Doctors' Orders Can Get Lost         (Jan 9, 2003)
In Translation for Immigrants

UTICA, N.Y. -- Ruvim Kluychits, missing school, sat next to his mother at noon one weekday in her dermatologist's waiting room.

Ruvim is 11 years old and moved with his family from Pinsk, in Belarus, to this upstate city two years ago. His Russian has begun to wilt, and his English is only budding, but his relatives speak no English at all. To tell doctors their troubles, they need an interpreter. Utica has a private interpretation service, but no insurer covers its fees and most doctors won't pay interpreters out of their own pockets. So Ruvim's relatives turn to a boy whose services are available free of charge.

"They do tests and stuff," Ruvim said as he followed his mother into the examination room. "I have to translate. All these doctor words, like fever."

Missed Symptoms

In big American cities, some doctors are old hands when it comes to foreign languages. But as more people who don't speak English scatter to places such as Utica, practitioners in the provinces have come to rely on family members, often children, to mediate millions of patient visits. To interpreters who work with doctors for a living, that is a dangerous mistake. It can lead to needless surgery, missed symptoms, prescription overdoses -- and, they say, to a violation of civil rights.

For a while, the government agreed. Now, as the medical profession pressures it to back off, the Bush administration isn't so sure.

In 2000, President Clinton ordered federal agencies to pull down language barriers to government and government-funded activities. He cited the 1964 Civil Rights Act ban on discrimination based on national origin. The mandate was meant for anyone receiving federal funds, including most doctors and hospitals. Applying the broad order, the Department of Health and Human Services issued standards that year saying that patients deserve "competency" from medical interpreters and that the use of amateurs is "life threatening." The standards didn't say who should pay for these services -- only that patients should get them free.

As some in the health industry began to organize interpreting services, the American Medical Association protested. Interpretation fees would saddle doctors with a "tremendous burden," it said. Last April, the Bush administration signalled a softer approach when it stepped in with a model standard for all federal agencies: Non-English speakers who "feel more comfortable when a trusted family member or friend" is available, it said, "should be permitted to use an interpreter of their own choosing."

Doctors Waiting

Objections poured in from pro-patient and pro-immigrant groups, led by the National Health Law Program and the National Council on Interpretation in Health Care. Now the medical world is waiting as Health and Human Services re-examines its earlier rules. The agency will "tailor" its guidelines "to serve the people who are affected by our programs," says spokesman Campbell Gardett. The outcome will establish what a medical interpreter is expected to do -- and whether someone such as Ruvim Kluychits can be expected to do it.

In the exam room, Ruvim had climbed up on the table beside his mother when Dr. Paul Palumbo came in and shut the door. Svetlana Kluychits had seen the dermatologist earlier for a fungal infection of the fingernails. He had prescribed taking certain pills for a week, but they hadn't worked.

"Maybe it's not enough to take the pills one week a month," Ms. Kluychits said in Russian to the doctor. (A reporter's tape of her visit was later transcribed by an independent interpreter.) "Maybe I should have taken them for a whole month."

Ruvim struggled to translate: "She thinks she needs to take more tablets than one week as a month."

After more talk in this vein, his mother was still confused. "Find out whether I should take the pills for a month or a week," she told Ruvim. He tried to ask the doctor, "Does she has to drink the tablets a week for a month -- "

Dr. Palumbo stopped him. Instructions, he said, would be provided in writing. His nurse soon appeared with a detailed prescription for medication to be taken once a day. Ruvim attempted to read it out loud, but he struggled again.

As his patient and her young interpreter left, Dr. Palumbo said, "The kid was pretty bright. He seemed to understand quite well. But I'd be curious. I guess I don't know if she really got the story."

Professional interpreters argue that the job of medical translating is too important to leave to amateurs. "You don't take a phrase and just convert it," says Bruce Downing, a linguist at the University of Minnesota. He has just started one of the country's first programs to teach medical interpreting as a specialty. "Liver spots in our language don't refer to our livers. In other cultures, liver may take the place of heart," Prof. Downing says. "Interpreting isn't that easy. Family members have an ignorance of what's important."

But Dr. Yank Coble, president of the American Medical Association, sees little need for specialized training. It is a doctor's duty to use words simple enough to roll off any bilingual tongue, he says. "I'm impressed at how conscientious patients are about bringing people with them who have a good command of English," he adds. "I'd much rather have a family member, somebody I know and trust."

Without a body of scientific evidence to establish its worth, or government money to pay for it, medical interpreting is an unfunded and unaffordable frill, Dr. Coble says. "It's not part of routine medical care in any country we know of."

Yet the U.S., in its scale and mix of languages, isn't just any country. The 2000 census counted 20 million people who speak poor English, 10 million who speak none. The White House Office of Management and Budget, in a 2002 report, estimated the number of patient encounters across language barriers each year at 66 million.

Hospitals in urban areas dense with immigrants often have interpreters on the payroll today. If not, they make do -- though not always successfully -- with freelancers, volunteers or bilingual staff. But now more immigrants are settling in Alaska, Iowa, Kentucky, Maine -- places where interpreters aren't locally grown.

Bosnian Siblings

Utica is an exhausted city that in the 1980s offered itself as an arrival station for refugees. They came from Vietnam, Burma, Sudan, Bosnia and Russia. Other newcomers spoke Polish, Spanish, Chinese and Farsi. Among 234,000 people in Utica and environs, the 2000 census tallied 22,000 who didn't speak English at home.

