Uno employee, dos jobs: Benefits of a bilingual staff

When family physician David Tempest, MD, started practicing in Moncure, N.C., 17 years ago, his patients were mostly black or white, and everyone spoke English. But when poultry-processing plants started opening in the area, the demographics shifted quickly as Mexican immigrants came for jobs.

Now more than one-third of the patients Dr. Tempest sees speak only Spanish. That's why his Moncure Community Health Center in mid-October posted job openings for a physician assistant and a patient care coordinator that state: "Bilingual in Spanish preferred."

Early on, he said, the sliding-scale-fee clinic hired bilingual employees to facilitate communication between doctors and patients. "We still do that. All of our support staff is cross-trained."

A staff member fluent in a language other than English is a necessity many practices are realizing, especially if that language is Spanish. These practices don't need to look at the U.S. Census Bureau numbers -- which say the nation last year had 43 million Hispanic residents, that Hispanics will grow to 25% of the population in less than 50 years, and that the fastest growth is happening outside the usual big-city entry points -- to know they increasingly are seeing a patient population that is not English-speaking.

The Health and Human Services Dept. requires any practice participating in a federal program, such as Medicare, to provide language assistance. That doesn't mean a practice is required to hire bilingual staff, but some are finding that doing so saves time and helps deliver better care through clearer communication.

Rather than hiring a dedicated medical interpreter, who might not be needed all day, hiring someone bilingual for an existing position can mean filling two jobs for the price of one. And some practices say that having bilingual staff is a way to show the burgeoning local immigrant population that it can best meet its needs.

Finding this staff member is not as easy as simply identifying someone who speaks the language. The ideal worker must be able to fill the office or medical job and be able to drop what they're doing and not only flawlessly interpret the words of both physician and patient but also understand the cultural background and look for clues that there's more to what a patient is saying.

To get this person, you might have to pay a premium, not only in salary but in training.

For many physicians, though, these costs are still lower than that of a dedicated interpreter. Median salary for this job is about $35,000, and most practices find that they need an interpreter at most a few times per day. And having a full-time interpreter is not required under HHS rules. Practices can use phone-based interpretation services, or patients can opt to use their family members or friends to translate.

But physicians and experts say using family members or friends can create an uncomfortable situation for the patient, who might not want to reveal something too personal. And the interpreters might not be able to translate the medical terminology correctly. Also, personal interpreters, as well as language lines, can grow cumbersome and time-consuming, physicians and experts say, especially if a practice is seeing a growing number of non-English-speaking patients.

Adding a bilingual employee can be the answer, although not necessarily an easy one.

"Really, the most crucial piece in pulling together your bilingual practice is finding the right person," said Roger Hanson, director of staffing solutions for Transperfect Translations, a global language service provider with headquarters in New York.

Hanson warns, and HHS agrees, that "it's not enough to assume fluency just because someone is from a country that speaks that language."

A basic knowledge of medical terminology and anatomy is crucial, Hanson said, as well as a familiarity with cultural issues that may influence treatment options or appropriate bedside manner.

The employee also must be able to transition smoothly between the role of an interpreter and a primary job.

The employee should be told the job expectations from the beginning. "You have to be up front with someone, or you may get a short-term fix," Hanson said.

He also warns doctors not to burden employees with unrealistic expectations. An employee must be able to satisfy both parts of whatever dual job role is assigned and be able to do it in a typical workweek, rather than trying to squeeze 80 hours of work into a 40-hour schedule.

Dr. Tempest, whose clinic is one of six operated by Piedmont Health Services, said he had an advantage in recruiting because Moncure is located less than 30 miles from the University of North Carolina, providing Spanish majors or minors for his initial hiring pool.

When Susan Call, office manager for the two-physician FirstCall Family Doctors Practice in Springdale, Ark., hired someone for the dual job of interpreter and business office assistant, that person had no formal interpreter training. It was difficult for the employee to transition quickly between English and Spanish. And not having a medical background made translating that terminology especially difficult.

Call decided to seek outside help with training a replacement. In September she enrolled the new employee into a medical interpreting program at the University of Arkansas. It is among a growing number of schools offering such programs in response to demand from physicians. Call said the difference the training made was immediate. "It was an educational experience for me."

But who pays?

As part of its Educating Physicians on Controversies in Health series, the American Medical Association released a video earlier this year that explores the issues of language barriers between physicians and patients. The Association's official policy is that "further research is necessary on how the use of interpreters -- who are trained and those who are not -- impacts patient care." But it does say that the cost burden of providing language services should not be placed on physicians.

Only 11 states reimburse for interpreting services provided to recipients of Medicaid or State Children's Health Insurance Programs, and a few private insurance plans cover interpreting. But reimbursement for specific translation services doesn't necessarily mean reimbursement for costs associated with bilingual employees.

Physicians must determine if any extra costs associated with hiring a bilingual employee will be worth it, compared with alternatives.

Hanson said the typical premium amount for a bilingual employee is a few dollars more per hour, and Call confirmed that she is paying her employee more because of the dual role.

But Moncure does not pay a premium wage. "We struggled with that," Dr. Tempest said. Some board members reasoned that when the clinic catered to a mostly black population it didn't pay the black employees more. "And [the black employees] understood the nuances of that community that we didn't understand. Ultimately, we decided that everyone brings something unique."

Further education can used, in lieu of premium pay, as an incentive for bilingual employees, said Javier F. Sevilla Martir, MD, an assistant professor of family medicine at Indiana University whose research concentrates on use of bilingual employees. Training also can thwart possible liability issues by teaching HIPAA requirements and the ethics involved with medical interpreting.

Because the pool of applicants often comes from the same community as the patients, there are several things doctors need to be cautious of, Dr. Tempest said.

Employees must have a thorough understanding of HIPAA laws and know that it's not OK to leave work and discuss who they saw and what they were treated for, he said. The HHS also warns that the interpreter should act as an impartial party and not offer advice or counseling, even if patient and interpreter know each other on a personal level.

In addition, discrimination laws dictate that you can advertise for a language skill but not for a nationality.

Also, Dr. Tempest said, while you don't have to bother with immigration issues as a doctor, as an employer you do. Documentation, such as a green card or an alien registration, permanent or temporary resident card, needs to be current and in hand for that person to be employed legally. A complete list of acceptable identification can be found on the U. S. Citizenship and Immigration Services Web site (link).

Changing times, changing strategies

In the end, some physicians and experts say, the benefits of having bilingual employees far outweigh any costs or hassles -- especially because the immigrant population is growing so quickly.

For instance, FirstCall's Springdale is home to the Tyson Foods headquarters, which has poultry-processing facilities that have drawn Hispanics, as have these plants in other parts of the country. A special 2005 census in Springdale shows Hispanics make up about one-third of its 62,000 residents -- up from 19% of its 45,000 residents in 2000.

It is only recently that the Springdale clinic has seen Spanish speakers start to come through its doors. But Call said the practice believed that having a bilingual employee not only would improve care and efficiency but also would be a good marketing tool.

That's the picture for the Moncure clinic, which Dr. Tempest says quickly become known as the "Spanish Clinic," after patients started to refer friends and family. Now patients who don't need to use the clinic for financial reasons still come because they're comfortable there.

"One thing is clear, and no one will argue, the [limited English proficiency] population is an underserved one," Hanson said.

"If a doctor is able to approach their practice from a business perspective and provide a service to this underserved population, they will be rewarded."