Guidelines For Working With An Interpreter

■ Choose a professional interpreter in preference to a hospital worker, volunteer, ^ or family member. Use the interpreter as a resource for cultural information. £ ■ Orient the interpreter to the components you plan to cover in the interview; ^ include reminders to translate everything the patient says.

C^ Arrange the room so that you and the patient have eye contact and can read i each other's nonverbal cues.

■ Seat the interpreter next to you and allow the interpreter and the patient to establish rapport.

■ Address the patient directly. Reinforce your questions with nonverbal behaviors.

■ Keep sentences short and simple. Focus on the most important concepts to ^ communicate.

■ Verify mutual understanding by asking the patient to repeat back what he or she ^^ has heard.

^ ■ Be patient. The interview will take more time and may provide less information. >

The Patient With Reading Problems. Before giving written instructions, it is wise to assess the patient's ability to read. Literacy levels are highly variable, and marginal reading skills are more prevalent than commonly believed. People cannot read for many reasons, including language barriers, learning disorders, poor vision, or lack of education. Some people may try to hide their inability to read. Asking about educational level may be helpful but can be misleading. "I understand that this may be difficult to discuss, but do you have any trouble with reading?" Ask the patient to read whatever instructions you have written. Literacy skills may be the reason the patient has not followed through on taking medications or adhered to recommended treatments. Simply handing the patient written material upside-down to see if the patient turns it around may settle the question. Respond sensitively, and remember that illiteracy and lack of intelligence are not synonymous.

The Patient With Impaired Hearing. Communicating with the deaf presents many of the same challenges as communicating with patients who speak a different language. Even individuals with partial hearing may define themselves as Deaf, a distinct cultural group. Find out the patient's preferred method of communicating. Patients may use American Sign Language, which is a unique language with its own syntax, or various other communication forms combining signs and speech. Thus, communication is often truly cross-cultural. Ask when hearing loss occurred relative to the development of speech and other language skills and the kinds of schools that the patient has attended. These questions help you determine whether the patient identifies with the Deaf or the Hearing culture. If the patient prefers sign language, make every effort to find an interpreter and use the principles identified above. Although very time-consuming, handwritten questions and answers may be the only solution, though literacy skills may also be an issue.

When patients have partial hearing impairment or can read lips, face them directly, in good light. Speak at a normal volume and rate, and do not let your voice trail off at the ends of sentences. Avoid covering your mouth or looking down at papers while speaking. Remember that even the best lip readers comprehend only a percentage of what is said, so having patients repeat what you have said is important.

Hearing deficits vary. If the patient has a unilateral hearing loss, sit on the hearing side. If the patient has a hearing aid, find out if he or she is using it. Make sure it is working. Eliminate background noise such as television or hallway conversation as much as possible. Patients who wear glasses should use them so that they can pick up visual cues that will help them understand you better. Written questionnaires are also useful. When closing, supplement any oral instructions with written ones. A person who is hard of hearing may or may not be aware of the problem, a situation you will have to tactfully address.

e Patient With Impaired Vision. When meeting with a blind pant, shake hands to establish contact and explain who you are and why you e there. If the room is unfamiliar, orient the patient to the surroundings and report if anyone else is present. Remember to use words whenever you respond to such patients, because postures and gestures are unseen.

Encourage visually impaired patients to wear glasses, if available, to ease communication.

The Patient With Limited Intelligence. Patients of moderately limited intelligence can usually give adequate histories. In fact, you may even overlook their limitations and omit their dysfunction from disability evaluations or give them instructions they cannot understand. If you suspect such problems, pay special attention to the patient's schooling and ability to function independently. How far have such patients gone in school? If they didn't finish, why not? What kinds of courses are (were) they taking? How did they do? Have they had any testing done? Are they living alone? Do they get help with any activities, for example, transportation or shopping? The sexual history is equally important and often overlooked. Find out if the patient is sexually active and provide any information needed about pregnancy or sexually transmitted diseases. If you are unsure about the patient's level of intelligence, you can make a smooth transition to the mental status examination and assess simple calculations, vocabulary, memory, and abstract thinking (see Chapter 16).

For patients with severe mental retardation, you will have to obtain the history from the family or caregivers. Identify the person who accompanies them, but always show interest first in the patient. Establish rapport, make eye contact, and engage in simple conversation. As with children, avoid "talking down" or using affectations of speech or condescending behavior. The patient, family members, caretakers, or friends will notice and appreciate your respect.

The Poor Historian. Some patients are totally unable to give their own histories because of age, dementia, or other limitations. Others may be unable to relate certain parts of the history, such as events during a seizure. Under these circumstances, you must try to find a third person who can give you the story. Even when you have a reasonably comprehensive knowledge of the patient, other sources may offer surprising and important information. A spouse, for example, may report significant family strains, depressive symptoms, or drinking habits that the patient has denied.

For patients who are mentally competent, you must obtain their consent before you talk about their health with others. Assure patients that any information he or she has already told you is confidential, and clarify what can be shared. Even if patients can communicate only by facial expressions or gestures, you must maintain confidentiality and elicit their input. It is usually possible to divide the interview into two parts—one with the patient alone and the other with both the patient and the second person. Each part has its own value. Remember that data from others are also confidential.

he basic principles of interviewing apply to your conversations with relatives r friends. Find a private place to talk. Introduce yourself, state your purpose, quire how they are feeling under the circumstances, and recognize and ac-owledge their concerns. As you listen to their versions of the history, be alert the quality of their relationship with the patient. It may color their credi-ility or give you helpful ideas for planning the patient's care. It is also im portant to establish how they know the patient. For example, when a child is brought in for health care, the accompanying adult may not be the primary or even frequent caregiver, just the most available ride. Always seek out the best-informed source. Occasionally, a relative or friend insists on being with the patient during your evaluation. Try to find out why and also the patient's wishes.

The Patient With Personal Problems. Patients may ask you for advice about personal problems outside the range of their health care. For example, should the patient quit a stressful job, move out of state, or have an abortion? Before responding, explore the different approaches the patient has considered and their pros and cons, whom else they have discussed the problem with, and what supports are available for different choices. Letting the patient talk through the problem with you is usually much more valuable and therapeutic than any answer you could give.

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