An Interview with James Rohack, MD

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An Interview with James Rohack, MD

Dr. Rohack

Dr. James Rohack is the Immediate Past President of the American Medical Association, serving from June 2009 to June 2010. He spoke with The ATA Compass in early August 2010.

The ATA Compass: What’s the biggest misunderstanding people have about LEP patients and interpreting?

James Rohack: It’s the failure to recognize that good communication with the patient is the keystone to providing good medical care. By definition, a limited-English-proficient (LEP) patient falls into the category of low health literacy, and studies are clear that patients with low health literacy have higher costs because they don’t understand medical instructions and treatment recommendations. Cultural differences are also important: understanding the beliefs and social order of patients from other cultures can play a role in patient-physician communication as well. The medical profession sees this as important enough that communication skills are now part of the general competencies required of medical students.

Compass: How important is an adequate patient history, and how does the language barrier affect that?

Rohack: The physical examination and patient history define the tests that are needed. If I can’t communicate with the patient well enough to get an adequate history—if I have only the exam and no history—I’ll cast a wider net of tests to compensate, and every test has its weaknesses, such as false positives and negatives. A good history helps narrow the preliminary diagnosis and reduce the number of tests you need, so poor communication means more tests and higher costs. The most efficient use of resources comes when you can correlate the history and the exam with the appropriate tests.

Compass: What role does the language barrier play in defensive medicine?

Rohack: Look at the common thread in lawsuits: it’s that the patient feels the doctor didn’t adequately explain why he did what he did. For example, if the risks of a particular surgical procedure aren’t adequately explained, the patient is more likely to feel that the doctor is responsible, that the doctor didn’t tell him or her everything.

Compass: So it works both ways: the doctor needs to understand the patient, but the patient also needs to understand the doctor.

Rohack:  That’s exactly right. Inadequate communication means more tests, but there’s also a higher risk of lawsuits.

Compass: What skills does a qualified interpreter need to have?

Rohack: The US is a melting pot of many cultures and languages. You need three key components in an interpreter: linguistic competence, medical competence, and cultural competence.  Cultural competence can be very important, because different cultures have different sensitivities. In some cultures, for example, it’s taboo to question an authority figure like a doctor. How do you get an informed consent under those circumstances? If you’re inadvertently violating cultural taboos, you may not get adequate communication.

Family members tend to do the interpreting, and while it’s important to have them there with the patient, a qualified interpreter is something different. In an emergency, you do what you have to do. But when you use family members as interpreters, you can put them in difficult situations, especially in sensitive areas like drug use, sexual history, and domestic abuse.

Appropriately trained interpreters are the ideal situation. Trained interpreters are part of the healthcare team, and what they say affects the patient. They also have a code of ethics: they aren’t just someone who knows the language and might put their own spin on what the patient has said.

Compass: How does the language barrier affect the physician’s approach to treatment?

Rohack:  The AMA has recognized that communicating with the patient is extremely important, and using properly trained interpreters is very, very helpful. But right now the federal government requires doctors to provide interpreting services without any charge to the patient, and that’s problematic. If you have to hire an interpreter and pay them twice the reimbursement you’re getting from Medicare or the patient’s insurance company, you can’t afford to run your medical practice.

So it becomes an access issue: the doctor wants to care for the patient but can’t afford to do it, because he has to pay for the interpreter but can’t bill Medicare, the insurance company, or the patient to cover the cost. It’s a Catch-22.

Interpreters need to be compensated appropriately: they maintain not just language skills, but also medical knowledge and cultural knowledge, and they’ve often gone through a certification process. They can take the doctor’s information and interpret it in ways that are understandable to the patient.

The AMA argues that interpreting should be paid for appropriately by insurers because competent interpreting reduces costs. Again, if you can get a better history, you don’t need to order so many tests; you get better compliance; and the overall cost comes down. The interpreter’s fee is an appropriate medical expense.

Compass: What’s your view on interpreter certification?

Rohack: It’s hard for doctors to determine interpreter qualifications. The certification system is still very young, and most physicians are unaware of any national system. But if you have ongoing needs to make a large community healthier, it’s good to have a certification program for medical interpreting. When you know that the person you hire has met a standard, it gives you a confidence level.

One nidus for training could be community colleges—they’re already doing medical programs; their infrastructure costs are lower, and they already have health profession schools, with one- to two-year programs for basic competencies.


Interview conducted and condensed by Lillian Clementi