By Aaron Troy
Peer Reviewed
23-year-old man with no past medical history presenting with 1 year of intermittent 7/10 left-sided chest pain lasting for 15-20 minutes. The pain feels like a “needle prick,” is non-exertional, and has no exacerbating nor alleviating factors. He has presented twice to the ED for evaluation, with workup benign on both occasions. Physical exam notable for mild tenderness to palpation in the 4-5th intercostal spaces mid-clavicularly.
“Edson Capela?” I called out. My patient, a recent Angolan immigrant, stood up. He looked my age—fit, wearing jeans, a crisp polo shirt, and beats headphones. He responded to my query by smiling, shaking his head “sorry,” confirming our interaction would not be in English.
We sat. I dialed the Bellevue interpreter phone, asking for Portuguese. After a minute of awkward smiles, an interpreter came on line. I began to elicit Mr. Capela’s chief complaint—recurrent chest pain—and narrow my differential. “Where did it hurt? How did it feel? When does it happen? Does anything make it feel worse or better?” With every question not answerable by a physical gesture, I became increasingly frustrated. He was giving lengthy, seemingly detailed descriptions, but the interpreter was conveying only one-word answers. “Here. A pinch. At night. Nothing.”
After characterizing a nonspecific chief complaint, I asked about triggers. “Have you had any recent physical trauma in this area?” He averted his gaze and gave his shortest answer yet. The interpreter: “Back home, a policeman stepped on my chest.” He had escaped persecution in Angola, leaving his family. My furrowed brow belied my surprise at his answer. I felt the deep pain and untold story behind his words. I leaned in, made direct eye contact, and told him how sorry I was that he suffered, but there was a long pause – the interpreter didn’t translate the message. I went on – “Do you ever find yourself feeling anxious or worried about them?” She briefly translated this specific question, glossing over my attempt to provide emotional support, and he began his response. I suppressed genuine anger: “I apologize, interpreter, but could you please translate everything I said? I really want all my messages to be communicated.” The interpreter paused, and finally spoke for what seemed the appropriate amount of time. At this, he looked directly into my eyes; tears streaming down his cheeks.
“I worry about my brothers. I came here; they went to Kenya. We haven’t heard from them in a year. They could be dead.” The middle-aged sounding female interpreter relayed his words; he put his head in his hands, attempting to hide his tears.
There was so much I wanted to say. At this point, musculoskeletal pain exacerbated by justified anxiety was at the top of my differential, a diagnosis benign enough to be reassuring, but one that left me feeling helpless nonetheless— no pills or procedures would cure his pain. I could only support, reassure, and ensure he had access to psychiatric help if necessary.
I felt even more helpless at my inability to properly support or reassure him. Every word of comfort or support I essayed felt stilted, insincere; my sentiments were lost in translation.
Ending the interview, I began the physical exam. The interpreter seemed eager to depart, leaving me to examine the patient silently. As I walked to the preceptor station to present Mr. Capela’s case, I realized how little I knew of his story, though it was enough to feel the weight behind his tears. I imagined the persecution he and his family must have faced; the isolation of building a new life in a country, across a linguistic chasm, all while enduring the pain and guilt of wondering whether his beloved brother is alive or dead. No wonder he had chest pain.
But what to do? As a student doctor, I love building rapport and solving problems. Here, I felt incapable of doing either.
This dilemma has been validated by a wide literature focusing on interpreters’ role in language-discordant care. Aranguri et al [1] transcribed clinical encounters between English-speaking physicians and dyslipidemic Spanish-speaking patients, finding that interpreters condensed and modified the content, meaning, repetition, and affect of physicians’ speech. Moreover, they found that visits including interpreters featured virtually no rapport-building conversation. Rapport-building is essential to the medical interview, enabling physicians to acquire complete histories, craft individualized plans, and form therapeutic alliances, thereby engaging patients in their own care.
Even my frustration with the phone interpreter’s failure to convey my emotional support is supported by multiple studies and reviews. Hsieh and Hong [2] interviewed and conducted focus groups with providers across multiple specialties to clarify their expectations and concerns regarding interpreters’ emotional support of their patients. They found the interpreter’s physical presence invaluable for rapport-building, therapeutic alliance, and patient satisfaction. Physicians, they found, expect interpreters to be active participants in patient care, slightly out-of-step from the traditional “conduit” model in which most interpreters are formally trained.
I do not mean to shift the struggles of this encounter solely onto the interpreter’s shoulders. Finding the balance between precisely conveying the clinician’s words, while preserving their message in a different cultural context and vocabulary, seems a near-quixotic task. The fault lies equally in the medical system and in society as a whole. Evidence is emerging that language-discordance adversely impacts patient outcomes, leading to, for example, worse glycemic and LDL control in diabetic patients with limited English proficiency, and increased mortality in foreign-born patients being treated for tuberculosis. [3][4] In the face of this growing problem, our medical system prioritizes non-indicated pan-scans and unnecessary procedures over high-quality interpreter services. And we don’t provide equal opportunity for people of varying regional and linguistic backgrounds to become physicians.
The desperation of that day’s encounter, however, seems to herald a tomorrow when this challenge may be overcome. Research on this topic, such as the studies I’ve highlighted above, has grown enormously in the past decade, leading people at all levels of the health system to seek out innovative solutions. For example, at Tisch, MARTI, a glorified iPad on a vitals cart, made similar encounters on my pediatrics rotation less daunting. Knowing that the interpreter would see my face, the emotions on the patient’s face, and even the room’s ambience, eased my mind and improved my ability to care for patients with limited English proficiency.
Edson Capela’s story will stay with me, as will my helplessness at being unable to provide him with the care he deserved. Language is more than mere spoken words: it is context, connotation, culture, and care. As I train, I will strive to find ways to more successfully bridge the language gap and ensure vital aspects of care do not get lost in translation.
Dr. Aaron Troy is a medical student at NYU School of Medicine
Peer reviewed by Margot Hedlin, MD,
Image courtesy of Wikimedia Commons
References:
- Aranguri C, Davidson B, Ramirez R; Patterns of communication through interpreters: a detailed sociolinguistic analysis. J Gen Intern Med. 2006;21(6):623-629. https://www.ncbi.nlm.nih.gov/pubmed/16808747
- Hsieh E, Hong SJ; Not all are desired: providers’ views on interpreters’ emotional support for patients. Patient Educ Couns. 2010;81(2):192-7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924452/
- Parker M, Fernández A, Moffet H, Grant R, Torreblanca A, Karter A. Association of Patient-Physician Language Concordance and Glycemic Control for Limited-English Proficiency Latinos With Type 2 Diabetes. JAMA Internal Medicine. 2007;177(3):380-387 https://www.ncbi.nlm.nih.gov/pubmed/28114680
- Gardam M, Verma G, Campbell A, Wang J, Khan K; Impact of the Patient-Provider Relationship on the Survival of Foreign Born Outpatients with Tuberculosis. J Immigrant Minority Health 2009;11:437-445 https://www.ncbi.nlm.nih.gov/pubmed/19127431