For years, doctors at Children's Hospital have observed how difficult it is for non-English speakers in the city's small, but growing Latino community to get care for their children. So, on Tuesday afternoons at the hospital's primary care center in Oakland, three doctors and a nurse have begun offering medical care in Spanish.
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(Dan Marsula, Post-Gazette)
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The health-care professionals are all native speakers and, beginning last month, the hospital began a modest advertising campaign to promote the Bilingual Pediatric Clinic. Thus far, only one or two patients whose parents struggle with English have shown up each week. But doctors expect the service to grow because the benefit of providing care in a patient's first language can be dramatic.
"Language barriers prevent parents from seeking appropriate primary care for their children," said Dr. Alejandro Hoberman, a native of Argentina who helped establish the program at Children's. "Different ethnic groups have different health beliefs that are brought into the medical encounter, but sometimes aren't shared. It's impossible to know about them unless you can ask."
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 This story is seventh in a monthly series. Previous stories.
MORE INFO
To learn about the Bilingual Pediatric Clinic at Children's Hospital, call the hospital's primary care center at 412-692-6000 and press 3.
Family Resources in East Liberty runs classes for foreign language medical interpreters and advocates for patients with limited English skills. Call the organization's International Outreach Program at 412-363-1702.
The Allegheny County Medical Society maintains a list of physicians who speak foreign languages. Call 412-321-3050.
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As federal and local officials put a spotlight on racial and ethnic disparities in health outcomes, they are bringing attention to one of the most fundamental barriers to good care for immigrant and refugee groups: The inability to communicate with doctors.
Foreign-language clinics such as the one at Children's could go a long way to solving the problem. But in a city like Pittsburgh, where there is a small percentage of non-English speakers, the most common solution is interpreters.
The question the federal government and physicians are grappling with is: Who should pay for it?
"It's sort of ridiculous to assume that good communication isn't important -- that's a fundamental part of good quality care," said Dr. Yank D. Coble Jr., president of the American Medical Association and an endocrinologist in Jacksonville, Fla.
But asking a community physician in private practice to pay for interpreters is unrealistic, he said, because that cost can exceed the reimbursement for an office visit.
What the law says
Title VI of the Civil Rights Act of 1964 prohibits any agency or individual that receives federal funds from discriminating on the basis of race, color or national origin. The protections also apply to people with limited English proficiency.
President Bill Clinton issued an executive order in 2000 reminding all federal agencies of their obligation to ensure meaningful access to services for non-English speakers. The U.S. Department of Health and Human Services that year issued guidelines to physicians on the subject -- those who participate in Medicaid, for example, must meetTitle VI requirements.
The guidelines said many common practices followed to bridge the language gap in doctor offices might violate the law.
Some doctors encourage non-English speaking patients to provide their own interpreters. Yet an untrained interpreter often can't understand and communicate medical concepts.
Non-English-speaking patients must sometimes rely on their minor children, neighbors or workers in the doctor's office to interpret. This could be illegal because non-English speakers could be reluctant to discuss intimate information in front of children or strangers.
The guidelines suggested that doctors could do better by hiring bilingual staff or staff interpreters. Or doctors could hire an interpreter service or arrange to use trained volunteer interpreters from the community. Finally, doctors could contract for the use of a telephone language interpreter service.
When the guidelines were published, the AMA hit the roof.
Doctors want to care for non-English speaking patients, but the expense of the requirements amounted to an "unfunded mandate," Coble said. The costs could lead doctors to opt out of the Medicaid program, thereby limiting access for vulnerable patients.
The real shame, he added, is that studies haven't been done to document the positive impact of interpreters.
"Lack of education and motivation could be more of a barrier than language," Coble said.
One size doesn't fit all
For now, the federal guidelines have been put on hold to make sure they comply with related rules published this summer by the U.S. Department of Justice. The revised guidance from HHS should come by the end of the year, said Rick Campanelli, director of the Office for Civil Rights at HHS.
Campanelli stressed that the guidelines don't promote a one-size-fits-all approach, meaning that doctors with limited financial resources or few non-English speaking patients wouldn't be expected to provide vast interpreter services.
"The department wants to eliminate health disparities and one way that we can do that is to encourage recipients [of federal funds] ... to promote access for persons who are limited in English proficiency," Campanelli said. "Ultimately, if an organization or recipient is not providing those services or refuses to, and this is the extreme example, but there are a variety of sanctions including the loss of federal financial assistance."
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Mike Doan, who is from Vietnam, visited the Allegheny County Health Department's immunization clinic in Oakland recently for vaccinations before a visit to his native country. The clinic frequently sees non-English-speaking patients. At the clinic level, where care is fairly straightforward, language differences may be less of an impediment to good care than in a doctor's office, where more complicated issues are discussed. (John Beale, Post-Gazette)
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There are more than 24,000 people in Allegheny County who speak a non-English language at home and speak English less than "very well," according to the 2000 census. When those patients seek health care, they usually bring an interpreter, doctors say.
At Renal Endocrine Associates in Bloomfield, Italians are one of the largest groups of non-English- speaking patients, said Lisa Simonton, executive director of the 13-physician practice. The office hasn't had to arrange for interpreters because one physician speaks Italian or patients bring their own interpreter.
But depending on what the federal regulations ultimately say, patient expectations could change much as they have among deaf patients, who know they have a right to sign-language interpreters.
"The cost of the sign-language interpreter is more than the payment for the office visit from the insurance company," Simonton said. "At our practice, we want to care for these patients, so you take the loss."
Dr. Nicholas DeGregorio, with Preferred Primary Care Physicians in the South Hills, said many non-English speakers patients at his practice have been Bosnian refugees who came with interpreters. That's likely because resettlement agencies such as Catholic Charities and Jewish Family and Children Services have staff trained as medical interpreters who accompany refugees to the doctor.
"It takes up a lot of staff time to do this," said Peter Harvey, director of refugee services at Catholic Charities. "It would be great if all hospitals had bilingual staff and had people on site that would interpret, but it's not the current reality."
Harvey said many refugees receive care at Mercy Hospital, which provides certified foreign language interpreters. When an interpreter can't be found, the hospital uses the AT&T Language Line, a dial-up service of the sort recommended by the delayed federal guidelines.
Khadra Mohammed, who runs the international outreach program at Family Resources in East Liberty, said growing numbers of limited English proficiency patients have been seeking health-care advocates from Family Resources.
Mohammed intervened for a patient who couldn't read a pain-killer prescription she received from her doctor. The woman recognized the numbers 1 and 2 on the label and concluded she was to take one pill twice a day. But the label actually advised taking 1 or 2 pills as needed for pain. Mohammed said the woman suffered needlessly because of the language barrier.
She says community volunteers trained in medical translation can inexpensively do the job. Family Resources offers classes that teach translators how to communicate medical issues to non-English speakers. And these kinds of services make immigrants want to stay.
"We're losing our immigrants and refugees to other communities," she said.
Christopher Snowbeck can be reached at csnowbeck@post-gazette.com or 412-263-2625.
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