The daughter of South American immigrants, Patty Gavilan served as the family English language interpreter from the time she was a young child. Though she managed to dodge catastrophe, Gavilan — now a registered nurse — looks back and recognizes the potential danger, especially in health care settings, of depending upon a child's understanding and ability to cope.
"No child is versed in medical language," she said. "In many cultures, children are taught to respect their elders to the point that they will say the first thing that comes into their heads to shield their parents from unpleasantness."
She recalls intervening "when I overheard a 10-year-old child being asked to tell his mother she had a Stage 4 malignant breast tumor," Gavilan said. "Another time, a daughter told her mother she was being treated for anemia, while she was actually getting chemo for leukemia."
Gavilan coordinates the comprehensive language services program at Bon Secours Health System, Inc. in Richmond, Va., that provides extensive interpreter training for employees who serve as patient translators. In 2007, she was part of a group of bilingual Bon Secours employees from the Richmond area who trained as medical interpreters at the Area Health Education Center in Washington, D.C. AHEC is a program developed by Congress in 1971 to help meet community health needs by recruiting and training health care professionals to care for the underserved.
After additional course work, Gavilan became the in-house trainer of other bilingual medical interpreters working for Bon Secours. She has trained approximately 60 of her coworkers, and all have been certified as medical interpreters by the local AHEC. National certification for medical interpreters was not available in most states until about two years ago, Gavilan said, and she planned to take that exam early in 2014.
All Bon Secours' certified interpreters have dual responsibilities and must set aside their normal hospital work when a patient needs their translation skills. Usually the interpreters are called upon during their work shifts, but other times they come in as volunteers, said Gavilan.
"The story I hear so often [from the interpreters] is very close to my personal story," she said. "They say, 'I am the child of immigrants, and I served as the family interpreter. I saw the struggle my family went through, and I want to help.'"
Bon Secours offers a very basic course in Spanish to all employees who are interested, but before being accepted into the translator certification program, volunteers are tested and must score at least an 80 percent proficiency in both English and the second language, Gavilan said. "Some volunteers come to us with openness and a good heart, but they may not have the skills."
After passing the proficiency test, volunteers are ready for a 50-hour training class that extends over six weeks. Bon Secours soon will increase the training to 60 hours, Gavilan said.
Finding volunteers among the staff has not been a problem. "We were doing very little recruiting," she said.
Those who fall shy of full language proficiency are given less extensive training for other language tasks, such as greeting patients as they enter the facility. Most of the certified translators are nurses, but there are translation volunteers working at every level in the hospital. "Some work in valet parking, some in dietary," Gavilan said. "They come from all walks. The more folks we have at every level, the better."
One crucial aspect of the training is to clarify the interpreter's role: bridging a gap between the doctor and the patient.
"Often the patient comes in with a low self-image. No job, no money and they can't speak the language," Gavilan said. "Many come from a culture where the doctor is one of the most important, most respected members of the community. The interpreter needs to close the gap between them."
With that role in mind, the interpreter must insist that the patient and clinician look directly at and speak to each other — not to the translator — even though the translator is interpreting for both, Gavilan said. "We get better outcomes when there is that connection and trust. Often times we get better compliance. I've heard patients say 'I took all my medications because Dr. Jones said I should.'"
Bon Secours covers the cost of the training, which totaled $550 per person when the interpreters were trained off campus. Developing an in-house program permitted Bon Secours to reduce training costs to $200 per volunteer, plus textbooks and other materials.
The program also occasionally accepts community volunteers whom Bon Secours asks to pledge 150 hours of service in exchange for the training. "We prefer that the service be at a Bon Secours facility, but it doesn't have to be," said Gavilan. "It can be anywhere in the community."
As America grows more diverse, so does the language program. More than a decade before the training and accreditation program was formed, Bon Secours started Care-A-Van, a full service, free clinic on wheels that travels through Richmond's poorest neighborhoods to serve the uninsured and underinsured. Quickly it became obvious that more than 60 percent of the patients did not speak English. Almost from the outset, Spanish-speaking employees were a necessary part of the mobile clinic's team.
