes." (Last week, he had a lot of dizziness, and he didn't have fever or anything, and his dad's family all suffer from diabetes.)

"Uh hum," replied the physician.

The mother went on. "A mí me da miedo porque el lo que estaba mareado, mareado, mareado y no tenía fiebre ni nada." (I'm scared because he's dizzy, dizzy, dizzy, and he didn't have fever or anything.)

Turning to Raul, the physician asked, "OK, so she's saying you look kind of yellow, is that what she's saying?"

Raul interpreted for his mother: "Es que si me vi amarillo?" (Is it that I looked yellow?)

"Estaba como mareado, como pálido" (You were like dizzy, like pale), his mother replied.

Raul turned back to the doctor. "Like I was like paralyzed, something like that," he said.

Story told by Dr. Glenn Flores in "Language Barriers to Health Care in the United States."

--
Sandra Bechan was a writer for the OMHRC. Comments? Email: Sandra M. Bechan.

Links

Flores, Glenn M.D. "Language Barriers to Health Care in the United States" New England Journal of Medicine. Volume 355:229-231. July 20, 2006. Number 3.

Cultural Competency at OMHRC
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=1&lvlID=3

Health Access Foundation
http://health-access.org/videomedint.htm