The doctor pokes, he prods, he pauses for a grimace or groan.

The response comes in Spanish or Russian. It’s all Greek to him.

Helen Fagan, co-chairwoman of Lincoln’s Medical Translation and Interpretation group, calls the poke-and-prod approach to treating non-English-speaking patients “veterinary care,” saying it can lead to misdiagnoses, even disaster.

It’s commonplace to augment pokes and prods with the translation skills of a 12- or 14-year-old pulled from school to help immigrant parents or neighbors — which can create problems.

So is the patient feeling any burning discharges? Erectile dysfunction?

Could you relay the danger of high triglycerides and its role in metabolic syndrome?

Gibberish in the other direction.

To avoid these and other potential problems, there is a move by some in Lincoln to push for the standards developed by the National Council on Interpreting in Health Care, eschewing family and children in favor of trained, professional medical translators.

“It’s like the evolution of how an RN became an RN,” said Fagan, who also works at BryanLGH Medical Center. “It’s another medical professional.”

Potential embarrassment and an inability to relate technical issues aren’t the only problems with using kids, says Lincoln psychologist Maria Prendes-Lintel.

When a child interprets for a parent, she says, “They are the ones that begin to learn how to solve problems … the ones in charge.”

When the adult tries to step back into the role of parent, the child may respond with: “What do you know?” I have to solve problems for you.”

If it doesn’t lead to defiance, child translation opens the door to guilt. In one situation, a child failed in an attempt to relay instructions about a new medication to his diabetic mother, who almost died.

“How would you feel if that was your mom?” Prendes-Lintel asks.

New position in Lincoln funded for three years

Professional translation has become commonplace in hospitals, Fagan says, and that’s raising expectations elsewhere.

Lincoln’s Medical Translation and Interpretation group, whose members are drawn from hospitals, Lancaster County and other organizations, recently appointed Lorena Pulgarin to coordinate projects aimed at providing better care for those termed LEP, or lacking English proficiency. The position is funded for three years and carries lofty goals.

Fagan and Pulgarin say using professional interpreters is not only good practice, it’s federally required.

“By law, entities that receive federal money must provide interpretation and translation to patients,” Pulgarin said. “And yes, that is a burden to some practitioners.”

So far, doctors say, most of the burden has fallen to them.

They’re wary, not because they’re satisfied with the status quo, but because of how the federal government has tried to interpret the law so that it pushes the costs of professional translating onto them.

If government believes this is a service that needs to be provided, says Dr. Cecil Wilson, a Florida physician on the national board of the American Medical Association, then it should pay for it when patients cannot.

“It’s a law that has good intentions but unintended consequences,” Wilson says, and one that, were it enforced, might lead physicians to withdraw from serving those who need it most.

The law is Title VI of the 1964 Civil Rights Act, which says those who get federal funds may not run their programs in a way that creates discrimination on the basis of race, color or country of national origin. In other words, physicians who accept Medicare or Medicaid payments should provide language services.

Prior to 2000, it was a law without guidelines and did not apply to federal agencies, leaving physicians to believe it didn’t apply to them.

And then in August 2000, outgoing president Bill Clinton signed Executive Order 13166, requiring federal agencies to provide guidance.

The Office for Civil Rights within the Department of Health and Human Services — similar offices exist in other departments — almost immediately released the guidance it had been preparing, requiring doctors to provide professional interpreters. Efforts to revoke the order after George W. Bush was elected president failed.

The American Medical Association then complained to the Department of Health and Human Services, requesting its 2000 guidance be tabled. The Office of Civil Rights said Congress would have to rescind the 1964 Civil Rights Act in order for them to withdraw guidance, but in 2003, it issued new guidance favoring physicians.

The National Council on Interpreting in Health Care responded, saying the new guidance allows doctors to make their own decisions about whether to provide language services. In a letter, the council listed disasters it believes were caused by the practice.

* Arizona. 13-year-old Griselda Zamora was the interpreter for her Spanish-speaking parents, but when she fell ill, she was unable to speak for herself. Complaining of severe stomach pain, she was given a pregnancy test, kept overnight and released. She later died.

