Working with Translators

[mathilda25]

Hello,

I am wondering if any of you have treated outpatients utilizing translators for patients who don't speak English. If so what have your experiences been? I realize that mental health issues are one of, if not the, worst things to talk about through a translator, but what if there just are not any bilingual professionals around?

Basically I am interested in how difficult it would be to treat outpatients through a translator. Psychotherapy seems especially problematic, but what about medication checks?

I'd really appreciate any thoughts on this. Thanks so much!

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[Solideliquid]

Well if you are in a training program I think the department/hospital would provide a translator. In that case that person would be beholden to HIPAA rules as a hospital employee, and this is easily explained to the patient.

On the other hand, if you are working in a private practice, I'd either learn the language (usually Spanish) most likely you'll be needing it in an area where lots of folks speak this language. However if it is something like Korean or otherwise difficult to learn and not used too often a trusted family member (usually spouse) who speaks English can help out.

 

[TheWowEffect]

Hello,

I am wondering if any of you have treated outpatients utilizing translators for patients who don't speak English. If so what have your experiences been? I realize that mental health issues are one of, if not the, worst things to talk about through a translator, but what if there just are not any bilingual professionals around?

Basically I am interested in how difficult it would be to treat outpatients through a translator. Psychotherapy seems especially problematic, but what about medication checks?

I'd really appreciate any thoughts on this. Thanks so much!

I have a patient who speaks one of eastern european languages and no English at all. She can only say, "please and thank you." Luckily she comes to appointments with her daughter who is quite fluent in English. Her condition is stable and she comes for med reviews only every 3 months. I tried finding another resident but none of our European IMGs know that language.

 

[Doc Samson]

I have a patient who speaks one of eastern european languages and no English at all. She can only say, "please and thank you." Luckily she comes to appointments with her daughter who is quite fluent in English. Her condition is stable and she comes for med reviews only every 3 months. I tried finding another resident but none of our European IMGs know that language.

Your facility is by law required to provide an interpreter for the patient, even if it's by telephone (most places I've worked have access to the AT&T language line). Using a family member for a psychiatric interview is suboptimal to say the least.

 

[OldPsychDoc]

First off, I've always been taught that it's a bad idea to use family as translators, and probably doubly so in psychiatry, where confidentiality and the ability to have a neutral eye for the patient's symptoms is important. We're fortunate in our hospital to have a corps of interpreters in the main languages found locally. If we can't get one of them, we have a range of contacts locally from private agencies, but they tend only to be available during the day. Finally, less desirable than a "warm body" face-to-face interpretation, but still better than family (who may have their own agenda), we can connect to the AT&T service for a phone interpreter*. In the clinics we tend to use the private agencies or AT&T as well.


* My personal pet peeve--we have a substantial community of Karen locally(a rural people group from the Burmese/Thai border area). Getting an AT&T interpreter 9 times out of ten involves having to repeat "I said Karen, NOT KOREAN", and then ending up with Burmese, which these folks speak about as well as a recently embarked migrant worker might speak English...

(Doc Samson beat me to the post again...)

 

[whopper]

In NJ, is is STATE LAW to talk to provide who doesn't speak English as a first language with a translator who is a hospital employee or someone designated with the hospital to be a translator (such as a telephone interpreter system).

The only exception is if the person is offered one but says they do not need one.

Family members are a problem. There's a conflict of interest that can possibly violate HIPAA rules. The family members, even with good intentions try to interpret what's going on & embelish & make judgements which really need to be made by the doctor, not the family member.

Family of course should provide input, but should be done within confines of obtaining collateral information, not as a translator.

And even if you're not in NJ, it is standard of care to still follow the same rules.

That being said, I generally have a problem with using a telephone interpreter system because it makes what could've been a 20 minute interview into a painful 40 minute interview. I prefer using hospital employees, who have the advantage of making things faster & also can interpret body language, but sometimes you can't find one who speaks the language & you got to use the phone.

