Cultural Competence

We have just completed the second medical interpretation training in Jerusalem (read here about the first one we conducted in October 2008). This time, 10 of the participants came from the Clalit HMO clinics from all over Jerusalem, while another 4 came from the Alyn hospital. This training is one of the components of the Jerusalem Cultural Competence in Health Project initiated by the Jerusalem Inter-Cultural Center and the Jerusalem Foundation. The medical interpretation training includes three elements: theoretical lectures on translation and interpretation, presented by Prof. Miriam Schlesinger and Dr. Michal Schuster from the Bar-Ilan University, simulations and case studies, and language-specific training on medical terms and their usage, in this case in Arabic, Russian and Amharic.

The Medical Interpretation Training at Clalit Medical Services

On February 13, 2010, after visiting our training, Judy Siegel-Itzkovich from the Jerusalem Post published an article titled “Risky misunderstandings”, asserting that “the state’s failure to require trained medical interpreters may pose a danger.” While most health systems and the state are not taking responsibility to do whatever is required in this life-risking situations, Siegel-Itzkovich describes our training as an important step towards resolving language barriers in medical treatment. The article can be found here, or downloaded as a PDF file (see below for full text).

It is important to note that in the near future the Hadassah Mount Scopus hospital, in partnership with the Jerusalem Foundation and ourselves, is planning to initiate a volunteer-based interpretation service in Arabic and Russian. The JICC will train the interpreters as well as provide additional cultural competency trainings to medical staff in the hospital. This can be seen as a first and important response of the Hadassah organization to the urgent need at the Hadassah Mount Scopus hospital, where 55% of the patients are Arabic-speaking (see our previous article about this issue here).

Appendix: full text of the Jerusalem Post Article:

Risky misunderstandings
By JUDY SIEGEL-ITZKOVICH
13/02/2010
The state’s failure to require trained medical interpreters may pose a danger.

Suppose you felt very sick, but when you reached an Israeli hospital, the doctors and nurses spoke only Swahili. You couldn’t describe your problem, ask or answer questions, understand the forms you had to sign or even identify the WC. Like the Bantu language of eastern Africa, Hebrew is spoken by only five to 10 million natives.

But even though no US hospital or clinic is eligible for federal funds unless it has a team of professional medical translators and experts in cultural competency, the Health Ministry has not set any requirements that will help masses of immigrants and Israeli Arabs communicate in health facilities. And Israel has an even higher proportion of immigrants speaking languages other than the native tongue than the US.

There have been some reported cases of non-Hebrew speakers dying because of their failure to understand or be understood in hospitals; surely other tragedies have not been reported.

But when asked by The Jerusalem Post to comment on this problem, Health Ministry associate director-general Dr. Boaz Lev shrugged and said: “I’m afraid I don’t have a good answer. I think it is a very important matter, but it isn’t on our list of top priorities. I wish we could ensure that there are professional medical translators everywhere.” He added that the matter of cultural competency in medical institutions was raised in the ministry’s executive and there were even seminar days to discuss it. “It is not foreign to us. But we don’t have the financial resources to deal with it seriously.”

WITH A vacuum left by the ministry, at least a number of voluntary and public organizations are trying to provide some training and services on a relatively small basis. The Jerusalem Inter-Cultural Center (directed by Dr. Hagai Agmon-Snir and with support from the Jerusalem Foundation) has begun to offer three-day medical interpretation courses for people – mostly women – employed in different capacities in hospitals and clinics. Established a decade ago, the Inter-Cultural Center on Mount Zion aims to promote dialogues among different cultures, so cultural competency and medical translation in medical facilities made it a natural for initiating the project.

Although they were never trained as medical translators or cultural “bridgers,” the class participants have been doing it without additional salary or benefits and not even after volunteering to do so. They are nurses, secretaries and even maintenance workers who speak other languages such as Arabic, Amharic, Russian and Spanish and were asked by their bosses to help out when patients could not understand or be understood. English is usually not a problem, as most doctors and nurses speak it adequately. Several of the particiipants, including a man from Beit Shemesh, were former Ethiopian immigrants, while many of the Arab women work in the Sheikh Jarrah outpatient medical center in east Jerusalem.

The Inter-Cultural Center found a teacher, and Clalit Health Services – the largest health fund – and Alyn Hospital (the National Pediatric and Adolescence Rehabilitation Center) sent 15 staffers (only one of them male) to take the first-ever course in Clalit’s community clinic in the capital’s largely low-income Katamonim quarter. Pazit Kalian of Clalit’s Jerusalem district was instrumental in getting her staffers to participate in the eight-hour-a-day course.

Almost two years ago, Alyn held a one-day symposium on cultural competency in medical institutions that featured experts from New York City’s Coney Island Hospital and described advanced work done there.

In front of the class in the Katamonim was Dr. Michal Schuster, who studied translation and interpreting at Bar-Ilan University, while Prof. Miriam Shlesinger – the veteran chairman of that BIU department – sat in to observe and comment.

THEY TOLD the Post that some medical institutions have specifically hired Ethiopian immigrant women to fill cleaning worker jobs so they could “double” as medical translators. Yet these maintenance staffers are not familiar with medical terms, psychology or the ethical boundaries of professional interpreting, they said.

