Case Scenario

During the past year, I have noticed an increasing number of Spanish-speaking patients coming to my practice. I'm fortunate enough to have a bilingual staff member—and I'm glad she is with me because I don't believe that my medical Spanish can adequately explore the complexities and nuances of patient interactions. However, this staff member has other duties to attend to besides interpreting, and I can't afford to employ a full-time interpreter. Sometimes my patients bring their own interpreter—usually a family member, and often a child. Because many doctor-patient interactions explore private or personal information, is it appropriate for me to use a child or other family member as an interpreter when interviewing or examining a patient? What are my ethical and legal obligations to my non-English–speaking patients? Can the quality of care be affected by a language barrier?

Commentary

Many physicians are facing a similar dilemma because the Hispanic population is growing rapidly, and Spanish is the preferred language for many Hispanic people. The use of interpreters is a multifaceted issue. First, the physician is ultimately responsible for communication. If a physician is not bilingual, the best alternative is to make use of the skills of a trained medical interpreter or translator. Use of remote interpreting services (such as telephone interpreters) also has proved to be successful.^1,2

According to the American Medical Translators, a medical translator or interpreter is a specially trained professional who has proficient knowledge and skills in a primary language or languages and who employs that training in medical or health-related settings to make possible communications among parties speaking different languages. The skills of a medical interpreter or translator include cultural sensitivity and awareness of and respect for all parties, as well as mastery of medical and colloquial terminology, which make possible conditions of mutual trust and accurate communication that lead to effective provision of medical health services.

It is important to be aware that errors of interpretation are made by well-intentioned interpreters, and that such errors occur more frequently with ad hoc interpreters (untrained nonprofessionals, such as family members, friends, and health care workers).³ The most frequent errors in medical interpreting involve omissions and editing, and they have potential clinical consequences.³ Patients, however, may prefer the use of friends and family members because of their ongoing relationship and their knowledge of the patient's needs; therefore, it is important also to look at the situation from the patient's perspective.⁴

Considerations in the use of interpreters often revolve around patient satisfaction and quality of care. The Institute of Medicine report released in April 2002 showed that health disparities exist in Hispanic populations. Patients state that they believe their quality of care is better when it is delivered by a person of their own culture or by someone who understands their culture. Timmins' systematic review⁵ of the biomedical journals from 1990 to 2000 looked at language barriers in health care for Hispanic patients in three areas: access to health care, quality of care, and health status/health outcomes. Six of seven studies found significant detrimental effects of language barriers on quality of care, including misdiagnosis, prescribing inappropriate medications, lack of patient information leading to poor compliance, lack of follow-up, and a decrease in preventive services. It benefits us all to be culturally sensitive and culturally competent, and to provide cultural and linguistically appropriate care, because the result will be better health outcomes and healthier patients.

There also is a legal obligation to provide cultural and linguistically appropriate care. The laws are well intentioned, but they are not as effective as anticipated because many do not have an enforcement arm and are unfunded mandates. Relevant laws include the following:

Title VI of the Civil Rights Act of 1964

This act, administered through the Office for Civil Rights of the Department of Health and Human Services, is the basis for legal obligations to provide language access accommodations for persons who are limited in English language proficiency when they access health care. This law applies to any health care provider who receives federal funds and includes physicians who treat Medicaid or Medicare patients, as well as hospitals that receive federal funds.

Title VI guarantees freedom from discrimination. The Office of Minority Health released a set of standards for culturally and linguistically appropriate services. Guidelines state that any agency receiving funds from the federal government should not deny a person who does not understand English a culturally competent translator.

Medicaid Law and Related Regulations

Several Medicaid provisions require Medicaid agencies and providers to eliminate language barriers. In several states, managed Medicaid health plans have expanded the availability of linguistically appropriate health care services. These contracts frequently require that plans enrolling Medicaid recipients provide appropriate interpreting and translation services to non-English–speaking enrollees.

The Hill-Burton Act

This act requires hospitals to address the needs of non-English–speaking patients.

Tort Liability

Providers performing medical procedures must communicate with their patients and obtain informed consent and all that it implies.

Cost definitely is an issue. Trained interpreters and telephone interpreting are expensive, and third parties do not pay for these services. Better options for reimbursement or easier access to resources must be available before we can expect a wider acceptance of the option/need of translators and linguistic competency. Surely, however, the best interests of patients are served by providing cultural and linguistically appropriate care.

The accompanying table lists Web sites that offer more information about cultural diversity and medical interpreting.