Questions:
 1 |
 2 |
3 |
... You are preparing for a new patient who you have not seen before.
You have his extensive medical record before you. Mr. Ramìrez
is a 72 year old Mexican American male who is three months post stroke
or Right CVA. He has hemiparesis in his left arm and leg (partial paralysis
with some movement though usually in synergy rather than isolated movement).
He ambulates with a quad cane (a special 4-legged cane providing greater
stability than single-legged cane) for short distances and a wheelchair
for longer distances. He has hypertension (high blood pressure) and diabetes.
His 71 year old wife is his primary care giver. They live in the home
that they have owned for 12 years. Prior to that they lived in the Central
Valley of California. They have five grown children.
.....The patient, his wife, and their oldest son have arrived. You wonder
whether you will need an interpreter/translator, or perhaps that is why
the oldest son is along. Your plan related to need for an interpreter/translator
is:
a. You make plans to have an interpreter/translator available.
b. You review the medical record further related to language needs, hoping
to find information.
c. You plan to use the wife or son as translators since that is probably
why the son came along.
.....You selected answer a: You make plans to have
an interpreter/translator available.
......If other information supports that there is no need for an interpreter/translator,
then you may have needlessly added expense to the patient's medical care,
even if it is not directly billed to the patient. You may also have allowed
yourself to think in a stereotype related to the potential educational
and language skills of the patient. You could create a communication
gap by making assumptions.
.....Hint: Either you or the office staff making patient appointments
can ask the patient or caregiver on the phone about the need for an interpreter/translator.
The culturally sensitive phrasing of such a question is: "Would
you like to have a MEDICAL interpreter available?" The use of "medical
interpreter" describes the special application of the interpreter
services and does not assume that normal conversation requires interpretation.
Interpreter is the correct description of these services since direct
translation does not always convey the meaning of questions or answers.
Even patients whose primary language is English occasionally need someone
to interpret medical information into easier to understand language.
.....Return to Question 1 and select another answer, or you may select
answer b or c from the grid above.
You selected answer b: You review the medical record
further related to language needs, hoping to find information.
......This is correct. Looking through the chart, particularly the social
history, admissions, social work, notes by other disciplines are likely
to provide indicators. You find that Mr. Ramìrez is a retired
lawyer who specialized in immigration issues. He was born in Mexico,
immigrated with his parents at the age of 12, and became interested in
law when his parents had immigration problems.
......Hint: Since you had to look for this information, add a note on
the medical chart in a prominent location so the next healthcare professional
with whom he will interact will not have the problems or make erroneous
assumptions about Mr. Ramìrez language skills.
.....More about Mr.Ramìrez: His language skills were not affected
by his CVA although intonation is flatter (the toneof his voice does
not accurately reflect his emotional expression), and he appears less
animated than the reported premorbid (before his stroke) intonation.
His education and age of immigration also provide clues about his social
history and life experiences. Since he lived in the Central Valley of
California, it is likely that he was involved in some way in the farm
worker organizations that had significant civil rights implications in
the 1960s and 1970s (where Cesar Chavez was active - See additional information
at the Mexican American Cohort Analysis**). This could indicate greater
insight by Mr. Ramìrez and his family related to cultural differences
and conflicts between main stream American culture and Hispanic/Latin
American cultures. He may be able to expand your own cultural competence
through discussion of issues of which he is aware. Many people enjoy
discussing cultural contrasts when conversation is based on genuine interest
and presented in a respectful manner. You may not have time while addressing
the medical issues of Mr. Ramìrez but he may become a resource
for you at a later time.
.....Even patients with less education than Mr. Ramìrez can offer
insights into cultural differences and barriers. The first task is to
recognize that barriers may exist. The barrier may be as obvious as language.
Other barriers may not be as obvious, such as those that occur related
to negative immigration experiences that include exclusion and prejudice
and can result in reluctance to share important information. Generalizations
must be avoided, since some studies show greater similarities between
people with more education who are from different cultures than between
those in the same culture who have widely differing educational levels
(see additional information at Cohort Life Events Analysis**).
......Detecting communication barriers among the ethnic elderly may be
confounded by depression, stress, early dementia, or nervousness in an
unfamiliar situation. Care must be taken to avoid attributing common
problems to cultural barriers and dismissing important cues related to
diagnostic and health issues. This is another reason that a person well
versed in English may still benefit from the use of a medical interpreter
(see answer 1-A for more details about medical interpreters).
......It is easy in the rushed healthcare environment, to rely on yes-no
questions, but for elders from different cultures these are as ambiguous
as any former student may recall the true-false questions of past exams.
Did true-false questions REALLY test your knowledge? The same can be
said related to yes-no questions asked a patient who may have language
comprehension problems.
The LEARN mnemonic, a communication tool for clinicians developed by
Berlin and Fowkes (1983) may be adapted to guide the patient-provider
interaction. It represents the following:
Listen with sympathy and understanding to the patient's perception of
the problem.
Explain your perceptions of the problem.
Acknowledge and discuss the differences and similarities (of these perceptions).
Recommend treatment.
Negotiate agreement (on a plan of care, including therapies and medications).
.Questions suggested by Johnson & Associates (1995) include:
What do you call your problem?
What causes your problem?
Why do you think it started when it did?
How does it work - what do you think the sickness does? - what is going
on in your body?
What kind of treatment do you think would be best for this problem?
How has this problem affected your life?
What frightens or concerns you most about this problem and its treatment?
**Cohort life events are part of a publication of the Stanford Geriatric
Education Center. The website with a condensed version of some of the
information in this publication is located at Cohort Life Events Analysis.
Information about ordering the publication can be found in the homepage,
and is titled "Cohort Analysis as a Tool
in Ethnogeriatrics: Historical Profiles of Elders from Eight Ethnic Populations
in the United States"
.....Continue on to Question 2, or you may wish to look at the information
for the answers you did not select.
You selected answer c: You plan to use the
wife or son as translators since that is probably why the son came along.
First, it is abroad assumption that the son has come along to be translator.
It is equally probably that he has provided transportation for his parents.
Second, having family act as translators has many cautionary considerations.
If personal questions are being asked, you are likely to get inaccurate
information since you may be asking about things that the elder either
would not share with the younger person, or would not discuss around
them. Topics that are uncomfortable or culturally inappropriate for intergenerational
discussion are better done through an impartial translator. Problems
can also occur when personal questions are expected to be translated
by a family member of a different sex than the patient. Translators must
be used at times, but information will be more accurate when it is not
a member of the family or a different sex than the patient.
Return to Question 1 or select one of the other answers from the grid
above.
