Interpreter services and Community House Calls

 

Beyond Medical Interpretation

The Need for Cultural Mediation and Provider Training

Clinics and hospitals which only 25 years ago served few non-English speakers now see large numbers of non-English speaking refugees and other immigrants. At Harborview Medical Center (HMC) in Seattle, health care providers treat patients from seventy different language groups with the help of an interpreter service which costs more than $2 million per year. In spite of the frequency with which health care providers treat non-English speaking patients and the fact that skillful medical interpreters are involved, the results can be less than adequate. Nationwide, most health care providers still do not receive training in the practice of cross-cultural medicine, nor do they have adequate access to cultural information about their patients. And medical interpreters, skillful though they may be, cannot overcome important language and cultural barriers through limited, discrete interpretation sessions which do not provide for cultural advocacy or dialogue.

 

Medical interpretation is an inherently difficult task, even under the best circumstances. It is especially difficult when it is confined to brief sessions such as one typically encounters in a medical setting. When language and culture are worlds apart or when trauma related to war or refugee experience is involved, it becomes increasingly difficult for the interpreter to adequately communicate the patient’s concerns, or for the provider to address the patient’s health needs in an effective way. Both patient and health care provider need a more sophisticated approach to interpretation which involves an expanded understanding of the language and cultural beliefs which affect their communication. A more detailed understanding of the patient’s family structure, health and cultural beliefs, and present situation is necessary before the provider can accurately address many health problems.

 

“Cultural interpretation” or “cultural mediation” provides a more comprehensiveunderstanding of the patient because it addresses aspects of health care and culture of which the provider may be completely unaware. For example, some Southeast Asian patients may strongly believe that the provider’s directive to give their child oral rehydration fluids will cause their child to become even

sicker. Unless the medical interpreter is capable of (and willing) to explain this notion to the provider, it will probably remain unexpressed. However, the parent’s opinion on the matter will certainly influence what happens after the family leaves the clinic, and the provider may never know whether the oral rehydration fluids were actually given to the child. Ideally, in a situation like this, the parents would be able to express their concerns through an interpreter cultural mediator, and a more agreeable option such as the use of a special porridge could be identified. Another example: an Oromo parent may feel undervalued by the suggestion that her child be given “water” when so many other medicines are available. However, if the interpreter cultural mediator can explain the function of the rehydration fluids in a culturally competent manner, it is more likely that the Oromo parent will make an informed decision to use or reject rehydration therapy and/or to explore other methods for rehydrating her child.

To be fully effective, cultural mediation is combined with case management.  The interpreter follows a family or patient over a period of time, becoming fully aware of the family’s needs, problems, and strengths. A case management approach enables the interpreter to provide cultural interpretation and

mediation, and to advocate for appropriate treatment based on a more thorough understanding of the patient. The interpreter can thus communicate cultural facts and social/familial histories to the health provider, offering the provider a way to gain valuable insights which can positively impact patient care. Problems such as poor housing, lack of child care or support for new parents, depression, isolation, and mental health problems can be identified and addressed using the interpreter cultural mediator approach.  While the interpreter cultural mediator cannot solve all the problems a family may contend with, avenues for communication are vastly broadened and cultural gaps in information more easily bridged when an ICM is involved in patient care.

 

Interpreter Cultural Mediator (ICM) Program Goals

Community House Calls has established the following programmatic goals, in recognition of the inherent difficulties that arise when health providers attempt to offer quality health care to a number of ethnically diverse populations, within a confined time frame and without adequate knowledge of patients’ language, cultural background or current living situation. These goals can be realistically achieved within the context of the ICM team approach as described in this manual.

• Create a common fund of knowledge between medical and ethnic cultures

• Decrease language barriers to care

• Change institutional practices that particularly decrease patient satisfaction for non-English speaking families

• Improve cross cultural health care education for providers and trainees

• Enhance efficient utilization of resources by “high risk/high need” families

 

These goals are achieved through providing a variety of health care and educational services, including continuity of interpreter services; case management for families with complex social or medical needs; home visits by ICM staff and health care providers; training for families, enabling them to make their own clinic appointments and obtain pharmacy refills; community health education; and training for health care providers in the practice of intercultural medicine.

 

How to refer a patient to the Community House Calls Program

** Fill out the form to the right.  Copies are located in the provider room.

 

Bria Chakosky RNIII, CCM supervisor, 680-6862, bria@u.

Christina Garces, Spanish, 997-2221, garcesc@u.

Jeniffer Huong, Cambodian, 995-1277, jhuong@u.

Kim Lundgren, Vietnamese, 663-3985, klundg@u.

Leticia Magana, Spanish, 680-8097, lmagnana@u.

Salma Mussa, Somali, 991-4964, salmam@u.

Yodit Wongelemengist, Amharic, 994-2834, yodit@u.

Tsehay Haile, Tigrinian, 993-5447, tsehay@u.

 

Guidelines for Interpreted Visits

Ellie Graham, MD
March 1, 1995

  1. Introduce yourself to the family and to the interpreter.
  2. Write down the interpreter's name and the interview language on the progress note.
  3. Do a pre-visit conference with the interpreter. This can be done in the room with the family unless sensitive issues need to be discussed. The following should be covered.
    • Establish the style of interpretation. Phrased interpretation where the provider interviews in short phrases that are translated as accurately as possible by the interpreter, is usually the easiest to use. Simultaneous interpretation is often confusing to both patient and provider but useful for short statement like how to take medicines. Summary interpretation, where the provider or the patient make long statements and the interpreter tries to summarize them can be used for simple problems and to explore sensitive areas such as sexuality but can lead to errors...use with caution.
    • Ask the interpreter for feedback. Ask them to tell you if they don't understand terms you use or the terms aren't easily translated. Tell them to also tell you if it seems that the patient is expressing a cultural related idea or concept that they think you may not understand.
    • Tell the interpreter where you want them to sit. Beside the provider or just in back of them is best because the patient looks at both the provider and the interpreter.
    • Establish the context and the nature of the visit."Nasara is coming in to see me today for a follow-up visit. She has been depressed and I will be discussing this first"..."Anh is a new patient to our clinic. I will be asking him many questions about his past health and his family and then will do a complete physical examination"...
    • Determine if there are any time constraints on the interpreter.
    • Ask the interpreter if they have any concerns that they want to share with you before the visit and step out into the hallway to talk with them.
  4. Direct questions to the patient, not to the interpreter unless they are meant for the interpreter. If you are going to pause and ask the interpreter a question in English, tell the patient that this is what you will be doing.
  5. Do a post-visit conference with the interpreter outside the room if you have concerns about the interview. This is particularly helpful if the history seems very vague and unclear. It can help determine if there was a language problem...the patient and the interpreter speak different dialects or have accents that are hard for each to understand, or if the patient is mentally ill or has some other problem that clouds communication.

Gender and age of the interpreter may be very important. In many ethnic groups, women and girls prefer a female interpreter and some men and boys prefer a male. Older patients may want a more mature interpreter. Don't use children as interpreters. This distorts power relationships within families and diminishes parents in the eyes of their children. It often provides poor quality interpretation because children may have limited native language skills.