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HMOs Confront Language Struggles

Posted on April 8, 2013 at 11:57 AM Comments comments (8)
HMOs Confront Language StrugglesLimited English Enrollees Have Tough Time With DoctorsBy Payers & Providers Staff Mar 7, 2013 California Region Forward/E-MailA new study by UCLA researchers has discovered a link between low levels of English proficiency among health plan enrollees and difficulty in accessing healthcare.According to the study, which was undertaken by the UCLA Center for Health Policy Research, as many as 1.3 million Californians with limited proficiency in the English language are enrolled in health maintenance organizations. Most are enrolled in plans that are designed to serve low-income enrollees, although nearly 10% are enrolled in commercial plans.About 12% of those enrollees – most of whom spoke Spanish as their primary language – said they had trouble communicating with their physicians.Despite state laws and regulations regarding provisions for interpretative services for these enrollees, about half of those surveyed said they did not receive them.“One of the problems with planning for and providing effective interpreter services for our LEP population in California is the lack of consistent training of interpreters,” said Dylan Roby, lead investigator on the study and director of the Center's Health Economics and Evaluation Research Program. “Although health plans are required to assess the language needs of their members and develop a plan to address them, there is quite a bit of variation in how they do so and who is expected to provide interpretation to patients at the bedside or during a visit.”The study also suggested that there was a “disconnect” between the expectations of health plans in dealing with language barrier issues and the actual reality confronted by their enrollees.The study showed significant gender and ethnic divisions when it came to language issues: About two-thirds of females said they had a hard time understanding their physicians, versus about one-third of males.Enrollees in commercial health plans were more likely to have communication issues than those in public plans, while Asians and Pacific Islanders had communication issues less than 20% of the time.Income divisions ran across similar lines: About two-thirds of those with incomes below 200% of the federal poverty level said they had trouble communicating. Only about one-third of respondents with incomes above that threshold said they had trouble communicating with their doctors.Given that as much as 36% of those Californians who receive healthcare coverage next year as a result of the Affordable Care Act, the study's authors suggested that health plans exercise more rigor in training bilingual staff and contracting for language interpretation services.


Posted on February 15, 2013 at 12:01 PM Comments comments (4)
Language, Culture, And Medical Tragedy: The Case Of Willie Ramirez

