Breaking Language Barriers

Dr. Fromer is a past president of the California Academy of Family Physicians and co-convener of the Medical Leadership Council on Cultural Proficiency. He practiced family medicine at the Prairie Medical Group in Santa Monica for 21 years before becoming a private consultant in 2004.

This article is reprinted from the May issue of Southern California Physician

ADDRESSING LANGUAGE access issues and boosting cultural proficiency are critical parts of delivering high-quality medical care. Yet those challenges can seem especially daunting in Southern California. Read on for practical tools and useful resources to bridge communications gaps between doctors and patients.

Delivering high-quality healthcare in 2007 requires that physicians provide care in the languages patients best understand. This can be a real challenge in California, where 12.4 million people speak a language other than English at home and 6.2 million people cannot understand or speak English well enough to communicate adequately in a health-care setting.

Physicians must meet this challenge, though, because the cost of failing to do so is too high. Most practicing physicians are personally familiar with cases in which the lack of interpreter services adversely affected patient care.

Consider the case of a pregnant, Spanish-speaking woman seen in an emergency room for preterm bleeding. Another patient was used to interpret; the pregnant woman left the ER believing everything was fine. Two months later, wondering why her baby had not grown, she again sought care. Upon reviewing her medical records, it was discovered the woman had in fact lost her baby that night in the ER.

Finding Language Access and
Cultural Proficiency Resources for Your Practice
Ensuring language access and cultural proficiency are critical parts of delivering high-quality care. Yet those challenges can seem especially daunting in Southern California. In Los Angeles County alone, there are significant communities of people speaking Spanish, Chinese, Tagalog, Korean, Armenian, Vietnamese, Farsi, Japanese, Russian, French, Arabic, Cambodian, German, languages of the Pacific Islands, Italian and Hebrew.

Thankfully, none of us is alone in this effort these days, as resources are increasingly available. The California Academy of Family Physicians, for example, has been a leader in helping physicians better serve limited English proficient (LEP) patients. We coordinated the development of the popular continuing medical education course, "Addressing Language Access Issues in Your Practice," now available online. Offering a toolkit, expert speakers and Web resources, the program helps physicians in California become comfortable and proficient in providing quality care to LEP patients.

Other resources include publications from The California Endowment, a foundation supporting healthcare improvements. On its Web site, the endowment provides a wealth of information about boosting language access, working with interpreters and developing cultural proficiency.

The Medical Leadership Council on Cultural Proficiency, a group of physician, healthcare and advocacy leaders convened by CAFP and supported by The California Endowment, provides on its Web site meeting summaries outlining federal and state mandates, policy developments, funding ideas and technical solutions for providing language access. On that same Web site, a new searchable database provides interpreter contact information, downloadable health education materials in numerous languages, and local resources for patient and family support in each county in California.

"Clearly understanding what a patient is saying is the cornerstone of gathering an adequate history and practicing good medicine," says Mark Dressner, MD, MEd, a Long Beach Memorial Medical Center Family Medicine Residency Program faculty member, a Los Angeles County Medical Association member and an "Addressing Language Access" faculty member. "Although this can be a challenge in the presence of so many different languages, there are ways we can organize a medical office efficiently and in a fiscally sound manner in order to provide LEP patients the same quality of care as patients who speak proficient English."

Making sure patients and physicians clearly understand each other can improve not only the actual medical care delivered, but bolster patient satisfaction and compliance. "The patient advocate in our health system finds that many complaints from patients with limited English proficiency are resolved when she reviews the chart and simply explains to patients why their care was delivered as it was," says Asma Jafri, MD, chair of family medicine at the Riverside County Regional Medical Center, director of the Family Medicine Residency Program, a Riverside County Medical Association member and an "Addressing Language Access" faculty member.

Communicating More Effectively With LEP Patients
There is a process to effective communication. "The first step is painfully obvious, but usually not done," Dr. Dressner says. "The practice has to identify the preferred language of all LEP patients. This should be accomplished during initial contact with a patient." The information can be recorded on paper or in the computer, but it must be easily retrievable and available early enough to arrange interpreter services. "There must be some kind of flagging system so that the preferred language is not discovered right at the time of the visit or even after the visit has started," he says.

The next step - providing interpreter services-is the most complicated, Dr. Dressner says. One should never use family members, except in an emergency, because confidentiality cannot be guaranteed and dealing with sensitive material is difficult. Children should never be used as interpreters - their understanding of complex medical issues is limited at best and addressing a parent's illness or health conditions can be stressful or even damaging.

Physicians can hire office personnel who speak the most prominent languages in their practices, but most staff members will require additional training in medical terminology and appropriate interpreting practices. Everyone doing interpretation - physicians and others - should be tested to determine the actual level of language fluency.

Office staff cannot cover every language possibility, Dr. Dressner notes, so at times an outside interpreter will be needed. Most charge for their services, but payment for services is provided by some health plans. "Having a staff member research how to obtain interpreters for each health plan for which one is a provider may take some time initially, but may pay off in the end with free [to the provider] interpreter services and ultimately a high standard of care for LEP patients," he says.

When staff or health-plan-provided interpreters are not an option, a physician must provide an interpreter by other means. "For quick interviews, telephonic interpretation is ideal," Dr. Dressner says. "Your medical office must have at least one phone set up in such a way that confidential interpretation for the patient can take place. This can include a speakerphone in at least one exam room or perhaps the use of a cell phone with extra attachments. You might also join together with other providers to contract services more economically." Increasingly, video interpretation and other technological innovations are also available.

In-person professional interpretation is another option, Dr. Dressner says. It can be costly, but may be necessary for prolonged patient encounters. "Here, too, a group of providers may be able to contract for services at a reduced price, and some cost-effective interpreter services may be available through a local hospital."

"I'm bilingual in Spanish and English, and bicultural," explains Michael Rodriguez, MD, MPH, an associate professor at UCLA's Department of Family Medicine, a LACMA member and an "Addressing Language Access" faculty member. "I also have patients who speak Mandarin, Korean, Russian and other languages, and it takes advance planning to be sure an interpreter is available, especially when serious health conditions must be addressed. We've all been in the situation where a family member or friend is interpreting, talking with the patient for several minutes and then gives the physician a simple yes or no answer. I worry during those encounters that valuable medical information is lost."

For more information on assessments and training for bilingual staff, ways to find and work with both paid and volunteer interpreters, ways to determine which language assistance options are best for the practice,when to use face-to-face vs. telephonic interpretation and much more, download the free publication "Addressing Language Access Issues in Your Practice-A Toolkit for Physicians and Their Staff Members" at www.familydocs.org/practice-resources/cultural-proficiency.php or call CAFP at (415) 345-8667 to order.

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