Medical Office Staff Training
Language Access &
Cultural Issues
Presenter: Rebecca J. Patchin, M.D.
Presented by the Riverside County Medical Association and the
San Bernardino County Medical Society
Supported by an educational grant from the California Academy of Family
Physicians and The California Endowment
Helping your Doctor Care
for Patients with Limited
English Proficiency
Resources Available
Ideas & Tools
What Others Have Done
In 1990, 8.6 million Californians spoke a
language other than English at home and 4.4
million were considered “limited English
proficient” (LEP).
By 2000, those number increased by 40%, with
12.4 million speaking a language other than
English at home and 6.2 million being identified
as LEP.
Figures released in late 2007 show that one in
five people in the US speak a language other
than English in the home.
Language Diversity
Many native & foreign-born Californians speak
a primary language other than English at home.
Statewide, more than 12 million Californians
speak languages in each of the 39 language
categories reported by the U.S. Census
Not surprisingly, Spanish is far & away the most
prevalent language spoken at home, after
However, among the top ten languages spoken
in CA, more than half are Asian languages,
Chinese, Taglog, Vietnamese, Korean and
Riverside County
Riverside County has a population of 1,545,387
Race & Ethnicity
 White: 65.5%
 Hispanic: 36.2%
Black 6.2%
Asian: 3.5%
14% of the total population (221,999) are limited
English proficiency (LEP)
Languages spoken in homes in Riverside County
 Spanish
 Korean
 Laotian
 Gujarathi
 Cambodian
Miao, Hmong
San Bernardino County
San Bernardino County has a population of 1,709,434
Race & Ethnicity
 White: 58.7%
 Hispanic: 39.2%
Black 8.9%
Asian: 4.6%
14% of the total population (240,549) are limited
English proficiency (LEP)
Languages spoken in homes in San Bernardino
County include
 Spanish
 Korean
 Laotian
 Gujarathi
 Cambodian
Miao, Hmong
Clear Communication
between Doctor & Patient
Results in:
More accurate diagnoses
Agreed and understood treatment plans
Increased adherence to medication
Improved health outcomes
Reduction in frustration of doctors and
office staff.
Increased patient satisfaction
What can YOU do to
provide/identify language access
issues in your practice?
Assess Your Practice’s Language
 Identify Existing Resources
 Develop a Plan for Improving Your
Practice’s Language Access
Hint: Use the “Addressing Language & Culture: A
Practice Assessment for Health Care Professionals” as your guide.
Health Care Interpreters
Health Care Interpreters
The fundamental purpose of health
care interpreters is to facility
communication between two parties
who do not speak the same language
and may not share the same culture.
Health Care Interpreters
With communication:
 Doctors can gather the information needed for an
accurate diagnosis.
 Patients & Doctors can better understand each others
views, concerns, values and priorities, and cultural
practices and perspectives.
 Patients & Doctors can negotiate treatment plans.
 Patients can understand how to care for themselves.
 Patients can understand their options and participate
in decisions regarding their health.
 Patients and Doctors are more likely to develop
trusting and caring relationships with each other.
Key Terms
Interpret: Language being interpreted from
Translate: Untrained and untested interpreter
Source language: Orally expressing a message
from one language to another
Target language: Language being interpreted to
Ad-Hoc Interpreter: Converting written text from
one language to another
Register: Vocabulary, grammar, and
pronunciation that usually reflects a speaker’s
educational and social background.
Definition of Culture
(one definition)
The thoughts, communications, actions, customs,
beliefs, values and institutions of racial, ethnic,
religious, or social groups.
Culture defines how health care information is
received, how rights and protections are
exercised, what is considered to be a health
problem, how symptoms and concerns about the
problem are expressed, who should provide
treatment for the problem, and what type of
treatment should be given.
In sum, because health care is a cultural
construct, arising from beliefs about the nature of
disease and the human body, cultural issues are
actually central in the delivery of health services
treatment and preventative interventions.
Culture …
By understanding, valuing, and incorporating
the cultural differences of America’s diverse
population and examining one’s own healthrelated values and beliefs, health care
organizations, practitioners, and others can
support a health care system that responds
appropriately to, and directly serves the unique
needs of populations whose cultures may be
different from the prevailing culture.
What Happens When Qualified
Interpreters Are Not Available?
Family members, children, friends, any bilingual
person in the area, and untrained bilingual
employees are asked to interpret. All have
good intentions and do not intend to cause
harm, but …
Patients are seen without an interpreter.
