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Featured Article from The ATA Chronicle (November/December 2013)

 

Overcoming Cultural Conflicts in Health Care Interpreting
By Haytham Boles

Health care interpreters facilitate communication between limited-English-proficient (LEP) patients and physicians, nurses, lab technicians, and other health care providers working in a variety of settings. When it comes to enabling communication in a clinical encounter between two parties who do not speak the same language
or share the same belief system, conflicts related to cultural differences are frequent. Such conflicts happen because what is considered normal and acceptable behavior in one culture could be offensive, threatening, or forbidden in another. The challenge for the interpreter is to manage the dialogue in a way that creates an atmosphere of trust and mutual respect, where the patient feels his or her voice is being heard because the health care provider is considerate of any personal boundaries related to cultural practices. Trained health care interpreters understand medical terminology in both languages and employ professional techniques to handle the complexities that arise with patients, families, and health care providers. The following presents four real-life experiences of cultural conflict in the health care interpreting setting involving Arabic patients and American health care providers.

Experience #1
I accompanied a male Iraqi friend to the emergency room to help as an interpreter and provide my support. The lab work showed that my friend was suffering from a serious heart problem, so the cardiologist decided to do a heart catheterization. Before they began the procedure, a male nurse came to shave my friend’s groin area. The problem was that the male nurse wanted to shave my friend in the presence of an accompanying female nursing student. For someone from a Western culture, this may be considered normal medical practice and not an issue for concern. In Arabic culture, however, for a man to expose his private area to a person of the opposite sex, even medical personnel, is unthinkable and embarrassing because it is contrary to modesty norms and religious restrictions.

My friend objected strongly, but the male nurse explained that it was necessary for the female intern to observe the process as part of her training. After I explained to my friend that this was a normal practice in American medical culture and that the female nursing student would be able to work more effectively by observing the other nurse, he reconsidered his initial objection to having a female in the room. The thought of the benefits the female nursing student would gain from observing the procedure, along with my encouraging words, eventually convinced him to give approval, although reluctantly. Throughout the procedure, however, my friend never felt comfortable. It was irritating and embarrassing for him and he felt ashamed. To me, as an interpreter who shares the same cultural beliefs and customs as my friend, the incident felt just as uncomfortable.

Experience #2
This incident happened when I was interpreting for an Iraqi Muslim woman wearing a hijab, the traditional scarf worn by Muslim women to cover the hair, neck, and sometimes the face. We were at an imaging center because the woman needed x-rays of her neck. We went into the x-ray room where we met three technicians: a man and two women. Everything seemed fine at first, but when one of the female technicians asked me to tell the patient to take off her hijab for the x-rays, I could sense a problem brewing. When I interpreted the message for the woman, she became restless, confused, and embarrassed. At this point, I stepped out of my usual role as a language conduit to act as a cultural educator. I told the technicians that the patient felt uncomfortable with their request to remove the hijab because doing so would be in opposition to her cultural beliefs. I explained that because of certain customs and religious practices in Arabic culture, some veiled women find it very difficult to expose their heads to members of the opposite sex who are not related to them. I then pointed out that both the male technician and I were unrelated strangers to the woman.

Upon hearing my explanation and seeing the woman’s discomfort, the male technician left the room swiftly. However, this did not solve the problem, so I had to come up with a solution. I told the patient that I was going to interpret with my head facing the wall. Doing so would give the woman personal privacy and help maintain
her modesty, and at the same time the technicians would be able to do their job comfortably and efficiently. A great sense of comfort appeared on the woman’s face. Likewise, the technicians were pleased by my suggestion. Because they were now sensitive to the patient’s cultural and religious needs, the technicians were able to do their job without subjecting the woman to further psychological distress. It was a win-win situation for everyone. The joy that I felt when I left the building was indescribable because I knew that I had done the right thing. My solution had enabled two parties who did not share the same cultural beliefs and medical practices to understand each other better, and it helped the technicians provide medical service in the most respectful, altruistic, and caring manner.

Experience #3
This situation happened to a colleague who was interpreting for a 40-year-old female patient from the Middle East. The patient had very serious vaginal bleeding and was rushed to the emergency room after she was seen by the primary care doctor. It is important to note here that the interpreter was asked to accompany the patient in the ambulance. Upon arrival at the emergency room, the doctor wanted to do a Pap smear to find the cause of the bleeding. When the interpreter told the patient about the doctor’s intention, the woman began to yell and objected to the doctor’s decision. She said she was still a virgin and did not want to lose her virginity to this medical procedure and begged the interpreter to intervene. Because the interpreter came from the same region and shared the same ethnic and cultural background as the patient, she understood why the patient objected so strongly to undergoing a Pap smear test.

The interpreter began to explain to the doctor what it meant for an unmarried woman in Middle Eastern culture to lose her virginity and of the importance of having the hymen intact to prove that she is a virgin in order to marry. Although from a medical standpoint, the patient would technically still be a virgin even if the hymen was removed or torn during the procedure, the prevalent point of view/mentality in many Middle Eastern societies is that virginity equals an intact hymen; in other words, virginity and an intact hymen are inseparable. (In some countries, women are even forced to undergo virginity testing before they are married.) In many Middle Eastern societies, a soon-to-be husband would be unwilling to marry a woman who could not preserve her virginity at any cost; he would think that she is worthless and perverted. As a result, a woman in this situation would bring shame to her family.