byGail Price-Wise Gail Price-WiseView Biographical InfoView posts from Gail Price-WiseStart Social Shares Bar End Social Shares Bar Editor’s Note: The November-December issue of Health Affairs contains essays by a physician and a medical interpreter on the challenges and perils of navigating language gaps between medical providers and patients in the absence of a trained medical interpreter. The essays appear in the journal’s “Narrative Matters” section, which is supported by the W.K. Kellogg Foundation. The post below by Gail Price-Wise explores the same themes as these “Narrative Matters” essays. Price-Wise sheds new light on the case of Willie Ramirez, one of the most well-known and tragic instances in which interpreting difficulties and cultural misunderstandings resulted in medical error.On the evening of January 22nd, 1980, eighteen year old Willie Ramirez was out with a friend when he experienced a headache. He attributed it to the smell of gasoline in his friend’s car:
I tried to ignore it because I wanted to be with my friend, and it went away for a while. All of a sudden, I had a sharp pain. I grabbed the back of my head. I sat on the floor. It felt like someone was sticking a needle through my head. My friend helped me to my car. I knew I was going to my girlfriend’s house – it was closer than my house. I couldn’t see right. Everything looked like things were moving around. I tried to find back streets to find the shortest route. I passed her house, slammed on the brakes and turned around and parked. I stumbled out of the car. I fell against the fence. Then her mom came out of the house and helped me in. I think I went in and out of consciousness. I remember a white coat. I think they were slapping my face. They were yelling, “What did you take?! What did you take?!” When I woke up, I didn’t know where I was. I already had the surgery, but I didn’t know anything. I didn’t know I was in a hospital. I didn’t know I was quadriplegic.
Willie Ramirez was taken by ambulance to a South Florida hospital in a comatose state. He became quadriplegic as a result of a misdiagnosed intracerebellar hemorrhage that continued to bleed for more than two days as he lay unconscious in the hospital. In the course of the law suit, it was asserted that Willie could have walked out of the hospital had the neurosurgeon been called in earlier. No neuro consult was ordered for two days because the Emergency Room physician and the doctor covering Willie in the ICU erroneously believed that Willie had suffered an intentional drug overdose and had treated him accordingly. The misdiagnosis was based on the physical exam which initially pointed to a drug overdose, and on complete confusion regarding the medical history. At the heart of this confusion, was the Spanish word “intoxicado” which is NOT equivalent to the English word “intoxicated.”
‘Intoxicado’ And ‘Intoxicated’: Similar In Sound, Very Different In MeaningAmong Cubans, “intoxicado” is kind of an all encompassing word that means there’s something wrong with you because of something you ate or drank. I ate something and now I have hives or an allergic reaction to the food or I’m nauseous. On the day Willie’s intracerebellar bleed began, he had lunch at a fast food restaurant, the newly opened Wendy’s. His mother and his girlfriend’s mother assumed that the severe headache he experienced that night was related to eating a bad hamburger at Wendy’s – that Willie was “intoxicado.” There are various accounts as to when and with whom the word “intoxicado” was used. Four people came into contact with the paramedics and the emergency room doctor: Willie’s mother, Iberia; his 13 year old sister; his 15 year old girlfriend; and his girlfriend’s mother, Concha. Distress clouds Iberia’s face when she denies she used the word, “intoxicado.” I feel like grabbing her by the shoulders and saying, “If it was you, it’s ok. It wasn’t your fault. It was the responsibility of the hospital to ensure their doctors can communicate with patients.”Only Concha admits to using the word, but she adds an important caveat. She insists she clarified to the ER doctor that there was no alcohol or drugs involved. Concha’s English is very difficult to understand. Her accent is thick. She pauses frequently to search for an appropriate English word. She often places the accent on the wrong syllable, distorting the word. But Concha is bold and outgoing and unafraid to speak in a foreign tongue. She’s worked hard to assimilate into America, desperately wishes to speak English like a native and is overconfident in her ability to do so. She informed me that since Iberia didn’t speak English, she spoke to the doctor – in English. She wanted to tell the doctor that the hamburger Willie ate made him sick: “I say him, doctor the amburger intoxiCAted him. I asplain him no alcol, no droogs.”In spite of the emphasis on the wrong syllable, the clearly pronounced “intoxiCAted” is clearly distinguishable, one of the few words that stands out as she relays the story. As Concha speaks, I wondered why she would have added the part about “no drugs, no alcohol,” since 28 years ago she didn’t know what “intoxicated” means in English and would not have recognized the potential for confusion. In recounting the story, she may have added this caveat to calm her conscious. There’s no way of knowing since the depositions have long since been destroyed. But if she truly said “no alcol, no droogs”, her accent may have rendered the words incomprehensible to an English speaker.Differing Memories And Cultural Confusion The ER doctor recalls:
The paramedics brought in an 18 year old comatose male, with no apparent trauma. In those days, we didn’t have a CT scanner in our hospital. All I had was my experience to draw from. His respirations were labored and I thought he might have a respiratory arrest. I intubated him and got his breathing stabilized. He had pinpoint pupils, which can be caused by opioid intoxication. He had no focal neurological sign, no palsy, no blown pupil, nothing to suggest a space occupying lesion. Healthy, strapping kids don’t come into the ER comatose unless they’ve been in a car accident or had an overdose. I thought my conversation with the family confirmed the diagnosis – that he had taken an overdose of drugs. I remember coming into lobby. His mother was there and I spoke to her through an interpreter that accompanied the family. I had some trouble understanding them, but the “gist” of the conversation was that he was upset about a fight with his girlfriend and had taken drugs.
Willie’s sister remembers the conversation with the ER doctor differently:
I remember him very clearly. He was tall and thin and light colored. We Cubans think a lot of Americans look light colored, but he was particularly light. The ER doc said to my mom that he thought it was drugs – that Willie’s condition looked like a drug overdose. My Mom was really upset that they said it was drugs. My mom and I spoke to each other in Spanish. My brother was an all-star baseball player, an athlete. He was really concerned about taking care of his body. We couldn’t imagine that he would use drugs. But a doctor said it – and you tend to believe what a doctor says. So we didn’t protest. We didn’t tell him this was impossible – that Willie never took drugs. In front of the doctor, we just said to each other in Spanish, “This just cannot be true.”