Patients are turned away unless they bring
someone to interpret for them.
Risks of Ineffective
Incomplete communication between
practitioners and patients plays a major role in
medical professional liability claims.
Numerous studies show that the majority of
patients do not fully comprehend the health
information that is presented to them and that
Doctors often make incorrect assumptions
about patients’ level of health literacy.
Scope of Low Health Literacy
(Institute of Medicine Report)
Nearly half of all American adults – 90 million
people – have difficulty understanding and
acting upon health information.
Forty million Americans cannot read complex
texts (e.g. informed consent forms) at all.
Even people with strong literacy skills may have
trouble obtaining, understanding and using
complex health information.
Health Literacy
It is not difficult to imagine how
misunderstandings or gaps in communication
can fuel patient anger over a poor outcome and
spark subsequent litigation.
Health literacy is defined as “the capacity to
obtain, process, and understand the basic
health information and services needed to
make appropriate health decisions.”
Key Findings in IOM Report
The readability levels of informed consent
documents exceed the documented average
reading levels of the majority of adults in the
Health professionals and staff have limited
education, training, continuing education, and
practice opportunities to develop skills for
improving health literacy.
Key Findings … IOM Report
Even signage and directions posted for
employees and visitors can often be
This report also noted that “identifying the
extent of limited health literacy is also
problematic because individuals tend not to tell
their Doctors about literacy problems that they
encounter in the increasingly complex health
system, including trouble understanding both
printed materials and the meaning of
discussions with Doctors.
An Example
A two-year-old is diagnosed with an inner ear
infection and prescribed an antibiotic. Her
mother understands that her daughter should
take the prescribed medication twice a day.
After carefully studying the label on the bottle
and deciding that it doesn’t tell her how to take
the medicine, she fills a teaspoon and pours the
antibiotic into her daughter’s painful ear.
The doctor may very well have told the patient’s
mother than the medication should be taken
orally, but the mother may not have understood
what this meant and may have been too
intimidated to ask.
In fact, “oral” appears on the following list of
medical terms that patients may not understand
and their translations into plain language.
List published by the AMA Foundation. This list is not
comprehensive but can serve as a reminder that common
medical terms can be confusing for the average American.
Medical Term
Translation into Plain English
Cardiac Problem
Health Failure
Pain Killer
Lessens swelling & irritation
Not cancer
Heart problem
Skin infection
Birth Control
Get bigger
Heart isn’t pumping hard enough
High blood pressure
Can’t get pregnant
Fat in the blood
Stopping periods, change of life
Keep track of, keep an eye on
By mouth
Soft, brittle bones
Going to die
Note: An English-Spanish Dictionary of Health Related Terms, 3rd Edition, July 2005, is available on
the MLC website at
Health Literacy & Informed Consent
Lack of informed consent is a frequent
secondary allegation in medical professional
liability claims
A patient alleges that he or she was not aware of a
particular risk or side effect
• For example, a vaginal birth after cesarean (VBAC) patient
may allege that she was not aware that her uterus could
rupture (or that she didn’t know what the term VBAC means)
• A patient on a long-term medication may allege that he was not
aware he could develop liver toxicity from taking that
From a risk management perspective, the informed consent
discussion is crucial to defending a physician. The
discussion, though, serves no purpose if patients cannot
comprehend what is being said.
Identifying and Addressing
Low Health Literacy
Test for health literacy when taking vital signs
 Literacy test available in both English and Spanish
that is designed to quickly assess literacy without
disrupting patient scheduling.
 Can be administered by a medical assistant while
taking other vital signs.
 Test based on the patient reading an ice cream label.
Patient is asked to determine total calorie count and
whether or not a person with a peanut allergy could
eat the ice cream based on ingredients.
 Although simple, the test can identify whether or not
the patient can read, do simple math (important for
calculating doses for medicine) and use abstract
6 Steps to Improve
Communication with Patients
Whose Health Literacy is Limited
Speak slowly & spend a small amount of additional
time with each patient.
Use plain, non-medical language.
Show or draw pictures, which can improve the
patient’s recall of ideas.
Limit the amount of information provided to pertinent
tasks at hand. Repeat the information to enhance
Confirm the patient’s comprehension by asking them
to repeat back your instructions.
Create an intimidation-free environment by making
patients feel comfortable asking questions. Enlist
the aid of others (interpreters, patient’s family,
friends) to promote understanding.