Even though someone from the U.S. or another Western country would find such cultural practices puzzling and easy to dismiss, this is a reality in many countries, so the interpreter needed the doctor to understand the full repercussions to the patient if he went ahead with the Pap smear. The interpreter explained that the patient had never been married, was engaged, and was going to get married in three months. In addition, she told the doctor that, “If this woman loses her hymen due to this invasive procedure, she most likely will not be able to get married.” She added that in the Middle East, a woman’s virginity matters as much to the woman as it does to the man, as well as to his immediate family and relatives, and that not having a hymen might be grounds for denying approval of marriage.

Despite the interpreter’s explanation, the doctor refused to take the patient’s objections into consideration. His reaction was that of surprise and shock. He also became angry and kept saying that the patient’s concerns for the loss of her virginity did not matter and that only her health was of primary importance. When the interpreter conveyed this to the patient, the woman became even more agitated. She told the interpreter, “Please, please! Do not let them do this to me. They are going to destroy my future!” At this point, the interpreter could not remain silent. She realized that she was obligated by the health care interpreter’s code of ethics to advocate for the patient.1 She told the doctor that the patient was not willing to undergo the Pap smear and that he needed to respect her wishes. She told him that according to the Health Insurance Portability and Accountability Act, the patient had the right to refuse this procedure.2 At the patient’s request, the interpreter also asked the doctor to find an alternative test that would be noninvasive. The doctor eventually abandoned the Pap smear and decided to do an ultrasound scan, although he said that it would not be enough because it would not be very clear. Nevertheless, he did what the patient desired. In addition, the doctor prescribed a birth control pill to regulate the woman’s irregular monthly periods.

This situation was very challenging, emotionally charged, and stressful for the interpreter. However, because she was well trained and knowledgeable about the code of ethics, familiar with the patient’s rights, and aware of her obligations as a professional, she was able to handle this situation competently. Would an ad hoc or untrained interpreter have known the proper way to act under such circumstances? Probably not. The result could have been physically and mentally detrimental to the patient. Was the patient happy about the outcome and the interpreter’s conduct? Absolutely. The patient was really happy and grateful to the interpreter because, thanks to the advocacy provided, she could receive the treatment to which she was entitled and, above all, maintain her honor.

Experience #4
Sometimes my role as a cultural facilitator can be misconstrued by patients to the point where they look to me as an authority who can make decisions for them. I encounter many situations where patients ask me to give them advice about whether or not to consent to some procedure they need to undergo. They usually ask, “What do you think, Haytham? Do I (we) give our consent for this procedure/test? I want your opinion as a friend.” When this happens, I decline to offer my counsel in a polite manner, explaining that I am legally obligated to abide by the interpreter’s code of ethics, which prohibits me from making such decisions. At the same time, I provide them with the necessary information about their rights as a patient to empower them to make informed decisions.

One such example occurred when I was assigned to interpret for a patient during his first appointment with a retina surgeon. While I was helping the patient complete registration forms, we paused over a consent form that would give the doctor permission to administer dilating eye drops. There was a section detailing several possible adverse reactions, and the risk of having narrow-angle glaucoma frightened the patient so much he refused to sign the form. The patient turned to me and said, “I want your opinion as a friend. What do you think? Do I sign it or not?” Because we came from the same culture, it was natural that the patient would want to treat me as a friend even though this was the first time we had met. I politely declined from giving advice, telling him that as a professional health care interpreter, I have to abide by the interpreter’s code of ethics and remain impartial. I explained that the code prevented me from giving him any personal opinion on this matter. The patient insisted a second time that I should tell him what he should do, but again I declined to offer advice. Although the patient did not like my answer, I think he understood my situation to some extent.

At this point, I thought that it was my ethical responsibility to educate the man about his rights as a patient. I told him that he had the right to discuss any concerns with the doctor before signing the form, which would enable him to make a more informed decision. When I handed the registration forms to one of the front desk staff, I told her that the patient did not want to sign the consent form because he was frightened of the possible adverse effects from the eye drops. She did not take what I told her seriously, however, and tried to influence the patient to sign the form. She told me to explain to the patient that there was no need to worry because the chance of having an adverse reaction to the drops was very slim. When I interpreted this information for the patient, he still did not want to sign the form.

I decided the best way to proceed was to make sure the doctor understood the patient’s reluctance to give his consent for the procedure. I told the woman at the front desk that as a professional health care interpreter, the interpreter’s code of ethics required me to inform the doctor of the patient’s wishes. The doctor would have to discuss any issues with the patient and then decide what to do from there. We met with the doctor and I explained the reason why the patient was reluctant to sign the form. I asked the doctor to discuss these fears with the patient, but reminded him that it would be in the best interest of all involved not to try to force the patient to sign the consent form. After I interpreted the doctor’s explanation of the minimal risk posed by the eye drops, the patient seemed satisfied and gave his consent.

