Speaking the same language
UF Health medical interpreters provide a voice for patients with limited English proficiency
By Marilee Griffin
Alfonso Melendez — a stocky, middle-aged man with kind eyes and salt-and-pepper hair — lies quietly as the neurodiagnostic technician dots his scalp with a red marker. The room in the EEG lab is purposefully low-lit. Soft music plays in the background to lull patients to sleep.
Winter, spring, summer or fall
Hey now, all you have to do is call
And I’ll be there, yes I will
You’ve got a friend
Alfonso’s wife, Milagros, breaks the silence with a question: “Se van a ver sus ondas cerebrales?”
Medical interpreter Roxana Urrutia turns to the technician: “Are you going to see his brain waves?”
“Yes,” replies the tech, who has begun attaching electrodes to Alonso’s scalp.
“Sí,” says Urrutia to Milagros.
A doctor has ordered an EEG for Alfonso because he shakes in his sleep. It’s gotten worse recently; sometimes he bites his tongue, other times he stops breathing. The doctor wants to rule out convulsions.
Soon, the wife, technician and medical interpreter are gathered around a computer screen, watching colorful rows of peaks march by. Milagros asks questions and the tech, Adam Shugan, answers — with Urrutia interpreting for both sides. Meanwhile, Alfonso is snoring.
Shugan finalizes the EEG test but it will be the doctor who will call with the results in a few days, he explains. As the couple leave, hand-in-hand, they seem relaxed and happy. They pause to tell both the tech and Urrutia, “muchas gracias.”
You’ve got a friend
While hospitals are required to meet the language needs of patients with limited English proficiency, the law doesn’t dictate how those needs are met. University of Florida Health opts for a system composed of several components: a team of onsite medical interpreters for Spanish-speaking patients, a 24-7 interpreter phone service for other languages and video remote interpreting terminals for patients who are hearing impaired.
Urrutia is one of three full-time medical interpreters at UF Health who assist Spanish-speaking patients during their hospital visits. In addition to achieving the standard national-level accreditation to become interpreters, the team has completed a specialty certification for the hospital setting.
Their team is part of the Office of Patient Experience and is available to assist patients and patient families on weekdays from 8 a.m. to 4:30 p.m. Last year alone, the team assisted patients in more than 6,000 encounters.
“To me, it’s a privilege to have an interpreter because we don’t speak English,” says Milagros before her husband’s appointment, through the interpreter. “It helps us to communicate with the doctor or the specialist — whoever is going to see him. It makes me feel more comfortable.”
UF Health also contracts with the company CyraCom to provide the phone service, and the Center for Independent Living of North Central Florida, a local community agency, to provide sign language interpreting. Each clinical area in the hospital system has at least two blue CyraCom phones that offer interpreter services in more than 200 languages. These phones also fill in for Spanish-only patients when an interpreter is unavailable, such as after hours or on weekends.
“We need to be able to care for patients to the best of our ability, so the phone service is a huge benefit,” says Christine Cassisi, director of patient experience in the Sebastian Ferrero Office of Clinical Quality and Patient Safety.
In 2015, the CyraCom interpreter phones provided 91,838 minutes of language services.
All you have to do is call
“It’s a very good thing to have an interpreter present,” says Alfonso. “It’s a tool that helps me to understand everything.”
This sentiment is common among patients the interpreter team works with, says medical interpreter Raquel Bourget-Gras.
“They are always relieved to see someone who can speak their language, who can understand them,” she says.
Bourget-Gras and her team share approximately 15 to 36 assignments, called “encounters,” each day, and the length of these encounters can range widely. It can be a quick call to a unit because a patient is asking to use the restroom, or a multi-hour session — such as when a cochlear implant is being fitted and tested.
“Basically, if there’s communication with a patient and it’s within our entity, we’re there,” says medical interpreter Charisa Lakin.
As a result, the interpreting team has witnessed and interpreted for a vast spectrum of hospital services: biopsies, breathing tests, CT scans, emergency care, pharmacy education, physical therapy, bone marrow transplants, pregnancy and delivery, pulmonary function tests … wherever limited English proficiency patients go, so go the medical interpreters.