 

[TheWowEffect]

In NJ, is is STATE LAW to talk to provide who doesn't speak English as a first language with a translator who is a hospital employee or someone designated with the hospital to be a translator (such as a telephone interpreter system).

The only exception is if the person is offered one but says they do not need one.
Family members are a problem. There's a conflict of interest that can possibly violate HIPAA rules. The family members, even with good intentions try to interpret what's going on & embelish & make judgements which really need to be made by the doctor, not the family member.

Family of course should provide input, but should be done within confines of obtaining collateral information, not as a translator.

And even if you're not in NJ, it is standard of care to still follow the same rules.

That being said, I generally have a problem with using a telephone interpreter system because it makes what could've been a 20 minute interview into a painful 40 minute interview. I prefer using hospital employees, who have the advantage of making things faster & also can interpret body language, but sometimes you can't find one who speaks the language & you got to use the phone.

This is what happened in my case. Of course, I have no way of making sure that her daughter said the same thing to her but the patient clearly shouted NO to my offer to getting a telephone interpreter.

 

[Doc Samson]

In NJ, is is STATE LAW to talk to provide who doesn't speak English as a first language with a translator who is a hospital employee or someone designated with the hospital to be a translator (such as a telephone interpreter system).

I'm pretty sure it's federal law.

 

[mathilda25]

Thanks for all the replies!

For those of you who have worked with translators in a nonacute setting how much did you feel it hampered you treating the patient? Has anyone treated a patient longterm through a translator?
I realize you have to get a translator when needed, I'm just curious regarding the outcomes.

 

[OldPsychDoc]

Thanks for all the replies!

For those of you who have worked with translators in a nonacute setting how much did you feel it hampered you treating the patient? Has anyone treated a patient longterm through a translator?
I realize you have to get a translator when needed, I'm just curious regarding the outcomes.

I feel that it totally hampers me. I would never try to do therapy, per se, with a translator. Translated outpatient visits are pretty much "checklist-style" med checks. That's just my experience. The only exception might be a deaf man with whom I at least feel a bit of connection (of course his eye contact is good in part b/c he's trying to read my lips). Even then, it's totally wierd having that other person in the room and him talking about whether his sexual side effects are better on Effexor than on Paxil...

 

[hippiedoc13]

I'm pretty sure it's federal law.

It is.

http://www.massmed.org/Content/NavigationMenu3/BackIssues/2003/February2003/YourPractice/default.htm

Relevant excerpts for this discussion:

If you are a physician receiving federal financial assistance, U.S. law requires that you provide interpreter services to your patients who are considered "limited-English proficient" (LEP).
LEP patients are those who cannot speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers.

Caution: Requiring, suggesting or encouraging use of friends, minor children or family members as interpreters may expose one to liability. A competent interpreter must not only speak both English and another language fluently but also be familiar with relevant clinical terminology and cultural customs.

Further, some states may have more restrictive laws than the federal statutes.

 

[Faebinder]

Err.... Hi. This is Dr. Faebinder... Yes, can I get an interpetor for my translator please? I have no idea what he is trying to say.

 

[michaelrack]

If you are a physician receiving federal financial assistance, U.S. law requires that you provide interpreter services to your patients who are considered "limited-English proficient" (LEP).
.

What does "physician receiving federal financial assistance mean?" Does that include any doc who takes Medicare?

 

[hippiedoc13]

What does "physician receiving federal financial assistance mean?" Does that include any doc who takes Medicare?

Yes, it includes any doc who takes Medicare or Medicaid.

 

[Anasazi23]

How the hell is "federal financial assistance" equate with a paycheck to a doctor for providing physician services?

They make it sound like we're receiving welfare.

 

[nancysinatra]

On a related note, does anyone have experience with speaking a foreign language themselves with patients? I've been able to do this on other rotations--medicine, surgery, peds, etc., but in psychiatry I would think the need for fluency would be higher. At what level of fluency is it ok to try to manage the conversation on your own? Assuming a translator is not nearby, is it a disservice to the patient to talk to them in their language if you are reasonably proficient, but less than completely fluent?