Some of the class participants, said Schuster, are “very bitter” about doing medical interpreting in addition to their regular job without getting any compensation. She also said one government medical center even turned down the free medical interpreting service provided by Rabbi Yechiel Eckstein’s International Fellowship of Christians and Jews. The hospital claimed some its own personnel were able to translate when necessary, and that a phone service “doesn’t fit the structure of the hospital.” Now the service will work specifically in Amharic and Hebrew with help from the Tene Briut organization and Magen David Adom. One need only call MDA’s 101 number to access it.

Shlesinger, who said she is “obsessed with translation and interpreting to help people overcome the language gap,” has set up many programs for the Jewish Agency and other organizations, but not until now not in the field of medical care. If immigration tapers off, “there will always be Arabs, deaf people and foreign tourists who need help, as well as older immigrants who don’t adequately comprehend Hebrew. Even my 90-year-old mother who came here from Florida 30 years ago wants to speak English when talking to her physician,” she noted.

“It has become our ideology that interpretion be available for healthcare. We really believe in it. It raises the participants’ self esteem. Big hospitals really should have in-house professional medical interpreters. But for this sea change to happen, there needs to be more lawsuits against hospitals and medical organizations by people who suffered a tragedy due to being unable to understand Hebrew. The Health Ministry needs a push,” said Shlesinger, who in the past has raised the issue with the ministry’s Dr. Lev.

SCHUSTER ADVISED the course participants not to be afraid when the doctors and nurses speak too fast. “You must not add any words of your own, or leave any out. Never give any advice not connected to treatment. It is forbidden for you to sell anything for your own benefit, or to arrange an earlier place in the queue if they want to give you something. You have to listen and know the medical terms and how the health system and procedures work.”

She added more advice: “Make sure you understand both the medical professional and the patient. Correct yourself if you are mistaken. Run a conversation that flows. Sometimes doctors use high-faluting language; sometimes they make up terms so the patient won’t understand. If it is not all clear to you, ask for details.” She advised participants not to believe in stereotypes such as that anyone who cant speak Hebrew or comes from a certain country is “stupid.” In addition, interpreters must “never get involved emotionally. “Don’t give your phone number to a patient. Don’t answer a doctor’s question instead of the patient just to save time. You must guard the boundaries.”

One of the most major issues is secrecy about patients’ medical conditions and other private matters. The course made numerous statements about protecting privacy. In a clinic where the interpreter may live just around the corner, it can be very difficult to translate or for the patient to agree. “In such a case, you really should ask if they are willing for you to interpret or find somebody else,” Schuster advised. There are very few exceptions to the secrecy rule, the instructor added. “If the patient tells you about violence in the family, against children or against herself, or that he wants to commit suicide, you are required to report it.”

Interpreters must also take care when asking patients questions not allowed by their religion or culture. An unmarried Arab or haredi Jewish teenager should not be asked whether they are virgins or use contraceptives, for example. There are also “spirits” called “zar” believed in by some older Ethiopian immigrants that have to be taken into consideration. An Ethiopian could say she had a “dry hand,” leading a physician unaware of such an expression to treat them with a dermatological cream, but in fact referred to “stiff joint” that requires a totally different treatment, Schuster said.

One of the course participants said she refuses to translate bad news, such as a patient being diagnosed with a terminal disease. “I am unable to do it. They have to find somebody else. There is nobody to give me support. You take such bad news home with you; I can’t cope with it. I once sat with a hospital psychologist who wanted me to ask the patient if he has suicidal tendencies. It was very hard for me, as I am not a social worker. I also can’t handle curses and other bad language that I sometimes hear.” A Moscow-born nurse was told by one patient that “all Russians are prostitutes” and asked “why didn’t you die in the Holocaust?” She recalled that she felt stung, especially when none of her bosses offered any sympathy.

Naomi, the Ethiopian cultural “bridger” who came on aliya as a young child almost two decades ago, said she recently encountered a patient who came to his Clalit clinic every day (a “bridger” is allowed to have separate talks and interventions with patients, unlike a translator). “He felt the doctors were not giving him all his test results, but they were. They said all tests were normal and just didn’t understand what his problem was,” but she gradually built up his confidence in the physicians.

She also helped a immigrant woman who had cancer and needed surgery. “She refused for months until we persuaded her. But suddenly she demanded that the operation be postponed. She was regarded by doctors as a ‘troublemaker.’ The woman claimed there would be ‘nobody to look after the children,’even though they were already adults. Naomi finally found out that she and her violent husband were in the process of getting a divorce. I advised her how important her health was and of getting early treatment. Finally, she agreed to the surgery.”

Agmon-Snir recalls that a few years ago, his own mother underwent hip replacement surgery. “Before she was discharged, the surgeon gave her quite a few instructions. There were some necessary accessories and equipment: a wheelchair, special pillows and devices to help lift objects. “If you don’t follow the directions I gave you and don’t use the equipment,” said the surgeon, “your leg won’t function the way it’s supposed to and the effects of the excellent and expensive surgery will be wasted.”

Lying next to her in the hospital were Palestinian women from east Jerusalem who had also undergone the same operation. “They were given the same instructions his mother received and sent to the same places for equipment. Yet there is good reason to suspect that, unlike my mother, many of them are limping today. Research carried out in Jerusalem hospitals shows that about half of the Arabic-speaking patients do not understand the instructions they are given for post-treatment care.”