In most UK towns and cities healthcare workers will need to communicate with patients who do not speak English. Often, there will be time to arrange an interpreter with experience in healthcare settings, and something approaching a normal medical conversation will be possible. But in the acute situation, when time is pressing, you may rely (in order of preference), on: relatives or friends > a passing colleague who happen to speak the same language > ‘language-line’ > high school French/Spanish etc > Google translate > gestures > ‘History unobtainable, assessment based on examination & results only’. The last three are pretty deplorable.
The most common medium, in my experience, is language-line. You ring the well-known ‘#’ number, state what language you need, give your details, and are quickly connected to someone on their books. If the phone you are using has speaker mode, a reasonable exchange can take place, but without it the phone is passed from patient to doctor as the absent interpreter relays first your words, then the patient’s back and forth, back and forth. When the rhythm of the conversation has been established, it begins to work. But it is functional. You use short sentences and get to the point rapidly. The focus is on the phone and on confirmation that the last sentence was understood, not the reaction.
I remember giving a non-English speaking patient some bad news. She did not speak a word of English, and her own language was an unusual one. I had established that there were no relatives around; none of my medical or nursing spoke the relevant language, nor did any of the house-keeping staff; I would have to use language-line.
Could I, should I, have postponed the conversation? This is a tricky point. She required a series of urgent investigations and procedures. She was caught in a whirlwind of activity. New clinical information had arisen in the last 12 hours. She had to be told what was going on. It was not realistic to postpone the conversation for three or four hours. Nor was it appropriate to call her closest friend and ask them to interpret over the phone – for they would be hearing the bad news and communicating it back to the patient simultaneously. So… the phone. It did not have speaker mode.
I introduced myself. Handed over the phone.
I asked what she knew. Handed over the phone.
I said that the scan on admission had showed some worrying changes in the ______. Handed over the phone.
She nodded, but I saw her expression alter from innocent curiosity to bewilderment, then deep concern.
I said that we were very worried about the possibility of cancer, but we weren’t a hundred percent sure yet, hence the need to for further tests today, and another procedure to help the symptoms. Handed over the phone.
Tears formed over her lower eyelids. She looked at me. The remove, the fact that my words had been processed by a third party, made it more difficult to find the correct emotional response. The nurse who was present placed a hand on the patient’s arm, a gesture that needed no translation. The F2 tapped a version of the exchange into the electronic record.
I said it was too soon to talk about the sort of definitive treatment that might be required; we needed a biopsy and to review the next scan result. Handed over the phone.
I asked if she wanted to ask me anything. Handed over the phone. Clearly, her mind was teeming with questions, doubts and fears. But now was not the time. This exchange was about raw information, planning the next steps, preparing the ground… but so cold, so ‘clinical’.
She asked a couple of questions. She handed over the phone.
We were done.
I walked away feeling that I, we, had done a bad job. A phenomenally bad job. There she was with no one to talk to, until a friend arrived who spoke the same, unusual language. Complete isolation.
Was there a better way?
Emina Hadziabdic and Katarina Hjelm wrote a good paper on this dilemma in 2013 – ‘Working with interpreters: practical advice for use of an interpreter in healthcare’. Some of their observations may seem obvious, but are worth reading:
In telephone interpretation, the conversation is transmitted by a loudspeaker, so there is no eye-to-eye contact with the interpreter. The main difﬁculty with interpretation by telephone is that the body language is lost. This communication process – where the transmission of a message between the sender and receiver is made with the aid of technical equipment and without eye contact – implies a risk of distortion of the communication.
The beneﬁts of telephone interpreters are accessibility for rare languages, demands for interpretation outside of normal working hours and conﬁdentiality. Yet some patients may ﬁnd this conﬁdentiality disturbing if they fear that the invisible interpreter might be able to identify them, whereas they cannot identify the interpreter. Furthermore, disadvantages of telephone interpretation can be lack of continuity and personal relationship, individual intolerance of phone use and possible problems with background noise.
I hadn’t thought about whether patients would be nervous about revealing their symptoms and concerns to an invisible person – it is a good point.
Regarding the use of friends and relatives (something I do frequently, knowing full well that it is not ideal), they make the following points:
The use of relatives as interpreters entails a risk that important information will not be interpreted because of limitations in language ability, cultural barriers and social ties to next of kin. Previous research has also shown that the use of bilingual healthcare professionals can lead to misunderstandings in contacts with healthcare staff, while the use of a professional and trained interpreter instead has been shown to prevent unnecessary investigations of patients.
Sometimes, especially in larger families or when particular members have been estranged, complex motivations become apparent. Staff become nervous that information will be transferred selectively, even nefariously. This is the main reason for avoiding the use of relatives, unless you are very confident about the nature of the relationship.
It is clear what ‘ideal’ looks like. Time to prepare, a trained professional, a comfortable space and an unhurried atmosphere. But the advice in the paper quoted above, which suggests –
it is also important to consider the interpreter’s competence, ethnic origin, religious background, gender, language or dialect, social group, appearance and attitude so that an appropriate interpreter can be ordered…
… seems rather ambitious!
Patients who do not speak English will always be disadvantaged in the NHS, just as we would be disadvantaged if we became unwell in a faraway county. In these situations, we may strive to provide the best care, and show kindness, but the fact is certain nuances will be lost. Patience and extra effort are required, as a flexibility and compromise. Certain steps may need to be deferred until we are sure the patient knows what’s going on (however anathematic to the drive to reduce ‘length of stay’). Ward rounds may be fixed, but it is often necessary to return to the bedside when all the right elements have been put into place. Hospitals move fast nowadays, but non-English speaking patients need time to catch up. Otherwise, the consent they give to operations, even blood tests, is poorly informed, and we risk treating a ‘body’ and not a person. Such patients rarely complain. It’s an easy trap to fall into. I know I have fallen into it.