Article from the Boston Globe’s On Call Magazine, June 2003

By Helen Osborne, MEd, OTR/L
President of Health Literacy Consulting

Some people identify themselves as deaf with an upper-case “D,” indicating they are part of a specific cultural and linguistic community. ASL (American Sign Language), the primary language for most people in that community, is the third most commonly used language in the United States. Healthcare professionals need to be as aware of ASL as they are of any other language spoken in the communities they serve.

American Sign Language (ASL) is likely the primary language of people who are born deaf or who lost their hearing in early childhood (before the age of 3) and never developed speech. ASL is not simply hand gestures that substitute for spoken English. It is a complex language that makes use of facial expressions and body movements as well as hand signs, and it has its own grammar and syntax. For example, the English phrase “Missed the boat” is expressed with a single sign that  translates as “traingosorry.”

Steven Barnett, MD, an assistant professor in the Department of Family Medicine at the University of Rochester School of Medicine and Dentistry in Rochester, NY, knows a lot about communicating with people who are Deaf or hard of hearing. Although hearing himself, Barnett is skilled in ASL and communicates in sign language with many of the patients he treats. He is not only aware of Deaf patients’ language needs, he’s also sensitive to their healthcare experiences.

Barnett says that a person’s deafness can have an impact on his or her fund of healthcare knowledge. This can happen, in part, because people who are Deaf do not experience “ambient information”  — information not necessarily directed to the listener that is overheard. For example, the first time a Deaf teenager goes alone to the doctor, there is a good chance he or she will not be aware of information relating to family history that was shared informally in conversation between the doctor and the teenager’s parents.

Providers need to make sure they use effective communication strategies when treating people who are Deaf or hard of hearing, just as they would with any other patient who comes from a community where English is not the primary language. Here are some ways Barnett says you can  help make sure your messages will get across.

Work with an ASL interpreter. Generally, the most effective way to communicate with patients who use ASL is through a trained interpreter. Barnett firmly believes that the interpreter doesn’t just help the person who is Deaf, but improves communication for everyone involved. “If one person needs an interpreter, both people need an interpreter,” says Barnett. Encourage patients to ask ahead of time that an ASL interpreter be present during their appointments.

Barnett strongly recommends using trained ASL interpreters rather than the patient’s family members. He has found that, despite the best of intentions, family members sometimes change or misinterpret words. For example, a daughter who is embarrassed when her mother feels depressed may tell the doctor that her mother simply feels tired.

When working with an ASL interpreter, the interpreter should sit a little behind and to the side of the health provider. This way, the patient can see both the provider and interpreter in the same visual field. The provider, in turn, can listen to the interpreter while looking directly at the patient.

Determine the preferred method for communicating. When you first meet a patient who is Deaf or hard of hearing, ask how that patient prefers to communicate. Be aware of what the patient tells you about what has and what has not helped in other settings. Have a place on the intake form to note whether people use a TTY (telephone typewriter), and make sure staff know how to communicate through a TTY relay operator. Throughout appointments, ask patients how they understand their plan of care.

Use available technology. Until recently, interpreters needed to be in the same room as the patient and provider. While this is ideal, it is not always possible. Thanks to technology, there are now other options.

These options include a video relay service that uses a high-speed Internet connection to allow an interpreter, patient, and clinician to communicate from three separate locations. Barnett cautions, however, that video-relay services have the potential for error due to choppy motion and frame drops when there is not sufficient Internet bandwidth. Another option is video-remote medical interpreting. Using TV cameras and dedicated lines, an interpreter at a remote location can facilitate communication between a provider and patient who are in the same room.

Don’t depend on communicating with written notes. It is widely assumed that all patients who are Deaf, regardless of whether or not they use ASL, benefit from written information. This is not necessarily so, says Barnett. He cites studies that show a majority of Deaf high-school students of normal intelligence read only at a fourth- to fifth-grade level  — well below the level needed to understand most written health materials. Barnett says there are many reasons for this. One is that people who are Deaf cannot sound out words,  a technique that hearing people commonly use to figure out unfamiliar words.

Don’t depend on reading lips. Another common assumption is that all people who are Deaf can read lips. Indeed, this is not always the case. Lip shapes are often ambiguous, with many words and sounds looking alike. Barnett estimates that 70 percent of lip reading is guesswork. The words “bed” and “men,” for example, look nearly the same on the lips.

Be aware of differences in nonverbal communication. Even nonverbal cues are sometimes misunderstood. For example, standing and closing the chart may mean  “We’re done” to a health provider, but be understood as  “We’re almost done with the main topic” to someone in the Deaf culture. Often, neither the clinician nor the Deaf patient realizes that their nonverbal cues are misunderstood.

Whether communication is signed, written, spoken, or nonverbal, Barnett says that providers should continually check with patients and confirm that information is accurately and completely understood.

To Learn More

Steven Barnett, MD, is an assistant professor in the Department of Family Medicine at the University of Rochester School of Medicine and Dentistry in Rochester, NY. You can e-mail him at Steven_barnett@urmc.rochester.edu.

Printed Sources

• Barnett S. “Clinical and Cultural Issues in Caring for Deaf People,” Family Medicine, January 1999. Vol. 31, No. 1: 17–22.
• Barnett S. “Cross-Cultural Communication with Patients Who Use American Sign Language,” Family Medicine, May 2002, Vol. 34, No. 5, 376-382.
• Barnett S. “Communication with Deaf and Hard-of-Hearing People: A Guide for Medical Education,” Academic Medicine, July 2002, Vol. 77, No. 7: 694-700.

Web Resources

• Massachusetts Commission for the Deaf and Hard of Hearing www.state.ma.us/mcdhh
• Laurent Clerc National Deaf Education Center, Gallaudet University
• Strong Connections: Telehealth Sign Language Solutions, www.urmc.rochester.edu/strongconnections