Now, Bon Secours' language services have expanded beyond Spanish — still the most common second language needed — to include employee volunteers certified in Russian, Chinese, Korean, Nepali and Vietnamese. Gavilan hopes to add a trained Arabic speaker.
She and others involved in the comprehensive language services program would like to see it expanded beyond Richmond to include all of Bon Secours' 19 acute care hospitals, its psychiatric hospital, five nursing care facilities and 14 home care or hospices in six states, most on the East Coast.
"It's a patient safety initiative," said Gavilan. "We want to make sure that our patients who do not speak English are receiving the same level of care. Patient safety is of the utmost importance. Things being lost in translation can be dangerous. A small, small misunderstanding can cause a patient to be harmed."
Bon Secours was well ahead of national accreditation standards aimed at making sure that patients understand and make informed health care decisions. The Joint Commission released the standards in 2011, five years after Bon Secours formalized its training program, and required hospitals to provide interpreter services as part of the accreditation process in 2012.
Some health care systems hire or contract with translators on an as-needed basis and use telephone and webcam interpreter services. Bon Secours also uses the electronic programs, but its extensive use of employee translators who have other roles in the system is unusual.
Still, even with a language-proficient translator, there can be misunderstandings rooted in culture — understanding a patient's culture can be as important as understanding the language, Gavilan said. She recalled a young Latina woman whose child was stillborn. "They spoke no English at all, and the mother became very angry. In the American culture it's common to say 'I'm so sorry.' When a nurse [who spoke a little Spanish] said 'I'm sorry' in Spanish to the mom, it was taken as very cold and unfeeling."
Gavilan had to broker a cultural difference with another mother whose baby needed an MRI. The baby was on a stretcher being prepared for the procedure, and the mother became almost hysterical.
"The problem was that the baby had a St. Gerard medal around her neck," Gavilan recalled. "The mother was from Puerto Rico, and in their tradition the medallion is given by a grandmother or godmother and is to be worn for the first year to keep the baby safe."
After the mother explained the tradition, Gavilan explained the danger to the baby of wearing metal during the imaging process. Together the women agreed that the medallion would be removed from the baby as she entered the machine and replaced as she exited the other side.
Bon Secours and other hospitals see patients from so many cultures that it would be almost impossible to have trained volunteers who speak all the languages, Gavilan said. Bon Secours contracts with CyraCom International Inc., an electronic service that translates 250 languages, including Mixtec. Mixtec is becoming increasingly important to Bon Secours language services because Mixtec-speaking members of an indigenous group from Mexico are becoming more numerous in the community. Communicating with Mixtec-speaking patients can present difficulties because the language is completely different from Spanish.
"Often the man who is head of the household is bilingual and speaks Spanish as well as Mixtec," she said. "But what happens if the problem is spousal abuse?"
JoAnn McCaffrey, administrative director of mission and diversity for Bon Secours Virginia facilities, oversees the comprehensive language services program. A former member of the Daughters of Charity of St. Vincent De Paul, McCaffrey worked for 13 years in the Democratic Republic of the Congo. She says the languages program has had its challenges, despite its success.
"The biggest challenge has been to continually raise awareness that this is not just fluff or icing on the cake," McCaffrey said. "Quality interpretation is accurate, reliable interpretation, and that is a quality initiative. That's becoming less of a challenge because the Joint Commission finally has made it a significant part of what they do."
She said it also is critical for the volunteer's supervisor and coworkers to be on board: "They are covering for a worker who takes 30 minutes or much longer away from the job to act as an interpreter. That's not easy."
Another, more subtle challenge, is just as important.
"Across the country there are people who ask, 'Why can't these people just learn English? They are living in our country!' That's a pushback from a lot of people in the United States who do not speak another language," she said. "I'm not saying I hear that directly a lot, but I think overcoming that mentality is challenging.
"We need to remind people that many persons for whom English is a second language are studying and working to learn English. But in the meantime, it's not ideal to have their health care delivered in a language they don't fully understand."
MARIE ROHDE is a freelance writer in Milwaukee.
Copyright © 2014 by the Catholic Health Association of the United States
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