Monday, July 24, 2006

Growing question in hospitals: Como esta?

Hispanic patient influx calls for interpreters

BY HOLLY AUER
The Post and Courier


Every day, Josie Silvagnoli finds the words to describe birth, death and much that comes in between.

The Medical University of South Carolina interpreter works in the valley between two languages, slipping easily between English and Spanish to help doctors and nurses communicate with patients who don't speak English.

She's a broker between cultures, ferrying information to doctors about a patient's symptoms and translating medical jargon and treatment details.

The people Silvagnoli serves are a growing part of the hospital's patient population. The number of patients who report Spanish as their primary language has more than doubled in the past two years, from 794 in January 2004 to 2,081 last month. The number of patients who speak Portuguese is rising, too.

Other Lowcountry hospitals report a similar surge in the number of Hispanics seeking care. They show up in emergency rooms after construction accidents, car wrecks and other bang ups; they come for appointments to manage chronic conditions such as diabetes; and they arrive, grimacing in pain, to bring new babies into the world.

As the nation's non-English-speaking population grows - it's up by 47 percent since 1990, to 49.6 million people, according to the U.S. census - medical interpreting is a growing field and more important than ever. Doctors and nurses with Spanish know-how are increasingly sought-after across the country, and medical schools are expanding cultural competency curriculums to better prepare students for work in multilingual environments.

Without an interpreter to guide Hispanic patients, the words that swirl around them in the hospital - stitches, pain medicine, cancer, blood pressure - have no meaning.

All hospitals that receive federal funds must provide interpreting services, whether in person or on the phone, for free. To meet the need, MUSC has built a medical interpreting program during the past five years. It now staffs 14 interpreters during the day. Overnight, doctors, nurses and patients rely on Language Line, a California-based telephone service.

No other Lowcountry hospitals employ interpreters, instead exclusively using Language Line, with occasional help from Spanish-speaking volunteers or staff members. Visits by Spanish speakers are rising within the Roper-St. Francis Healthcare system, up by about 25 percent since 2004 at St. Francis Hospital in West Ashley. Statistics for Trident Health System, which runs hospitals in North Charleston and Summerville, were unavailable, but officials said that, among its calls to Language Line, 90 percent are for Spanish speakers.

Even as their numbers continue to grow, MUSC's interpreters are strained - their pagers beep enough to keep them criss-crossing the campus all day long - and waiting for one to arrive sometimes takes 20 minutes. That's precious time in a busy health care environment, and physicians can't always wait.

"We're not going to be able to keep up with the demand in the near future," said Jason Roberson, a Spanish interpreter who coordinates the hospital's cultural competency program. "The only way to keep up is to recruit more Spanish speakers" to other parts of the staff.

Despite its federal mandate, Roberson's program is not immune to the heated immigration debate in the United States. Some complain that federal dollars should not be spent on illegal immigrants. Roberson has often heard other patients question why Hispanics "don't just learn English" or why the hospital pays for translation services.

Studies show that the answers come down to simple economics: Failure to properly care for health problems among non-native speakers carries enormous costs, especially when treating pediatric patients or managing chronic conditions such as high blood pressure.

Visits that require interpreters tend to take about twice as long, and studies show that, because of the language challenges, clinicians sometimes take shortcuts, leading to increased medical needs down the line. One 2005 study published in the journal Pediatrics, for instance, relied on a nationwide household survey conducted in both Spanish and English. Children whose parents responded in Spanish had a poorer health status overall than those who filled out the form in English, and they were more likely to visit the emergency room or be hospitalized.

Sloppy or missing interpreting can have "deleterious effects" on health care in that population, according to an article published recently in the New England Journal of Medicine. In one recent case, a mix-up between the words "nauseous" and "intoxicated" left a Spanish-speaking teen a quadraplegic, leading to a $71 million malpractice settlement from the hospital.

Who should translate?

During office or hospital visits, patients may use a relative or friend as an interpreter, but they're usually asked to sign a waiver releasing the provider from liability if incorrect information is exchanged in translation. Researchers have found that's a common problem: One study found that, on average, 31 errors occur during each clinical encounter that relies on a translator. Mistakes committed by family members, friends or nonclinical hospital staffers - bilingual secretaries or janitors, for instance - are more likely to have health consequences than those committed by trained hospital interpreters.

