When Translation is Law

“The single biggest problem in communication is the illusion that it has taken place.”George Bernard Shaw.

As a follow up to Intro to Translation, I would like to review exactly what types of documents physicians are required by law to translate for their practices.

If a physician has a practice which provides care to a substantial number of non-English speaking, or LEP (limited English proficiency) patients, then providing these patients with translated documents has a number of benefits. The United States federal government defines LEP as a patient’s own self-assessment of his or her ability to speak and understand English as less than very well.

Patient satisfaction surveys have consistently shown that LEP patients have 36% lower satisfaction rates than English speaking patients and 47% --almost HALF of them – are more likely not to return for future care as a result. Although there are 6 types of medical documents that must be translated in order to remain compliant with federal law, it may be worthwhile to consider including other practice materials, such as patient education materials or patient survey forms, in an effort to improve the LEP patient experience.

Under the Civil Rights Act of 1964, Title IV, patients cannot be discriminated against because of national origin by any institution that receives federal funding. When documentation is not provided in a language the patient can understand, this too is considered discriminatory under this act. The specific requirements for translation were further elucidated upon in 1997 by the Critical Access Hospital Program which focused on hospitals in areas of the U.S. that have a higher percentage of LEP patients. The six types of documents that must be translated are:

1 – notices of free language assistance

2  - eligibility for services of language assistance

3 – patient intake forms

4 – informed consents

5 – patient complaint forms

6 – discharge instructions

The Office of Civil Rights (which is part of the Department of Health and Human Services) requires that these documents be translated when “the LEP language group constitutes 5% or 1000 persons – whichever is less – of the population served.”

State government interpretations of this law may be more strict, as in the case of New York State, where the requirement given by the Office of Civil Rights has been expanded to “1% of the hospital service area.”

It is further important to note that the Affordable Care Act (ACA) has shifted incentives for doctors and hospitals to offer better quality, not quantity, of care. In essence, there are financial repercussions to providing care that does not result in patient satisfaction. Medicare provides higher rates of reimbursement with more readmissions. Doctors receive bonuses or penalties if they receive high or, conversely, low scores on patient satisfaction surveys.

Therefore, it is in the doctor’s best interest, aside from satisfying the legal translation requirements for providing care to LEP patients, to try to overall improve the LEP patient’s entire office experience by offering as much patient material as possible in the language the LEP patient can understand. These include as mentioned earlier in this blog entry: patient education pamphlets, surveys, and marketing materials.

The consent forms I have been referring to in this article apply to procedural consents provided to patients. In my office, they would include cataract surgery, laser iridotomy, chalazion/eyelid lesion excision, selective laser trabeculoplasty and YAG capsulotomy consent forms- to name a few. However, it is important to note that research-related consent forms are also included in this category.

The Institutional Review Board (IRB) requires that consents for research must be written in the language in which the patient interview is conducted. Further, according to information provided on the Language Scientific website regarding IRB-specific consent forms, there are 4 specific scenarios to consider when deciding if consent forms have to be translated from English:

1 – If the patient/participant has the ability to read and understand sixth-grade level English, then no translation is necessary. Forms may be provided in English.

2 – If the patient/participant cannot read but understands spoken English, then it is possible to have someone read the consent form to them with a witness present. Understanding by the patient must be documented and the patient, witness and reader of the consent must all supply signatures at completion.

3 – If the patient/participant cannot read or understand spoken English, but is fully literate in another language, then the consent and all related materials may be translated into the language the patient understands.

4 – If the patient/participant cannot read or understand spoken English, nor is literate in another language but can understand another language when spoken, then the consent must be translated into the other language and another person must read the translated consent to the patient with a witness present, documenting that the patient understands all that is being said. In the end, the patient, the reader of the consent and the witness will provide their signatures to this effect.

Further, the IRB “.. must review and approve all translated versions of an informed consent form before the form is used in a study.” If the study itself is complicated or carries with it significant clinical risk, then an added safety measure for quality assurance of a proper translation must be provided to the IRB via a back translation. A back translation is one where the translated document is translated back into the original English by a separate translator, to ensure that everything written in the language correctly reflects that which was written in the original English.

References

duMont-Perez, Suzy .“The 6 Medical Documents You Must Translate to Remain Compliant.” LanguageLine Solutions. http://blog.languageline.com/6-medical-documents-must-translate-to-remain-compliant (Accessed July 22, 2016).

