October 2017 VOL 8, NO 10
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Barriers to Care
Lost in Translation? Use an Interpreter
When non–English-speaking patients seek medical care, interpreters can play an important role in facilitating an accurate exchange of information, but along with the benefits, there can be pitfalls, explained Phyllis Butow, PhD, Director of the Medical Psychology Research Unit at the University of Sydney, Australia.
“A large literature shows there are disparities in survival, treatment, and quality of life among immigrants, along with higher anxiety and depression. When treating a patient with cancer from another culture, language proficiency and cultural competency are important,” explained Dr Butow, speaking at the 2017 Annual Meeting of the Multinational Association of Supportive Care in Cancer.
Cultural competence in medical care is needed to address increasing waves of immigration as refugees flee their countries for asylum. In the United States, 21.1% of the population does not speak English at home, and another 8.7% have limited proficiency in the English language, according to the US Census of 2015.
“Interpreters are thought of as being the solution to this problem. Professional interpreters improve medical outcomes. Research shows quality of care is significantly worse [for non–English-speaking patients] if a professional interpreter is not used. Patients and families have inadequate understanding and worse symptom management when an interpreter is not present during consultations,” Dr Butow told listeners.
Patients prefer face-to-face video interpreter consultations to video consultations and to telephone consultations, according to research. In a study of patients who had interpreter consultations at the Royal Melbourne Hospital in Australia, 82% preferred video to telephone, and 84% preferred face-to-face interpreting to video (Aust Health Rev. 2015;39:395-399).
“Although having a trained, accredited interpreter is considered ideal, this doesn’t often occur,” Dr Butow said.
A US survey of interpreter use over the past 12 months included 111 medical oncologists, 65 radiation oncologists, and 171 oncology surgeons. Among physicians who used interpreters, only 41% used a trained medical interpreter, 21% used a telephone interpretation service, 76% used bilingual staff members not trained in medical interpretation, and 86% used patients’ family or friends. Survey respondents were allowed to indicate use of more than one type of interpreter. In the same survey, only one-third of those surveyed reported good availability of trained medical interpreters (Health Serv Res. 2010;45:172-194).
In another study, doctors cited the following reasons for not using interpreters: It is such an enormous hassle to organize; there is no language problem; I am a good doctor; my medical information is not complex; and patients don’t want an interpreter (J Contin Educ Health Prof. 2015;35:249-254).
Many doctors are untrained in running interpreter sessions, making it more challenging, Dr Butow continued. To demonstrate this, she and colleagues tape recorded and transcribed the first 2 consultations after diagnosis of metastatic disease with an interpreter usually present (could have been a family member); the study included 144 patients who were Arabic, Greek, and Chinese, with English-speaking controls (J Clin Oncol. 2011;29:2801-2807).
Patients were getting less information than what was actually said. On average, what was said was translated correctly and fully about 60% of the time. More information was communicated with professional interpreters present than with family and friends who translated for the patient, Dr Butow said. Further, 32% of the nonequivocal sessions were judged to have a potentially negative effect. Fifty percent of what the doctor said and 59% of what the patient said were not interpreted or interpreted nonequivalently.
She gave the following examples of inadequate translations by interpreters/family members:
- The doctor said, “You must take the tablets every day for them to work.” The interpreter said, “You must take the tablets every day.”
- The oncologist tells the interpreter he wants the patient to know her diagnosis, so the patient can trust the doctor. The doctor says she has stage IIIA lung cancer, and the interpreter tells the patient the lung cancer is initial stage.
“Some family members directly asked the interpreter not to give the patient the accurate prognosis. They said, ‘he/she doesn’t need to know. It will just scare her.’ This places the interpreter in a difficult position,” Dr Butow said. “Patients were often aware that information was not being disclosed and stated that they wanted to know the truth.”
“Professional interpreters make a difference! Doctors and interpreters need to work together to optimize outcomes for non–English-speaking patients,” she stated.
Tips for Doctors/Nurses
Training modules are available to help doctors work with interpreters. Here are 2 that Dr Butow cited:
- Friedman-Rhodes E, Hale S. Teaching medical students to work with interpreters (The Journal of Specialised Translation. 2010;14:121-124)
- Psychosocial Research Group. Effective cultural communication in oncology: a training program for oncology health professionals. https://edumodules.eviq.org.au/Resources/CALD/Intro/EG/index.html
Dr Butow recommended using an accredited interpreter when health and health outcomes information is to be communicated; when the person requests an interpreter; and when the patient’s English skills are judged inadequate.
“Ideally, the doctor and interpreter should meet before the consultation to clarify roles and ensure that medical terms and concepts are understood. Also, they should discuss cultural issues and optimal ways to convey messages,” she suggested.
“In situations where the family and patient refuse to have an interpreter, explore the reasons why, accommodate their concerns if possible, and highlight the benefits of having an interpreter. The doctor should emphasize that the interpreter is there to help the health professional and has an obligation to maintain confidentiality. Family members are welcome for support. The interpreter ensures that the communication will be effective,” she stated.
“If the patient or family continues to refuse an interpreter, document that and renegotiate at each visit,” she added.
When using an interpreter, she advised that the doctor sit facing the patient, with the interpreter on one side between them. “Speak directly to the patient, be aware of body language, and avoid looking at the interpreter. Always speak in the first person, and don’t ask the interpreter to summarize what you have said. You should summarize and then ask the interpreter to translate that,” she said.
In general, culturally competent care with an interpreter present relies on some of the same principles as patient-centered care: individualized care, getting to know the patient and building trust, picking up cues where misunderstanding occurs, and using language that is simple enough for the patient to understand.
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