That's because even those with Spanish fluency might lack the vocabulary to describe complex medical symptoms or conditions, Roberson said. People younger than 18 aren't allowed to be interpreters, according to national guidelines.

"It breaks down the whole social structure of a family," Roberson said, for children to be asked to deliver bad news or talk about sensitive issues such as sexually transmitted diseases.

Physicians say adding bilingual support staff is key. Now, when Spanish-speaking patients call Ashley River OB/GYN to make an appointment, receptionists have to pull Puerto Rico-born Dr. Joyce Noriega out of exams to speak to them. Same when Hispanic patients get lost on their way to the office and call for directions, or when women who have just given birth need instructions in Spanish.

"It's a little bit disruptive to the access of care," Noriega said. "It makes it hard for me to care for a lot of patients if I have 20 people that I'm having to answer the phone for."

Among nonclinician interpreters, those with combined skill-sets - such as social workers with Spanish fluency - are in greatest demand. Paying for them, however, is another story.

Local hospital interpreters make about $30,000 a year, but it's often a struggle for private clinics to carve those salaries out of their budgets.

"It's hard to pay people what they're worth," said Clara Lobo, office manager at Angel Oak Family Practice on Johns Island, where about 60 percent of patients are Hispanic.

Costs of confusion

Further studies examining how insufficient interpreting services affect long-term care outcomes for Spanish-speaking patients are under way across the nation. In the meantime, patients say interpreting services are inconsistent, and some worry the results mean life or death.

Bethel Alvarado, 30, has been living in the United States for three years and was diagnosed with cervical cancer this year while pregnant with her son, Julio. Chemotherapy and radiation treatment swiftly followed his birth, but months later, she remains ill.

Before moving to Murrells Inlet last year, Alvarado lived in California. Because of language problems she had while being treated there, she said she was afraid when she arrived at MUSC.

"My fear was that they wouldn't give me the attention of care I deserved because I was Hispanic," Alvarado said through Silvagnoli, who has guided her during treatment. Instead, she has received printed materials about her disease and treatment in Spanish, and she said the interpreters at MUSC are "very clear and very specific."

When the talk is unclear, doctors say continuity of care breaks down. Noriega recalls seeing charts of pregnant patients where health histories were incomplete or incorrect because of language barriers. Essential elements such as whether they'd had a baby before and, if they had diabetes, how and when they'd been treated, were prone to be wrong, she said.

In tough situations, it's likely to be family members who need translation services. Nitza Tyus, a Spanish-speaking family support counselor for LifePoint, South Carolina's organ procurement agency, recalls working with a man whose son had been gravely injured in a fall.

"There was nobody there to explain to him that he's almost brain dead, he's almost gone," Tyus said. "He just thought, 'Get him better.'?"

But after she stayed with him for two days and explained in Spanish what was happening as his son's condition worsened, the man understood that it was time to let go. And he decided his son should be an organ donor.

Making a connection

Obstetrics is one area where the need for Lowcountry translators is particularly great. Twenty-five percent of the babies delivered at MUSC are born to Spanish-speaking mothers. No interpreters are available there after 11 p.m., so moms who find themselves in labor at night must rely on the Language Line to communicate with care providers.

Videos and printed materials help, too. When Jessica Moldonado, who has lived in the United States for slightly less than a year, checked in recently to deliver her baby, nurses immediately set her up with a series of Spanish movies that taught her about the features of her room, such as how to use the mechanized bed, and how to care for her newborn baby.

Kristie Appelgren, a fourth-year medical student at MUSC who majored in Spanish as an undergraduate, found her fluency and knowledge of Latin America especially helpful last year during her OB/GYN rotation.

"If I was pregnant and happened to be in Russia when I went into labor, I would be petrified," Appelgren said. "It just helps to make a connection however you can."

1 Comments:

Blogger shivakumar said...

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11/12/12 9:45 AM  

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