Breaking down language barriers

The doctor was confused.  He was trying to determine whether or not the 90-year-old Cuban woman sitting in front of him in the examination room at Northeastern Hospital, a satellite hospital of the Temple University

The doctor was confused.  He was trying to determine whether or not the 90-year-old Cuban woman sitting in front of him in the examination room at Northeastern Hospital, a satellite hospital of the Temple University Health System, was demented. She had, for the most part, come across as mostly coherent. Until he asked her how she felt.

“I feel like a coconut,” she told him in Spanish.Now he wasn’t so sure. But Jessica Ruiz Lebron, a Spanish translator at the hospital, was there to explain to the doctor that the patient was using a Cuban idiom to describe her condition.

“At the moment he glanced at me, I had to step out of my role and say, ‘This is a phrase that’s commonly used and it means I feel good, I feel strong, I feel like a coconut,'” Lebron said.

Lebron is one of 10 full-time language interpreters within the Temple University Health System, who works in the Office of Cultural and Linguistic Affairs. The office was originally set up in 2003 as part of Hablamos Juntos, or “We Speak Together”, a grant given by the Robert Wood Johnson Foundation to increase the capacity for medical interpreters and teach interpretation services and strategies
in health care systems.

TUHS now spends $1 million a year maintaining a linguistic and cultural bridge between English speaking physicians and the high concentration of foreign language speakers, most of whom speak Spanish, in North and Northeast Philadelphia.

Despite a net loss of more than 120,000 citizens in the past 15 years, the city’s Hispanic population – driven mostly by the ever-ascending costs of living in New York – has grown by 65 percent, according to the U.S. Census Bureau, and the bulk of this population is choosing to call North Philadelphia home.

Roughly 20 percent of TUHS’s patient base speaks a foreign language, said Deborah Caputo Rosen, director of Healthcare Outreach at TUHS.

For most hospitals that tend to have a smaller amount of non-English speaking patients, translation services are often provided by third party companies using a landline phone in order for the hospitals to meet federal regulations requiring them to provide interpretation.

But TUHS had to adapt to the job of serving
the most highly concentrated area of Spanish speakers in Pennsylvania and it has done so by hiring 25 dual-role interpreters. These interpreters work in other sectors of the hospital
and undergo a rigorous certification process to double as translators.

These employees are particularly valuable
in trauma or labor situations when a full-time interpreter is not available and using a telephone can be impractical and ineffective.

“Having person-to-person [contact] makes a world of difference,” Teresita Pointer, a nurse and dual-role Spanish interpreter, said. Pointer recounted an incident in which a patient experienced bursts of anxiety and difficulty breathing after undergoing a urological procedure.

“She needed someone there to calm her down, to tell her she was receiving oxygen,” Pointer said. “She was disoriented. I don’t think you could hold on to the telephone when you’ve got an oxygen mask on your face. It would have just added to her whole anxiety.”

The landline phone services are used by TUHS either when an interpreter is not available or a patient who speaks a less-common language is treated. Since the inception of the OCLA, the number of phones has increased from 100 to 410.

“If a patient says, ‘I speak Urdu,’ our obligation is to make sure access and care are delivered to the patient with assistance from a qualified speaker of Urdu,” Rosen said. Currently,
TUHS has no Urdu speakers and must use the landlines.

The use of interpretation services at TUHS has increased by 60 percent in the past four years due to the expanded capacity of interpreters and policies implemented by the Hablamos Juntos grant. The grant obligates TUHS’s staff to inform patients of their right to communicate with speakers of their native language.

But many patients, a number of whom are illegal immigrants, are worried about their status and therefore more reluctant to ask for interpreters, Rosen said.

“If people are afraid that they will be retaliated against, they might be afraid that if they offend their doctor, their doctor won’t like them anymore and won’t take good care of them,” Rosen said. “Those are not necessarily legitimate worries, but they sometimes stop people from advocating on their own behalf.”

Beyond the moral obligations a hospital has to its patients, the chances of misdiagnosis due to a lack of translation services also poses considerable financial risk. Prompted by such concerns, Gov. Ed Rendell recently unveiled “Prescriptions for Pennsylvania,” a sweeping health care plan that would also require hospitals
to make foreign language interpreters readily available.

An ill boy admitted to another Pennsylvania
hospital provides a case study. The boy had been prescribed two teaspoons of cough syrup four times a day, but the family, which was Asian and used chopsticks for eating utensils, administered the medicine using the closest thing to a teaspoon available in their home: a serving spoon.

“The cost to make him better from that was very substantial,” said Amy Kelchner, a spokeswoman for the Governor’s Office of Healthcare Reform. “That’s a good example of what we’re trying to prevent.”

Like the OCLA, hospitals will not receive funding to implement the regulations. TUHS recently appealed to Harrisburg officials about the possibility of state funding, said Charles Soltoff, associate vice president of marketing at TUHS, although he declined to share the outcome of the conversation. The example of the boy also illustrates the cultural barriers that must be overcome and the role of interpreters as cultural brokers when interacting with patients who may also grapple with standards of American health care, such as regulations and pharmaceuticals.

Pointer says Hispanic families will often benevolently keep their sick family members in the dark so as not to worry them. This is illegal under the Health Insurance Portability and Accountability Act, which requires patients to be aware of everything around them. In addition to the hiring of interpreters – the target of most of the funding – the program also allowed the creation of medical Spanish language classes at the School of Medicine.

Bilingual medical students had already begun to take notice of the propensity of Spanish speakers and, five years ago, decided to meet informally to learn and teach basic medical terminology in Spanish.

After the Hablamos Juntos grant had been in place for two years, those lunchtime meetings were transformed into a structured elective taught by Spanish speaking students for first- and second-year medical students.

“To me, that is one of the successful outcomes that was left as a result of having had the grant from RWJF for three years,” said Dr. Raul de la Cadena, assistant dean of the School of Medicine.

“It really allows to move and enhance what used to just be a student-based activity with no structure, no syllabus and no recognition to become an elective.”

“Granted we won’t be able to train them all to become translators, but we’d like them to have some level of proficiency. So in a trauma situation, in the event that a translator can’t be there immediately, there can be some level of contact until a translator is there,” Peter Murray,
a second-year medical student who teaches
one of the classes, said.

“I want my people to be understood.”

Andrew Thompson can be reached at

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