Care for patients with limited English proficiency begins with medical interpretation

Mr. O was my new patient but had been known to our practice for several years.  He was 74 years old. He had been complaining of “dizziness” for some time.  He came in for his visit accompanied by his home health aide.  He was born in the Dominican Republic, and he spoke Spanish with limited English proficiency.  I scanned his former notes and saw that his aide typically provided translation.  I would learn that his aide spoke English as well as I spoke Spanish, which I’m sad to report is almost as good as a 3 -year-old child.

Since it was our first visit, I asked to see him alone in my office and indicated that I would obtain formal medical interpretation via the phone line.  I wanted to ensure confidentiality as well provide my patient the opportunity to tell his story in his own words.  I could also learn how much, if any, of his medical information he felt comfortable sharing with his aide or anyone else in his family.

When I got the formal medical interpreter on the line, the first thing my patient said was, “I want to talk about my dizziness.  I don’t understand why I have it, and nothing helps.”

His medical problems included type 2 diabetes which he indicated was always controlled and obstructive sleep apnea for which he used CPAP.  A review of his meds included meclizine, but he stated that it didn’t help his dizziness.   He had been referred to neurology in the past — his dizziness had been labeled vertigo, and he had had a fairly substantial workup including an MRI of his brain which was normal.

As internists come to know, dizziness is a common complaint and working it up is satisfying once you understand the framework for approaching.  The etiology of dizziness typically falls neatly into four categories:  cardiovascular or lightheadedness, vertigo, disequilibrium, or functional or psychiatric.  It’s important to get patients to explain in their own words what their “dizziness” is like.  My patient described his dizziness as unsteadiness and reported that he felt he couldn’t keep his balance.  He walked with a cane because he felt he would fall.  He noted pain in his feet and legs and reported pins and needles in his feet as well.  He denied a spinning sensation in his head or lightheadedness.  A thorough review of the hospital record where he had former studies revealed an MRI of his lumbosacral spine that showed severe spinal stenosis, and a monofilament exam revealed that he had decreased sensation in both of his feet as well as decreased sensation in the L5 dermatome.  While my new patient had been diagnosed with vertigo, and had been treated as such for years, in fact, he very likely was suffering from disequilibrium given his age, spinal stenosis, and peripheral neuropathy.  The diagnosis was easily made once I was able to get his story, in his own words, in his preferred language.

Though there’s not much data about physicians in private practice using formal language interpretation, I suspect the data that an internal medicine resident and I gleaned from a QI project in another institution can be generalized to many primary care physicians and specialists in private practice.  We learned that most physicians do not utilize formal medical interpretation, preferring to use family members and aides, or available medical staff.  We learned that the front staff frequently told patients to bring someone to translate.  Physicians pointed to lack of time and lack of access to formal interpretation as reasons.

If we want to ensure accurate medical information, we need to get the history from the patient. Otherwise, we risk inaccurate, incomplete histories that will lead to wrong diagnoses, and just as importantly, endanger the relationships we have with our patients. Moreover, the time needed to ensure interpretation should be factored into the patient visit when there is language discordance between the patient and health care professional.  Obtaining formal interpretation is one of the essential cornerstones to providing patient-centered care for our patients with limited English proficiency.

Maria Maldonado is an internal medicine physician and director, Education for Cross Cultural and Patient Centered Communication, Icahn School of Medicine at Mount Sinai, New York City, NY.

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