Markert, Cory. “Medical Translation: Is Translation of Vital Documents Enough?” LanguageLine Solutions. http://blog.languageline.com/medical-translation-is-translation-of-vital-documents-enough (Accessed July 22, 2016).

“Office Guide to Communicating with Limited English Proficiency Patients.” American Medical Association. https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=what+is+the+definition+of+an+LEP+patient (Accessed July 23, 2016).

“6 Things to Know About Translating Informed Consent Forms.” Language Scientific. http://www.languagescientific.com/6-things-to-know-about-translating-informed-consent-forms-2/ (Accessed July 24, 2016).

Dubrovnik, Croatia. Courtesy: D. Hromin

Intro to Translation

“Translation is that which transforms everything so that nothing changes.” –Gunter Grass

I recently completed an 8-month long translation course focusing on English to Spanish translation. My initial intent was to focus solely on medical translation: consent forms, patient information pamphlets and the like. However, this course offered a variety of material: legal, business, economic, and fictional narratives to be translated from the English source material to Spanish. It definitely was a demanding class, requiring much reading, researching, writing and editing, but it helped me improve my written Spanish communication immensely. Reading and writing a language is also a superb way to increase vocabulary and grammar knowledge. It’s easy to graze over grammatical errors when we speak, but writing hides nothing. There it is, in black and white, for the reader to see: spelling mistakes, run-on sentences, incorrect punctuation, missing accent marks and all.

I plan on shifting my blog focus for several future entries on written Spanish. This is because working as a physician demands not only the ability to dialogue with patients, but to also provide them with various forms of reading material in Spanish. You cannot orally describe a surgical procedure to a patient in Spanish, only to hand them the consent form written in English. Because Spanish is the second most popular language spoken in U.S. homes, there is a wealth of reading material available in the various areas of medical specialty that physicians can obtain for their patients.

However, there are always office-specific procedural forms, consents and materials, research study descriptions and consents, that need to be translated. Take, for example, a study design on cytomegalovirus-induced uveitis in immune-compromised patients below. This was one of my class assignments for translation.

While comparing the translation to the original, take note that there are several factors to consider when translating a document. A few to consider are: Who will the reading public be? Should certain names and/or abbreviations be left in the original English? Are numbers and measuring units written the same way in the target language as in the source? Do you keep the same formatting? Answering these questions first helps to create a successful and cohesive translation.

Methods

Patients
Patients with AIDS and newly diagnosed, active cytomegalovirus retinitis were enrolled at 18 clinical sites in the United States. Eligible patients had to be at least 18 years old, and their best corrected visual acuity had to be 20/200 or better in at least one affected eye. Exclusion criteria included opacities that would prevent visualization of the fundus, contraindications to intraocular surgery or to therapy with intravenous ganciclovir, the presence of overt signs or symptoms of extraocular cytomegalovirus infection, an absolute neutrophil count below 500 cells per cubic millimeter, a platelet count below 25,000 cells per cubic millimeter, a serum creatinine concentration above 1.5 mg per deciliter (133 µmol per liter), and a Karnofsky score below 60. Informed consent was obtained from all patients.

Base-Line Evaluation and Randomization
Before randomization, patients underwent a complete base-line examination, which included nine-field fundus photography. The randomization was stratified so as to distribute patients with unilateral and bilateral cytomegalovirus retinitis equally among the three treatment groups, and blocking was used to assign patients equally to the treatment groups over time.

Treatment and Follow-Up
Eligible patients were assigned with equal probability to receive one of three treatments: an intraocular implant (Vitrasert, Chiron Vision, Irvine, Calif.) with a release rate of 1 µg of ganciclovir (Cytovene, Roche Laboratories, Nutley, N.J.) per hour, an intraocular implant with a release rate of 2 µg of ganciclovir per hour, or intravenous ganciclovir. A 2-µg-per-hour implant was included to determine whether a release rate higher than that used in a previous study³⁷ (1 µg per hour) would have greater efficacy. Investigators and patients were unaware of the release rate of the ganciclovir implant. The surgical procedure to insert the implant has been described elsewhere.^35,36 Patients assigned to receive intravenous ganciclovir received an induction dose of 5 mg per kilogram of body weight twice daily (total daily dose, 10 mg per kilogram) for at least 14 days, followed by maintenance therapy at a dose of 5 mg per kilogram once daily.
For patients in the implant groups, ophthalmic examinations were performed on postoperative days 1, 3, 4, 5, and 7. Patients in all three groups were examined at weeks 2, 4, 6, and 8 and then monthly until there had been eight months of progression-free follow-up or until progression of cytomegalovirus retinitis, death, or another event specified as leading to the termination of follow-up occurred. At follow-up visits from week 2 on, a complete ophthalmic examination was conducted, including measurement of visual acuity with modified Bailey–Lovie charts,⁴⁴ slit-lamp examination, indirect ophthalmoscopy with the eyes dilated, and bilateral, nine-field photography of the fundus.

