CASE 23

Miguel Cortez

A 9-year-old Mexican boy with asthma

Noel B. Rosales, MD

Children’s Hospital of Philadelphia, Philadelphia, PA, USA

Educational Objectives

TACCT Domains: 4, 5, 6

Case Summary, Questions and Answers

Miguel Cortez is a 9-year-old Mexican immigrant with asthma who comes with his mother for the first time to the outpatient general pediatric clinic to follow-up on his recent hospitalization for an asthma exacerbation, about 1 month ago. Whereas Miguel is fluent in Spanish and English and reads English, his mother, Adela Cortez, does not speak English. The pediatrician, Dr. Eisen, enters the room and greets Mrs. Cortez, asking how Miguel is feeling. The mother looks at Miguel and asks him in Spanish, “What is the doctor saying?” Without answering his mother, Miguel tells Dr. Eisen, “I am fine,” without elaborating further. Dr. Eisen again turns to Miguel’s mother and asks, “Is he really fine?” With embarrassment she responds, “No English.”

1 What issues arise when conducting a medical evaluation of a 9-year-old child without an interpreter if his mother does not speak English?

Relying on this 9-year-old to speak for himself instead of obtaining an interpreter is certainly very problematic for a number of reasons. Obviously, children at this age, even very intelligent ones, lack the sophistication and communication skills to adequately respond to medical-related questions and/or may have trouble recalling important details, such as the onset, duration, and frequency of his/her own symptoms. Further, 9-year-old children may also lack awareness and insight, which may prevent them from providing accurate information about their own condition. For example, it is not uncommon to see a 9-year-old child with severe asthma and little air movement who will tell you that nothing is wrong. There is, however, a more fundamental concern. Allowing the child to speak for himself, while excluding the mother, has the potential of creating a sense of inadequacy in the mother and marginalizing her as a parent as well as harms the child by parentifying him (or setting adult expectations inappropriate for a child). This change in the power dynamic ultimately may undermine the parent–child relationship and/or contribute to future adherence problems.

2 Why is it important to use a trained medical interpreter when working with patients who do not speak English?

Medical interpretation may be provided by ad hoc interpreters (family members, friends or available, untrained medical or nonmedical staff), trained/professional interpreters, or telephone interpreter services. There is ample evidence that, for patients with limited English proficiency (LEP), the use of trained interpreters (either on-site or via telephone) results in better heath care experiences, outcomes, and the use of services. A skilled, trained interpreter ideally transmits information in a seamless way between the clinician and the patient as accurately as possible with minimal distortion. If done well, these trained interpreters can further help to simplify medical information in a way that ensures the patient understands what the clinician is trying to say, teach, or advise. Their previous experiences with medical terminology can further help to facilitate the conversation. Although there are admittedly unavoidable situations, given the above, the use of ad hoc interpreters is not encouraged.

Having said all of this, some of the potential limitations should be noted. First, it is important to acknowledge the challenges faced by a trained interpreter in faithfully acting as a neutral, two-way conduit of information, behavior which, although expected, some would argue is not always desirable. Second, the language barrier and the presence of an interpreter inevitably tends to stifle some of the purely social and spontaneous interactions, “small talk,” that could and does occur between patient and physician who communicate directly to each other in the same language. For groups where this kind of interaction is important, its absence may diminish some of their satisfaction with the physician encounter. Aranguri and colleagues also suggest that the lack of social discourse limits the physician’s ability to diagnose any psychosocial disorders or compliance/adherence issues related to the social situation of LEP patients. Appendix 1 describes how to effectively position an interpreter.

Upon learning that Mrs. Cortez does not speak English, Dr. Eisen arranged for a hospital provided interpreter to join the interview. Through the interpreter, Mrs. Cortez reported that, when Miguel was discharged from the hospital, he had been prescribed fluticasone and albuterol. Upon discharge, because she did not speak English and an interpreter was not available, she was given written instructions in Spanish. These instructions explained that Miguel should continue the medicine every day in order to suppress the inflammation and prevent future asthma exacerbations. She admitted that as Miguel was feeling better, she stopped giving these medications over the last 2 weeks.

3 Why might Mrs. Cortez have stopped giving Miguel his asthma medications?

One potential issue is how the discharge instructions were explained to the patient and parent. When providing written instructions to patients and/or families, their literacy level and ability to read should not necessarily be assumed as it is not valid to assume that literacy exists in every patient. This is particularly important for immigrant populations, where the educational opportunities in their native country may have been limited. In this case, Miguel’s mother received discharge summary instructions that were written in Spanish, assuming that she was literate in Spanish. In fact, Mrs. Cortez is unable to read (Spanish) and, therefore, did not understand the inflammatory nature of asthma and the need to continue the steroids (i.e. fluticasone) to maintain suppression of the airway inflammation. Certainly in this situation, it would have been important to have an interpreter to provide her with verbal instructions.

