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Language, culture pose health-care challenges

Monday, December 15, 2008

If Dr. Charlie McKay had a holiday wish list for the cancer-care practice that he runs, the top request would probably be a Hispanic oncologist, or at least one fluent in Spanish.

With his offices in the diverse community off Nolensville Road, it's not unusual for McKay to encounter patients who don't speak English. And that can pose challenges to delivery of care. Doctors are obligated, for example, to provide written information, in a patient's language, on certain drugs or treatments that are still in clinical trials. Also, the medical team offering the care must have a member who is fluent in the patient's language.

"It would be tremendous and I think it would serve such a purpose," McKay said about fulfilling his No. 1 wish, adding that his only Spanish-speaking doctor retired a year ago. "It's the biggest demographic group for language problems that we have."

McKay's experience reflects how physicians and other health-care providers are facing language and other barriers arising from fast growth in Nashville's immigrant population. As a result, they're hiring interpreters and front-desk staff who speak languages from Arabic to Somali, signing up for services that offer telephone-based translators or send in-person interpreters, or adding satellite clinics in diverse areas of Nashville.

Between 2002 and 2007, the foreign-born population in the Nashville-Davidson-Murfreesboro metro area grew by more than 50 percent to 101,932, according to the U.S. Census Bureau's American Community Survey. The annual survey also found the number of Davidson County residents speaking any language other than English at home jumped 51 percent between 2002 and 2007.

Past language to culture
In McKay's case, the language issue is significant because cancer treatment often involves drugs or therapies in clinical trials. Before those medications or procedures can be administered, patients must consent and acknowledge that they understand the risks.

McKay recalls once having to treat a patient from Cambodia who suffered from an aggressive form of lymphoma that required chemotherapy. McKay tried to get "informed consent," but it was clear the patient - who spoke a dialect that couldn't be translated, and apparently had no family in Middle Tennessee - didn't understand the situation.

He treated the patient anyway because the tumor was growing so rapidly. On a subsequent visit, the patient was a bit upset and kept pointing to his freshly bald scalp, McKay said, adding that the cancer eventually went into remission.

McKay, chief executive of Tennessee Oncology PLLC, which has bilingual staff at some of its clinics statewide, said the challenge extends beyond language to culture.

For instance, he's been known to ask female breast cancer patients from certain countries or religious groups whether they'd prefer their husbands stay in the exam room or if they'd prefer to be examined by a female nurse practitioner.

Even when a relative or someone else who speaks a patient's language is around, McKay worries that some feelings may get lost in translation. "It's almost like me speaking French," he said. "I can get the general gist, but the nuances I miss."

Cultural differences can pop up in other less expected ways.

Mary Bufwack, CEO of United Neighborhood Health Services, a nonprofit with five neighborhood clinics, tried to fill a front-desk job involving customer service several times before finding a female Somali candidate who accepted it. Husbands of several of those who turned down the job didn't want their wives to go to work, especially where men also worked.

Cost of access reduced
Having an employee handle both roles of being an interpreter and providing customer service is one way that United Neighborhood controls its costs, Bufwack said. If patients can't read in their own language, interpreters can read medical information to them, she said.

On average, a patient visit costs United Neighborhood's clinics $100, but if interpreters were hired independently, that would add 5 percent to 10 percent to the cost of a visit, she said.

In Hispanic and other immigrant communities, many newcomers use safety-net clinics and hospitals where they can pay for services based on income or receive charity care.

The Siloam Family Health Center, for instance, has seen refugees from 103 countries since it started serving that population in the mid-1990s, CEO Nancy West said. "We try to provide culturally sensitive health care for these patients," she said.

Many newcomers also seek out providers known within their communities or seek care from doctors and other providers who speak their native tongue.

Dr. Adriana Bialostozky, a Mexican-born pediatrician in Nashville, estimates that 99 percent of her patients speak Spanish. She considers the lack of bilingual speech pathologists a problem because the communications gap may make it harder to diagnose and treat language delays in children.

Efforts by community advocates to bridge the language gap include the release this month of a Nashville Bilingual Health Guide with information in English and Spanish - such as which Nashville-area clinics have bilingual staff or interpreters on-site or available over the telephone.

"We're taking proactive action," said Juan Canedo, chairman of the Nashville Latino Health Coalition behind the guide. He also is director of Progreso Community Center, a grass-roots organization.

Canedo, whose organization along with several partners surveyed 500 Hispanic adults in Nashville last year, considers access to care as big an issue as the language barrier. Results showed that 80 percent of respondents had no health insurance. About 56 percent of those surveyed said they spoke little or no English.

Providers add services
With growth in that non-English-speaking population, local health-care providers are expanding services such as the use of interpreters.

"In 2000, a handful of clinics had bilingual or multilingual support," said Pamela C. Hull, associate director with the Center for Health Research at Tennessee State University. "Today, it's more or less expected that clinics will have at least interpretation service."

At Vanderbilt University Medical Center, the interpreter services department has grown from a single interpreter/coordinator seven years ago to 10 full-timers, including nine Spanish speakers and one who speaks Arabic.

Last year, Vanderbilt's outpatient clinics saw 56,570 patients with limited English proficiency. They included 36,000 Spanish speakers, 6,000 Arabic, 3,000 Somali, 2,000 Chinese and 2,000 Kurdish speakers, officials said.

In recent years, Saint Thomas Health Services has opened clinics with bilingual staffs in South and West Nashville that saw 24,800 patients last year. About 90 percent of the patients at the South Clinic, where all of the staff speaks Spanish, are Hispanic, although patients last year came from 32 countries.

The West Clinic saw patients from 39 countries, said Paul Lindsley, a spokesman for Saint Thomas.

For hospitals, spending money on interpreters helps ensure patient safety.

"One bad outcome that results in a lawsuit would more than outweigh what you spend on interpretation service," said Lee Ann Hannah, director of education with Centennial Medical Center.

"It's not about money and dollars; it's about doing the right thing."

Reach Getahn Ward at 615-726-5968 or

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