[ Source http://content.nejm.org/cgi/content/full/337/2/83, New England Journal of Medicine]

Métodos

Pacientes

Los pacientes con el síndrome de inmunodeficiencia adquirida (SIDA) y la retinitis activa por citomegalovirus (CMV) de diagnóstico reciente se inscribieron en dieciocho sitios clínicos en los Estados Unidos. Los pacientes elegibles tenían que tener por lo menos dieciocho años, y la agudeza visual mejor corregida tenía que ser 20/200  o mejor en al menos un ojo afectado. Los criterios de exclusión  incluyeron: opacidades que impedirían la visualización del fondo del ojo, contraindicaciones de la cirugía intraocular o la terapia con el ganciclovir intravenoso, la presencia de signos o síntomas evidentes de la infección por citomegalovirus extraocular, un recuento absoluto de los neutrófilos debajo de 500 células por milímetro cúbico, un recuento de plaqueta debajo de 25.000 células  por milímetro cúbico,  una concentración de creatinina sérica arriba de 1,5mg por decilitro (133 µmol por litro) y índice de Karnofsky debajo de 60. El consentimiento informado se obtuvo de todos los pacientes.

Evaluación inicial y  randomización

Antes de la randomización, los pacientes tuvieron una evaluación inicial  que incluyó la fotografía de nueve campos del fondo del ojo. La randomización se estratificó para distribuir de manera equilibrada los pacientes con la retinitis por citomegalovirus unilateral o bilateral entre los tres grupos de tratamiento, y el bloqueo de los datos se utilizó para asignar a los pacientes por igual a los grupos de tratamiento a través del tiempo.

Tratamiento y  seguimiento

Los pacientes elegibles se asignaron con probabilidad igual para recibir uno de tres tratamientos: un implante intraocular (Vitrasert, Chiron Vision, Irvine, Calif.) con una tasa de liberación de 1 µg de ganciclovir (Cytovene, Roche Laboratories, Nutley, NJ) por hora, un implante intraocular con una tasa de liberación de 2 µg de ganciclovir por hora, o ganciclovir intravenoso.  Un implante de 2µg por hora se incluyó para determinar si una tasa de liberación superior a la utilizada en un estudio previo³⁷ (1µg por hora) tendría mayor eficacia. Los investigadores y los pacientes no estaban al tanto de la velocidad de liberación del implante de ganciclovir. El procedimiento quirúrgico para insertar el implante se ha descrito en otra parte^35,36. Los pacientes asignados a recibir el ganciclovir intravenoso recibieron la dosis de inducción de 5mg por kilogramo de peso corporal dos veces al día. (la dosis diaria total, 10mg por kilogramo) por a menos 14 días, seguido por el tratamiento de mantenimiento con las dosis de 5mg por kilogramo cada día.

Para los pacientes de los grupos con implantes, se realizaron exámenes oftalmológicos en los días postoperatorios 1, 3, 4, 5, y 7.  Los pacientes en los tres grupos se examinaron en semanas 2, 4, 6, y 8 y luego mensualmente hasta que había pasado ocho meses del seguimiento sin progresión o hasta que la progresión de la retinitis por citomegalovirus, la muerte, o cualquier otro evento especificado como la causa de la terminación del seguimiento. En las visitas de seguimiento de la semana 2 y demás, un examen oftalmológico completo se realizó y se incluyó la medida de la agudeza visual con los gráficos  modificados de Bailey-Lovie⁴⁴,  el examen por la lámpara de hendidura, la oftalmoscopia indirecta con ojos dilatados, y  la fotografía de nueve campos del fondo de nueve campos del fondo del ojo bilateral.