Cultural differences complicated the language issue. The ER doctor did not consider that in certain cultures, people never contradict what an authority figure, like a doctor, has said. The doctor needed to engage the family in a deeper discussion to understand the family’s persepective – that Willie was strongly opposed to drugs and could therefore never suffer an intentional overdose. In my interview with Willie, he said, “I rarely even drank a beer. I was totally against drugs. In fact, I was afraid of them.” The family would have told this to the doctor if they had been put at ease to speak freely. This would certainly have required a professional interpreter.In my interview with the ER doctor, he continues his version of the story, “If I had a Mom who said, “My son would NEVER use drugs,” I may have thought differently.”The ER doctor believed Willie had a fight with his girlfriend that upset him to the point of taking drugs. In my interviews with them, Willie and his girlfriend each told me that they frequently argued. Like many adolescent romances, they would break up one day and get back together the next day. His girlfriend, who was 15 at the time, likely found this to be endlessly fascinating and may have relayed it to the ER doctor. Willie’s mother would have known that her son never took the spats seriously and that this discussion was simply a distraction from the relevant medical history. But she didn’t speak English and was therefore relegated to silence. Most of us would shudder to think that an adolescent girl chattering about her boyfriend could influence life and death decisions in a hospital. This is the power given to bilingual children whose parents don’t speak English.Neither the ER doctor nor the family requested a professional medical interpreter because each side believed they were communicating adequately.According to the 2006 American Community Survey of the US Census Bureau, nearly one in five Americans speak a language other than English at home. At least one in 11 people older than the age of five report that they speak English less than “very well.” In the absence of readily available professional medical interpreters, health care providers turn to people without adequate skills to interpret. Ad hoc interpreters defined as family members, friends, untrained staff, or strangers from the waiting room are significantly more likely to make mistakes and to omit valuable information when interpreting than are professional interpreters.The Power Of Personal ExperienceI’ve spent most of my professional career trying to improve health care services for cultural and linguistic minorities. Privately, I never understood what was so wrong with using a bilingual friend or family member to interpret, especially if the topic wasn’t of a personal nature – meaning sex, or bladder and bowel functions. I changed my mind when my stepmother suffered a vertebral fracture after being thrown from a horse while on vacation in French-speaking Guadeloupe. Unhappily, I was the only person who could interpret in the hospital. My French isn’t fluent, but I would guess that it’s better than the English spoken by many family members who are asked to interpret in US hospitals. The fear of a spinal cord injury added urgency to my attempts to accurately interpret a foreign language. “Does she have neurological damage or not?” I struggled to pronounce “neurological” in French and hoped they would understand me. The response: “There doesn’t appear to be any neurological damage.” I didn’t understand the French phrase for “there doesn’t appear to be” and asked the doctors several times to repeat it, as family members waited wide-eyed for me to interpret what was being said.It’s easy to make serious errors when interpreting. If you don’t understand a word or two, it’s natural to skip that part and just interpret what you understand. You just convince yourself that the few missing words probably weren’t important anyway. Like the ER doctor in the Willie Ramirez case said, you can still get the “gist” of the conversation. As I interpreted for my step-mother is Guadeloupe, I was only missing the French words “there doesn’t appear to be” – followed by the words that were clear to me, “neurological damage.” In getting the “gist” I had a 50:50 chance of interpreting correctly, that there either was or wasn’t neurological damage.Then there was the task of relaying her medical history. Like Willie, my stepmother had suffered a brain aneurysm as a young woman. I assumed this to be an important part of her history, but unfortunately, the word “aneurysm” had never come up in my high school French class. I struggled to explain and believed they understood what I was saying, but I didn’t know if they did. In the end, she recovered fully – in spite of the limitations of her ad hoc interpreter.‘Embarazada’ Versus “Embarrassed” And Other Translation Pitfalls There are lots of pitfalls to avoid when interpreting. Particularly dangerous are false cognates, which are words like “intoxicado” that sound the same in both languages, but mean something different. “Embarazada” in Spanish does not mean embarrassed. It means pregnant. Imagine the woman in her first trimester struggling to explain her condition to the ER staff in her rudimentary English, “I am embaras.” Because of this word, a fetus might be exposed to harmful x-rays or drugs.It’s also easy to simply be offensive. “Excitado” in Spanish is only used to denote sexual arousal. One would not be “excitado” about seeing an old friend – except if that friend is a real or imagined sexual partner. In English, “he is a character,” is different from “he has character.” “I am boring” is easily confused with “I am bored.” These expressions cannot be translated word for word because they won’t make any sense in other languages. “Caliente” means, “hot” in Spanish, but, like “excitado” is often used to refer to sexual arousal, or to food at a high temperature. It would be inappropriate to call yourself “caliente” in a doctor’s office, but you could say that your feverish child feels “caliente” to the touch.One 2-year-old girl with a clavicular fracture was mistakenly placed in child protective custody for suspected abuse as a result of such a mistake. In the absence of an interpreter, a medical resident who may have spoken some Spanish misunderstood “se pegó” to mean the girl was “hit by someone else” instead of the girl “hit herself” when she fell off her tricycle. To a non-Spanish speaker, such an error would seem highly unlikely, but in fact, both translations for “se pegó” – “she hit herself” and “she was hit” are correct. In this situation, a medical resident who spoke some Spanish was worse than a provider who spoke no Spanish. A professional interpreter was needed to glean the correct meaning from the context. Errors in interpretation occur frequently, because it takes years to learn the nuances of a language.Willie Ramirez: Conclusion And AftermathAs a result of the miscommunication, Willie Ramirez was admitted to the intensive care unit with a diagnosis of “probable intentional drug overdose.” The attending physician did not question the diagnosis. Willie’s mother recalls that he had to be restrained because he was pulling out tubes with arms that still worked. After nearly two days, the attending physician recognized that Willie was no longer moving his arms and called in a neurologist who found a serious loss of eye function, indicating brain damage. The left lateral rectus muscle, which normally causes the eye to look to the side, was no longer working, leaving the medial rectus muscle unbalanced. The result was that Willie appeared to be looking at his nose, at least with his left eye.During the exam, Willie experienced a respiratory arrest. He was put on a respirator and whisked away to one of the few hospitals in South Florida that had a CT scanner in 1980. The scan revealed a left intracerebellar hematoma with brain-stem compression, and an acute subdural hematoma. Emergency surgery was performed but it was too late to prevent the brain damage that left Willie quadriplegic. The law suit resulted in a settlement over Willie’s lifetime of approximately $71 million, assuming he lives to age 74.There are other casualties in this story. Willie’s family and friends who tried to explain what was wrong with him and the doctors who tried to diagnose and treat him carry enormous sorrow, not only for Willie’s tragic loss of function, but for the painful thought that it didn’t have to be. In the words of the attending physician 28 years after the event, “You don’t know the agony of being blamed for something like this.

