CHAT: language gap article on the Wall Street Journal

[Guest guest]

An interesting article about medical interpretation was published

today on the Wall Street Journal.

Regards from Miami,

Pilar Saslow

English to Spanish Translator

..........

Language Gap: For Ill Immigrants, Doctors' Orders Get Lost in

Translation

Physicians Question the Cost And Need of Prescription

For Professionals to Help --- Ruvim, 11, Gets Tongue-Tied

By Barry Newman

Wall Street Journal

Jan. 09, 2003

UTICA, N.Y. -- Ruvim Kluychits, missing school, sat next to his

mother

at noon one weekday in her dermatologist's waiting room.

Ruvim is 11 years old and moved with his family from Pinsk, in

Belarus,

to this upstate city two years ago. His Russian has begun to wilt,

and

his English is only budding, but his relatives speak no English at

all.

To tell doctors their troubles, they need an interpreter. Utica has a

private interpretation service, but no insurer covers its fees and

most

doctors won't pay interpreters out of their own pockets. So Ruvim's

relatives turn to a boy whose services are available free of charge.

" They do tests and stuff, " Ruvim said as he followed his mother into

the

examination room. " I have to translate. All these doctor words, like

fever. "

In big American cities, some doctors are old hands when it comes to

foreign languages. But as more people who don't speak English

scatter

to

places such as Utica, practitioners in the provinces have come to

rely

on family members, often children, to mediate millions of patient

visits. To interpreters who work with doctors for a living, that is a

dangerous mistake. It can lead to needless surgery, missed symptoms,

prescription overdoses -- and, they say, to a violation of civil

rights.

For a while, the government agreed. Now, as the medical profession

pressures it to back off, the Bush administration isn't so sure.

In 2000, President Clinton ordered federal agencies to pull down

language barriers to government and government-funded activities. He

cited the 1964 Civil Rights Act ban on discrimination based on

national

origin. The mandate was meant for anyone receiving federal funds,

including most doctors and hospitals. Applying the broad order, the

Department of Health and Human Services issued standards that year

saying that patients deserve " competency " from medical interpreters

and

that the use of amateurs is " life threatening. " The standards didn't

say

who should pay for these services -- only that patients should get

them

free.

As some in the health industry began to organize interpreting

services,

the American Medical Association protested. Interpretation fees would

saddle doctors with a " tremendous burden, " it said. Last April, the

Bush

administration signalled a softer approach when it stepped in with a

model standard for all federal agencies: Non-English speakers

who " feel

more comfortable when a trusted family member or friend " is

available,

it said, " should be permitted to use an interpreter of their own

choosing. "

Objections poured in from pro-patient and pro-immigrant groups, led

by

the National Health Law Program and the National Council on

Interpretation in Health Care. Now the medical world is waiting as

Health and Human Services re-examines its earlier rules. The agency

will

" tailor " its guidelines " to serve the people who are affected by our

programs, " says spokesman Gardett. The outcome will

establish

what a medical interpreter is expected to do -- and whether someone

such

as Ruvim Kluychits can be expected to do it.

In the exam room, Ruvim had climbed up on the table beside his mother

when Dr. Palumbo came in and shut the door. Svetlana Kluychits

had

seen the dermatologist earlier for a fungal infection of the

fingernails. He had prescribed taking certain pills for a week, but

they

hadn't worked.

" Maybe it's not enough to take the pills one week a month, " Ms.

Kluychits said in Russian to the doctor. (A reporter's tape of her

visit

was later transcribed by an independent interpreter.) " Maybe I should

have taken them for a whole month. "

Ruvim struggled to translate: " She thinks she needs to take more

tablets

than one week as a month. "

After more talk in this vein, his mother was still confused. " Find

out

whether I should take the pills for a month or a week, " she told

Ruvim.