* Oregon. A Mexican laborer loses sight in one eye after failing to communicate with a clinic by telephone that the metal in his eye from a nail gun was different from the wood chip in his eye for which he had previously been treated.

* New Mexico. An abusive husband causes pre-term labor, then serves as interpreter for his Vietnamese wife.

Costs often fall to physicians

Locally, professional medical translation costs roughly $35 an hour with a one-hour minimum, and it must be arranged in advance. Medicaid typically pays the doctor a lesser or equal amount for seeing the patient.

Often, says Lincoln’s Dr. Les Spry, patients don’t show, but the physician still must pay the translator.

Physicians say they encounter a multitude of situations and do their best to provide practical solutions.

Sometimes, a professional interpreter may be necessary, Spry says. Sometimes a medical problem can be determined by tests, observations, other means. A kidney doctor has different communication needs than a family practitioner caring for pregnant women.

The point AMA’s point, he said, is that the physician ought to be able to figure out the information he or she needs and then make whatever provisions necessary to obtain it.

For about 10 years, one Lincoln option has been a phone translation service. It’s an evolving service, with occasional changes in hours,  and is limited by a lack of body language.

It is available for the most common languages: Spanish, Vietnamese, Croatian, Russian and Arabic, but Lincoln has more than 50 different languages.

Spry also disputes the idea that family interpreters are inherently bad.

“Family often has lots of information,” he says.

And not even all native-born Americans comprehend some of his medical explanations.

When he sees a typical patient, he adds, “That’s not someone trained in interpreting medical terminology.”

Advocates of professional interpreters say they save money and may reduce patient no-shows in the long run.

Fagan related the story of an immigrant woman whose health issues related to torture went misdiagnosed five years, resulting in expensive and unhelpful treatments. Relying on unprofessional translators, the woman’s medical records even listed her nationality incorrectly.

“In terms of costs, you either pay it now, or pay it later,” Fagan says.

Drive for state to fund interpretation

Prendes-Lintel says more accurate diagnoses and improved patient-doctor interaction would lead patients to view physician visits as a higher priority, and that would lead to compliance.

One of Pulgarin’s goals as coordinator will be to coordinate a drive for state legislation that would fund interpretation for poor immigrants.

Currently, a dozen states provide some reimbursement, says Mara Youdelman of the National Health Law Program in Washington, D.C. Total program costs vary.

Last year, Kansas spent $47,000 on interpreters in Medicaid-managed care. Minnesota spends $1.6 million on professional interpreters, she says.

States have two options to obtain partial federal reimbursement: straight Medicaid, receiving up to 50 percent back; or declare interpreting an administrative expense under other state programs and get as much as 58 percent from Medicaid and up to 71 percent from the State Children’s Health Insurance Program.

Need for professional interpreters exists locally

Pulgarin, Fagan and Prendes-Lintel say the need for professional interpreters exists, especially in Lincoln.

Lincoln’s Medical Translation and Interpretation grew out of the Community Health Endowment’s 2002 Blueprint Project, which identified the community’s 40 worst health issues.

Interpretation returned as an issue again in the 2004 Urgent Matters report, which showed the local poor tend to choose emergency departments for care, receiving expensive but incomplete treatment.

From there, the issue advanced to the New Americans Task Force, made up of representatives of nearly 40 human service agencies. Nine focus groups then dissected the problem, reaching eight goals. Funding for interpreters is one. Public and physician education is another. A couple of goals were administrative, setting up mechanisms for change.

For more than a year, groups researched the issue and traced what has occurred locally to avoid reinventing wheels.

Then in July, they appointed Pulgarin, a 13-year Lincoln resident with two children, married to an instructor at Lincoln High School.

She managed hospital and real estate offices in Colombia before coming to the United States. She arrived here thinking she knew English, only to find she didn’t. She progressed from needing a medical interpreter to working as one.

Medical interpretation is a need in our country, Pulgarin says. “It’s a need to be addressed by all members of our community.”

Reach Mark Andersen at 473-7238 or mandersen@journalstar.com.