The interpreter’s code of ethics saved me from taking the risk of giving personal advice to the patient and influencing his decision. Who knows what might have happened if I had not abided by the code of ethics? In the end, the patient felt happy when we left the doctor’s office because he felt that his voice had been heard.

Cultural Competence in Health Care Interpreting
The point I want to stress by sharing the examples above is that cultural conflicts arise frequently when interpreting during a medical encounter, and health care interpreters need to be alert and prepared so they can respond quickly when they detect a problem. Besides the necessary linguistic competence, cultural competence is of paramount importance for the job. In general, a culturally competent health care interpreter can be defined as an interpreter who is mindful of his or her own cultural biases, has adequate knowledge of the cultures of both the provider and the patient, and puts this knowledge to work by offering explanations when cultural differences and conflicts between the two parties arise in the clinical encounter. Such cultural competence can be acquired through formal training, attending seminars and professional conferences, extensive reading, and finally, speaking with other interpreters.

Without proper cultural knowledge and training in the field, health care interpreters run the risk of ignoring, misinterpreting, or mishandling situations involving cultural conflict that arise during a health care encounter. In such situations, the LEP patient might experience much psychological distress that could be avoided. The essence of medicine, however, is to care for both the physical and mental well-being of the patient. To ensure that this is achieved, health care providers need to accommodate the cultural needs of LEP patients as much as possible, and it is the interpreter’s ethical responsibility to inform the provider of such needs. According to the Code of Ethics created by the National Council on Interpreting in Health Care (NCIHC) in 2004, the “ethical obligation of interpreters is to possess enough understanding of culture and cultural practices and beliefs to be able to facilitate communication across cultural differences, seeking to minimize, and, if possible, avoid, potential misunderstanding and miscommunication based on cultural assumptions and/or stereotyping.”3 Addressing the question of whose responsibility it is to be culturally competent, NCIHC states: “The answer to this question is simple: cultural competence is a value and an ethical principle that should be shared by all members of the medical team, including the interpreter. The reality, however, is that in most instances, interpreters will still be the member of the team most likely to have the knowledge and understanding of cultural factors that impinge on the process of communication and the creation of meaning. Therefore, in keeping with the principle of fidelity to the original message and in keeping with the goal of the clinical encounter—the well-being of the patient—interpreters have the obligation to develop their understanding of the cultures of relevant others in the encounter and to bring this knowledge into their practice.”4

I wish I had my current level of training when I acted as the interpreter for my friend in the first incident. (Incidentally, interpreting for family or friends is something that our professional code discourages.) If I had been aware of my role as a cultural, as well as language, interpreter, I could have saved my friend the suffering he went through. But at that time, like many other novice interpreters working in the field, I was not aware of the existence of a code of ethics for interpreters. In conclusion, health care interpreters must be culturally, as well as linguistically, qualified in order to be able to do their job efficiently and ethically. Ignorance of the cultures of the parties for whom we interpret is not an excuse. The best practice is advance preparation.

I look forward to your feedback and comments. Have you encountered any cultural situation while interpreting in the medical setting? Please share your experiences with me (haythamboles@gmail.com). We all benefit when we learn from each other.

Thanks
I want to thank Aileen Gulan for generously sharing the cultural interpreting situation she encountered in her work.

Notes
1. “When the patient’s health, wellbeing, or dignity is at risk, the interpreter may be justified in acting as an advocate. Advocacy is understood as an action taken on behalf of an individual that goes beyond facilitating communication, with the intention of supporting good health outcomes. Advocacy must be undertaken only after careful and thoughtful analysis of the situation and if other less intrusive actions have not resolved the problem.” From A National Code of Ethics for Interpreters in Health Care (National Council on Interpreting in Health Care Working Papers Series, 2004), 3, www.ncihc.org/ethics-and-standards-of-practice.

2. U.S. Department of Health and Human Services Health Information on Privacy, www.hhs.gov/ocr/privacy/hipaa/administrative/statute/index.html.

3. A National Code of Ethics for Interpreters in Health Care (National Council on Interpreting in Health Care Working Papers Series, 2004), 18, www.ncihc.org/ethics-and-standards-of-practice.

4. A National Code of Ethics for Interpreters in Health Care, 19, www.ncihc.org/ethics-and-standards-of-practice.


Additional Resources for Medical Interpreters

ATA Interpreters Division
www.atanet.me/ID

International Medical Interpreters Association
www.imiaweb.org/code

Interpreting: Getting it Right
www.atanet.org/publications/getting_it_right_int.php

National Council on Interpreting in Health Care
www.ncihc.org


Haytham Boles has an MA in translation from the University of Mosul, Iraq. He has
over four years of experience interpreting and translating for Iraqi refugees in San Diego County. His working languages are Arabic and Chaldean. He has been working as a part-time Arabic health care interpreter with the International Rescue Committee in San Diego for almost two years. Besides working as a freelance interpreter and translator, he also has experience teaching English as a second language and Arabic. Contact: haythamboles@gmail.com.