Hospitals struggle to provide interpreters for patients who don't speak English.

Posted on May 22, 2012 at 11:11 AM Comments comments (41)
Hospitals struggle to provide translators for patients who don’t speak English
Hospitals and other medical providers are in a tough spot, say experts. The law prohibits them from asking patients to pay for translation services, and they may not receive adequate or in some cases any other reimbursement. “It’s a civil rights law, not a funding law,” says Mara Youdelman, managing attorney in the Washington office of the National Health Law Program.A dozen states and the District reimburse hospitals, doctors and other providers for giving language services to enrollees in Medicaid, the joint federal-state program for low income people, and in CHIP, a federal-state health program for children, according to Youdelman. Virginia and Maryland do not. /article_body Personal Post INLINE_BB AD BEGIN INLINE_BB AD END/article-side-rail A 2008 survey by America’s Health Insurance Plans, an industry trade group, found that 98 percent of health insurers provide access to interpreter services, but providers and policy experts question that figure. According to a survey by the Health Research and Educational Trust, in partnership with the American Hospital Association,
3 percent of hospitals received direct reimbursement for interpreter services, most of that from the Medicaid program. “Most hospitals that make this a priority make it a budget item,” Youdelman says. Lost in translation Hospitals and other providers realize that offering competent interpreter services can help ensure that they don’t miss or misdiagnose a condition that results in serious injury or death, experts say. Trained interpreters can also help providers save money by avoiding unnecessary tests and procedures. Youdelman cites the example of a Russian-speaking patient in Upstate New York who arrived at an emergency department saying a word that sounded like “angina.” The emergency staff ran thousands of dollars’ worth of tests, thinking he might be having a heart attack. The real reason for his visit: a bad sore throat. Like many hospitals, Children’s Medical Center of Dallas provides interpreter services around the clock via varying modes of communication — face-to-face, telephone and video — delivered by a mix of trained staff interpreters and outside contractors.When Nadia Compean, 23, was six months pregnant, her doctor in Odessa, Tex., told her that her baby had spina bifida, a condition in which the spinal cord doesn’t close properly, leading to permanent nerve and other damage.The local hospital wasn’t equipped to handle the birth and subsequent surgery that her daughter would require, so Nadia and the child’s father traveled to Dallas, about 350 miles away.Neither speaks much English, but at Children’s Medical Center of Dallas, interpreters helped them understand what to expect, Nadia said (through an interpreter).Nadia says she learned that her daughter, Eva, would be born with a lump on her back and would require immediate surgery. She also learned about problems that Eva may experience walking and using the toilet, she says.Eva was born March 6. Because of her medical needs and the lack of adequate interpreter services in Odessa, the couple is considering relocating to Dallas, where the father hopes he can find construction work.This column is produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente.

