st. louis — The discussion in the examination room had gone on for about 30 minutes. Patient and doctor were frustrated.

The young woman from Iraq said she remains in constant pain. Solid food feels like a stab to the stomach. Her head is filled with "heaviness" and the medicines she has been prescribed are not working.

An X-ray and other tests have not pinpointed a cause for the pain, said Dr. Arpit Agrawal. What the 29-year-old woman needed was a visit to a psychiatrist — something she is dead set against.

In the middle of the discussion at Barnes-Jewish Hospital was interpreter Buddy Sultan. Toggling between English and Arabic, he explained the young woman's resistance. She had been referred to a psychiatrist during an earlier exam at the hospital. A transportation mix-up left her stranded for hours after her appointment in Chesterfield. She is not willing to go through the anxiety again. Besides, she doesn't think there is anything wrong with her mind and is upset that doctors continue to focus their attention there. And, as Sultan said in an interview later, in Iraqi culture, there is a strong stigma that comes with mental illness.

Sultan works for the hospital's Refugee Health and Interpreter Services, an office increasingly called upon to assist in communication throughout the hospital as the region becomes more diverse. Just as importantly, the office focuses on making sure the patient eventually gets the health care suggested by the doctor, including reminders on follow-up office visits.
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In 1996, the office had 7,300 encounters with patients in 13 languages. Last year, the office had 41,311 encounters in 81 languages, from Albanian to Zapotec.

"When you cannot communicate, there is frustration by the patient and the doctor and trust decreases, which is toxic to the entire encounter," said Barbara Bogomolov, director of Refugee Health and Interpreter Services.

When doctors are unable to assess the problem in a conversation with a patient, they are more apt to order unnecessary — and expensive — tests, she said. Hospital stays are longer and readmissions increase because a patient is less likely to adhere to a treatment plan. Health care studies show that the main reason for medical mistakes is a breakdown in communication.

Effective interpretation, however, must go beyond translation, said Eduardo Vega, project coordinator for Language Access Metro Project, which provides interpreter services in specialty fields such as medical and legal.

"One of the fundamentals of doing interpretation correctly is that not only are you the interpreter, but the cultural broker," Vega said. "For example, in Asian cultures, they might have a home remedies procedure that might sound strange to a Western person. But the interpreter has to, in his or her way, explain the meaning of the esoteric concept."

Bogomolov says that cultural understanding is why her 35 interpreters are refugees or immigrants as opposed to linguists. Her office is a part of the Center for Diversity and Cultural Competence.

The center is charged with creating a more diverse work force, and offering training to hospital staff on understanding and recognizing cultural differences. Those trained work in various departments, from housekeeping and security to nursing and human resources. After completing the program, employees train coworkers.

Most of those who sign up for the program do so on their own. In some cases, though, supervisors have suggested an employee could benefit from the training.

FLIERS, NOT GUNS

"It's important to touch all parts of the hospital," Bogomolov said. She cites a security guard approaching a man lighting a cigarette near a "No Smoking" sign as an example.

"Imagine if this guy has just come from a war zone and sees a man armed with a gun coming his way," Bogomolov said. "He's going to think that the guard is going to take me away and I won't come back."

As a result, security guards now carry fliers they can hand out, which explains the new no smoking policy in 14 languages.

The 18-hour training for employees includes "understanding that our world view isn't the same as someone else's," said Jelena Todic, a center program manager.

For example, in some cultures, health care decisions of women are made by the husband or by family elders. Some cultures see breast cancer as a shameful disease brought on as a curse for bad behavior and reject treatment. And children have come to the U.S. labeled as retarded when in fact they were not responding and interacting in a traditional way because they were deaf.

St. Louis ranks 10th nationally in the number of refugee resettlements. The city is viewed by the State Department as an attractive place to settle refugees based on a good supply of affordable housing, access to health care, and an expansive web of social services agencies including the International Institute.

At the Language Access Metro Project, better known as LAMP, Spanish interpreters are in greatest demand followed by Bosnian and Vietnamese, Vega said. Dari, spoken in Afghanistan, and Farsi, spoken in Iran, are growing in popularity as is Arabic, reflecting the increased Iraqi population in the region.

'CONSTANT CHALLENGE'

The increased number of languages and cultures keeps health care providers constantly on their toes, Bogomolov said.

"It's a constant challenge," she said. "But just because a language is exotic, I don't get a pass."

When a patient arrives who speaks a language not covered by her office, Bogomolov works with LAMP locally and other agencies nationally to find someone who can translate, even if it means interpretation by telephone.

The Joint Commission, an independent nonprofit, is the accrediting agency for more than 17,000 health care organizations and programs in the U.S. At the crux of its evaluations is what the agency refers to as its vision statement: "All people always experience the safest, highest quality, best-value health care across all settings."

Barnes and other hospitals keep that in mind as they work to improve their efforts to provide health care to a population that gets more diverse in language and cultural differences, Bogomolov said.

On her desk is the case file of the Iraqi woman who is fighting psychiatric treatment. She suffers from post-traumatic stress disorder and has not been getting treatment for it although she came to the U.S. nine months ago.

"There was no way this was going to be solved in a single doctor visit," Bogomolov said. She said she and an interpreter will talk with the woman about how treatment is for the head and the body and that her pain will not go away unless attention is given to both. They will also work to get her husband solidly behind the hospital's proposed treatment.

"We'll figure out a way to get her on the meds," Bogomolov said. "We'll win ultimately."