Medical Protection’s Dr Rachel Birch explores some of the risks involved in treating patients whose first language is not English.
It is likely that we have all consulted with patients whose first language is not English. How often we do so will depend on the demographics of the practice population. There are potential risks, both to the patient and the doctor, as the case below demonstrates.
Dr X was running late during a busy afternoon surgery. Her next patient was Mrs H, who had recently moved to the area from Romania. She told Dr X that she had pain in her tummy and appeared to be in some distress. Mrs H had limited English and could not understand some of Dr X’s questions so she called in her 15-year-old daughter to translate for her.
Dr X restarted the consultation, trying to establish details of when the pain started, the nature of the pain and its location. She asked if there was any possibility that Mrs H may be pregnant. The daughter responded directly, without translating the question, stating that her mother could not be pregnant as her father had been working offshore for the past three months. Dr X persisted and asked the daughter to relay the question to Mrs H, who upon hearing it indicated that she may be pregnant.
Mrs H was admitted to hospital by ambulance and had surgery for her ectopic pregnancy.
- Beware of the translator answering the question on behalf of a patient. Explain to them that you must obtain an answer from the patient directly.
- Always ensure that the translator asks the question to the patient and that they provide the patient’s answer back to you. If in doubt, consider asking the question again.
- Be aware that patients themselves may be reluctant to answer certain questions in front of family members. You may need to consider asking the family member to leave and arrange professional translation services for the patient.
How can doctors reduce language risks?
The GMC emphasises in Good Medical Practice that effective communication is key to the consultation:
It states: “You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.”
The gold standard, when consulting with non-English speaking patients is to arrange for an accredited professional interpreter to be present. The risks of misinterpretation and mistakes are likely to be low in such circumstances. If an interpreter is not present, then you may wish to consider using a telephone or video interpretation service, such as LanguageLine.
When using interpreters, ensure that you look at the patient and not the interpreter − this allows you to monitor the patient’s body language and non-verbal cues, as well as alleviating any anxiety the patient may have. The use of an interpreter may take more time than a usual consultation, and practices should ensure they take steps to facilitate this.
Questions should be asked in plain English. Remember that some English phrases could have more than one meaning, so if the patient appears confused by the question, ask it in a different way.
When taking consent from a patient using a translator, it is particularly important to take time to ensure that they are fully aware of the risks and benefits, especially if the decision is complex.
Family members as translators
Patients will often attend with family members and ask them to act as translators. There are potential pitfalls here that doctors should be aware of.
Before starting, you should ensure that the patient is happy to discuss their symptoms in front of their family member. If in any doubt, offer a translation service.
Make it clear that the family member must translate word for word what the doctor and the patient say.
Ask the family member to let you know if there is any phrase that they feel they cannot translate.
Document the presence and name of the translator and the discussion you have had.
Family members may try to add their own personal opinion and information to the consultation. If they are keen to do this, suggest that they do so separately, once you have finished taking a history from the patient. Ensure that they translate this information for the patient too.
Whilst most family members will be happy to act as a translator for the patient in good faith, doctors should be aware that there may be situations when it may not be in the patient’s best interest.
For example, using children to translate may prevent mothers from providing vital information, as could so easily have happened in the case study. It would not be appropriate to use young children as translators and you may need to assess an older child’s capacity to ensure they are aware of their responsibility to translate accurately.
Occasionally, a family member may appear to be controlling the information that is given to the doctor. It is important to be aware that domestic abuse and child abuse can happen in any community. Seek advice from social services or child and adult protection leads if you have any concerns in this regard.
For older patients lacking capacity, establishing their needs and wishes may be difficult, and if their carer is also their translator, there may be a conflict in these two roles.
Other communication resources
Doctors should also be aware of SignTranslate as a resource to aid communication with non-English speaking patients. It is a web-based communication tool and translates over 300 medical questions into British Sign Language, and 12 foreign languages. The questions are designed to have 'yes' or 'no' responses or the patient can point at a diagram on the screen.
The Red Cross has published an Emergency Multilingual Phrasebook, containing the most common medical questions and statements in 36 languages. This enables basic communication between doctors and patients who do not speak English. It may be most useful in a medical emergency, allowing the doctor to make an initial assessment while an interpreter is contacted.
NHS Choices has a translation link on every page and provides a variety of printable resources relating to NHS services, health promotion and medical conditions. It also provides links to resources in other languages on other websites.