Interpreters ratify contract with 99% "yes" vote!

Posted on July 15, 2011 at 8:04 AM Comments comments (17)
Federation-represented medical interpreters today ratified their first-ever – and groundbreaking – contract with the state with a 99 percent yes vote.

The vote was 256 to accept and 3 to reject, with 30 ballots voided. This first two-year collective bargaining agreement takes effect July 1.

It’s the first-ever such agreement in the nation for independent contract interpreters.

We’ll have much more in the coming weeks and months on the personal impact of this victory.

But in the big picture, it stands as a moral victory for some 2,000 medical interpreters under contract with the state – many of whom are first-generation Americans seeking the American dream of freedom and fairness.

The pact covers about 2,000 independent interpreters under contract with the state. These “language access providers” help doctors and others communicate to patients and clients for whom English is a second language.

The program came about because of a civil rights lawsuit settlement. Federal law requires that health care providers ensure their Medicaid patients can communicate with doctors. Without the state program, doctors and hospitals would shoulder the costs of hiring interpreters proficient in dozens of languages. And those costs could be passed along to consumers, driving up already high medical costs.

One of the goals of the unionized interpreters is to streamline the program and keep overall health costs low.

In combination with 2011 legislation, the interpreters’ contract reforms an archaic and costly brokerage system where middlemen sap up millions of state and federal dollars before they ever get to interpreters providing the services required by federal law. Ending the costly brokerage system will free up necessary funds; more savings will come from a new online system and resulting scheduling efficiencies. This comes even with a 24 percent budget cut. That current system ends Jan. 1 when a new delivery system for medical interpreter services will start.

The new agreement also aims to retain qualified and quality interpreters. Under their first-ever contract, the state medical interpreters achieved improved work rights and minimum hourly pay of $30. The contract provides an agreement to return to the table to discuss economic compensation after the brokerage system ends in January.

The interpreters began their grassroots campaign to win a contract nearly two years ago. They objected to more taxpayer dollars going to middlemen – an estimated 44 percent of the budget – plus bureaucracy and poor treatment by brokers and agencies. They won union rights from the Legislature in 2010, voted to make WFSE/AFSCME their union and began the groundbreaking contract talks.

The interpreters will use their new contract to continue their fight to maintain quality services in the face of budget cuts.

The interpreters’ comprehensive campaign that included winning the new contract has lowered administrative costs from 44 percent to 28 percent. The union provided data showing the state’s assumptions – based on the number of medical appointments and inflation -- were unnecessarily high. The union will continue to push for administrative costs closer to those for Medicaid of about 4 percent.

