Malpractice

Rosa was frightened. Her little boy Diego was sick again. Diego had asthma, he’d had a positive TB test, he had recurrent ear infections and had been operated on twice to have tubes placed to drain his ears. Two months ago a doctor told her Diego had salmonella, and the clinic had mailed her a letter about it, but she couldn’t read it because it was in English. Now Diego had been up all night with a fever and vomiting, and his ear hurt again. When they came to the clinic, there was no-one to interpret, so Diego’s twelve year old sister Juanita had to do it.

Juanita did her best, but when she tried to translate her mother’s questions, the doctor just ignored her, or wouldn’t even let her speak. Juanita tried to tell the doctor that Rosa was worried about a lump on the baby’s lip, that she wanted to know what the letter said about the salmonella, that Diego had had diarrhea and fever. But the doctor just said the letter was too old to worry about. Then the doctor asked Rosa what Diego took for his asthma, but Juanita didn’t translate the question correctly. The doctor asked how long ago Diego had his last asthma attack but Rosa thought she had asked how often he took medicine for his asthma, and the doctor’s question was never answered. Rosa tried to ask what was wrong with Diego’s ears, and what she should do if he kept vomiting, but her questions were never translated. Then the doctor said to give him Tylenol or Advil, but Juanita told her mother to give him both.

When my colleague Irma Rodriguez interviewed Rosa after the visit, she asked if the family had been back to Puerto Rico to visit. No, said Rosa, nor can we. Why not? “Because the father of the children is hunting us to kill us.” Rosa said she was going to keep on living and fighting for her children, but now they were staying in a homeless shelter. Juanita had seen her father repeatedly beating her mother, and was in psychiatric treatment for post-traumatic stress. But the doctor never learned any of this.

Communication is the most fundamental requirement of medical practice. Taking care of people is not just about biomedical science, although technically precise communication is essential. It depends on mutual trust, rapport, and the exchange of experiences, beliefs and feelings. Facilitating communication across a language barrier is a demanding professional skill. An interpreter must be truly fluent in both languages, but much more than that is required. Interpreters must be conversant with medical concepts and terminology. They must possess special skills for mediating the structural differences among languages and the deeply embedded differences in world view. Interpreters must also have skills to mediate culturally determined expectations about interactions, the physician and patient role, and theories of physiology and disease. Interpreters must meet high ethical standards. They must scrupulously respect confidentiality and avoid injecting their own judgments into an interaction that properly belongs to physician and patient.

Obviously, children can never meet these requirements. Furthermore, having children interpret places demands on them that may be overwhelming and frightening, and may expose them to inappropriate or upsetting information. A 15 year old girl told us that she was serving as interpreter for her mother, when she found she didn’t understand what the doctor was saying, so they called for a Spanish-speaking secretary to help. “Don’t you understand what they’re telling you?” the secretary asked her. The girl went on, “’No, I said.’ She tells me, ‘They’re telling you’re your mother has,’ some sort of thing, cancer, I don’t know, I was like, ‘No, I don’t understand what you’re saying’ . .. and the lady was just so rude.” Doctors in England have told of a child from India who was traumatized by having to interpret for her family during her brother’s fatal illness.

In California, regulations have been proposed to forbid the use of children as interepreters. Naturally, the hospitals are expected to oppose the regulations. Let me make this absolutely clear:

Having children serve as medical interpreters is medical malpractice, and child abuse. It should be a crime, everywhere.