American Medical News
By — Posted Aug. 5, 2013
More than 55 million people over age 5 living in the United States speak a language other than English at home. Of that number, 9 million don't speak English very well, and 4.5 million don't speak any English at all, according to the U.S. Census Bureau.
Given these numbers, and the fact that immigration is no longer limited to urban areas and border states, chances are good that someone whose first language is not English will walk into your practice seeking medical care. Under Title VI of the Civil Rights Act of 1964, limited English proficiency patients have the right to a trained interpreter, and practices are supposed to comply. But, as with many other mandates, most insurance companies and the federal government don't pay for these services, which can be expensive.
There are several interpretive options practices can use to accommodate such patients, some of which are free, and all have advantages and disadvantages. Among the options:
Because of the potential costs of outside services, many practices rely on patients' family members and acquaintances to be interpreters between doctor and patient.
The advantages are that their services are free, and the patient often is more comfortable with the relative present. “The family member is usually in that role [of interpreter] anyway,” said Susan Childs, a health care consultant in Raleigh, N.C. Disadvantages include confidentiality issues, the fact that the relative probably doesn't know medical terminology, and the possibility that the doctor's words aren't always relayed to the patient correctly.
“This is the simplest and easiest way to interpret, but it requires a level of trust that the physician needs to put in the family member,” said Eric Dickerson, a health care recruiter in Plano, Texas.
Richard F. Madden Jr., MD, a family physician in rural Belen, N.M., where 32% of the population older than 5 speaks a language other than English, said he'd rather not use family members as interpreters. He said he knows enough Spanish — the primary language spoken by his patients — to realize that some don't interpret him correctly. Plus, there is the confidentiality issue. He said sometimes things you don't expect come up during the visit that could embarrass the patient if a relative is present.
Dickerson said the ideal situation from an economic and confidentiality standpoint is for the physician to be bilingual, or for the practice to have a trained interpreter or bilingual staff member who does other duties as well. He said this works especially well in areas like Texas, where Spanish speakers are predominant.
Advantages include having no cost to the practice other than the person's salary, although a salary bonus could be provided for having the extra skill. There is no worry about the doctor being misinterpreted. Also, no additional time or special scheduling are needed for the office visit, as is often the case when using interpretive services.
It's also a good marketing tool for practices, said Forney Fleming, MD, director of the MS in Healthcare Management Program and clinical professor at University of Texas-Dallas, who previously was in general surgery practice for 35 years.
Disadvantages include the possibility that a staff member is taken away from other duties while translating. If the practice is in an area where multiple foreign languages are spoken, it might be impractical or impossible to hire staff or physicians who can speak any possible tongue. Some states have laws about who can perform medical interpretation. You should check with state health officials before asking a bilingual staff member to serve as an interpreter.
If your patient list includes people of different ethnicities, it could be worthwhile to hire on-site interpreters on an as-needed basis. They have formal education in medical interpreting and follow a professional code of ethics that includes confidentiality and accuracy.
The advantages are the interpreters are fluent in the language needed, are familiar with medical terminology and have experience in health care. The disadvantages are they're expensive, and the office visit usually lasts longer than normal. An in-person interpreter typically costs from $50 to $145 an hour, with some requiring a two-hour minimum, according to CostHelper.com, a free consumer information and shopping resource. Some also charge for travel costs. You would need to pay for the service even if the patient is a no-show. They also must be booked in advance.
Dr. Forney said the costs can be trimmed by scheduling people requiring an interpreter in one block, or hiring a local college student fluent in the needed language at a lower cost.
Phone services offer interpreters who are fluent in more than 150 languages. This service is less expensive than hiring an on-site interpreter, costing an average of $1.25 to $3 per minute, according to CostHelper.com.
Advantages include a price lower than on-site help, accessibility to many languages, and no need to work around schedules or other work duties. A disadvantage is that the interpreter does not have face time with the patient and might miss important visual cues.
“I use this as a last resort,” said Larry Abrams, administrator at Workmen's Circle Multicare Center, a subacute rehabilitation center in the Bronx, N.Y., which serves people of many different ethnic backgrounds. “I always like face-to-face visits better. Sometimes people can't find the words to describe their pain, but it's clear when you see their face.”
Dr. Madden said his clinic uses an online audiovisual service that works well for the primary care practice, especially when sign language is needed. Sign language services are required under the federal interpretation mandate. The patient and doctor share one audiovisual unit and the outside interpreter has another unit, allowing all parties to see and hear one another.
“It's very helpful to be able to see someone's facial expressions,” Dr. Madden said.
Other advantages: It can be cheaper than other options (Skype charges $2.99 a minute for its phone program). Some services provide more than 150 languages, and you pay only as you need them. The patient's privacy is protected, because the service is done in a closed room with only the doctor and interpreter seeing the patient. The disadvantages are there is still a charge and the length of the office visit is about double the normal time when using the service.