They know where to stand to give a patient receiving a rectal exam the most privacy. They’ve run — literally run — to the trauma unit to shout alongside 20 providers who are working to save a life. They’ve stood beside mothers-to-be who projectile vomit after receiving an epidural. They’ve seen kidneys being kept alive by a machine. They’ve smelled necrotic tissue. They’ve witnessed tragedies. They’ve witnessed miracles.
“I think every professional sees a lot more than we do in their own field, but the mix and the range we cover is unique,” Urrutia says.
Whenever a patient in one of these areas needs an interpreter, a dispatcher looks to see which interpreter is next in the queue and calls her with the assignment. When the interpreters complete the encounter, they report to the dispatcher and are added back to the queue. Alternately, health care providers can schedule an interpreter ahead of time if they know a Spanish-speaking patient has an appointment — which helps ensure availability.
Prearranged appointments also allow the interpreters to do a little preparation. They can read the patient’s medical record, speak to his or her case manager or research key terms in Spanish that may help with an unfamiliar procedure or diagnosis.
“It’s helpful to look at patient’s chart ahead of time if we get a chance, especially if it’s a rare disease or condition,” Urrutia says. “We might not know the word for a specific type of cancer, or a specific disease.”
In the right hands
Within the electronic hospital medical record system, limited English proficiency inpatients are flagged as such and require interpreter services. In addition, their medical consents require an interpreter stamp or an interpreter ID number to be considered official.
“Sometimes staff wants to change a patient’s status because they think they can speak English, but we have to make sure,” Urrutia says. “A lot of our patients will nod, but it’s cultural — that doesn’t mean they understand. They’re just being respectful to you when they’re nodding.”
Along those lines, patient family members cannot serve in the place of a medical interpreter; neither can unauthorized bilingual health professionals who happen to be on site.
People are well-meaning, but amateur interpreters can often falter once the discussion leaves the realm of conversational Spanish, Urrutia says. Accuracy is crucial, especially when it comes to medical information — so is the ability to remember everything that is said.
“We want to make sure everybody’s compliant with hospital policy,” Urrutia says.
It’s this devotion to patient care that separates full-time medical interpreters from freelance interpreters.
“A freelance interpreter wouldn’t advocate — they just repeat. We advocate for the patient and for the hospital,” she says.
However, health professionals at UF Health who are interested in serving as interpreters in a limited capacity can do so by contacting the interpreter team and completing a test. Currently, there are about 80 such providers in the UF Health system who are able to interpret French, Mandarin, Portuguese and Spanish, among other languages — and the medical interpreter team is always on the lookout for new candidates.
Found in translation
The medical interpreter team also provides translation services for UF Health. They’re quick to note that translation and interpretation are not synonyms; the former specifically relates to the written word, and the latter relates to the spoken word.
The team assists with translating written materials for UF Health, such as patient education packets, discharge instructions and consent forms and other medical paperwork. Translating and reviewing discharge paperwork alone can take up to four hours.
“All of this information that’s in English must be translated into Spanish, so seven pages can turn into 15,” says Bourget-Gras. “Obviously, that takes more than 30 minutes.”
Oftentimes, the interpreters proofread each other’s translations and will read these finished documents aloud to their teammates for feedback.
“We work together when doing translations because sometimes one of us will pick up a mistake or say ‘that doesn’t really sound right. Let’s change it to this,’” says Bourget-Gras.
Because the interpreter team makes a habit of handing out business cards during each encounter, they also field quite a few phone calls from patients who need assistance with some aspect of their hospital visit, such as setting up an appointment or refilling a medication.
“When patients get discharged and have an issue, they have no one who can really understand and help them out, so they call our office,” says Bourget-Gras. “Other times, new patients who aren’t yet in the system call and we have to figure out what’s going on.”
It’s often up to the interpreters to find the right health professional or clinic before they can help facilitate the phone call.
A voice in moments of sadness and joy
Victor Manzanares is 11. With his shock of dark red hair and gap-tooth smile, he looks a little like Alfred E. Neuman of Mad Magazine. He’s also bright-eyed, talkative and a good student; he gets himself up for school every morning at 5 a.m.
Victor also has severe burns over 20 percent of his body. He was burned in a freak firecracker accident in early January, but now, barely a month later, everyone who sees him remarks on how well he’s recovering. The burns, which are primarily on Victor’s hands, legs and thighs, stand out against his skin in red and pink stripes — but they’re clearly healing. The wounds will always be a little noticeable, says Donald McCurry, the physical therapist/wound care specialist working with Victor today, but it will eventually be much better.
