Nothing makes the importance of the history more evident than being unable to communicate with the patient, an increasingly common experience. In 2011, the Census Bureau reported that more than 60 million Americans speak a language other than English at home. Of these, more than 20% have limited English proficiency. Spanish is the primary non-English language, spoken by 37 million Americans.65 These individuals are less likely to have regular primary or preventive care and more likely to experience dissatisfaction and adverse outcomes from clinical errors. Learning to work with qualified interpreters is essential for optimal outcomes and cost-effective care, 66–70 Experts take this one step further, "If it isn't culturally and linguistically appropriate, it isn't health care."

If your patient speaks a different language, make every effort to find a trained interpreter. A few words of clinical Spanish may enhance rapport, but they are no substitute for the full story. Even if you are fluent, you may miss important nuances in the meanings of certain words. Recruiting family members as translators is equally hazardous—it may violate confidentiality, and information may be incomplete, misleading, or harmful. Lengthy patient explanations may be telescoped into a few words, omitting significant details. The ideal interpreter is a "cultural navigator" who is neutral and trained in both languages and cultures. However, even trained interpreters may be unfamiliar with the multiple subcultures in many societies.

When you work with an interpreter, begin by establishing rapport and reviewing the information that will be most useful. Ask the interpreter to translate everything, not to condense or summarize. Make your questions clear, short, and simple. Help the interpreter by outlining your goals for each segment of the history. After going over your plans, arrange the seating so that you have easy eye contact with the patient. Then speak directly to the patient… "How long have you been sick?" rather than "How long has the patient been sick?" Having the interpreter sit close to the patient, or even behind you, keeps you from turning your head back and forth. 

When available, bilingual written questionnaires are invaluable, especially for the review of systems. First, however, be sure that patients can read in their language; otherwise, ask the interpreter for help. In some clinical settings, use speakerphone translators, if available.

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