Medical Office Staff Training

Language Access & Cultural Issues

Presenter: Rebecca J. Patchin, M.D.

Presented by the Riverside County Medical Association and the

San Bernardino County Medical Society

Supported by an educational grant from the California Academy of Family Physicians and The California Endowment

Helping your Doctor Care for Patients with Limited English Proficiency

Resources Available Ideas & Tools What Others Have Done

Background In 1990, 8.6 million Californians spoke a

language other than English at home and 4.4 million were considered “limited English proficient” (LEP).

By 2000, those number increased by 40%, with 12.4 million speaking a language other than English at home and 6.2 million being identified as LEP.

Figures released in late 2007 show that one in five people in the US speak a language other than English in the home.

Language Diversity

Many native & foreign-born Californians speak a primary language other than English at home.

Statewide, more than 12 million Californians speak languages in each of the 39 language categories reported by the U.S. Census Bureau.

Not surprisingly, Spanish is far & away the most prevalent language spoken at home, after English.

However, among the top ten languages spoken in CA, more than half are Asian languages, Chinese, Taglog, Vietnamese, Korean and Japanese.

Riverside County Riverside County has a population of 1,545,387

Race & Ethnicity White: 65.5% Black 6.2% Hispanic: 36.2% Asian: 3.5%

14% of the total population (221,999) are limited English proficiency (LEP)

Languages spoken in homes in Riverside County include Spanish Tagalog Vietnamese Korean Chinese Japanese Laotian Persian Hindi Gujarathi Urdo Thai Cambodian Miao, Hmong

San Bernardino County San Bernardino County has a population of 1,709,434

Race & Ethnicity White: 58.7% Black 8.9% Hispanic: 39.2% Asian: 4.6%

14% of the total population (240,549) are limited English proficiency (LEP)

Languages spoken in homes in San Bernardino County include Spanish Tagalog Vietnamese Korean Chinese Japanese Laotian Persian Hindi Gujarathi Urdo Thai Cambodian Miao, Hmong

Clear Communication between Doctor & Patient

Results in:o More accurate diagnoseso Agreed and understood treatment planso Increased adherence to medication instructions. o Improved health outcomes o Reduction in frustration of doctors and office staff.o Increased patient satisfaction

What can YOU do to provide/identify language access issues in your practice?

Assess Your Practice’s Language needs

Identify Existing Resources Develop a Plan for Improving Your

Practice’s Language Access

Hint: Use the “Addressing Language & Culture: A Practice Assessment for Health Care Professionals” as your guide.

Health Care Interpreters

Health Care InterpretersThe fundamental purpose of health

care interpreters is to facility communication between two parties who do not speak the same language and may not share the same culture.

Health Care Interpreters

With communication: Doctors can gather the information needed for an

accurate diagnosis. Patients & Doctors can better understand each others

views, concerns, values and priorities, and cultural practices and perspectives.

Patients & Doctors can negotiate treatment plans. Patients can understand how to care for themselves. Patients can understand their options and participate

in decisions regarding their health. Patients and Doctors are more likely to develop

trusting and caring relationships with each other.

Key Terms

Interpret: Language being interpreted from Translate: Untrained and untested interpreter Source language: Orally expressing a message

from one language to another Target language: Language being interpreted to Ad-Hoc Interpreter: Converting written text from

one language to another Register: Vocabulary, grammar, and

pronunciation that usually reflects a speaker’s educational and social background.

Definition of Culture (one definition)

The thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious, or social groups.

Culture defines how health care information is received, how rights and protections are exercised, what is considered to be a health problem, how symptoms and concerns about the problem are expressed, who should provide treatment for the problem, and what type of treatment should be given.

In sum, because health care is a cultural construct, arising from beliefs about the nature of disease and the human body, cultural issues are actually central in the delivery of health services treatment and preventative interventions.

Culture …

By understanding, valuing, and incorporating the cultural differences of America’s diverse population and examining one’s own health-related values and beliefs, health care organizations, practitioners, and others can support a health care system that responds appropriately to, and directly serves the unique needs of populations whose cultures may be different from the prevailing culture.

What Happens When Qualified Interpreters Are Not Available?

Family members, children, friends, any bilingual person in the area, and untrained bilingual employees are asked to interpret. All have good intentions and do not intend to cause harm, but …

Patients are seen without an interpreter. Patients are turned away unless they bring

someone to interpret for them.

