PEDIATRICIAN Spring 2003 - AAP-CA

Culturally Appropriate Communication Is
Good Medical Practice
Allan Lieberthal, M.D., FAAP
California is the most culturally
diverse state in the country. Fortyseven
percent of the population
is white, 32 % Hispanic, 12 % Asian and
Pacific Islander, 7 % African American, and
1% Native-American. As many as 46% of
the population has Limited English Proficiency
(LEP). Over 100 languages are spoken
including, in addition to English and Spanish,
Tagalog, Armenian, Chinese, Thai, Korean,
Arabic, Vietnamese, Hebrew, Russian, Farsi,
and Hindi. We, as pediatricians, face a constant
challenge to communicate with our patients
and parents effectively. Many of us speak
Spanish or another language, in addition to
English. Some of us are fluent in that language
while others try to get by with limited fluency.
We are used to getting by with interpretation
by children, friends, other parents, or a combination
of the parent’s limited English and what
little we may know of their primary language.
The consequence may be that important information
is miscommunicated or omitted during
the medical encounter.
A recent article in Pediatrics 1 points out
the pitfalls of inadequate interpretation. In a
sample of 13 encounters, six with a hospital
interpreter, six with ad-hoc interpreters and one
with an 11-year-old child interpreting, there
were an average of 31 errors per encounter.
Seventy-seven precent of errors made by the
ad hoc interpreters and the child had clinical
significance. This was significantly more than
the 53% of clinically important errors made by
the hospital interpreters. Errors included omission,
false fluency, substitution, and addition.
Recognizing that poor communication
results in inferior medical care, the federal government
has set standards for Culturally and
Linguistically Appropriate Services (CLAS)
(www.hhs.gov/ocr/lepfinal.htm). Standards
published by the Department of Health and
Human Services (HHS), Office of Civil Rights
(OCR) apply to covered entities that include
“any state or local agency, private institution
or organization, or any public or private individual
that operates, provides or engages in
health, medical or social service programs that
receive or benefit from HHS assistance.” The
federal CLAS standards require covered entities
to identify the language needs of patients
and to provide proficient interpretation in a
timely manner. At the state level, Assembly
Bill 292 (Yee) has been introduced and, if
passed and signed into law, would prohibit the
use of children as interpreters.
There are many approaches to providing
adequate interpreter services. Kaiser-Permanente
in Panorama City has introduced a prototype
program to comply with the standards.
Employees who serve as interpreters must pass
the language proficiency test for interpretation.
These are mostly Spanish speakers. We rarely
have interpreters available for the many other
languages we encounter in our multi-ethnic
practice. In order to meet the needs of all of
our LEP patients, patients are identified as
needing interpretation at the time of making
an appointment and at check-in. A printed
area on the registration papers indicates the
preferred language of the patient and whether
interpretation services are needed. If there is no
interpreter available, we are using Language
Line Services (www.languageline.com), a
telephone-based service that can provide interpretation
in over 140 languages. This can be
done in the exam room using a pair of portable
phone extensions, one for the patient/parent
and one for the physician. The process requires
only a small increase in time as compared to
having an interpreter on site.
Shortly after the Language Line Service
was in place, I was seeing one of my Armenian
patients whose mother speaks very limited
English. It appeared to be a routine sick visit.
Through halting English, I understood the
symptoms of a common cold, but felt a little
uneasy because the mother did not appear to
understand my English instructions. I tried the
Language Line and soon found out that I had
totally misunderstood the illness. In fact the
child had a history consistent with cough variant
asthma. Had I been forced to communicate
in English, I am sure the mother would not
have understood my explanation and instructions.
Using the Language Line it was easy
Over 100 languages are spoken including, in addition to English
and Spanish, Tagalog, Armenian, Chinese, Thai, Korean, Arabic,
Vietnamese, Hebrew, Russian, Farsi, and Hindi.
to get a good history and to explain what her
child had since she was hearing it in her own
language. The mother, who I had seen on several
previous occasions without interpretation
services, was effusive in thanking me and telling
me how happy she was with the visit. From
initial skepticism, I became a convert.
Unlike pediatricians in private practice
or in network managed care practices, I do not
have to deal directly with the cost and reimbursement
for interpretation services. This is
especially important for doctors practicing in
poor communities with a high percentage of
ethnic minorities. Use of the Language Line
may cost as much as $15 for a 10 minute visit.
If a practice has a large number of patients
requiring interpretation by a nurse, workflow
may be impaired or additional personnel may
be needed. This should be recognized as an
additional expense and must be reimbursed
appropriately.
Even consistent professional interpreter
service will not bring us to a single standard
of medical care. The reality is that there is a
severe shortage of qualified health professionals
in all minority groups. Until our patients
can receive competent care from clinicians
who share their culture and language, we must
do our best to be sensitive and responsive to
their needs.
REFERENCE
1. Flores G, Laws B, Mayo SJ, et. al. Errors
in medical interpretation and their potential
clinical consequences in pediatric emergencies
Pediatrics 2003(1):111:6-14
CALIFORNIA PEDIATRICIAN — SPRING 2003/ 5