Developing Plain-Language
Educational Materials
Visual materials can support effective
Experts have noted that “when reading
messages, readers look at the visual first, the
caption second, and the text last.”
Research has shown that for patient health care
instructions, visuals can increase patient
understanding, and compliance.
CA Standards for Healthcare
Confidentiality: Interpreters treat all
information learned during interpreting as
Impartiality: Interpreters are aware of the
need to identify any potential or actual
conflicts of interest, as well as any personal
judgments, values, beliefs or opinions that
may lead to preferential behavior or bias
affecting the quality and accuracy of the
interpreting performance.
Respect for Individuals and Their
Communities: Interpreters strive to support
mutually respectful relationships between all
three parties in the interaction (patient, doctor,
interpreter), while supporting the health and
well-being of the patient as the highest priority
of all health professionals.
Professionalism and Integrity: Interpreters
conduct themselves in a manner consistent
with the professional standards and ethical
principles of the health care interpreting
Accuracy & completeness: Interpreters
transmit the content, spirit and cultural context
of the original message into the target
language, making it possible for patient and
provider to communicate effectively.
Cultural Responsiveness: Interpreters seek to
understand how diversity and cultural
similarities and differences have a fundamental
impact on the health care encounter.
Interpreters play a critical role in identifying
cultural issues and considering how and when
to move to a cultural clarifier roles. Becoming
culturally sensitive and culturally responsive is a
life-long process that begins with an
introspective look at oneself.
Three-Way Partnership
Recognizes the three unique relationships in an
interpreting encounter and the expertise of each party.
 Relationship 1: Patient-Doctor
 Relationship 2: Doctor-Interpreter
 Relationship 3: Interpreter-Patient
Primary Relationship: Patient-Doctor
 In most situations, interpreters support and reinforce
the primary relationship between the patient and the
Patient Privacy
Interpreters treat all information learned during the
interpreting as confidential.
Advise all parties that they will respect the confidentiality of
the patient/doctor interaction
Advise all parties in the interpreting session to refrain from
saying anything they do not wish to be interpreted
Decline to convey to Doctors any information about the
patient gained in a community context (Note: in cases
where the interpreters are privy to information regarding
suicidal/homicidal intent, child/senior abuse, or domestic
violence, interpreters act on the moral, if not legal,
obligation to transmit such information to the provider, in
keeping with institutional policies, interpreting standards of
practice and code of ethics and the law.
Decline to convey to patient any personal information about
the doctor
Protects health information in oral, written or
electronic form.
Defines when patient information can and
cannot be used and disclosed without patient
In general, patient authorization is required to
released protected health information except for
purposes of treatment, payment, and health
care operations (e.g. quality improvement,
audits, training of health care professionals)
and when legally required to do so.
Protecting Patient
Confidentiality for Interpreters
in Your Day-to-Day Work
DO safeguard written logs, schedules, or
activity sheets that contain protected health
DO look for private space or lower your voice
when discussing protected health information
DO be aware that just leaving out a patient’s
name may not be enough to protect the
patient’s confidentiality. Other information may
make it possible to identify the individual, even
without the name
DO refer requests for protected health
information back to the patient, doctor or other
health care professionals or staff when
possible. Avoid providing protected health
information when the patient or others involved
with the patients care can do so.
DO destroy or shred any documents (such as
notes taken during the medical visit) that
contain protected health information before
throwing them away
DON’T share protected health information with
anyone unless it is needed to do your job or
their job.
DON’T share more information than is
necessary for you or others to do your jobs.
DON’T access patient information unless you
need it to do you job.
DON’T send email containing protected health
information unless it is encrypted.
Additional Resources
Medical Leadership Council Web site
Patient Education Materials in multiple languages
Language Access Database
• CA County-specific contact information for interpreters and
county-specific, statewide and national listings for
organizations and web sites providing services in languages
other than English
Educational Tools
English-Spanish Dictionary of Health Related Terms
“Practice Assessment for Health Care
Professionals” – each participant
receives a free copy
The Body (El Cuerpo)
el brazo (arm)
la cabeza (head)
la cadera (hip)
la cara (face)
la cintura (waist)
el cuello (neck)
el dedo (finger)
el dedo del pie (toe)
el hombro (shoulder)
la mano (hand)
el pecho (chest)
el pie (foot)
la pierna (leg)
la rodilla (knee)
el tobillo (ankle)

Addressing Language & Culture