Participants in both the morning and afternoon sessions worked in small groups to come up with additional ways of conveying numeric concepts. Here are some highlights:

Quantity & Calculations

·        Separate concepts, such as in a discharge brochure asking people to keep track of medication by time of day, quantity of each dose, and total per day. Have separate sections for: When do I take medication? How many pills do I take? How much medication am I taking?

·        Compare new concepts to familiar ones. To explain why babies breastfeed so frequently, explain that "a newborn's tummy is the size of a chickpea, then a cherry, then a walnut. That's why they feed so often." 

·        Define and use words consistently. Decide how you and colleagues will use words such as "risk" and "maybe."

·        Build on television commercials, such as the one from Verizon that shows a few and then a lot of sprinkles.

·        Have people fill in pictures of clocks, such as teenagers showing how much they sleep and what they think is sufficient.

·        Avoid vague terms such as "adequate," "moderate," and "plenty."

·        Take advantage of existing websites, such as those that compare costs of brand-name, generic, and over-the-counter drugs.

·        Consider culture, even when using the "plate method" to show portion size. Some cultures use bowls, not plates. Not everyone uses silverware. Modify visual aids to be culturally appropriate.

·        Use technology such as pedometers and talking scales.

·        Make it fun. For children, you might say "We'll get to Grandma's house in 3 Batman shows from now." 

Time:

·        Help those without clocks, watches, or even homes keep appointments by relating to something they regularly do, such as "Come to the clinic after you go to the soup kitchen on Tuesday."

·        Relate to activities in a person's everyday life. For a child, this might be "You can have more pain medication after you watch 2 cartoons."

·        Consider using text messages, cell phone reminders, or portable timers.

·        Help patients remember about medication with a device modeled after robots used to dispense medication in hospitals.

·        Associate timed activities with music, such as "Brush your teeth for as long as you hear your favorite song" and then play it.

·        Choose soap with beads that change color after so much time to indicate when to stop washing.  

·        Tie activities with daily landmarks such as before/after school or at breakfast and dinner.

·        Print calendar grids so people can add checkmarks when they take medication. This way, they won't have to remember whether they took it.

·        Have forms and calendars to show causality. For instance, someone who gets headaches might need to include the timing of sleep, food, and symptoms. 

·        Use technology such as cell phones, alarms (set when you're together), electronic pill boxes, and text messages.

·        Use the calendar function on cell phones, email, or outlook.

·        Send out automated emails as reminders.

·        Put stickers on calendars, showing activities to do each day.   

Risk:

·        Teach 1-1 or in a small group class.

·        Say "3 out of 10" rather than "30%."

·        Say "chance" versus "risk."

·        Personalize information, such as showing a picture of a staircase and saying "Here you are and here are options to get where you want to be."

·        Show a DVD or use software program that shows situations visually.

·        Give a common analogy. For example: To explain why not to use antibiotics for treating viruses, relate to "not using bug spray to get rid of weeds in your garden."

·        Use numbers needed to treat (NNT), such as "We would need to treat 500 people for 1 to get benefit from this." Or "If we do surgery on 100 people, 30 will get real benefit." NNT can help people put statistics into perspective.

·        Frame information in as positive a way as possible.

·        Use colors (such as red, green, yellow) to compare items and show which is positive/negative, or more risky and less risky. 

·        Do not equate risk with flipping coins as some cultures have superstitions about that.

·        Use a visual teach-back approach. This might be having a picture with 100 stick figures and asking the person to circle how many are at risk for [x]. This is a good way to find out whether people internalized concepts of relative or absolute risk.

·        Adapt what people know from television, such as how to tell when cars are at risk.

·        Allow more flexibility. For instance, for BMI let people overflow beyond rigid boxes. 

·        Combine strategies such as explaining risk with humor, pictures, and color. 

·        Have a videogame of someone doing a risky behavior and what happens as a result.

·        Stack up risks in columns; the higher the column, the more risk.

·        Consider whether you really need to use numbers at all. 

Additional Resources:

·        Ariely D. Predictably Irrational, Revised and Expanded Edition: The Hidden Forces That Shape Our Decisions (May 19, 2009). As described by a workshop participant, this book highlights how our brains are programmed to function in ways that are not always rational in terms of numbers. 

·        Apter et al, "Numeracy and Communication with Patients: They Are Counting on Us," J Gen Intern Med 23(12):2117-24.

"Working Effectively with LEP Patients and Medical Interpreters"

Elizabeth Abraham, MA, M.Sc.

Increasingly, the field of health literacy recognizes the importance of the oral exchange.  Discussions of how to use and build on the teach-back technique and questioning to ensure that patients have understood and have been understood are gaining attention.  But what do you do when the effectiveness of these techniques are limited by the fact that the patient and the provider do not share the same language?  Elizabeth Abraham, M.A., M.Sc., manager of interpretation and translation services at the University Health Network in Toronto and President of the Board of Directors of the Healthcare Interpretation Network, looked at the use of interpreters to address this challenge.

The Problem

Ms. Abraham is well versed in the challenges that a multi-lingual population presents to the healthcare arena.  She works in Toronto, the most ethnically diverse city in the world, where 146 languages are spoken and nearly half of the population has as their native tongue a language other than English or French.  In the University Health Network alone, she said, there are approximately 15,000 interpreted healthcare encounters a year. 

