Staff stories: When language is a barrier to good patient experience

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.