Program teaches interpreters how to translate medical jargon with sensitivity

Posted on June 2, 2011 at 7:46 AM Comments comments (55)
Years ago, when Rodney Ramos came to the U.S. from Puerto Rico he was the first one in his family to learn English. So when he was 11 years old and his grandmother became ill, it fell to him to try interpret the doctor's diagnosis that his grandmother had a detached uterus and possibly cancer.
It was an experience he never forgot.
"A child can't be asked to do that," he said, adding that he often served as his family's interpreter.
Out of his experience as a child and then as an adult interpreter at a hospital in Racine, Ramos said he continued to be dissatisfied with the training and outcomes of interpreters trying to communicate between Spanish-speaking patients and doctors.
So after doing a lot of research and consultation, he developed a yearlong medical interpreter technician program that he has taught for the last seven years at Milwaukee Area Technical College.
Earlier this month, 18 students completed the two-semester program that teaches not just language fluency, but also medical terminology, cultural sensitivity, dialectical differences among various Spanish-speaking countries, ethics, values and nonverbal communication skills.
With the growth of the Latino community and changing demographics, health care providers are challenged by the demand to provide professional health care interpreters, said Ramos, 45, who has a bachelor's degree in Spanish with concentrations in English and philosophy.
"There's an incredible need for medical interpreters," he said.
Kristin Neitzel, the patient amenities and family services manager at Children's Hospital of Wisconsin, agrees.
"The need has been around for a long time," she said. "We want to provide interpreters because civil rights law dictates that we do. But more than that, there's a lot of research that shows that service and outcomes are better when an interpreter is used."
Skilled medical interpreters are sometimes also good for a medical facility's bottom line, because if a health issue is well understood and identified early, it can keep the number and cost of diagnostic tests down, she said.
Cultural comfort
It's also important that patients and families feel comfortable culturally, so that they can accurately communicate with doctors and nurses, she said.
"A lot of times families will nod or say 'yes' and that's not what they mean. Or they don't understand and don't want you to know that they don't understand," Neitzel said.
Years ago, people used to say that if you live in this country you should speak English, she said. "But imagine if you were in another country with a sick child or family member and didn't speak the language and couldn't communicate."
In 2000, the U. S. Census Bureau estimated that more than 21 million are of limited English proficiency, she added.
Children's Hospital has five full-time and four part-time interpreters and 29 other interpreters that it brings in through a local company, Neitzel said. All but two of the interpreters speak Spanish; one speaks Hmong and one is a sign language interpreter.
"We don't have the ability to hire all the interpreters we need because it's a cost to the organization and there's no reimbursement for it," she said.
Neitzel, who is a member of the advisory board of health care professionals that Ramos has assembled to provide feedback on the curriculum, said some of the interpreters who work at Children's have gone through the MATC program.
"Rodney has really taken his program to a new level," she said.
Before a student begins the program, Ramos gives a Spanish proficiency assessment, both written and oral, to test comprehension, fluency and limitations. He also conducts a conversation in Spanish and English with the student for additional input.
Ramos then develops an individual educational language plan for each student to elevate a person's language skills. Together the students work in classes in medical terms, culture, ethics and techniques of interpretation.
"The size of the class is kept at 18 because beyond that it's not manageable to produce the level of quality we want," he said. "I think the success of the curriculum is the individualized plan."
He claims a 100% graduation rate from his program.
Most of the students in his classes are Latino but "culturally broader," he said. "They're not polarized, like I'm Puerto Rican. They need to understand the wonderful variations, regionalisms, and that there's no one right way. He who knows the most ways of saying something can cater to the most patients."
Interpreter's role
The role and importance of an interpreter, he said, is to be "a conduit, clarifier and cultural broker."
His goal at MATC is "to lead the state and the Midwest in the quality of medical interpretation."
Every hospital administers its own interpreter test, even if the person has completed the MATC program, he said.
Only in the last year have efforts begun for a national certification program for medical interpreters, and that's still evolving, said Ramos and Neitzel. She said she would like to see Wisconsin have a licensure program for interpreters, but there is none now.
Medical interpreters can earn from $16 to $25 an hour, said Ramos.
"Mr. Ramos is a great teacher who tells you how it is with patients," said Rigoberto Valle, 25, who said he had firsthand experience with interpreters when his mom suffered a stroke. "There were misinterpretations and what I call 'false fluency,'" he said.
Yvette Martinez, 25, who was born in Mexico and is a native Spanish speaker, said she walked into the class thinking she knew what she was doing but soon learned differently.
"I went through a one-week interpreter training course, but I quickly found out I needed more training," she said after completing the MATC program.
"It's so important to be accurate and complete and to convey what the patient is feeling and saying to the doctor," said Manal Rivera, 32. "You see what your family and others go through. That's why I want to do this professionally."