When a patient's family is eager to interpret, doctors in the area say they are inclined to oblige. That's how it was when Mustafa Andelija wheeled his sister Zehra into a clinic run by one of Utica's two hospitals, Faxton-St. Luke's Healthcare.

The Andelijas are Bosnians. Mustafa, 36, has been here eight years; his 40-year-old sister, one. She suffers from cerebral palsy and diabetes. On this day, she had what seemed like a very bad cold. "I take care of her," Mr. Andelija said. "I never say OK if I don't understand what is mean." He stood behind his sister's wheelchair in an exam room. Dr. Renee Rodriguez Goodemote stood in front of it.

"I want to figure out if she has a urine infection," Dr. Goodemote said, speaking over her patient's head. "One of the other things I'd like is an X-ray of her stomach. With respect to the chest, I want to see if she's got fluid on her lungs. That's going to require a chest X-ray. You can start telling her that so far."

A Bosnian interpreter later helped transcribe a tape of what Mr. Andelija told his sister in Serbo-Croatian. Bending toward her ear, he said: "For a pain in your lungs and that fluid that you have, the only thing she's going to do is send you for a chest X-ray. After the chest X-ray, they're going to know what's going on."

The doctor said she would order blood tests for "signs of an infection," which Mr. Andelija translated as, "They are going to do blood work to check your infection." The doctor said she would order an electrocardiogram. Mr. Andelija said, "OK," but nothing more.

As her brother pushed her out of the clinic, Zehra Andelija wouldn't have known she was headed for a heart test or a stomach X-ray, or that it wasn't certain that she had an infection.

After they left, Dr. Goodemote said that even English speakers don't always follow her instructions. She was pleased to have Zehra Andelija's brother do the interpreting because relatives "make sure when she goes home that what I say gets done."

There is an alternative in Utica: In 1999, Cornelia Brown, who has a doctorate in Russian literature, founded a commercial medical-interpretation service, which now has 25 part-time interpreters on call. If a patient were deaf, a doctor would have to supply a professional sign-language interpreter at no charge, under the federal Americans With Disabilities Act. But people who don't speak English don't qualify as disabled, and there is no comparable law forcing doctors to pay Ms. Brown's fees of up to $60 an hour.

Often, that's more than Medicaid's rate for a whole visit, a lot more than Utica's doctors say they can afford. Only eight states reimburse any interpreting fees. New York isn't one. Ms. Brown's business grossed just $124,000 last year, less than she had expected. In Utica, even medical organizations that acknowledge the need for interpreters want to find a less costly way out.

For hospitals, the telephone is often an answer. Utica's St. Elizabeth's Medical Center has an account with Language Line Services, a 140-language interpreter bank on call at all hours. The hospital does summon Ms. Brown's people on occasion. But hospital nursing chief Robert Scholefield says, "If you're communicating a concept, the phone does the trick."

While phones work well in some situations -- an unexpected emergency-room crisis, for example -- some concepts are more difficult to handle than others. Hataija Pehlic, a Bosnian woman of 50, suffers from depression. At St. Luke's Hospital in 2000, she was served by a succession of phone interpreters on a squawk box for two hours a day during a month of psychotherapy.

They spoke a common language, "but I felt really bad," Ms. Pehlic says through one of Ms. Brown's interpreters. "They had different accents" -- accents, that is, of Serbians and Croatians, the enemies who had killed her son and driven her husband to suicide during the Balkan bloodshed of the 1990s. "I think it was a misunderstanding," Ms. Pehlic says.

Bringing Help

In office visits, much less psychotherapy, phone interpreters can be clumsy and still not cheap. Few Utica doctors use them. If patients don't bring their own help, many doctors say they simply won't give them appointments. But Dr. Stanley Weiselberg, a gastroenterologist, is one who does.

When Ana Gonzalez, a Dominican housekeeper on Medicaid, went to see him about her liver, she took Tony Colon. Puerto Rican by parentage, he comes from the Bronx and works for Ms. Brown. Like all of her interpreters, he is trained never to summarize and to intervene only to clarify. The patient's welfare officer recommended the service, and Dr. Weiselberg paid the $45 fee.

"You know who her family doctor is?" a nurse asked Mr. Colon. He said, "Speak directly to her, like I'm not here." The nurse turned to Ms. Gonzalez and said, "Who's your family doctor?" When Ms. Gonzalez couldn't recall, Mr. Colon said, "The interpreter wishes to interject," and told the nurse the doctor's name.

When Dr. Weiselberg entered the exam room, he didn't need prompting from Mr. Colon. As the interpreter whispered in Spanish, the doctor faced his patient and told her she had an infected liver.

"I recommend you have what's called a biopsy," Dr. Weiselberg said. He explained that this would allow a more precise diagnosis but that Ms. Gonzalez could choose to go on medication right away. As the doctor described success rates and side effects of various drugs, Mr. Colon's interpretation, as a review of the tape later showed, was almost verbatim.

"It's no big deal, at least for me," the doctor joked about the stab of the biopsy needle. A beat later, after listening to Mr. Colon, Ms. Gonzalez laughed.

"It feels like a dull punch," said the doctor. ("A punch not so hard," Mr. Colon made it.) Ms. Gonzalez said in Spanish, "I'm getting pain just thinking about it." And, a beat later, the doctor laughed.