A failure to communicate

THE PHRASE ‘limited English proficiency’ is becoming much more familiar to doctors across the UK as our society grows increasingly multicultural.

The significance of language and cultural differences between doctor and patient is such that the BMA has identified them as “the most important barriers to healthcare in Britain”. So how can you overcome these barriers?

Patients with limited English come from a variety of backgrounds, from EU and Commonwealth economic migrants to asylum seekers and refugees. Whatever the circumstances, when a language is not shared between doctor and patient it is advised to use a trained interpreter as failure to do so could lead to medico-legal problems.

One case handled by MDDUS involved a member who relied on a patient’s husband to translate for her. But it later emerged that his interpretation of his wife’s medical needs was wholly inaccurate and this led to a complex complaint.

Using a professional interpreter is more likely to result in effective communication between you and your patient but there are a number of important steps to follow to minimise the risk of a misunderstanding.

Firstly, it is important to confirm the interpreter is qualified and appropriate for the consultation. The skills required of a trained interpreter are detailed in a Code of Conduct published by the National Register of Public Service Interpreters.

Before the consultation starts, tell the interpreter that you must hear all the information offered by the patient. In order to encourage an open and effective consultation a few rules of thumb can be applied:

• Speak slowly and in short sentences, and request that the patient does the same.
• Reassure the patient that the same respect of confidentiality applies.
• Maintain eye contact and speak directly to the patient in the first person.
• Avoid the use of medical jargon and metaphors which may be difficult to translate.
• Ask one question at a time and if the required information is important try asking in different ways to ensure understanding and consistency of the details obtained.
• Make sure that everything you say is translated.
• Make sure you say everything that you would if you were consulting with an English-speaking patient and leave extra time to allow for the translation process.
• It is helpful to meet and brief the interpreter first – particularly for difficult meetings such as breaking bad news – to ensure that the aim of the consultation and important issues are clear.

It is important to approach the consultation in the same way as you would any consultation, ensuring the patient is centre of your attention. Greet the patient directly in order to establish contact. Check via the interpreter that the patient is comfortable with the situation and ensure the patient sits closest to you and is not tempted to shy away behind the interpreter.

As always, be aware of tone of voice and your own body language, as well as the patient’s non-verbal responses, but remember that gestures may have different meanings in different cultures. A good interpreter should be able to provide guidance if offence is likely to be caused. Finally, remember to document the presence of the interpreter and provide an account of the information shared. Make sure you also note the interpreter’s name and contact details.

If it is not practical to have a trained interpreter attend in person, there are other options to consider, including:

• an ‘ad hoc’ interpreter (often a relative or friend)
• a multi-lingual healthcare professional
• a telephone interpreter.

Be cautious if using an ad hoc interpreter. While patients may prefer to consult through someone they know, there is always the worry that using an informal interpreter could undermine both patient confidentiality and the objectivity of the consultation. There is also no guarantee of how well an untrained interpreter understands both languages or can effectively communicate what both parties are saying. They are unlikely to have the relevant experience of medical terminology and phrases of a trained interpreter.

The use of relatives or friends may also make it difficult for the patient to discuss sensitive issues, such as the case where a 12-year-old boy was brought along by his mother to interpret during her smear appointment. In more serious circumstances, these encounters may allow a relative to hide abuse or exert undue influence over the patient and their medical care.

In cases where a translator is not immediately available, one useful resource is the Emergency Multilingual Phrasebook, produced for the NHS by the British Red Cross. It lists key medical questions in 36 languages to help first-contact staff communicate with patients and make an initial assessment while an interpreter is contacted. It tells you how to ask things like “When did you become ill?” and “Have you any bleeding?” in languages from Albanian to Vietnamese. It can be downloaded from the Department of Health website at www.tinyurl.com/645423

Joanne Curran is associate editor of GPST