Lost in translation

THE PHRASE ‘limited English proficiency’ didn’t mean much to me before I started my GP foundation training. But on day one of my rotation in a busy Glasgow surgery, I quickly found out what it meant. As I struggled to communicate with some of the people who came to the practice, I realised that the ethnically diverse community we serve would put my communication skills to the test.

Consulting patients with limited or no English was initially a daunting and uncomfortable experience for me and, I suspect, also for them. But now, a few weeks down the line, it has become a day-to-day occurrence and one I am getting better at dealing with. The significance of language and cultural differences between doctor and patient is such that the BMA has identified them as “the most important barriers to healthcare in Britain”.

So how can we overcome these barriers and deliver the healthcare that patients deserve? Unless you happen to have enrolled in evening classes for every language under the sun, you’re likely to need an interpreter at some point in your career. One useful resource is the Emergency Multilingual Phrasebook, produced for the NHS by the British Red Cross. It lists key medical questions in 36 languages to help first-contact staff communicate with patients and make an initial assessment while an interpreter is contacted. It tells you how to ask things like “When did you become ill?” and “Have you any bleeding?” in languages from Albanian to Vietnamese. It can be downloaded from the Department of Health website

Establishing rapport

It is important to approach the consultation in the same way as you would any consultation, ensuring the patient is centre of your attention. This is likely to be even more important than usual in gaining their trust and establishing rapport.

Greet the patient directly in order to establish contact. Check via the interpreter that the patient is comfortable with the situation and explain that the same respect of confidentiality applies. Ensure the patient sits closest to you and is not tempted to shy away behind the interpreter. Maintain eye-contact and speak directly to them in the first person.

As always, be aware of tone of voice and your own body language, as well as the patient’s non-verbal responses, but remember that gestures may have different meanings in different cultures. A good interpreter should be able to provide guidance if offence is likely to be caused. Finally, remember to document the presence of the interpreter and provide an account of the information shared. Make sure you also take note of the interpreter’s name and contact details.

If you are dealing with a patient who speaks limited or no English, there are a few different types of interpreter to consider. These include:

• an ‘ad hoc’ interpreter (often a relative or friend)

• a multilingual healthcare professional

• a telephone interpreter

• a trained interpreter who attends in person.

‘Ad hoc’ interpreters

Patients may prefer to consult through someone they know. This can be an advantage because the interpreter in this case is likely to have some awareness of the patient’s complaints, an appreciation of the purpose of the visit and can be a reassuring familiar presence for the patient, providing more empowerment for them in an unfamiliar culture and language.

But it’s important to bear in mind that interpreting through a relative or friend is not without its disadvantages. There is always the worry that using an informal interpreter could undermine both patient confidentiality and the objectivity of the consultation. There is also no guarantee of how well the untrained interpreters understand both languages and whether they can effectively communicate what both parties are saying. They are unlikely to have the relevant experience of medical terminology and phrases of a trained interpreter.

The use of relatives or friends may also make it difficult for the patient to discuss sensitive issues. In more serious circumstances, these encounters may allow a relative to hide abuse or exert undue influence over the patient and their medical care.

In one case, concerns of sensitivity and control arose when a non-English-speaking teenager attended the practice to discuss her failure to conceive. The patient appeared timid and submissive while her rather pushy motherin- law gave an account of the young girl’s wishes and details of her sexual health and practices. Similarly, consultations can be awkward for the interpreting relative as well, such as the case of the 12-year-old son brought along by his mother to interpret during her smear appointment.

Trained interpreters

The use of trained interpreters is preferable wherever possible and can help to avoid the medico-legal pitfalls that may arise from inaccurate translation within a medical consultation. Using a professional interpreter is more likely to result in effective communication between you and your patient. However, scope remains for misunderstandings and you can never be entirely sure of what message is conveyed by and to the patient. In one consultation, a trained male interpreter was booked to interpret for a 14-year-old female patient. The patient gained my sympathies when it became apparent that the complaint was of an embarrassing nature but had me bewildered when the interpreter explained she was worried because she had two breasts. Examination revealed the patient’s accessory nipple and the interpreter’s lack of terminology.

More commonly I find myself dubious as to whether or not all the information offered by the patient was actually translated. It seems that several minutes’ worth of dialect between patient and interpreter can be translated in a few seconds of English. It may be that the interpreter is particularly efficient in identifying the relevant details or simply that the meaning is conveyed more easily in English, but whatever the reason it is worth establishing that you require to hear all the information offered by the patient. In order to encourage an open and effective consultation a few rules of thumb can be applied:

• Speak slowly and in short sentences, and request that the patient does the same to avoid details being omitted.

• When you are speaking to the patient look at them, not the translator.

• Avoid the use of medical jargon and metaphors which may be difficult to translate. Ask only one question at a time and if the required information is important try asking in different ways to ensure understanding and consistency of the details obtained.

• Make sure that everything you say is translated (interpreters do at times need reminding).

• Make sure you say everything that you would if you were consulting with an Englishspeaking patient. Remember that these consultations will inevitably take longer as everything has to be said twice and often clarified so allow time for this. Patience and perseverance at this stage may avoid repeated consultations, unnecessary investigations and lead to timely effective management.

• For difficult meetings such as breaking bad news, it is helpful to meet and brief the interpreter first to ensure that the aim of the consultation and important issues are clear. This will allow the interpreter to clarify understanding and consider appropriate phrases where literal translation would not convey the meaning.

As with every experience, try to learn something from it. The interpreter may be able to provide you with advice for future consultations and help strengthen your cross-cultural communication skills.

Dr Sarah Birney is in her second year of foundation training