Joan of Arc, Jules Bastien-LePage

All the better to Hear you with, my dear

When you talk, you are only repeating what you already know. But if you listen, you may learn something new. –Dalai Lama

I have been using Spanish daily in my work for at least 15 years now, and I’ve been studying it for 28+. I have what I like to call a professional fluency. I know vocabulary, phrases, questions, answers and conversation centered on the ophthalmologic exam.  I can converse outside this, but I have many more years to go before considering myself at near-native level. I have found during this time period that my reading and writing skills in the language from very early on far surpassed my listening and speaking ability. I could never understand why. I looked at studies that analyzed how people learn in general, and then at studies that focused on the mechanisms that go into language learning in particular. I looked at articles that documented the neurophysiology of language acquisition, the best brain periods of a person’s life to absorb a language. The best conclusion – scientific conclusion – that made sense to me was that neurologically, we are wired to become accustomed to the sounds (language sounds) we hear as an infant and child growing up, and our brains “prune away” neurologic connections for foreign sounds. I suppose for survival purposes, this adaptation increases survival ability. It allows a person to hone in on conversations and communications he can understand and respond to, and keeps “foreign” and confusing sounds that would lead to a break down in communication, out.

But then there’s the argument, what do you say about the people who pick up languages easily later in life? People that can be thrown into a crowd of individuals speaking another tongue and, given some time, they begin to verbally communicate and understand, having never seen one written word. Or what about those individuals who learn multiple languages? How do their brains get accustomed to hearing, accepting and analyzing varied sounds? How do their brains reconcile the differences in those sounds? How do they not confuse the languages when they speak? Is this just an extra “gift” that a person has? A talent? Like being a concert violinist or a world-renowned sculptor? Can the average individual re-teach his brain? Can he force his brain to accept that to which it is not accustomed?  

In pondering these questions, I turned to the first open source of information available: the Internet. I searched: “How to improve my listening skills in a language?”.  A multitude of hits came up, which I eagerly perused hoping for the answer. The one that piqued my interest the most is an article written by a guest blogger on Benny the Irish Polyglot’s website Fluent in Three Months.

In his article, How to Improve Your Listening Skills in a New Language, author Andrew Barr talks about the need for something he calls ‘high stakes active listening’. What he is referring to is the fact that many language programs today encourage passive listening as a way to learn a language. An example of passive listening is listening to a CD of native speakers while on your drive to work: you’re hearing them, but you’re not actively engaging in conversation. You have no impetus to have to understand everything they’re saying. Instead, Mr. Barr encourages active listening:  listening because you have to hear and understand the answer in order to accomplish something. He gives an example of when he experienced this type of listening for the first time during his trip to Spain. He had parked his car in a public garage and needed to find out if he would be able to get access to the garage after hours, otherwise, he would have been stranded without a car in the city that night. He had a reason, a true need, to communicate with the parking attendant and figure out what the man was saying in order to get his car later.

After reading this, a light bulb went off! I realized that the reason my communication skills in Spanish have increased tremendously over the last ten years in medical practice is because I, too, have experienced this type of high stakes active listening. In my case, there is a very important need to find out crucial information related to my patients’ medical history. I need to know symptoms, duration, medication, and allergies to ultimately correctly diagnose and treat the patient. When a patient tells me something in Spanish and I don’t understand completely, I ask them to repeat it. Even though I don’t want to appear foolish - even though I want to look like I understand everything easily and readily, the need for accurate information outweighs my linguistic ego. The need to know increases the stakes of learning. I have to know this information, and that gives me the drive to really listen and make sense of what I’m hearing. 

So, to go back to my earlier question: how does someone improve her listening skills in a language? Is there a specific technique, or must you be born with a talent for languages?

The answer is: you don’t need to be born with a special linguistic talent. Anyone can improve his skills in any language, but in order to do so he must take an active role interacting in that language. You can’t build muscle simply staring at equipment in the gym. You must use the equipment. The next time someone speaks to you in Spanish, don’t just listen to words spoken, really listen. Hear the words. Then, make sure to respond to them.

References

Barr, Andrew. “How to Improve Your Listening Skills in a New Language.” Fuent in Three Months  Web.  http://www.fluentin3months.com/listening-skills/

Salt Flats, Death Valley, CA