Risks of Ineffective Communication Incomplete communication between

practitioners and patients plays a major role in medical professional liability claims.

Numerous studies show that the majority of patients do not fully comprehend the health information that is presented to them and that Doctors often make incorrect assumptions about patients’ level of health literacy.

Scope of Low Health Literacy (Institute of Medicine Report)

Nearly half of all American adults – 90 million people – have difficulty understanding and acting upon health information.

Forty million Americans cannot read complex texts (e.g. informed consent forms) at all.

Even people with strong literacy skills may have trouble obtaining, understanding and using complex health information.

Health Literacy

It is not difficult to imagine how misunderstandings or gaps in communication can fuel patient anger over a poor outcome and spark subsequent litigation.

Health literacy is defined as “the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions.”

Key Findings in IOM Report

The readability levels of informed consent documents exceed the documented average reading levels of the majority of adults in the U.S.

Health professionals and staff have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy.

Key Findings … IOM Report

Even signage and directions posted for employees and visitors can often be inadequate.

This report also noted that “identifying the extent of limited health literacy is also problematic because individuals tend not to tell their Doctors about literacy problems that they encounter in the increasingly complex health system, including trouble understanding both printed materials and the meaning of discussions with Doctors.

An Example

A two-year-old is diagnosed with an inner ear infection and prescribed an antibiotic. Her mother understands that her daughter should take the prescribed medication twice a day. After carefully studying the label on the bottle and deciding that it doesn’t tell her how to take the medicine, she fills a teaspoon and pours the antibiotic into her daughter’s painful ear.

Example…..cont.

The doctor may very well have told the patient’s mother than the medication should be taken orally, but the mother may not have understood what this meant and may have been too intimidated to ask.

In fact, “oral” appears on the following list of medical terms that patients may not understand and their translations into plain language.

List published by the AMA Foundation. This list is not comprehensive but can serve as a reminder that common medical terms can be confusing for the average American.

Medical Term

AnalgesicAnti-InflammatoryBenignCarcinomaCardiac ProblemCellulitesContraceptionEnlargeHealth FailureHypertensionInfertilityLateralLipidsMenopauseMensesMonitorOralOsteoporosisTerminalToxic

Translation into Plain English

Pain KillerLessens swelling & irritationNot cancerCancerHeart problemSkin infectionBirth ControlGet biggerHeart isn’t pumping hard enoughHigh blood pressureCan’t get pregnantOutsideFat in the bloodStopping periods, change of lifePeriodKeep track of, keep an eye onBy mouthSoft, brittle bonesGoing to diePoisonous

Note: An English-Spanish Dictionary of Health Related Terms, 3rd Edition, July 2005, is available on the MLC website at www.medicalleadership.org

Health Literacy & Informed Consent

Lack of informed consent is a frequent secondary allegation in medical professional liability claims A patient alleges that he or she was not aware of a

particular risk or side effect• For example, a vaginal birth after cesarean (VBAC) patient

may allege that she was not aware that her uterus could rupture (or that she didn’t know what the term VBAC means)

• A patient on a long-term medication may allege that he was not aware he could develop liver toxicity from taking that medication.

From a risk management perspective, the informed consent discussion is crucial to defending a physician. The discussion, though, serves no purpose if patients cannot comprehend what is being said.

Identifying and Addressing Low Health Literacy Test for health literacy when taking vital signs

Literacy test available in both English and Spanish that is designed to quickly assess literacy without disrupting patient scheduling. www.newestvitalsign.org

Can be administered by a medical assistant while taking other vital signs.

Test based on the patient reading an ice cream label. Patient is asked to determine total calorie count and whether or not a person with a peanut allergy could eat the ice cream based on ingredients.

Although simple, the test can identify whether or not the patient can read, do simple math (important for calculating doses for medicine) and use abstract reasoning.

6 Steps to Improve Communication with Patients Whose Health Literacy is Limited1. Speak slowly & spend a small amount of additional

time with each patient.2. Use plain, non-medical language.3. Show or draw pictures, which can improve the

patient’s recall of ideas.4. Limit the amount of information provided to pertinent

tasks at hand. Repeat the information to enhance recall.

5. Confirm the patient’s comprehension by asking them to repeat back your instructions.

6. Create an intimidation-free environment by making patients feel comfortable asking questions. Enlist the aid of others (interpreters, patient’s family, friends) to promote understanding.

