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Saturday, January 12th 2013

Culturally Competent Care In A Rush

Providing culturally nuanced medical care is held up, sometimes, as a right of patients and a goal that should be paramount in medical care; even with all else that needs attention. Sometimes the emphasis on culturally component care is stressed to a laughable degree. As if a physician practice, without a significant east African patient population, should have immediate access to an in person female Somali speaker, of the same dialect as the patient,

Though the state requires all medical providers to offer translation, current services fall short. Most rely on special phone lines for translation, which are based out of state and offer little control over the gender (Muslim women prefer female translators) and dialect of the translator.

Even with phone services available, a slapdash approach to translation is the status quo. Providers and patients often rely on neighbors or children, who cannot legally act as interpreters in California.

I’m not saying culturally component care isn’t important. Although the term is broad, it leads to better outcomes through better communication and better patient compliance with therapy. But there is obviously a limit to what can be achieved in most of health care within reason and examples like the above show a naïveté amongst proponents of such care.

Then of course, there are examples of the opposite.

I train in a city where more than half the population speaks Spanish as a first language. Obviously that figure is likely even more impressive for the specific population served by the county hospital. The encatchment area of the hospital extends into territories where the prevalence of Spanish is even more complete. Many of these patients do not speak English in addition. And while translation services are often relatively easy to maintain the established process is haphazard and in more than one instance has failed.

This story has obviously been changed substantially but I think it is in line with some recent experiences which have frustrated me.

I had a patient recent who needed a neurosurgical procedure. He was an inpatient and it was my first time meeting him and his first time meeting a neurosurgeon; their was no established repoire or understanding about what we were about to discuss. He was a Spanish speaking only gentleman with no family. He had had extensive, destructive sinus surgery which had made him nearly unintelligible in speech at times. While the surgery wasn’t urgent, there was an opportunity it done the same day and move the patient’s care along. That obviously depended on, most importantly, discussing such with the patient.

So, after my halting introduction of myself in Spanish, knowing I was over my head I went to his nurse, who did not speak Spanish, and asked if he could help me find someone to translate. He rather unhelpfully, but not rudely, merely offered up a name of a tech who was on the floor who could translate. So I went to the front desk and inquired for the tech with the clerk, who not having seen him recently paged him overhead to the patient’s room. I went back and waited awkwardly with the patient. No one showed. Back to the clerk I went and inquired again. This time I asked for the charge nurse who the clerk promised to find and in the meantime she suggested I use the translation phone that exists on every ward and unit. While trying to explain that the patient’s speech was garbled, I still took the phone while I waited. I set up the phone and dialed in and the translator on the other end did his best but essentially could not comprehend the great majority of the patient’s responses. At the end of my discussion and introduction of what I thought we needed to do next for the patient, with surgery, he offered up questions which were useless and devolved into me trying to read his Spanish writing over the phone to the translator. The patient merely shook his head finally, shrugged and said, I think, in English, “Is okay.”

During the conversation over the translation phone the nurse popped in again and left, on a journey he said to find a translator. He didn’t return with any haste.

The entire ordeal took perhaps twenty or thirty minutes. No doubt the institution failed. I’m not sure, serving a majority Spanish speaking population, that organized, readily available, in person Spanish translation can even be called something like cultural competency under such circumstances. It seems even better practice than that; a necessity. And yet here we are.

To be fair I could’ve done better. A surgical intervention is a major life altering point and thirty minutes looking for the appropriate translator was worse than my patient deserved. I should called up the line of command in my pursuit. But in house, with sixty patients under care and consults stacking up in the emergency room, real time pressure exists. Not that I got, say, four consults while I was talking to the patient, only that there are other pressing things that require attention. A reason; not an excuse.