 

[SamusLives]

I've interviewed pts in Spanish (i'm fluent) and I think it makes a big difference in Psychiatry. It helps build rapport, improves compliance with therapy, and helps in picking up subtleties in language.

Just out of curiosity I've listened in on translated interviews (by a hospital translator) and it's just not the same. The translators are great and their spanish is great, but they're not doctors and a literal translation doesn't always convey the right meaning. Many times the pt won't understand the question and the translator can't clarify b/c they don't know what the point of asking particular questions (ie. what information they're trying to elicit). And of course the interview takes 2x as long. Its much easier using a translator for non-psych stuff.

In the end, what can you do. If you need to use a translator, then you gotta do it.

 

[Lauraaa]

I did a year of psych research in a foreign country. I loved it but working with translators was tough. I was not doing the actual psychiatric assessment - I was doing the assessment of which group the participants would fall into during the study, which had to do with some pretty cut and dry criteria concerning demographic factors - and even then it was at times very painful working with translators. Often I felt like I was Bill Murray's character in "Lost in Translation" when I would ask a question and there would be about 5 minutes of converstion between the participant and the translator and then the translator would turn to me and say "He says 'yes'." Here in the US my experience has been that it is a more strict word for word translation with no extra interpretations thrown in by the translators, which is great. Even still though, I feel a lot of distance from the patient when I need to use translators, over and above what I would assume would be a cultural distance, and I really don't like that distance at all,, but maybe it just takes on average longer to establish a rapport in those situations.

 

[Still Kickin]

I have an intermediate level Spanish; on my psych rotation we used the AT&T telephone interpreter for some of the patients. (Note: this was acute inpatient, not outpatient which the OP was asking about...) Anyway, my Spanish is good enough that I could follow what the patient was saying (and the translation) and I must say that the AT&T interpreters are EXCELLENT. They are true, PROFESSIONAL translators. (They give a much higher-quality translation than some kindly bilingual staff member who is just trying to help out.) For example: our patient went into an extended monologue about her day - myself with my limited Spanish I would have translated this something like "she's talking about her day and how she took her dog for a walk." The translator translated EVERYTHING, perfectly (I don't know how she could remember everything SO EXACTLY by the time that 3-5 min "monologue" concluded.) (Example [compare to "my" translation, above]: "Well, doctor, you see it's like this. That morning I had forgotten to set my alarm but I woke up at about 6:30 a.m. anyway because my dog, Pepe, was licking my face. I always take him for a walk at 6:30 and he was ready to go. He even had his leash in his mouth...)
I had one Spanish-speaking patient that I worked with in Spanish - she was high-functioning and would realize when I wasn't getting something and slow down with her speech or simplify the language she was using... My Spanish has been up to snuff for *most* of my clinical rotations but overall on my Psych rotation it just wasn't enough for working with the REALLY ill patients. If someone can't comprehend social clues, etc., they just don't "get" the fact that it's time to slow down or simplify with the vocab. Also, things like "Santa Claus Ford Pickup blue baby upstairs phonecall New York sweet potato pie" don't make much sense in ENGLISH, so NO WAY would I EVER "follow" something like THAT in a language that was not my native tongue.
(But, yeah, with an interpreter, everything DOES take a REALLY LONG time...)

 

[whopper]

For those of you who have worked with translators in a nonacute setting how much did you feel it hampered you treating the patient? Has anyone treated a patient longterm through a translator?

I have worked long term, doing psychotherapy on a patient who speaks Urdu (the native language of Pakistan).

It is not as effective as speaking the same language of the patient. Its slower, you may miss some body language because its not being timed exactly with the spoken word, and you could get a bad interpreter that's not too bright that misses a lot.