Helping Patients Understand Their Medical Treatment

Posted on April 14, 2011 at 10:06 AM Comments comments (21)
Helping Patients Understand Their Medical Treatment googleoff: all googleon: all
Topics: Delivery of Care, Quality, Public HealthBy Sandra G. Boodman Mar 01, 2011
This story was produced in collaboration with (Illustration for Kaiser Health News by Jack Black)An elderly woman sent home from the hospital develops a life-threatening infection because she doesn't understand the warning signs listed in the discharge instructions. A man flummoxed by an intake form in a doctor's office reflexively writes "no" to every question because he doesn't understand what is being asked. A young mother pours a drug that is supposed to be taken by mouth into her baby's ear, perforating the eardrum. And a man in his 70s preparing for his first colonoscopy uses a suppository as directed, but without first removing it from the foil packet.Each of these examples provided by health-care workers or patient advocates illustrates one of the most pervasive and under-recognized problems in medicine: Americans' alarmingly low levels of health literacy — the ability to obtain, understand and use health information.Translating Medical JargonSome technical terms and what they mean in plain English:
  • "myocardial infarction" (heart attack)
  • "hyperlipidemia" (high cholesterol)
  • "febrile" (feverish)
A 2006 study by the U.S. Department of Education found that 36 percent of adults have only basic or below-basic skills for dealing with health material. This means that 90 million Americans can understand discharge instructions written only at a fifth-grade level or lower. About 52 percent had intermediate skills: They could figure out what time a medication should be taken if the label says "take two hours after eating," while the remaining 12 percent were deemed proficient because they could search a complex document and find the information necessary to define a medical term.Regardless of their literacy skills, patients are expected to manage multiple chronic diseases, to comply with drug regimens that have grown increasingly complicated and to operate sophisticated medical devices such as at-home chemotherapy equipment largely on their own.Health literacy "affects every single thing we do," said Susan Pisano, a member of the Institute of Medicine's health literacy roundtable and vice president of communications for America's Health Insurance Plans, the industry trade association. "The implications are mind-boggling."As recently as a decade ago, the problem of health literacy was largely the province of academic researchers who published study after study documenting the glaring mismatch between the dense, technical and jargon-heavy materials routinely given to patients, some written at the graduate school level, and their ability to understand them.These days, health literacy is the focus of unprecedented attention from government officials, hospitals and insurers who regard it as inextricably linked to implementing the health-care overhaul law and controlling medical costs. The new law, which contains explicit references to health literacy, requires that information about medications and providers be made accessible to those with limited skills. In October, President Barack Obama signed the Plain Writing Act, which will boost that effort by directing federal agencies to use plain language in their materials.Adding urgency to those endeavors is the projected influx into the health care system of 32 million currently uninsured Americans who will begin to get coverage in 2014 under the new law.See DetailsSee details of the National Action Plan To Improve Health Literacy "Health literacy is needed to make health reform a reality," Health and Human Services Secretary Kathleen Sebelius said last year as she launched the National Action Plan to Improve Health Literacy, an effort designed to eliminate medical jargon and the complex, often convoluted explanations that pervade handouts, forms and Web sites."A whole bunch of new people are going to be entering the health-care market and making decisions that involve not just cost and 'Is my doctor in the plan?'" but also complicated trade-offs about risks and benefits, said Cindy Brach, a senior policy analyst at the Agency for Healthcare Research and Quality, which has made improving health literacy a priority.Keeping It Simple Studies have linked poor health literacy, which disproportionately affects the elderly, the poor and recent immigrants, to higher rates of hospital readmission, expensive and unnecessary complications, and even death. A 2007 study estimated the problem cost the U.S. economy as much as $238 billion annually.Starting this year, the Joint Commission, the group that accredits hospitals, is requiring them to use plain-language materials and to "communicate in a manner that meets the patient's oral and written communication needs" in providing care.Hospitals and health plans increasingly are turning to computer software that analyzes materials given to patients and flags overly technical language such as "myocardial infarction" (heart attack), "hyperlipidemia" (high cholesterol) and "febrile" (feverish). One program, developed by Bethesda-based Health Literacy Innovations, is being used by the National Institutes of Health, CVS and Howard University Hospital. It analyzes texts for complexity and suggests ways to simplify them.Employers are pushing insurers to demonstrate that the materials they give patients are simple and intelligible, said Aileen Kantor, founder of Health Literary Innovations.Instead of handing a patient pages of instructions, some hospitals and clinics are using videos or handouts with lots of pictures.Doctors at Boston Medical Center have pioneered an innovative program called Project RED, short for Re-Engineered Discharge, an effort that between 2006 and 2007 reduced readmission rates for the first month after discharge by 30 percent and costs by 33 percent. Instead of standard instructions, RED patients received a personalized discharge booklet, along with help making follow-up appointments and a call from a pharmacist a few days after they arrived home.