Today Victor is getting his bandages changed. Even with medication, it’s a painful process that takes almost two hours and five health professionals to complete. Throughout it all, his mother, Alta, never leaves his side. The same can be said for Urrutia, who stands at Mom’s elbow — always calm, always engaged, always right in the action. Her near-constant interpreting hums in the background as the team works — talking to each other, talking to Victor, answering Mom’s questions.
Alta is from El Salvador, and unlike her son, only speaks a handful of English words. Victor is fluent, and only switches to Spanish when the pain is too intense. In those brutal moments, when the room is quiet except for his cries of agony, Urrutia murmurs, “Tranquilo … tranquilo, Victor.”
This scene is an unfortunate but all-too-real part of what goes on at a hospital, and the medical interpreters see many like it. The births, the deaths, the joys, the sorrows; they’re in the middle of it again and again, providing a voice for patients.
“The first time you see skin being opened, the first few times you see a patient die, it affects you,” she says. “I hate to say you get used to it, but then you see it’s part of your job. Imagine if every doctor, every nurse got upset … there would be no one working. You can’t. You have to form a callous.”
It’s easy to imagine that this mindset would be crucial during times when Urrutia and her team have to tell a patient she has cancer, for instance.
“That exact second the person knows they have it, you can feel their anguish and anxiety,” she says.
“They transmit it — I can’t even explain it. And when they’re happy, they transmit that happiness. You feel it. It’s palpable.”
During these emotional encounters, Urrutia’s philosophy is likely mirrored by other health professionals: “Even when it’s sad, it’s gratifying. You go home appreciating life.”
But the job is not always so extreme. There are also moments of laughter, like when an older patient repeatedly tells an anesthesiologist he’s “so handsome” and the interpreter has to explain it isn’t her opinion but the patient’s. There are even moments of wonder, such as the first time the interpreters witness a cutting-edge procedure.
“It’s just mesmerizing, the things they can do now,” says Lakin. “The first time I went to see a heart catheterization, they injected the dye and you see all the veins around the heart — it’s like fireworks!”
The fine line
In their unique roles, the medical interpreters don’t just repeat what’s said. They can also advocate for patients. Their unique understanding of patients’ backgrounds and cultures can be helpful in fostering communication; they just can’t interject opinions or advice.
“Medical interpreters walk a fine line when it comes to patients,” says Urrutia. “We don’t add or take away anything, but we have a little bit of flexibility.”
Sometimes that flexibility takes the form of recommending a doctor simplify technical information.
“We have some patients who can’t read in Spanish or have not gone to school. We also have some indigenous patients that come from Latin America who also speak a different language other than Spanish as their main language,” says Urrutia. “For example, someone may have leukemia but has no idea what red blood cells or platelets are. The physician has no way of knowing that the patient doesn’t understand. You have to ask them to explain the very basic aspects.”
In these cases, sometimes the interpreters will suggest a simplification, and once getting approval from the doctor, will relay it to the patient.
“The patient needs to be informed,” says Bourget-Gras. “They need to know what’s happening to them.”
Walking the line also includes maintaining a friendly but professional relationship with the patients they interpret for. It’s all right — even culturally expected — to make small talk, especially at the beginning of an interaction, but then they focus on care. Why? To avoid a scenario in which a patient feels more comfortable with the interpreter than the provider they don’t share a language with.
“We don’t want that patient to have the opportunity to feel like they can tell something to the interpreter and then say ‘but don’t tell the doctor,’” Urrutia says.
Even so, it can be challenging to be so involved and yet remain detached.
“We are human, so it’s very hard when you see patients day in and day out not to have some kind of attachment, but we always play it very professional,” says Bourget-Gras.
But that doesn’t mean they can’t make a difference. In cases where the interpreters realize a patient or a patient family has a need, such as a change of clothes, they inform the social worker on the case, who can procure those items.
In addition to being advocates for the patients they work with, medical interpreters help form a cultural bridge between the patients and their providers.
“We are also cultural brokers for the providers,” says Bourget-Gras. “There are certain, specific things that patients from different cultures and different countries do in a particular way.”