He tried to ask the doctor, " Does she has to drink the tablets a week

for a month -- "

Dr. Palumbo stopped him. Instructions, he said, would be provided in

writing. His nurse soon appeared with a detailed prescription for

medication to be taken once a day. Ruvim attempted to read it out

loud,

but he struggled again.

As his patient and her young interpreter left, Dr. Palumbo said, " The

kid was pretty bright. He seemed to understand quite well. But I'd be

curious. I guess I don't know if she really got the story. "

Professional interpreters argue that the job of medical translating

is

too important to leave to amateurs. " You don't take a phrase and just

convert it, " says Bruce Downing, a linguist at the University of

Minnesota. He has just started one of the country's first programs to

teach medical interpreting as a specialty. " Liver spots in our

language

don't refer to our livers. In other cultures, liver may take the

place

of heart, " Prof. Downing says. " Interpreting isn't that easy. Family

members have an ignorance of what's important. "

But Dr. Yank Coble, president of the American Medical Association,

sees

little need for specialized training. It is a doctor's duty to use

words

simple enough to roll off any bilingual tongue, he says. " I'm

impressed

at how conscientious patients are about bringing people with them who

have a good command of English, " he adds. " I'd much rather have a

family

member, somebody I know and trust. "

Without a body of scientific evidence to establish its worth, or

government money to pay for it, medical interpreting is an unfunded

and

unaffordable frill, Dr. Coble says. " It's not part of routine medical

care in any country we know of. "

Yet the U.S., in its scale and mix of languages, isn't just any

country.

The 2000 census counted 20 million people who speak poor English, 10

million who speak none. The White House Office of Management and

Budget,

in a 2002 report, estimated the number of patient encounters across

language barriers each year at 66 million.

Hospitals in urban areas dense with immigrants often have

interpreters

on the payroll today. If not, they make do -- though not always

successfully -- with freelancers, volunteers or bilingual staff. But

now

more immigrants are settling in Alaska, Iowa, Kentucky, Maine --

places

where interpreters aren't local grown.

Utica is an exhausted city that in the 1980s offered itself as an

arrival station for refugees. They came from Vietnam, Burma, Sudan,

Bosnia and Russia. Other newcomers spoke Polish, Spanish, Chinese and

Farsi. Among 234,000 people in Utica and environs, the 2000 census

tallied 22,000 who didn't speak English at home.

When a patient's family is eager to interpret, doctors in the area

say

they are inclined to oblige. That's how it was when Mustafa Andelija

wheeled his sister Zehra into a clinic run by one of Utica's two

hospitals, Faxton-St. Luke's Healthcare.

The Andelijas are Bosnians. Mustafa, 36, has been here eight years;

his

40-year-old sister, one. She suffers from cerebral palsy and

diabetes.

On this day, she had what seemed like a very bad cold. " I take care

of

her, " Mr. Andelija said. " I never say OK if I don't understand what

is

mean. " He stood behind his sister's wheelchair in an exam room. Dr.

Goodemote stood in front of it.

" I want to figure out if she has a urine infection, " Dr. Goodemote

said,

speaking over her patient's head. " One of the other things I'd like

is

an X-ray of her stomach. With respect to the chest, I want to see if

she's got fluid on her lungs. That's going to require a chest X-ray.

You

can start telling her that so far. "

A Bosnian interpreter later helped transcribe a tape of what Mr.

Andelija told his sister in Serbo-Croatian. Bending toward her ear,

he

said: " For a pain in your lungs and that fluid that you have, the

only

thing she's going to do is send you for a chest X-ray. After the

chest

X-ray, they're going to know what's going on. "

The doctor said she would order blood tests for " signs of an

infection, "

which Mr. Andelija translated as, " They are going to do blood work to

check your infection. " The doctor said she would order an

electrocardiogram. Mr. Andelija said, " OK, " but nothing more.

As her brother pushed her out of the clinic, Zehra Andelija wouldn't

have known she was headed for a heart test or a stomach X-ray, or

that

it wasn't certain that she had an infection.