A Positive TestJaved Butler, a heart surgeon at Emory University Hospital in Atlanta, said one obstacle to improving health literacy is the language that doctors typically use. "When we say 'diet,' we mean 'food,' but patients think we mean going on a diet. And when we say 'exercise,' we may mean 'walking,' but patients think we mean 'going to the gym.' At every step there's a potential for misunderstanding," said Butler, who added that he tries not to lapse into "medicalese" with patients.It's not a problem only for those with basic skills. Paula Robinson, a patient education manager at the Lehigh Valley Health Network, which includes three hospitals in eastern Pennsylvania, said that even highly educated patients are affected, particularly if they're stressed or sick.She cites the
initial reaction of former New York Mayor Rudolph Giuliani, who thought he was cancer-free when his doctor told him several years ago that his prostate biopsy was "positive." Actually, a positive biopsy indicates the presence of cancer.Many patients, Robinson said, won't ask questions or say they don't understand, either because they are intimidated or worried about looking stupid. Some simply tune out or shut down, she said, and "a lot of people take things literally because of anxiety."Robinson recounts one such case: A patient who had been prescribed daily insulin shots to control his diabetes diligently practiced injecting the drug into an orange while in the hospital. It was only after he was readmitted with dangerously high blood sugar readings that doctors discovered he was injecting the insulin into an orange, then eating it.AHRQ's Brach said that some time-strapped doctors have complained that their schedules are too packed to add literacy concerns to the list.But she said simple measures that are not unduly time-consuming can be integrated into the visit. They include a method called "teach back," which asks patients to repeat in their own words what they have just been told.Illinois geriatrician Cheryl Woodson said she avoids making assumptions about her patients' health literacy. "You can't tell by looking," said Woodson, a solo practitioner in Chicago Heights."I never ask, 'Do you understand?'" she added, "because they say, 'Uh-huh,' and you don't know what they understand. So instead I'll say, 'I know your daughter is going to want to know about this, so what are you going to tell her?'"No Literacy Sometimes the problem is not health literacy, but the ability to read or write at all. It is estimated that 14 percent of adults are illiterate, but many find ingenious ways of compensating and take great pains to hide the problem.Archie Willard said he avoided going to the doctor for years before he learned to read at age 54. Even today Willard, now 80, said he struggles with reading — he is severely dyslexic — and identifies his medication by the shape and color of the pill, not by reading the label.Willard, who divides his time between Iowa and Arizona, said that before he learned to read he employed a strategy in medical settings common among those who cannot read or write. "I would say I couldn't fill out the paperwork because I forgot my glasses. And I didn't even wear glasses."Many experts predict that efforts to boost health literacy may benefit even the minority who are proficient. "People worry about dumbing things down," Brach said, "but in the research, no one has ever complained that things were too simple. Everybody wants clear communication."

Do Hospitals Measure up to the National Culturally and Linguistically Appropriate Services Standards?

Posted on December 2, 2010 at 8:11 AM Comments comments (27)
Background: Federal regulations require that health care organizations provide language services to patients with limited English proficiency. The National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS standards) provide guidance on how to fulfill these regulations. It is not known how US hospitals have incorporated them into practice.Objectives: To assess how US hospitals are meeting federal regulations requiring provision of language services using CLAS as a measure of compliance.Research Design: Cross-sectional survey.Subjects: Hospital interpreter services managers (or equivalent position).Measures: Degree of meeting each of the 4 language-related CLAS standards.Results: Many hospitals are not meeting federal regulations. The majority reported providing language assistance in a timely manner in their first, but not their third, most commonly requested language. Although hospitals reported that they informed patients of their right to receive language services, many did so only in English. A majority of hospitals reported the use of family members or untrained staff as interpreters. Few reported providing vital documents in non-English languages. Overall, 13% of hospitals met all 4 of the language-related CLAS standards, whereas 19% met none.Conclusions: Our study documents that many hospitals are not providing language services in a manner consistent with federal law. Enforcement of these regulations is inconsistent, and thus does not motivate hospitals to comply. Compliance will likely come with new guidelines, currently being written, by many of the regulatory organizations. Our study reinforces the importance of these efforts and helps target interventions to improve the delivery and safety of care to limited English proficient patients.
© 2010 Lippincott Williams & Wilkins, Inc.
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Medical Interpretation and Translation

Posted on November 25, 2010 at 11:46 AM Comments comments (52)
I'm very happy to see the way the Medical Interpretation and Translation field is evolving. Thanks to associations like TAHIT (Texas Association of Healthcare Interpreters and Translators) the medical interpertation and translation field is now being seen more as a respcected profession that requires professional training just like any other profession.