Developing Plain-Language Educational Materials Visual materials can support effective

communications. Experts have noted that “when reading

messages, readers look at the visual first, the caption second, and the text last.”

Research has shown that for patient health care instructions, visuals can increase patient understanding, and compliance.

CA Standards for Healthcare Interpreters Confidentiality: Interpreters treat all

information learned during interpreting as confidential.

Impartiality: Interpreters are aware of the need to identify any potential or actual conflicts of interest, as well as any personal judgments, values, beliefs or opinions that may lead to preferential behavior or bias affecting the quality and accuracy of the interpreting performance.

Respect for Individuals and Their Communities: Interpreters strive to support mutually respectful relationships between all three parties in the interaction (patient, doctor, interpreter), while supporting the health and well-being of the patient as the highest priority of all health professionals.

Professionalism and Integrity: Interpreters conduct themselves in a manner consistent with the professional standards and ethical principles of the health care interpreting profession.

Accuracy & completeness: Interpreters transmit the content, spirit and cultural context of the original message into the target language, making it possible for patient and provider to communicate effectively.

Cultural Responsiveness: Interpreters seek to understand how diversity and cultural similarities and differences have a fundamental impact on the health care encounter. Interpreters play a critical role in identifying cultural issues and considering how and when to move to a cultural clarifier roles. Becoming culturally sensitive and culturally responsive is a life-long process that begins with an introspective look at oneself.

Three-Way Partnership

Recognizes the three unique relationships in an interpreting encounter and the expertise of each party. Relationship 1: Patient-Doctor Relationship 2: Doctor-Interpreter Relationship 3: Interpreter-Patient

Primary Relationship: Patient-Doctor In most situations, interpreters support and reinforce

the primary relationship between the patient and the provider

Patient Privacy

Interpreters treat all information learned during the interpreting as confidential. Advise all parties that they will respect the confidentiality of

the patient/doctor interaction Advise all parties in the interpreting session to refrain from

saying anything they do not wish to be interpreted Decline to convey to Doctors any information about the

patient gained in a community context (Note: in cases where the interpreters are privy to information regarding suicidal/homicidal intent, child/senior abuse, or domestic violence, interpreters act on the moral, if not legal, obligation to transmit such information to the provider, in keeping with institutional policies, interpreting standards of practice and code of ethics and the law.

Decline to convey to patient any personal information about the doctor

HIPAA

Protects health information in oral, written or electronic form.

Defines when patient information can and cannot be used and disclosed without patient authorization.

In general, patient authorization is required to released protected health information except for purposes of treatment, payment, and health care operations (e.g. quality improvement, audits, training of health care professionals) and when legally required to do so.

Protecting Patient Confidentiality for Interpreters in Your Day-to-Day Work

DO safeguard written logs, schedules, or activity sheets that contain protected health information

DO look for private space or lower your voice when discussing protected health information

DO be aware that just leaving out a patient’s name may not be enough to protect the patient’s confidentiality. Other information may make it possible to identify the individual, even without the name

DO refer requests for protected health information back to the patient, doctor or other health care professionals or staff when possible. Avoid providing protected health information when the patient or others involved with the patients care can do so.

DO destroy or shred any documents (such as notes taken during the medical visit) that contain protected health information before throwing them away

DON’T share protected health information with anyone unless it is needed to do your job or their job.

DON’T share more information than is necessary for you or others to do your jobs.

DON’T access patient information unless you need it to do you job.

DON’T send email containing protected health information unless it is encrypted.

Additional Resources Medical Leadership Council Web site

www.medicalleadership.org Patient Education Materials in multiple languages Language Access Database

• CA County-specific contact information for interpreters and county-specific, statewide and national listings for organizations and web sites providing services in languages other than English

Educational Tools English-Spanish Dictionary of Health Related Terms

“Practice Assessment for Health Care Professionals” – each participant receives a free copy

el brazo (arm)la cabeza (head)la cadera (hip)la cara (face)la cintura (waist)

el cuello (neck)el dedo (finger)el dedo del pie (toe)el hombro (shoulder)la mano (hand)

el pecho (chest)el pie (foot)la pierna (leg)la rodilla (knee)el tobillo (ankle)

The Body (El Cuerpo)