After they left, Dr. Goodemote said that even English speakers don't

always follow her instructions. She was pleased to have Zehra

Andelija's

brother do the interpreting because relatives " make sure when she

goes

home that what I say gets done. "

There is an alternative in Utica: In 1999, Cornelia Brown, who has a

doctorate in Russian literature, founded a commercial

medical-interpretation service, which now has 25 part-time

interpreters

on call. If a patient were deaf, a doctor would have to supply a

professional sign-language interpreter at no charge, under the

federal

Americans With Disabilities Act. But people who don't speak English

don't qualify as disabled, and there is no comparable law forcing

doctors to pay Ms. Brown's fees of up to $60 an hour.

Often, that's more than Medicaid's rate for a whole visit, a lot more

than Utica's doctors say they can afford. Only eight states reimburse

any interpreting fees. New York isn't one. Ms. Brown's business

grossed

just $124,000 last year, less than she had expected. In Utica, even

medical organizations that acknowledge the need for interpreters

want

to

find a less costly way out.

For hospitals, the telephone is often an answer. Utica's St.

's

Medical Center has an account with Language Line Services, a

140-language interpreter bank on call at all hours. The hospital does

summon Ms. Brown's people on occasion. But hospital nursing chief

Scholefield says, " If you're communicating a concept, the phone does

the

trick. "

While phones work well in some situations -- an unexpected

emergency-room crisis, for example -- some concepts are more

difficult

to handle than others. Hataija Pehlic, a Bosnian woman of 50, suffers

from depression. At St. Luke's Hospital in 2000, she was served by a

succession of phone interpreters on a squawk box for two hours a day

during a month of psychotherapy.

They spoke a common language, " but I felt really bad, " Ms. Pehlic

says

through one of Ms. Brown's interpreters. " They had different

accents " --

accents, that is, of Serbians and Croatians, the enemies who had

killed

her son and driven her husband to suicide during the Balkan

bloodshed

of

the 1990s. " I think it was a misunderstanding, " Ms. Pehlic says.

In office visits, much less psychotherapy, phone interpreters can be

clumsy and still not cheap. Few Utica doctors use them. If patients

don't bring their own help, many doctors say they simply won't give

them

appointments. But Dr. Stanley Weiselberg, a gastroenterologist, is

one

who does.

When Ana , a Dominican housekeeper on Medicaid, went to see

him

about her liver, she took Tony Colon. Puerto Rican by parentage, he

comes from the Bronx and works for Ms. Brown. Like all of her

interpreters, he is trained never to summarize and to intervene only

to

clarify. The patient's welfare officer recommended the service, and

Dr.

Weiselberg paid the $45 fee.

" You know who her family doctor is? " a nurse asked Mr. Colon. He

said,

" Speak directly to her, like I'm not here. " The nurse turned to Ms.

and said, " Who's your family doctor? " When Ms.

couldn't recall, Mr. Colon said, " The interpreter wishes to

interject, "

and told the nurse the doctor's name.

When Dr. Weiselberg entered the exam room, he didn't need prompting

from

Mr. Colon. As the interpreter whispered in Spanish, the doctor faced

his

patient and told her she had an infected liver.

" I recommend you have what's called a biopsy, " Dr. Weiselberg said.

He

explained that this would allow a more precise diagnosis but that Ms.

could choose to go on medication right away. As the doctor

described success rates and side effects of various drugs, Mr.

Colon's

interpretation, as a review of the tape later showed, was almost

verbatim.

" It's no big deal, at least for me, " the doctor joked about the stab

of

the biopsy needle. A beat later, after listening to Mr. Colon, Ms.

laughed.

" It feels like a dull punch, " said the doctor. ( " A punch not so

hard, "

Mr. Colon made it.) Ms. said in Spanish, " I'm getting pain

just

thinking about it. " And, a beat later, the doctor laughed.

***