The Boston Globe | November 15, 2012

By Kiran Gupta

Mr. V was one of my first primary care patients. He arrived at my outpatient clinic with a complex array of medical problems, having recently been discharged from the hospital following a massive heart attack and still undergoing treatment for cancer. An elderly gentleman who had spent much of his life abroad without medical care, he was thrust abruptly into an American healthcare system filled with doctors’ visits, tests, and treatments. As if his medical history wasn’t overwhelming enough, Mr. V spoke no English – like many patients under my care.

Over the next few months, he came to see me frequently, always with a medical interpreter who translated while I examined, explained and prescribed. Waiting for her to repeat everything that Mr. V or I had said was cumbersome at times, but the interpreter’s presence was invaluable. When I changed a dose or suggested a new treatment option, Mr. V would smile and nod, seemingly in agreement. I felt that we had established a rapport.

But the language barrier, I came to learn, presented a serious challenge to building a relationship with him. When various test results repeatedly came back different from what I expected, I began to suspect that Mr. V wasn’t doing what we had discussed, which given his health problems worried me deeply. Some of his prescriptions were absolutely vital – without them, he could have another heart attack, a stroke, or die from a fatal heart rhythm. So I asked him to come back for another visit.

This time, I asked Mr. V point blank whether he was taking his medications as prescribed. Guarded at first, he eventually admitted that he often took “medication holidays” to give his body time to rest. Through the interpreter, I tried to convey the grave consequences that his decision might pose. My words were being translated literally, but looking at his face, I couldn’t quite tell if he fully grasped my warnings.

Studies have shown that patients who do not speak English generally fare worse in our healthcare system. They are often diagnosed with more advanced disease, have difficulty taking medications as prescribed, and spend more time in the hospital. Medical interpreters are essential in bridging this gap, lending meaning to our interactions with non-English speaking patients. Yet sometimes the barrier between patient and provider is greater than language alone, one that no interpreter, regardless of how skilled or compassionate he or she may be, can surmount.

For Mr. V that barrier stemmed from a cultural belief, instilled in him at a young age, that medications poison the body. He associated feelings of illness or fatigue with his prescriptions, attributing his symptoms to the very medications upon which his life depended. How could I, as his doctor, overcome such deeply embedded perceptions in a twenty-minute office visit while communicating through a medical interpreter?

As physicians, we are advised not to allow our patients’ friends or family members to act as translators. In addition to lacking the linguistic capability to translate complex medical terms, they may let their emotions, personal beliefs or biases get in the way. But sometimes, these individuals can help us bridge underlying cultural divides with non-English speaking patients and provide essential context that professional medical interpreters alone cannot.

While working in the emergency room last year, I met an elderly Indian woman who spoke only Hindi and was rushed to the hospital by her family after a bad fall. Communicating through a hospital interpreter as I examined her, she insisted that her pain was minimal. Afterward, her adult son took me aside and explained that his mother would never reveal how much her leg was actually hurting – out of concern for unnecessarily causing her family to worry. Upon reexamining the patient with the interpreter, I gently advised that she take some pain medicine. Eventually she relented, visibly relieved to be released from her quiet suffering.

Last year, a middle-aged Middle Eastern woman who spoke very little English came to see me for a routine pelvic exam. She had already rescheduled our appointment twice, and I was growing concerned. This woman felt deeply uncomfortable about having a stranger in the examination room, even though the clinic’s female interpreter would remain behind a privacy curtain the entire time. Eventually, the patient told me that she was willing to undergo the exam with the interpreter present as long as I let her sister, who spoke English, sit behind the curtain as well; I decided to let her do so, and the exam went smoothly.

As our healthcare system adapts to meet the needs of an increasingly diverse society, we must recognize that gaps in understanding – driven by language and culture – often leave patients and providers feeling that something is lost in translation. Professionalizing functions like interpretation is necessary if we are to provide care for a growing non-English speaking population. But we should take a holistic approach to treating such patients, engaging with their families and friends who may serve as essential links in bridging such divides.

A few months ago, Mr. V began complaining that he was feeling lightheaded and dizzy, likely because he wasn’t taking his medications. Concerned that this might lead to another hospital admission – or worse – I called his daughter, who lives out of state, and encouraged her to come with him for our next appointment. She agreed to do so. Although the interpreter was present, Mr. V’s daughter often interjected, talking to both her father and myself, switching back and forth from English to their native language. I could tell that Mr. V was engaged. Rather than smile and nod politely, he leaned forward and asked many questions. I learned that several of his family members had had negative interactions with the healthcare system in his native country, leaving him with tremendous distrust for medications and tests. After deliberating with his daughter, he finally agreed to start taking at least some of his vital medications regularly. I now know that he didn’t agree with everything I was conveying through the interpreter, but a deeper transformation in his understanding – and our relationship – has begun, thanks to context his daughter has provided.

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Link to print version (published on November 19, 2012)