I had one interpreter where I asked the patient yes/no questions and she'd give me answers that were not yes/no. I started considering that the patient might've been psychotic or had some type of cognitive disorder because the questions were not being answered properly. Turned out the translator was not answering properly & trying to add her own interpretation of what was going on & mixing that in the answers. I got another translator who then answered literally. Turned out the patient just had a bit of adjustment disorder.

 

[tr]

On a related note, does anyone have experience with speaking a foreign language themselves with patients? I've been able to do this on other rotations--medicine, surgery, peds, etc., but in psychiatry I would think the need for fluency would be higher. At what level of fluency is it ok to try to manage the conversation on your own? Assuming a translator is not nearby, is it a disservice to the patient to talk to them in their language if you are reasonably proficient, but less than completely fluent?

I'd say that one has to know one's own limits. When the disadvantages of your imperfect language skills outweigh the disadvantages of translation, it's time to call a translator.

I've done many psych interviews in Spanish, a language in which I am very functional but not native. It works fine, definitely better than having a translator. Definitely definitely improves rapport - they love you instantly just for speaking their language.

 

[Hurricane]

My pet peeve is when I ask the patient a question, and the translator and the patient have a 2 minute back and forth, and then the translator turns to me says "no."

 

[Faebinder]

Dr Faebinder: "Could you ask him if he has any psychiatric history please?"

Translator: "Xocpsdj #$dkjpma Skidjwm sdkoamldok skoldpl, kojdhyw?"

Patient: "ksdhua soikdso, jsdjsd ksdkdws msdkjwu sdjkisdiaj sdijqwidj isdjoduw djiwjwid djiwdjwdo wdjiwdjwdkwdo sdjij. Dkosadjo djsuwj hjaijfuqa dkoajfu dlkoajodoi. Dkoajdk pdkid kodkow omdijwdojkdco kdowdaskjoass."

Translator: "Kosduian jmdija idhamoid?"

Patient: "Sjkdija khjdijask jidnjaoisja jdiw2ehjoaj kadojjas. Askoajsd kosjaioj askjodjjwiu kdjuhrfwlakx. Asjk Akis."

Translator: "He said no."

 

[Still Kickin]

So - I'm on my Psych ER rotation right now. They have this videocam/telephone translation service. (Kind of like a webcam; I'm not sure if it was via the internet or more "traditional" phone line [and of course - is there really any difference between the two anymore?])

Anyway, it is the same healthcare system as my inpatient rotation that I mentioned previously, where we used telephone interpreters. I don't know if this is a new techology that they've implemented since my previous rotation, or if it's just something we have at some locations and not at others.

Anyway, I saw someone else using the device yesterday & thought it was pretty cool. And TODAY I got my own chance to use it. I was SO EXCITED!

 

[Anasazi23]

FYI for board purposes. I had a question on this:

When using a translator, speak directly to the patient, and allow the translator to translate, which if they know what they're doing, will phrase the question in the exact way (or close to it) you did.

 

[hippiedoc13]

I recently used telephone interpreter services for a Laotian-speaking patient with a psychotic disorder on the inpatient psychiatry service. We used the interpreter on a daily basis for my interviews with her. I found it helpful to "brief" the telephone interpreter on the situation before we got started, so that I could get as much info from them as possible. ie, I'd let the interpreter know that I am working in an acute psychiatric setting, and this patient is very ill and psychotic, and I will be asking some questions that might sound kind of funny. And she might give some answers that might sound kind of strange. But please just do your best to convey exactly what she's saying as closely as possible, because it's important to me to hear how she puts ideas and words together, not just the actual content of her answers.
Also, my experience with these interpreters is that they are excellent, and if you probe them with the right questions after the interview they can give you very valuable information about speech and thought process. So I give them a heads-up at the beginning that those things are important info for me, and I will be asking them about that stuff at the end of the interview. It really helps me in my assessment of the patient, and I just document in the mental status exam something like, "per interpreter, patient's speech was notable for lack of spontaneity and poverty of content with a lot of repetition of stock phrases." These are things I would never be able to pick up if I didn't ask for the interpreter's impressions.