As if the practice of medicine were not complex enough, add cultural and language challenges. When a patient cannot speak English or has come from a country where certain American medical procedures practices are considered taboo, the difficulty of practicing medicine may become even more complicated.

Hospitals throughout Georgia are meeting the multicultural challenge head on, through in-house interpreters, telephone interpretation services and even specialized clinics.

At Northeast Georgia Medical Center in Gainesville, there are 10 patient representatives who are fluent in Spanish and staff the hospital 24 hours a day, seven days a week. They serve as interpreters throughout a patient's medical experience - from the time they come into the hospital for help with paperwork through the examination and treatment phase. The medical center also has an online interpreters service based in Atlanta that can respond within minutes to a variety of language and cultural situations.

Hall County has the state's fastest-growing Hispanic population; nearly 35 percent of the county is Latino. The medical center also sees some Russian and Asian patients. The health care system has made it a priority to serve this community. From creating bilingual signage in the hospital to printing many forms in two languages, Northeast Georgia Medical Center is reaching out.

However, providing interpreters can be tricky business. As in many hospitals, the medical center Northeast Georgia Medical offers one-on-one interpreters who are more than bilingual.

"They serve as helpers to patients to act on their behalf," said Mimi Reyna, supervisor of the Patient Representative Department. "They must be fluent in both English and Spanish, but they also must understand cultural differences." Such differences may affect the way a patient accepts treatment.

"For instance, many new Latino mothers want to cover their own heads, wear socks and a sweater when they leave the hospital with their newborn, even in the summer," Reyna said. "They don't want to catch cold; it's cultural. They also tend to wait in labor longer before coming into the hospital because many of their own mothers had babies at home instead of in a hospital. And the men are not as involved in labor and delivery as American men are."

Other hospitals are also responding to the needs of their diverse patients.

Understanding cultural differences is especially important for the staff at Children's Healthcare of Atlanta. The hospital has 11 staff interpreters who can collectively work accurately in 30 to 40 languages, including American Sign and Contact Sign. However, beyond simply providing communications between patients and providers, interpreters must understand cultural nuances.

"In many cultures, taking someone's blood is a big deal, perhaps for religious reasons or because the family fled to the United States from a war-torn country," said Andrea Henry, coordinator for Multicultural Translation Services at the Scottish Rite campus of Children's Healthcare of Atlanta. "It might even be akin to taking an organ. So our interpreters are skilled in various cultures so that they can help bridge the communications gap between a physician and a family."

Interpretation in the health care arena must be precise. Having the language interpretation skills is more critical than understanding the practice of medicine.

"Interpreters must know their boundaries. They are ethically bound to interpret accurately in the exact same spirit in which they hear what the physician or provider is saying," Henry said. "That's why we used skilled interpreters. No one in a family should be used as an interpreter. We remind staff about the safety, consequences and family dynamics. The parents make the care decisions, based on information provided by the physicians and properly interpreted." "An interpreter must have the ability to hear something and then be able to repeat in the language of the patient without changing the message," she said. "We don't want our interpreters to paraphrase. This is not interpreting. It's not their job to buffer or fix a statement but to repeat it in the way it was stated and in the spirit it was said."

Children's Healthcare of Atlanta began its formal multicultural program by hiring its first staff interpreter five years ago. Henry joined the health system in 2003 to head the department and guide the system in effectively serving these diverse populations. Interpreter services are provided at no additional charge.

"We're here to provide safe medical communications to our patients and if we need to provide an interpreter, we need to cover those costs ourselves."

Grady Memorial Hospital in the heart of downtown Atlanta city is the only Level One trauma hospital within 100 miles. Known for its burn center and its emergency services, Grady is also a leader in provides health care for many of Georgia's multicultural residents. For three years, Grady has offered medical services to the Latino population in a clinic staffed by health care providers for whom English is a second language.

Now called the International Medical Center, the department has two bilingual nurses, three bilingual clerks, plus a cadre of physicians and medical residents who are speak fluent in Spanish. The center's staff sees Latino patients during regular clinic hours each week.

"We really are bilingual," said Ingenia Genao, M.D., the director of the International Medical Center at Grady. "It is important that when we serve any population that we understand their culture and the differences."

The program at Grady began from a recognized need to go beyond providing interpreters to help with the delivery of medical care to other cultures.

"There was a need at our main campus to serve this (Latino) population, even though we have nine neighborhood health centers in the community so that patients can easily access health care," Dr. Genao said. "Patients from other cultures usually don't see health care as a top priority and in some cultures, people only come to doctors when they're sick."

She said that before the International Medical Center was established, patients from other cultures may have wandered around the hospital trying to find the assistance they needed. With this in mind, Grady established the clinic on the ground floor; the hospital has also added bilingual signage. In addition, the center is expanding its reach to other cultures.

"The process always starts with a dialogue with members of the specific community, because each community knows what it needs and what is really going on," she said. For instance, working with the Ethiopian Association of Atlanta, Grady has recently established a health care program for the Ethiopian community, with clinic hours every other Friday.

In addition to the International Medical Center, Grady offers in-house interpreters for a variety of languages though the Department of Multicultural Affairs. They are accessible 24 hours a day, seven days a week, by phone. As metro Atlanta and Georgia become more and more culturally diverse, the medical community will expand to help deliver care to these growing populations. Hospitals are responding in a variety of ways, based on the populations they serve and their own resources. While Hispanic patients seem to make up the bulk of multi-cultural patients, the need to reach into the diverse Asian community and the African community is also great.

"Serving these diverse communities requires commitment and training to be aware of the cultural differences," Dr. Genao said. "We really do rely on each [cultural] community to tell us how best to serve them."