Bridging the Language Gap
Some hospitals make non-English-speaking patients feel right at home
There is no Room 1504 on 15 East, the new Chinese unit at St. Vincent's Hospital Manhattan."The number 4, in Chinese, sounds the same as the word for death," says Frances Wong, the hospital's director of Asian services. "Chinese people think that's really bad luck. What's worse, there was one room, 1523, which in Chinese means 'definitely not easy to live.'" For a hospital hoping to make its Chinese patients comfortable, you couldn't think of more unfortunate signage. "That was changed to 15A," says Wong.
There are other cues this is not a typical hospital floor. Visitors are greeted by a Chinese sign: "We have all the health services available to serve you." The waiting area sports a red-and-gold "longevity" sign, and Asian art adorns the corridor. Among those assigned to the unit are two physicians, a nurse, and six nursing assistants--all of Chinese background and fluent in the language. In the rooms, patients eat a lunch of congee, a traditional warm watery rice porridge. It's comfort food. Chinese don't like to eat or drink anything cold when they are sick.
Located near New York's Chinatown, St. Vincent's has a patient population that's 10 percent Chinese, and 15 East brings western medicine to them on their own terms. In Chinatown, English--and American culture--barely exist for many people. And when hospitals and patients can't communicate, the result is bad medicine. This spring, the New York Academy of Medicine released a report on healthcare among immigrant families, reporting that 55 percent complained that language barriers hampered their care. "There's pretty solid evidence of adverse consequences," says Glenn Flores, a pediatrician and director of the Center for the Advancement of Underserved Children at the Medical College of Wisconsin in Milwaukee, who has published numerous studies on language problems. "You get a lower rate of mammograms. Kids with asthma are more likely to have a crisis and get intubated." In one case reported this spring, a 10-month-old infant ended up vomiting and on an IV in a hospital because a nurse with limited Spanish at a clinic hadn't explained the proper dose of an iron supplement to the Spanish-speaking parents. The parents had given the baby a typical teaspoon of medicine--more than 12 times the intended dose.
Widespread concern. St. Vincent's cultural makeover is the most visible portion of a movement affecting hospitals across the country, as such language problems are increasing. Current population surveys show that 28 million Americans were born in another country, and 22 million of them have limited or no ability to speak or understand English.
Hospitals of all shapes and sizes are trying to keep pace. "There's been a huge increase in requests for advice during the last five years," says Shiva Bidar-Sielaff, cochair of a committee of the National Council on Interpreting in Health Care that released the first national standards on medical interpreting last year. Institutions want to know, for example, how to set up language services and train their staffs. "It's a whole new way of looking at our patients," says Elita Christiansen, who runs what's called a "cultural competency program" for Inova Fairfax Hospital in Falls Church, Va., where an estimated one third of households in the region have limited English skills.
Good intentions. But many hospitals are struggling. There are no national numbers on how many of them offer language services, but a recent survey by Flores of all hospitals in New Jersey found that 97 percent didn't have any full-time interpreters. Some 80 percent provided no formal training for staff on working with medical interpreters.
Untrained--though well-meaning--bilingual people acting as interpreters can create many problems. In a 2001 study, when researchers videotaped 21 Spanish-speaking patients at a Southern California clinic that used nurses as interpreters, they found that just over half of the interactions had bad enough miscommunications that doctors didn't completely understand the patients' symptoms. In a 2003 study, Flores found that hospital staffers used as interpreters--who had no formal training--were particularly prone to "false fluency" errors: misinterpreting words or concepts based on a limited understanding of the language. For instance, one interpreter used a Puerto Rican colloquialism for mumps when talking to a Central American mother, who didn't understand it. Other interpreters didn't know the right Spanish words for "medicine" and "results," while others didn't ask about drug allergies.
AnMed Health Medical Center is trying to do better than that. The community hospital in Anderson, S.C., population 25,000, has been part of a project funded by a Robert Wood Johnson Foundation program to improve hospital language services in the region. "Five percent of our patients now speak a language other than English," says Juana Slade, the hospital's director of diversity and language services. "Most of those are Spanish speakers, but there's also Russian, Chinese, and deaf people who use American Sign Language."
Before Slade's department was created in 2001, "things were really decentralized and a little confused," she says. Each nursing unit had its own list of bilingual interpreters on the staff and would call on them when needed. Often, Slade says, that meant patients and doctors would have to wait until a staffer was finished with his or her regular job. Or--since doctors are in a hurry--it meant doctors or nurses would charge ahead into a sea of misunderstandings.