In general, healthcare workers are not well prepared to serve limited English proficiency (LEP) patients, and this can lead to unfortunate consequences, said Ms. Abraham.  The patients pick up on the frustration of the front-line staff and the impatience of providers.  The underlying tension present in the encounter impedes the creation of a connection between patients and providers, she said, which leads to a lack of trust on the part of the patients and, often, to "poor adherence and poor outcomes."

Clearly, interpretation in these encounters is necessary to ensure patient-centered care and patient safety, for risk management and cost control, and to meet the needs of the diverse patient population, she said.  And fortunately, the cost of using an interpreter in a clinical encounter is about the same as the cost of an x-ray. Yet, according to Ms. Abraham, healthcare workers still do not call for interpreters as often as they should. 

Convincing the Organization

The Massachusetts General Hospital Disparities Solution Center, in its report titled Improving Quality and Achieving Equity: A Guide for Hospital Leaders (www.mghdisparitiessolutions.org), offers compelling information on the need for solutions for working with LEP patients.  This report illustrates that an increase in the use of trained interpreters leads to a decrease in costs, thanks to:

• shorter inpatient stays
• fewer readmissions
• fewer emergency visits
• fewer diagnostic tests
• more accurate diagnoses
• greater likelihood of patients attending follow-up appointments, and
• better patient adherence to treatment plans.

A cost-benefit analysis comparing the options of not using interpreters, using untrained interpreters, and using trained interpreters revealed that the use of interpreters was related to a number of patient and institution benefits, said Ms. Abraham.  It compared mortality rates from chronic, manageable diseases for English-speaking and LEP patients.  It also compared proportions of admissions, emergency room visits, and outpatient visits of the two groups, she said.  The analysis revealed that integration of interpretation services led to a reduction of disparities in mortality rates between English-speaking and LEP patients for specific diagnoses, a shift in utilization from inpatient and emergency services to outpatient clinics and primary care, a reduction in diagnosis codes for LEP patients, and reduced overall healthcare costs. 

Risk Management

The use of interpreters also affects risk management, she noted.  Risk management looks at the use of interpreters and asks whether it is an essential service and whether action should be taken.  "If it is not essential and we don't act, there are no consequences.  If it is not essential and we do act, we have spent money, but it is a tiny amount compared to the money spent on keeping patients in the hospital longer than necessary.  If it is essential and we don't act, there are delays in diagnosis, poor patient outcomes, medical errors, lawsuits, negative impacts on reputation, and increased overall costs.  If it is essential and we do act, we see lower overall costs, better patient outcomes, patient-centered care, patient safety, and positive impacts on reputation," she said. 

Risk managers are concerned with informed consent, too, pointed out Ms. Abraham.    She holds that interpreters are necessary to the consent process.  "To treat patients without their consent is battery," she said.  Family members and bilingual staff are not acceptable substitutes for medical interpreters when seeking consent or discussing a negative diagnosis, home care, or medication instructions, she said.

Standards of Practice

Professional medical interpreters are bound by certain professional standards and ethics.  They include:

• Accuracy-Interpreters strive to render all messages accurately, as faithfully as possible and to the best of their ability without addition, distortion, omission, or embellishment of the meaning.
• Confidentiality-Interpreters will not disclose and will treat as confidential all information learned, either uttered or written, in the performance of their professional duties, while adhering to relevant requirements regarding disclosure.
• Impartiality-Interpreters strive to maintain impartiality by showing no preference or bias to any party involved in the interpreted encounter.
• Respect-Interpreters demonstrate respect toward all parties involved in the interpreted encounter.
• Role Boundaries-Interpreters strive to perform their professional duties within their prescribed role and refrain from personal involvement.
• Accountability-Interpreters are responsible for the quality of interpretation provided and are accountable to all parties and the organizations engaging the interpreter's service.
• Professionalism-Interpreters at all time act in a professional and ethical manner.
• Continued Competence-Interpreters commit themselves to life-long learning in recognition that languages, individuals, and services evolve over time and a competent interpreter thrives to maintain the delivery of quality interpretation.
• Confidentiality-Psychiatrist says that the interpreter is the most important person in the room.  Are interpreters required to disclose abuse of children or threats?  In Canada, they are.  Ask them to destroy notes, journals, once done. 

Working with Medical Interpreters

Healthcare professionals also have some responsibility in clinical encounters involving interpreters, Ms. Abraham reminded the attendees.  She offered some best practices for healthcare professionals using the services of a medical interpreter.

Before the encounter

• Bring the patient into the exam room when the interpreter arrives.
• Brief the interpreter outside the exam room/patient room.
• Start the encounter by letting the interpreter introduce him/herself.

During the encounter

• Focus on the patient; maintain eye contact.
• Speak in the first person.
• Speak at an even pace.
• Break every 1-2 sentences.
• Check in with the interpreter if you suspect the entire message wasn't interpreted.
• Check in with the patient for comprehension.
• Remember that everything uttered is interpreted.

After the encounter

• Document the interpreter's name in the patient chart.
• Debrief with the interpreter, if required.

The use of professional medical translators clearly supports the value of health literacy and leads to more patient-centered care.  It addresses the problem of literacy and care disparities among the population and positively impacts both the problem of disparities in patient health outcomes and the organizational challenges of costs and risk management.   There are clear health reasons and financial reasons for healthcare systems to make the use of medical translators standard practice.  But perhaps the most important reason to embrace and optimize the practice is the fact that, "language rights are human rights," concluded Ms. Abraham.