Doctors, nurses need competent multilingual interpreters

ANNE T. DENOGEAN

The head of Tucson Medical Center recently received a disturbing call from the daughter of an elderly woman being cared for at his hospital.
The 80-year-old woman, who spoke only Spanish, had been taken off all her oral medications, reportedly at her request. That included eight medications for diabetes and other serious conditions.

But the daughter said the woman actually had refused only one medication, because it was making her nauseated. And the nurses, who spoke only English, misunderstood her wishes, said TMC President and CEO Frank Alvarez.

So if you ask Alvarez whether language barriers can affect the quality of care patients get in Tucson hospitals, the answer would be an unambiguous "yes."

"You can't help but know intuitively that if you are not able to communicate effectively with your patient, then errors are going to happen," he said.

On a daily basis, in every hospital in Tucson, medical staffers face the challenge of treating patients who speak little or no English. Most often, the patient's primary language is Spanish. Patients who speak Russian, Vietnamese, Korean and Mandarin Chinese are also not uncommon.

Nationwide, studies show that the millions of Americans who are limited in their English proficiency often do not get an interpreter at all, that the interpreters often have little or no training, and that mistakes are commonly made by both hospital interpreters and temporary interpreters, such as family members, friends, nonclinical staff, clinical staff without interpreter training and strangers pulled from waiting rooms.

TMC and other hospitals in town rely largely on bilingual staff members and a small number of qualified interpreters to provide interpretations, based on availability. They also use a Tucson-based medical interpretation service called CyraCom that covers about 150 languages in interpretations done primarily over a dual-handset phone system. (See related story.)

Representatives of most local hospitals say they do an adequate to good job of bridging the language gap.

"I've been a nurse for 25 years, and I've never had an experience where there has been a problem because something was misinterpreted or not translated correctly," said Katie Gleason, a registered nurse who is director of Northwest Medical Center's emergency department and its medical-surgical units. "I think we make every effort to meet the needs of our patients.

"At any given time I could walk onto any unit in the hospital and would have at least several educated staff members who speak Spanish."

Adaline Klemmedson, a University Medical Center vice president, said UMC uses trained volunteer interpreters and CyraCom. The hospital tries not to use staffers because their proficiency hasn't been tested. It also does not use relatives of the patient because their translation can be unreliable, she said.

Alvarez said hospitals nationwide should be doing more to address the language issues posed by the diversity of our population.

One of his goals at TMC is to improve the Spanish-language abilities of all caregivers through hospital-sponsored classes, some of which begin today.

Tucson Heart Hospital offers its staff classes in basic Spanish and Spanish medical terminology.

Alvarez's view of things is bolstered by recent studies finding that the extent and quality of interpretation for patients are lacking.

In a study in the January 2003 Pediatrics Journal, Dr. Glenn Flores, then of the Boston University School of Medicine and now at the Medical College of Wisconsin, and his colleagues found that errors in medical interpretation are common.

The researchers found that 63 percent of all the errors had potential clinical consequences. An average of 31 interpreter errors per encounter were found in their evaluation of taped encounters in a pediatric clinic in which both professional and ad-hoc interpreters were used.

The temporary interpreters - including a nurse, social worker and an 11-year-old family member - were more likely to commit errors with potential clinic consequences. Yet, more than half of the hospital interpreter errors also were of that type.

The study concluded that professional hospital interpreters are necessary and that they need more training.

"Fewer than one-fourth of hospitals nationwide provide any training for medical interpreters," the researchers wrote in the study.

The issue is becoming more critical with the growth of a U.S. population that is not proficient in English, Flores said.

He cited U.S. census data that show the number of Americans designated as limited in English proficiency jumped from 14 million in 1990 to 21.4 million in 2000.

Arizona, he noted, has nearly 540,000 residents, or 11 percent of its population, who are LEP. Eighty-five percent of those are Spanish-speakers.

Providing adequate translation is also a safety issue and a potential liability issue, Flores said, noting a successful $71 million Florida lawsuit in the case of a teenager who was left a quadriplegic.

"He was an 18-year-old who went to a sporting event at his high school, wasn't feeling well and walked over to his girlfriend's house. Just before he collapsed he said, 'Me siento intoxicado.' The paramedics came along, and the girlfriend didn't speak a lot of English, and the mother of the girlfriend didn't, either. They mentioned that word, and the paramedics said, "Oh, yeah, intoxicado, that means intoxicated. So they took him to the emergency room.

"He ended up going to the intensive-care unit because he had gone into a coma, and for 48 hours they were working him up for drug abuse. Then they finally did a CT scan, and it turned out he had actually had a brain aneurysm and that it burst, and he got a huge intracranial bleed," Flores said.

Intoxicado, in fact, can mean nausea.

"That is one example of why, if you spent $30 for interpreter, you wouldn't have had to spend $71 million to settle a lawsuit," he said.

TMC's Alvarez said hospitals must be proactive with patients who don't speak English.

"If somebody needs to have a bath, you don't need a qualified interpreter there. But if you are going to talk medications, if you are going to talk discharge planning, if you are going to talk procedure and informed consent, you need to have somebody that knows how to do this properly," he said. "Sitting back and just saying, 'God, I just wish these people would learn English' isn't enough. A hospital has got to do more than that if we are going to continue to save lives."