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ANU research shows effects of interpreter under use in health consults

By Associate Professor Christine Phillips

Every day Australian doctors see patients whose spoken English can be insufficient to communicate their symptoms or to understand their treatment. Sometimes the person’s lack of English is obvious to everyone. Often the person can talk in English but may struggle to understand technical language. Occasionally people’s command of English has deteriorated due to age or illness. 20 per cent of Australians speak a language other than English and by their own estimate 16 per cent of them speak English poorly. Australia is one of the world’s most multilingual countries and at the same time one of the most monolingual.

Over 200 languages are spoken in this country and yet 80 per cent of us can only speak English. The linguistic diversity of the population is so great that no matter how multilingual the doctor is the languages of doctor and patient rarely match. Most doctors will need to make a decision about whether or not to use an interpreter every day. Here is one day in a typical general practice in a suburb, the one where I work. The practice has eight doctors, two nurses, and around 9000 patients. Although the identifying details have been altered all of these are real cases.

10.30 am.

Dr Hut Win a junior doctor training to be a General Practitioner (GP) calls me into his room. He stares glumly at his elderly patient Sara who has booked to see him because she thought he spoke her language, the Myanmar language. ‘My parents are from Myanmar but I can only speak kitchen Myanmar language’.

He and Sara make small talk about food for four minutes while I ring the Translating and Interpreting Service (TIS National). The interpreter comes on line and Dr Win is able to work out that Sara has gastritis. He explains how to test for bacteria in her stomach. Four minutes doesn’t sound like much but that’s more than a quarter of the allocated consultation time. Time is one of the major reasons cited by doctors for not using interpreters.

Efficient medical practices delegate contacting interpreters to the front-office staff. Dr Win has learned to clarify before the consultation begins that he needs an interpreter, ask the patient to wait while reception contacts TIS National, and use that four minutes to read the patient notes and prepare himself.

12.30 pm.

I’m called by the nurse to see Amina who has presented with a sore belly after having her first baby six weeks ago by caesarean section. Her young husband hovers in the background. If they had been in their home country an extended family of aunties and sisters would now be helping her to recover from surgery and care for her baby son.

The nurse shows me the problem; Amina’s wound still has the staples used to close it. I stare aghast at the angry wound with its ridges of infected skin, trying to bury the metal staples. These should have come out five weeks ago. When she was discharged from hospital the staff had explained using Google Translate that she had to get the staples removed in ten days. Amina had not understood and had been too embarrassed to say so.

2 pm.

I have a regular appointment with Bruno who has started psychiatric treatment for depression and wishes to speak about his experiences in the war ten years ago. We have booked an on-site interpreter who speaks his language. The interpreter crosses her arms, bows her head, and becomes Bruno’s words as he speaks of massacres. I wonder about the impact on the interpreter of living through Bruno’s war vicariously, and we debrief for a few minutes afterwards.

4 pm.

The receptionist calls. Hana, who has been in the country for five months stands crying at the front desk with a three year old child in her arms. Her daughter has ’eaten an electric’. We have a huddled consultation with a phone interpreter in the treatment room. The child has swallowed the lithium battery from a toy. It will need to be removed by an endoscope under general anaesthetic. Hana wants to wait till her husband, who speaks better English, comes home from work. But there’s no time to waste. The practice pays for a taxi, and through the interpreter the nurse explains the urgency of the situation. I ring the hospital to say they will need to get an interpreter on the phone for the consultation.

Not every consultation where the person has limited English will need a professional interpreter. Sometimes the situation is of low acuity and the patient can make themselves understood. For example, in Amina’s case I had rarely used interpreters as her general English was sufficient to manage a cough or a Centrelink certificate. There is no doubt however that interpreters are underused in Australian medical practice. For every 100 consultations of a patient who speaks poor English, only one will a professional interpreter be used.

There are four circumstances where doctors looking after people, whose command of English may be—at that moment—suspect, must think of using a professional interpreter, and have a defensible reason for not using one. These situations are consent, complexity, crisis and to assess the competence of the patient to make decisions on their own behalf. The doctors who perform the endoscopy and general anaesthetic on Hana’s daughter who swallowed the battery will need to use an interpreter to ensure that Hana consents to the procedure. Performing a procedure without informed consent is an assault.

Yet all too often people with limited English proficiency are asked to sign a paper thrust in front of them, or have it explained by a family member whose technical English may be very limited. A recent investigation of refugees’ accounts of surgical treatments uncovered accounts of patients who had operations including a tubal ligation, a gall bladder removal, and dental extractions with no understanding of the procedure they had ’consented’ to.

Amina’s discharge instructions are an example of a complex message that warranted an interpreter. Even though Amina spoke some English, her understanding was compromised because she was recovering from a major procedure, and she had no prior experience of wound staples. Denied the opportunity to clarify, Amina left hospital believing that staples could be left in permanently. Complexity is also the reason that pharmacists can access TIS National.

Mistakes in medication dosage can have major impacts on the patient, as in a case in our study of a patient who overdosed on a medication that was to be taken intermittently, resulting in major neurological side-effects. In a crisis professional interpreters are often overlooked in favour of any available person. In a famous case in the United States of America, a nine-year-old child who suffered a severe reaction to a medication was herself used as interpreter in the emergency department.

Her sixteen-year-old brother was subsequently co-opted into interpreting to their parents when she died. Failure to use an interpreter in a crisis is an indefensible approach when there is a 24-hour priority phone line to access interpreters. Without an interpreter we would not have understood what had happened to Hana’s child, nor would we have been able to convey the urgency of treatment.

On the way home from work I called into a nursing home to see Wilf, an octogenarian whose ability to speak English, his third language, had declined as he aged. 42 per cent of non-English speakers over the age of 75 have poor facility in English. The absolute numbers have increased by two thirds over the last ten years to at least 100,000 people. Wilf was ignoring staff and refusing meals, and the staff were worried about his mental competence.

As I walked down the corridor to his room I called the telephone interpreter service. Wilf sat up clutching the phone to his ear and wept as we talked in his language. ’I cannot speak to anyone,’ he said, over and over. No staff member and no other resident in the nursing home spoke Wilf’s language. Wilf was perfectly competent, but starved of conversation. In a huge linguistically-diverse country like Australia the majority of interpreted consultations by doctors will always be by telephone.

Rather than being a secondary fall-back option doctors should think of telephone interpreting as their best option. Using a telephone interpreter requires some practice, good administrative processes that empower reception staff to access interpreters, and telephones with speaker facility. Once mastered, telephone interpreting helps doctors to be safer, more efficient and most importantly, to provide better service to their patients.

This article was originally published in the Summer 2017 edition of Talking TIS and is reproduced with permission.