Other issues beyond the lack of proper instructions that have to be considered include the influence of native beliefs about the nature, cause, and treatment of asthma, or lung diseases in general, and a fear of her child being harmed by or becoming “addicted” to the medications. The possible importance of these additional factors to immigrant health in the U.S. is highlighted by the study of Bearison and colleagues, who surveyed mothers from a Dominican American community regarding their beliefs about asthma and asthma treatment. It was noted that most mothers in this group of Hispanic women (72%) reported that they did not use prescribed medicines for the prevention of asthma, instead substituting home remedies derived from their folk beliefs about health and illness. Further, nearly two-thirds thought their children did not have asthma in the absence of an acute exacerbation, and 88% believed that medications were overprescribed.

Through the interpreter, the physician asks mom if Miguel is wheezing (“Jadeo”) at night. The clinician notices that mom seems puzzled by the word Jadeo. She says to the interpreter in Spanish, “What do you mean?” Despite further effort on the part of the interpreter to clarify the question, she still does not understand what is being asked.

4 Why might Mrs. Cortez have trouble understanding the concept of wheezing when asked by the interpreter?

Mrs. Cortez is Hispanic, specifically Mexican. The term “Hispanic” refers to ethnicity and not race and is defined by the federal government as including a person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin. According to the U.S. Census Bureau, as of census 2000, there were 37.4 million Hispanics in the U.S., which constituted 13.3% of the population. Current data suggest that Puerto Ricans have higher prevalence and mortality rates of asthma than other ethnic groups or other Hispanic subgroups, whereas Mexican Americans appear to have a lower risk of asthma compared with other groups.

Table 23.1 An informal sampling of Spanish words used to describe wheezing

Source: Noel Rosales, MD, The Children’s Hospital of Philadelphia, 2009. Used with Permission.

Spanish word May be used in Comments/translation
Pito, peruvia Mexico “Whistling sound”
Ronquer “Snoring”
Jadeo Cuba “Panting”
Resuello, Silbido Puerto Rico
Sibilancia Dominican Republic
Hervor de pecho Central American “Boiling in the chest”

As in all languages, there are different dialects and word usages in Spanish that can create challenges when trying to understand the patient’s symptoms, even when an interpreter is being employed. For example, the English word “wheezing” does not directly translate into one Spanish word and so it is expressed differently depending on the patient’s particular Spanish. (Table 23.1) Similarly, instructing the patient to take “two puffs” from their inhaler may not be easily interpreted as shown in Table 23.2. Therefore, it is usually helpful to ask the patient what words they use to describe a particular symptom.

Miguel is started again on fluticasone and albuterol, and an asthma care plan is formulated. Using a trained medical interpreter, the care plan is explained in both Spanish and English so both the mother and Miguel can follow it. Mrs. Cortez is able to demonstrate her understanding of the care plan by using a “teach back” approach, where her understanding of the treatment is confirmed by having her repeat back what was instructed. If there appears to be misunderstanding or confusion, the instructions or information are again repeated, presumably in a way that better facilitates their understanding, and the patient/family once again is asked to describe what they have heard. The process is repeated until understanding has been achieved.

However, over the next several months, despite adherence to the treatment plan, Miguel’s asthma becomes difficult to control. Because of this, Dr. Eisen wants to enroll Miguel and his family in an asthma care program that includes home visits to assess for environmental triggers for asthma. It is explained (through an interpreter) that the program is free of charge and could greatly benefit Miguel, but Mrs. Cortez becomes very defensive and adamantly refuses to participate in the program. Despite vigorous encouragement, Dr. Eisen is unable to convince Mrs. Cortez to enroll in this initiative and is very puzzled by her refusal.

5 Why might Mrs. Cortez refuse to participate in this program?

There may be undocumented immigrants at home, and so Mrs. Cortez may be reluctant to enroll in this program because of a fear that strangers entering the house might discover these individuals and report them to the authorities. This concern about being reported may lead undocumented immigrants to delay seeking medical treatment or result in incomplete disclosure of relevant medical or personal information. This is an example of a psychosocial issue that, along with biological and environmental factors, might increase the morbidity of asthma in Hispanics.

Table 23.2 For”two puffs” of an inhaled medication from a metered dose inhaler

Source: Noel Rosales, MD, The Children’s Hospital of Philadelphia, 2009. Used with Permission.

Spanish phrase English translation
Dos inhalaciones Two inhalations
Dos pulsaciones Two pulsations
Dos puffs Two puffs
Dos Sprays Two sprays
Dos Soplos Two blows
Usar in bomba dos veces Use the pump two times
Dos apretatas de inhalador wo squeezes of the inhaler
Dos empujadas de inhalador Two pushes of the inhaler
Inhalar dos disparos Inhale two blasts or firings

References: Case 23

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