Healthcare providers must comply with many directives, some of which can contradict each other in specific cases. The patient’s privacy must be protected, so that he feels able to disclose information and discuss all treatment options openly.
The highest good is that the patient will have his health care goals met AND have his cultural needs met. The organization must also follow the law with respect to providing competent language support if the patient cannot communicate fully with the care team in English. Without doing this the organization becomes liable to later lawsuits from the patient as well as to censure by the Department of Justice. Finally, the organization must support its licensed professional providers in providing the best possible care, which requires effective communication between patient, family, and care team.
Every hospital and clinic has many instances in which patients or family members protest the use of a professional interpreter and insist on having a family member or friend interpret. Often this refusal of an interpreter is couched in terms of not wanting interpreters from the community to know the family business. The first response of the Language Services Manager is to sort out whether this is truly a privacy issue, or more commonly, an insistence of the family member on controlling the communication with the patient.
This sort-out between a dominant family member and need for privacy is accomplished by offering a remote interpreter and assuring that the patient’s name will not be mentioned by the provider during the remote interpreting session. If the family member is trying to maintain control of the communication, he will not accept remote interpreters. But most patients who really are fearful of the community knowing their business will accept a remote interpreter as long as the safeguards such as not naming them are observed. We recommend using the name John or Jane Doe and substituting a clearly fake medical record number such as 222222 as ID for that remote session. This procedure works well for minor patients who are victims of sexual abuse, for domestic violence victims, and for patients with HIV. HIPAA allows for a patient to prevent his identity from being listed in a hospital inpatient directory, so there is precedent for the patient to have his name hidden from business records such as remote call reports.
Now, however, let us consider the actual case of a family with a greater than usual fear of disclosure to the community. This case is presented by Kristin Neitzel, our guest contributor from Children’s Hospital of Wisconsin.
“The story is related to a father of a Hmong patient. Dad did not want to use an interpreter. Although dad’s English skills were not strong and mom spoke no English, dad did not want someone from his Hmong community to know what was going on with his child. The family was not from Milwaukee so dad was refusing both the in-person interpreter and the phone/video interpreter. There were a few dynamics taking place. First, the illness was considered “shameful” in the Hmong community; and second, the parents were making decisions for care that were not necessarily approved by the Shaman. The parents were taking medical steps for the wellbeing of their child that the Hmong spiritual community would frown upon. Dad much preferred to keep this information out of the eyes/ears of other Hmong community members. We did our best to support dad and provide him with options for communication that might work better for him. He continued to refuse.”
(Note from editor: the book The Spirit Catches You and You Fall Down presents useful background to understand Hmong traditional health practices. The family seen at Children’s faced a similar challenge of seeking care in the American system without flouting traditional community values.)
How could we provide good communication in similar situations without laying out the entire situation to any one interpreter who might be able to identify the family?
The content of the conversations could be broken up so that explanation of the actual condition of the patient was kept separate from the conversation about treatment options. A different remote interpreter could be engaged for each topic. The consent for care discussion could be done with yet a third interpreter, without mentioning the option chosen by name, just having the mom and dad both state why they were in favor of going ahead with the proposed treatment. The age, name, and possibly even gender of the patient could be actively disguised for each remote session. (The provider note for each encounter should indicate the specific fake patient name used for remote interpreting, in case the fact that an interpreter WAS used comes into question down the road.)
Depending on the parents’ understanding of biology, anatomy, physiology, or pathology, the provider could lean heavily on diagrams, pictures, and videos related to the patient’s condition and possible treatments, rather than depending on the interpreter to explain huge amounts of background information in words. This cuts down on the parents’ concern about how involved the interpreter is in the care discussion. The doctor could even use a Hmong interpreter, without the family being present, to interpret the doctor’s explanation of the background situation, and record this in an audio file that the family could listen to on their own before or during their next appointment. Thus, there would be no identification of the family at all on the interpreter request.
Another possibility is to find a Hmong healthcare interpreter who works as a staff interpreter or preferred interpreter for a hospital somewhere in the country, who has a perfect reputation for maintaining the privacy of patients. Once the parents were convinced that they could trust this professional interpreter, they could relax.
Special thanks to our contributor Kristin Neitzel.
Kristin Neitzel is a Manager in Patient Amenities and Family Services at Children’s Hospital of Wisconsin (CHW) and holds the LEP Officer title for Civil Rights Compliance. Kristin is the manager for the Language Services team and also manages the Welcome Center team, Patient Transport, Surgery Family Waiting, Accommodations and has regulatory responsibilities related to The Joint Commission. She has been with Children’s for 21 years and in her current role for 12. Kristin has been instrumental in improving access to language support for families by leveraging technology and contract partnerships. She has also increased quality of service and reduced overall cost of language support within CHW. Kristin has over 30 years of leadership experience in various industries including health care, human resources, banking and temporary help. Kristin holds a Bachelor’s Degree in Business Management and is currently pursuing her MBA.