Posted on 07/25/2006 12:48:22 AM PDT by neverdem
A 12-year-old Latino boy arrived at a Boston emergency department with dizziness anda 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.
If Raul received inappropriate care owing to his misinterpretation, he would not be alone. One interpreter, mistranslating for a nurse practitioner, told the mother of a seven-year-old girl with otitis media to put (oral) amoxicillin "in the ears."1 In another case, a Spanish-speaking woman told a resident that her two-year-old had "hit herself" when she fell off her tricycle; the resident misinterpreted two words, understood the fracture to have resulted from abuse, and contacted the Department of Social Services (DSS). DSS sent a worker who, without an interpreter present, had the mother sign over custody of her two children.2 Clearly, catastrophes can and do result from such miscommunication.
Some 49.6 million Americans (18.7 percent of U.S. residents) speak a language other than English at home; 22.3 million (8.4 percent) have limited English proficiency, speaking English less than "very well," according to self-ratings. Between 1990 and 2000, the number of Americans who spoke a language other than English at home grew by 15.1 million (a 47 percent increase), and the number with limited English proficiency grew by 7.3 million (a 53 percent increase, see graph). The numbers are particularly high in some places: in 2000, 40 percent of Californians and 75 percent of Miami residents spoke a language other than English at home, and 20 percent of Californians and 47 percent of Miami residents had limited English proficiency.
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Yet many patients who need medical interpreters have no access to them. According to one study, no interpreter was used in 46 percent of emergency department cases involving patients with limited English proficiency.3 Few clinicians receive training in working with interpreters; only 23 percent of U.S. teaching hospitals provide any such training, and most of these make it optional.1 Data collection on patients' primary language and English proficiency is frequently inadequate or nonexistent. Although no federal statutes require the collection of such information, no statute prohibits it, either.4
Language barriers can have deleterious effects.1,5 Patients who face such barriers are less likely than others to have a usual source of medical care; they receive preventive services at reduced rates; and they have an increased risk of nonadherence to medication. Among patients with psychiatric conditions, those who encounter language barriers are more likely than others to receive a diagnosis of severe psychopathology — but are also more likely to leave the hospital against medical advice. Among children with asthma, those who confront language barriers have an increased risk of intubation. Such patients are less likely than others to return for follow-up appointments after visits to the emergency room, and they have higher rates of hospitalization and drug complications. Greater resources are used in their care, but they have lower levels of patient satisfaction.
Inadequate communication can have tragic consequences: in one case, the misinterpretation of a single word led to a patient's delayed care and preventable quadriplegia.1 A Spanish-speaking 18-year-old had stumbled into his girlfriend's home, told her he was "intoxicado," and collapsed. When the girlfriend and her mother repeated the term, the non–Spanish-speaking paramedics took it to mean "intoxicated"; the intended meaning was "nauseated." After more than 36 hours in the hospital being worked up for a drug overdose, the comatose patient was reevaluated and given a diagnosis of intracerebellar hematoma with brain-stem compression and a subdural hematoma secondary to a ruptured artery. (The hospital ended up paying a $71 million malpractice settlement.)
In 1998, the Office for Civil Rights of the Department of Health and Human Services issued a memorandum regarding the prohibition, under Title VI of the Civil Rights Act of 1964, against discrimination on the basis of national origin — which affects persons with limited English proficiency. This memorandum states that the denial or delay of medical care because of language barriers constitutes discrimination and requires that recipients of Medicaid or Medicare funds provide adequate language assistance to patients with limited English proficiency. In 2000, a presidential executive order was issued on improving such persons' access to services. Thirteen states currently provide third-party reimbursement (through Medicaid and the State Children's Health Insurance Program) for interpreter services. Unfortunately, most of the states containing the largest numbers of patients with limited English proficiency have not followed suit, sometimes citing concerns about costs. Although the Office for Civil Rights issued guidelines in 2003 that seem to allow health care facilities to opt out of providing language services if their costs are too burdensome, Title VI provides no such exemption.
Ad hoc interpreters, including family members, friends, untrained members of the support staff, and strangers found in waiting rooms or on the street, are commonly used in clinical encounters. But such interpreters are considerably more likely than professional interpreters to commit errors that may have adverse clinical consequences.1,5 Ad hoc interpreters are also unlikely to have had training in medical terminology and confidentiality; their priorities sometimes conflict with those of patients; and their presence may inhibit discussions regarding sensitive issues such as domestic violence, substance abuse, psychiatric illness, and sexually transmitted diseases.5 It is especially risky to have children interpret, since they are unlikely to have a full command of two languages or of medical terminology; they frequently make errors of clinical consequence; and they are particularly likely to avoid sensitive issues.1,5 Given the documented risks associated with the use of ad hoc interpreters, it is of concern that the 2003 guidance from the Office for Civil Rights states that such use "may be appropriate."
Later this year, the California legislature will consider a bill prohibiting state-funded organizations from using children younger than 15 years of age as medical interpreters. Leland Yee, the California speaker pro tempore, proposed the bill, prompted by his experiences interpreting for his mother and, later, as a child psychologist. The bill requires organizations receiving state funding to establish a procedure for "providing competent interpretation services that does not involve the use of children."
Although this legislation may emerge as a state model, as an unfunded mandate, it will have limited power to improve care. Perhaps the time has come for payers to be required to reimburse providers for interpreter services. The provision of adequate language services results in optimal communication, patient satisfaction, outcomes, resource use, and patient safety.1,5 A 2002 report from the Office of Management and Budget estimated that it would cost, on average, only $4.04 (0.5 percent) more per physician visit to provide all U.S. patients who have limited English proficiency with appropriate language services for emergency-department, inpatient, outpatient, and dental visits. This seems like a small price to pay to ensure safe, high-quality health care for 49.6 million Americans.