An easy example of this relates to filling out a birth certificate. Unlike the traditional method in the U.S. wherein a baby may take the father’s last name or else may have a hyphenated last name, this is not the case in Spanish-speaking countries. Instead, the baby takes one last name from its father and one from its mother — and it’s the father’s last name that gets passed on to the next generation.
Interpreters also assist if there’s confusion surrounding the birth certificate, which can cause issues for a baby throughout his or her life, especially regarding medical records.
But names are just the tip of the iceberg. In fact, “tip of the iceberg” is an English idiom that may not translate when a physician tries to use it to describe a disease like leukemia. Urrutia has a story about a pediatrician referring to a baby girl as “very smart — like a fox!” In Spanish, referring to a female as a fox is an insult. It was a chance to culturally educate.
“I told him, ‘I’m sorry, I shouldn’t repeat that. The parents won’t understand. I’m going to change that word for you,” says Urrutia. “In Spanish, we say ‘lista como una ardilla’ — ‘smart like a squirrel.’”
Of course, within the 21 Spanish-speaking countries, certain words may mean something in one country and something else in another.
“Each country has different accents and dialects. Each has its own native languages, its own slang, its own accents from north, south, east and west. Then multiply that by 21,” Urrutia says.
For example, she knows at least eight words for beans. But by taking a little time to get to greet the patients they work with and to ask where they’re from, the interpreters are often able to determine which “beans” to use.
Urrutia recommends that those interested in becoming interpreters spend some time living in a country that uses the language they’re studying.
“It’s more than just the grammar and the language,” she says. “You have to absorb the culture.”
Looking back, looking forward
The interpreter service has grown quite a bit since 2007, when Bourget-Gras was hired. At first, it was just Bourget-Gras and a pager. Eight years later, the team includes three full-time and one part-time interpreter and the pagers have been replaced with the phone dispatch method.
Both Urrutia and Lakin came onboard approximately two-and-a-half years ago. Pablo Paz, the part-time interpreter, joined the team late last year.
Beginning in 2013, the team began reporting to the Office of Patient Experience under the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety.
“Only in retrospect did we realize what an extraordinarily good decision it was because of their unique role,” says Cassisi. “The medical interpreters are really there on the front line of care. There are lots of patient safety issues they’ve been able to identify because of their role.”
The team is managed by Anne Meiring, senior quality improvement specialist, and ultimately reports to Cassisi.
The in-person relationships the interpreters build with patients decrease the chance of adverse events due to miscommunication and significantly improve quality of care, Meiring says.
“The team truly makes a difference for our hospitals,” she says.
Shawn D. Larson, M.D., the physician working with Victor to heal his burns, agrees: “The interpreter service is absolutely vital,” he says. “It helps to effectively communicate the treatment plan and ensure the best outcomes for the patients. Personally, I find when the interpreters are there, the families are much happier. There’s a more natural flow of conversation.”
The expansion of the interpreter team and its scope is due, in part, to the passion the interpreters feel about the service they provide, as well as the patients they serve. It drives them to meet patient needs wherever they arise.
“I’m really proud of how Anne and the team have been using almost every vehicle possible to proselytize the benefits of interpreter services,” says Cassisi. “You can see this by the number of the patient encounters increasing. People are seeing how important this is for our patients — and the implications for patient safety.
“The interpreter team just owns it and lives it and breathes it.”
UF Health interpreters make a medical catch
By Morgan Sherburne
Being a Spanish-speaking patient in an English-speaking hospital can be daunting — but it also can lead to a potentially life-saving medical catch.
One of these catches happened recently in the case of a Spanish-speaking patient. The UF Health medical interpreters knew that the patient was regularly prescribed Lovenox, a blood thinner. So when Raquel Bourget-Gras, pictured above, was translating the patient’s discharge instructions from English to Spanish, she found it strange that the patient’s discharged papers instructed her to stop taking Lovenox.
Bourget-Gras brought the issue to the attention of the nurse, who in turn contacted the patient’s physician — who verified the error. Because of this catch and others like it, the medical interpreters received a UF Health Shands Great Catch award.
Translating those instructions gives the interpreters familiarity with each patient’s treatment and offers them the opportunity to notice errors. Several such errors have been caught thanks to the interpreters’ translations, which have prompted the creation of an interdisciplinary performance improvement team.
The team is creating a standardized template to help health care providers when writing the discharge instructions. The goal is to help patients more easily read and understand those instructions.