When language is a barrier to good patient experience

Comments: 3

Abigail Gaunt, a GP trainee, here describes the challenge of ensuring good patient experience when patients don't speak English and communication is difficult. This is one in a series of stories that the Point of Care programme is presenting on the issues that staff face in trying to ensure a positive patient experience. The views given in this series are of the authors and do not necessarily represent the views of The King's Fund.

It's 5 o'clock on a Friday evening. An ultrasound report for one of our patients has just come back and we need to start her on intravenous antibiotics. Before leaving, I just need to inform the patient of the result and explain why we'd like to start the antibiotics.

Unfortunately, this patient is an older female who speaks no English. I go to see whether or not I can convey the results of the scan to her. She doesn't seem to understand either my charade of explaining what is wrong or my invitation to come to the nurses' station to try to use the telephone interpreting service.

Instead, she repeatedly types a number into her pink mobile phone until a friend finally answers. Apparently there are no family members. I try to explain to the friend what is wrong, our recommended treatment and its reasoning.

I hear that the patient is unhappy to have treatment from us; she would like to be discharged to see her GP for antibiotics on Monday. I try to explain that we feel she needs inpatient treatment and observation. I have not even seen her leave her bed, she lives alone and I am concerned about what would happen should she become unwell at home.

Again I am told that she wishes to leave and I must write a letter for a GP. The caller asks: will I call a taxi for the patient?

I try to explain that if the patient wishes to discharge herself, she needs to sign a form. I would need to be happy that she understands the risks of discharging herself. I propose that the patient comes to the ward telephone so that I can use a formal interpreter to explain. Alternatively, I suggest we wait for a friend or family member to come in, so that we can have the conversation face to face. I can get no response from her, via her friend, that I am happy with – I am simply repeatedly asked for a taxi and a discharge letter.

Eventually I give up, telling her that I will leave her to think about it; I cannot let her self-discharge unless I am sure she understands the risks and I cannot be sure of this from the conversation.

I hand her over to the evening on-call doctor to come back later to reason with her. I go home eventually, unhappy that despite 90 minutes of talking our communication was clearly failing.

Her family did actually arrive almost immediately, and the on-call senior house officer reported no difficulty in explaining to the patient, via the family, the diagnosis and recommended management plan. She accepted straight away, stayed for the weekend, and went home safely on the Monday. I felt justified that I had not let her self-discharge via her own telephone interpreting friend, and still wonder exactly what information had been passed on.

A significant proportion of our population do not speak English, and their care must not be compromised as a result. For the patient, it must be an incredibly frightening experience. For the doctor, the lack of an adequate interpreter is risky and can lead to over-use of investigations in an effort to compensate for insufficient communication.

So much diagnostic medicine is based on a precise history, and a successful management plan requires clear communication. A colleague recently shared an experience in which neither the patient nor the accompanying relative were able to state which language they spoke or which country they were from. Even communicating the need for an interpreter is not always as easy as one might imagine.

We need to be flexible. Relatives are often used as interpreters, but the timing of visiting hours usually rules out their presence at consultant ward rounds, thus often denying the patient a conversation with the consultant themselves (instead a junior comes back during visiting hour). We need to plan for this and be alert to the vulnerability of these patients. We must work hard on all aspects of our communication and strive to be as unthreatening as possible to those who cannot understand what we are saying.

Abigail Gaunt, ST2 GP trainee at the London Deanery

Comments

#850 Christine Burns
Equality and Diversity Specialist
Plain Sense Ltd

This is a fascinating tale of life at the coal face and I'm glad you've shared it. The only concern I have, which isn't a criticism of how you sought to handle this, is that it's important to stress the reasons why family members are not always the most appropriate people to act as translators. As I say, I appreciate the real world constraints that mean you might sometimes not have a choice. I suspect from between the lines, that you're well aware of what the pitfalls could be. However, as you didn't address it directly in your blog, I thought I should raise it as a caution.

#851 Isla Dowds
Patient Engagement & Experience

I echo Christine's comments, and also to highlight that the also common practice of using staff as interpreters is also less than ideal, and while it may be the only option in an emergency, there is no really acceptable substitute for a professional interpreting service, whether by phone or face to face, but where this almost always falls down is lack of advance planning in scheduled care, and poor or poorly understood systems in urgent care situations. The other perennial wrangle is budget, or even whose budget - and in secondary care this can even mean is it the hospital or he PCT who pays! This is pretty inexcusable when you consider the potential conseqences of getting it wrong - both for you and for the patient. Doubly inexcusable in areas where this scenario can arise pretty regularly.

The bottom line is that for too many purse-string holder interpreting and translating services ( including BSL and Makaton etc) is a very low priority. When that translates into inequlity of access and treatment at ground level, then it is time for a wake up call. The simple but effective exercise of asking the person saying ' we can't afford it' how they would feel if they were a country where no-one understood or spoke your language and you needed a diagnosis and treatment is always worth a shot, backed up with some up to date demographic information and a proper scoping exercise. There are plenty competitive providers out there now eager to provide services. Please use them.

There are also some tools to help with the basics of language identification, and some basic phrases and medical communication phrases - if this had been available and used - the lady might have been able to understand that there was an interpreter on the phone to help her.

#855 Abigail Gaunt

Thank you for your comments. Formal interpretors are used wherever possible in my experience, but this is usually when they have been booked in advance for an outpatient clinic. On the wards, they are used when really needed, but often they are busy and you may therefore need to wait 48 hours for a slot, especially if it is a less commonly used language. Out of hours, usually the only option is telephone interpreting.

Within the working day there are multiple occasions when you would talk to a patient, and providing a formal interpretor for every communication, as well as the daily ward round, would be fabulous but extremely costly.

Tools for basic communication in other languages would be useful, but I have never come across these on the wards. Obviously many patient information leaflets are available in other languages, but these are not available for every possible diagnosis and consultation. I have seen colleagues giving out written information, translated, from commonly used encyclopaedic sites, but one has to be careful about the validity of such information, particularly if you cannot read the language yourself.

If there are simple tools for translation that could be made more widely available, this would be extremely useful.

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