Patients presenting with physical health complaints may often have emotional trauma as a cause of their symptoms. In these vignettes, a patient’s complaint of sleeplessness is triggered by worry about her friends and family in her home country. Iraq is the example here, but over the last decades patients have come to the US from wars in Vietnam, Guatemala, Cambodia, Bosnia, Congo, Honduras, Ethiopia, and Syria, just to name a few. Emotional trauma doesn’t emerge solely from war, however. It is important to remember that patients may have trauma due to domestic violence, homelessness, neglect, chronic physical illness, joblessness, childhood events, and innumerable other sources. The goal of these vignettes is to show examples of well-intentioned help that goes wrong and juxtapose it with balanced medical care and interpreting that communicates compassion for the trauma while focusing on the present complaint.
In the first scenario, the patient presents with difficulty sleeping and attributes it to worries about war in her home country. As she describes her worries, the interpreter, who is from the same country, starts to share with her news of additional bombings and mentions specific people who have been affected by them.
Sometimes, it is helpful for interpreters to provide additional information during an encounter. In medical interpreting, we call this ‘cultural brokering’ – providing additional cultural information to the patient or provider so that both parties understand one another better. However, it is necessary for interpreters to use discernment when adding this information: Does the supplementary information aid in providing better care or does it distract from the focus of the encounter? As the patient states in this debrief, the interpreter’s additional information is not helpful to her; rather, it piles on more concern. The physician also states that when the interpreter is from the same region as the patient it is possible that the interpreter has lived through the same trauma. However, it is never appropriate for the interpreter to work out his/her personal concerns while working with a patient.
Discussion of Scenario 1
In the second scenario, the patient presents with the same sleep difficulty and worries about war in her home country. As she explains the situation, the physician begins to ask pointed questions about the war, factions, religious divisions, and ISIS.
As physicians work to understand their patients and build rapport with them, they will often ask more personal or deep questions. Physicians must also use their judgement when asking questions that deviate from the medical topic of the appointment: Do these questions help me understand my patient’s current complaint or do I ask them to satisfy my own curiosity? Am I helping or am I hurting? A useful framework for physicians is Trauma Informed Care Project. This model guides providers to appropriately recognize and respond to patients’ trauma while carefully not re-traumatizing them. As the physician states in this debrief, it can be hard to know how much to ask. The interpreter suggests stepping out of the role of interpreter and into the role of advocate. He proposes taking a time-out with the provider to explain the possible effects of this line of questioning and offers to give supplemental information to the physician after the medical encounter is over.
Discussion of Scenario 2
In the third scenario, the patient presents with the same sleep difficulty and worries about war in her home country. In order to understand her better, the physician asks just a couple of questions about her worries, expresses empathy, and then moves directly into questions about her health.
The physician shares in this debrief that his goal is to try to understand his patient, while not making her responsible for teaching him about war in her home country. Here, the physician and interpreter work together to provider optimal communication and medical care.
Discussion of Scenario 3
These scenarios highlight pearls for both the interpreter and the provider:
- Cultural brokering: A valid part of the medical interpreter’s role is to offer cultural context to patients and providers as needed. That said, interpreters must carefully decide how much and what type of additional information may be suitable in a given encounter.
- Advocacy: Occasionally, an interpreter may find it beneficial to the patient to momentarily step out of the interpreter role and advocate for the patient. This should be done only sparingly and should be communicated transparently to all parties.
- Trauma Informed Care: Physicians are able to give better patient care when they have a thorough understanding of the situation presented. It is necessary to be thoughtful about the types of questions asked in order not to derail the conversation or cause unnecessary re-traumatization.