STAY IN YOUR LANE

In spite of their fragile and easily shattered egos, at times we simply must shake a select subset of our newly hatched doctors out of their complacency and overwhelming sense of entitlement, in order to gently guide them closer toward following their oath to do no harm. To that end, I am writing up another babydoc today, this time a first year resident in Neurology. Unable to limit herself to the “meet and greet” in the patient’s language, and then move on to appropriate use of interpreter services, anxious as a new doctor, lacking confidence in her budding yet fragmentary specialty skills, and eager to display knowledge – on any topic – she confused and endangered the patient. I do believe it is mere ignorance coupled with subconscious bias and nothing overt or ill-intentioned, but her very lack of awareness is what harms her patients. I am reporting Dr. X in the hopes that she and others can get needed training. It will read something like this:

Today, I was interpreting via video remote for the neurology team with a cancer patient who has developed seizures and numbness post-surgically along with severe dizziness. Dr. X, who I presume is a new first-year resident, needs some additional training in working with interpreters that I am not able to provide during video remote rounds. I am concerned for the quality of the communication, the unnecessary confusion, and for patient safety, as well as this patient’s fundamental access to interpreters after he clearly requested and requires this service. Dr. X does not seem to be aware of our hospital system’s language policy.

When I was called, Dr. X was already mid-conversation, speaking in her Spanish to the patient. I interrupted to introduce myself and my role. Instead of continuing the visit per our policy by speaking through the interpreter, the doctor kept interspersing words in both languages, talking at the same time as the interpreter and sometimes even talking over the patient to eagerly show that she believed she had understood, interrupting me before I had the chance to render his utterance. Several times, she even cut the patient off to eagerly offer her English rendition of what she thought he had said so far, leading me to wonder whether she may have been trying to interpret for the team before I was brought in as video interpreter.

I announced clearly at the beginning of the session that “doctor, you are talking over the patient and the message is being garbled. I am hearing several voices at once.” I later asked her directly to please speak one a time, and pause for the interpreter. The doctor tried, but continued to be anxious to display her knowledge and could not stop herself from popping out words or phrases throughout the session, even while others were speaking. This created confusion and interfered with communication.

Patients who regularly use interpreters are very used to the flow of Spanish and English, and when the staff switches to Spanish (or any other language) the patient will commonly automatically feel compelled – even as they are unaware that they are doing it – to switch to English. I have seen this phenomenon hundreds of times. This patient did this as well, and made his best attempt at answering a couple of the questions in English, in response to the doctor’s attempts at Spanish questions, and then mixing the two languages as Dr. X was doing. This added to the confusion.

I had to remind Dr. X on several occasions during the session to “use the interpreter” and “go ahead and speak English” so the patient can understand (as is his right!) But through to the end of the session, Dr. X was still focused on practicing her second language, to the point that she was not fully engaged in patient safety or the medical care she was supposed to be providing. For example, she told him to “get up and walk across the room so we can see how you walk”, and he had to tell her “no, I am a high fall risk. I have to use a belt and have assistance to get up and move, and they even have an alarm on my bed!” She did not seem to have understood that when the two of them spoke alone off-camera, or to have read the fall-risk notes that are routinely displayed both on the door and the wall chart, with her unnecessary focus on practicing her Spanish.

With video, I do not have an easy way to confer with staff about this for our “on-site in-the-moment teachings” beyond a few quick suggestions and comments. I did everything I possibly could within the context of video remote. At one point while discussing his medicine regimen with three sets of 2-week dosage changes as a precursor to titrating down on a medication suspected of causing his dizziness, I told the doctor that “as you were talking over the patient while he was explaining his meds, I will need the patient to repeat what he just said” she responded before I had the chance to ask him for repetition, stating, “No, that’s okay, I understood him!” and moved on.

The specifics were vital details related to anti-seizure and blood pressure meds and how to titrate or adjust them to avoid dizzy spells and interactions – very important to patient safety and fall risk. There were several times when due to poor video reception I asked for repetition of the medication names or dosages and was told “that’s okay, I already know”. I have no way of knowing whether the supervising physician off-camera was clear on what this patient reported about his medication regimen at home. It sounded like the patient is discharging today and traveling out of state tomorrow. This adds to my concern.

Dr. X also brought up what she had mistakenly understood the patient to say before the video interpretation session began. For example, she told him, “I know you said you never walk outside the house” (thus presumably his dizziness is not such a big issue for fall risk after discharge). The patient replied, “I never said I don’t go outside! I said I do go outside, I even go shopping and hold onto the cart to move around the store to buy groceries, although I cannot load them in the trunk these days.” This was not what Dr. X had understood when communicating with him directly, and this is nowhere near as complex as the medical information to be gathered and communicated.

I want to be clear that as interpreter, I have no opinion about the medical advice given, as a matter of course. I am absolutely not trying to second-guess the medical advice given, or make any suggestions outside the scope of my profession, as I raise my concerns for the welfare of the patient as behooves any member of the care team. My concern is strictly with the quality of communication that needs to happen, so that our excellent doctors can convey their excellent medical advice in a clear and understandable fashion, and understand everything the patient is saying. My only concern here is to help make sure that our medical staff know and agree to follow our language policy.

With the best of intentions, new residents especially may wish to “help out” and display some of their knowledge to the team, but it is not appropriate to take over the role of the interpreter. Refusing to call the interpreter, or calling and refusing to use the interpreter, is exclusionary, racist, goes against our language policy and best practices, and beyond being dismissive and disrespectful, can even endanger our patients.

I hope that Dr. X, and eventually all new staff, can be trained that when they refuse or in any way hinder or discourage the interpreter service that the patient requires, they create a completely avoidable barrier to care, a safety risk, and offer a second-class, lower standard of communication to an already vulnerable patient population. As our hospital invites us to erase more and more of these disparities in healthcare delivery, and some of the less obvious barriers to equal access to care, I hope that our new reporting system can help encourage training especially for new staff, and in this case, Dr. X.