Source Information
Dr. Flores is director of the Center for the Advancement of Underserved Children and a professor of pediatrics, epidemiology, and health policy at the Medical College of Wisconsin and the Children's Research Institute of the Children's Hospital of Wisconsin, Milwaukee.
An interview with Dr. Flores can be heard at www.nejm.org.
How very ironic that as the US becomes increasingly the international language that we waste our time with these people who have no intention of learning the language.
Meanwhile entire continents speak the language extremely well, and we limit immigration from skilled, university-educated individuals. Why? Well, is there even an answer out there that makes sense?
I have French, Romanian, Russian, and Croatian friends who would love to come to the US. Can they? NO! They all speak English extremely well, are all university educated, speak at least three languages, and our nation ignores them for Lupe who can't even hold a conversation about her son's health.
I'm going to be treating these people in time, and I'm going to learn Spanish. That said, I'm not happy about it, and nor should anyone be who desires a solvent healthcare system.
What this article didn't mention is that dear little Raul left the doctor that day without paying a dime, and Mike, Tyson, and Shigeiki paid for his appointment (and his mom never thanked them).
The problem with our health care are the free-loaders who
drain our resources.
Why can't the Mexicans fix their own problem?
The NEJM believes that American taxpayers are obligated
to fund illegal aliens from south of the border.
Let's send those pampered poodle bureaucrats to Mexico. Every illegal Mexican using our welfare systems could be paid in kind with oil from Fox's corrupt Mexico.
Tough! Good God, this is absurd. There's a solution to this, Learn English! My people did.
When in Rome. Do as the Romans.
If you dont want to learn the language of the country you are in then dont go there, or suffer the consequences.
Here in NY, every doctor guide from insurance companies tells if the doctor (or someone in his/her office) speaks another language. And it's not just Spanish. You can find doctors who will understand you if you speak (Haitian) French, Chinese and Korean, among other languages.
Besides the fact that it is immoral to withheld medical care from someone who needs it, it's good business to be able to speak the language of your patients. You notice I'm not saying that the government should be multi-lingual. But private entities are because it is good business.
One last question -- have you ever traveled abroad? Let's say you find yourself in Russia on vacation and develop appendicitis. Do you speak enough Russian to be able to tell the doctor your symptoms? Or do you hope and pray s/he speaks English?
??
Learn to speak Spanish. It's my language. You need to know it.
Give me top of the line medical care.
Give it to me for free -- I can't posibly afford medical insurance, so don't expect me to pay anything.
I deserve all this, because ... because ... because
Amen.
"I don't know about your ancestors, but mine didn't speak English before they got here or even right when they got off the boat. The parents never spoke good English at all, and their children were expected to interpret for them (just as in this case). But, unlike what this particular situation seems like, late 19th/early 20th century immigrant children learned English in school, because there was no bilingual education."
Exactly the experience of my people, on both the Greek and the Irish (County Kerry; they spoke Irish) sides.
"One last question -- have you ever traveled abroad? Let's say you find yourself in Russia on vacation and develop appendicitis. Do you speak enough Russian to be able to tell the doctor your symptoms? Or do you hope and pray s/he speaks English?"
Quite a bit and for that reason I've made it a point to learn several languages well enough to do business in and two others to the point where I can make myself understood. As for Russian, no, I don't speak Russian...but I can sort off get by in Serbian. :)
Luckily, if one speaks English, French and Spanish, its pretty easy to get around most everywhere. The only place I have ever been where that didn't hold true was in Poland where I used my very bad German.
IF the story is true, the most likely explanation is because everyone who spoke Spanish was already translating. What are the chances that the entire staff of any Boston ER working on any shift would not contain a single person who spoke Spanish?
Probably up around Powerball Lottery odds; like a million-to-one against.
As for my asking you if you'd been ill abroad, it was rhetorical. It's the principle of the thing -- if one falls ill in a place where one does not speak the language, one has no option but to hope and pray that the medical people there speak one's language. It's not a reason to denigrate people.
And, after all this, I will say without hesitation that I believe that English should be our national language. I just don't look at this particular situation in black and white. As in many areas of life, there are shades of grey here.
"If that is indeed the case, then why are you so unsympathetic to the people in this particular story?"
It is indeed the case! The reason I have little or no sympathy for them is because in every single immigrant community I know of, and I live among several and have all my life, there are always a number of people in the community who speak English. The Hispanics have the least to complain of. The priest always speaks English for example.
By the way, a form of ESL existed even in the early 20th century, though it was usually set up in a school just for immigrant kids. My mother attended one. Growing up we spoke Greek and English at home (I went to "Greek as a Second Language School" after American school) and French on the street as I when I grew up here, French was the majority language not English. I haven't a drop of French blood in me but I speak it fluently...because I had to learn it. Nothing has, or at least should have changed when it comes to learning the dominant language in a given area.
What's happened in NY is that they've passed an unfunded mandate that physicians need to provide interpreters ... even in the boro of Queens which might be the most ethnically diverse population in the US. So it's apparently not just Bush's fault ... it's the doctors' fault that folks don't learn English or don't provide their own interpreters. Sheesh!
Ping for later read...
Does Mexico require English translators on their hospital staffs?? I seriously doubt it.
ping
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