Slade set out to avoid these problems by instituting a system that starts the moment a patient arrives. Admitting clerks ask about preferred language. "If it's not English, or they have trouble answering questions in English, that's a full stop," Slade says. "The computer screen won't let the clerk continue until a language is identified." (For emergency admissions, a triage nurse does much the same thing after a patient is stabilized.) That language preference follows the patient to every medical appointment, every clinical encounter. "If they go to radiology, we're there waiting for them," says Slade. "If a doctor comes in for rounds, we're there too." If a nurse has an unscheduled chat with a patient about pain or medicine, she is under strict instructions to page language services first; someone is there in five minutes.
And that someone is properly trained. Every one of the 20 interpreters has gone through a 40-hour course on medical interpreting. "People joke and call me a language cop, but this is really important," says Janine Ferra, the hospital's language services manager. One of the major lessons: An interpreter is there to translate word for word what the patient says to the doctor and vice versa. "You are not there to be an advocate or to add information you think is important," says Ferra.
That neutrality is perhaps the hardest part of the job, says Heather Cazarin, one of AnMed's Spanish interpreters. "You see people not getting it, and it's real tempting to add more explanation," she says. "I'm not a doctor, I'm not a radiation technician, and I should not be explaining medicine or radiation." Cazarin had to explain the difference between a bacterial and viral infection to Lucia Lau, mother of a 15-day-old girl, Britani, who was admitted with a fever. "I came to the U.S. five years ago, from Peru," says Lau, through Cazarin. "I know some English but don't understand everything the doctors say to me." Doctors had to tell Lau they had ruled out a bacterial infection but needed to keep Britani on antivirals for a while until some tests came back.
Cazarin has to deal with cultural disconnects as well. In some very traditional Hispanic cultures, for instance, a wife tends to defer to her husband in medical matters or the husband insists on interpreting for the wife. "I can hear the husband editing the wife's answers," says Cazarin, "and I have to tell him--politely--to let her speak for herself."
Medical staff needs to be sensitive, too. "A lot of times, if there are children in the room, even grown children, patients will minimize symptoms," says Wong of St. Vincent's Chinese patients. "It's part of the culture not to trouble your children." These dynamics change as the parent ages, as they will tell the doctor to let the son or daughter decide on treatment. "That makes it hard to know if you are really getting informed consent," says Wong.
Talk easily. Mon Lam, a 58-year-old man on 15 East with a bleeding gastrointestinal tract, hasn't relied on his children as much as he has on Faith Zhao, the physician assigned to the floor. "It's very good to be in a place like this," says Lam. "I can talk easily to the doctors and nurses." It turned out he had a malformed junction of an artery and vein near his stomach. In a relatively simple procedure, doctors sealed off the junction, and Zhao, speaking in Lam's native Cantonese, tells him he's OK to go home but to stay on soft foods for a while.
St. Vincent's also has patients who are Hispanics, western Europeans, Indians, or Hasidic Jews who speak Hebrew. There are bedside cards in Chinese telling patients about language services but not in many of the other languages. And while Ellen Gayama, the language coordinator, uses five full-time interpreters plus 120 members on the hospital staff who speak 30 foreign languages--from Albanian to Yiddish--only 30 of them have, so far, been through the hospital's 32-hour certification course covering medical terminology and ethics. (More classes are scheduled.) "This is a work in progress for us," says Dennis Greenbaum, chair of St. Vincent's department of medicine. "We don't have the resources to do everyone at once."
At least the hospital is aware there are cultural differences. "Some hospitals around the country say there are no disparities and they treat everyone equally," says Amy Wilson-Stronks, a health services researcher at the Joint Commission on Accreditation of Healthcare Organizations. Wilson-Stronks is in the middle of a project evaluating language and culture service at 60 hospitals. "There's definitely a learning curve, and hospitals are on different points of that curve."
The Office of Minority Health in the Department of Health and Human Services has developed 14 guidelines for culture and language services, including one that states that organizations must provide interpreter services at no cost. Though the guidelines don't have the power of law, Garth Graham, the office's director, says they do help, and "folks are moving to the standard of culturally competent care." JCAHO is also starting to ask detailed questions about language services. Since a negative survey report from the commission can ruin a hospital's ability to get insurance reimbursement as well as to attract staff, executives tend to pay close attention.
And for those hospital executives who feel the United States, with a long history of immigration, has done just fine without special language services in the past, Bidar-Sielaff has a reply: "We also used to be a nation that had people with different skin color drink from different water fountains and going to different schools. Things have changed. We should do better now."
This story appears in the July 17, 2006 print edition of U.S. News & World Report.