A Haitian woman preparing for a doctor appointment at the Generations Health clinic in Norwich was asked to fill out a form that asked her sexual orientation. The staff member at the office attempting to help the woman, who did not speak fluent English, phrased it this way: "do you like men, women, or both?"

"I like both," the woman replied, not realizing the question referred to her sexuality.

Flor Rivera, a community health worker at Generations Health, overheard the conversation and suspected something was getting lost in translation. She stepped in to explain; was the woman sexually attracted to men and women?

"She jumped out of the chair," when she realized the mistake, Rivera said.

Medical appointments can be confusing even when both patient and doctor speak fluent English. But when a language or cultural barrier keeps doctors and patients off the same page, misunderstandings can have real effects on patients’ health, so a growing number of staff in federally funded medical offices are getting trained in the art of making a doctor's orders clear no matter what language the patient speaks.

In July 2016, a provision of the Affordable Care Act went into effect that requires any health care provider or insurance company that uses federal dollars to provide a qualified interpreter, either in person or over the phone, to patients with limited English skills.

That meant that sending in a bilingual staff member or a family member to interpret a medical provider's questions and instructions no longer met legal requirements; the interpreter had to be trained and certified.

Since 2010, the regional office of the federal Area Health Education Center program has been training local health workers in the language of doctors' appointments. The students — bilingual nurses, medical students, aspiring doctors and medical office staff — learn the precise language and cultural skills needed to make sure none of the details of a medical appointment gets misunderstood.

Rivera, who speaks fluent English and Spanish, said she and other bilingual workers in the office would often get called away from their main duties to interpret for Spanish-speaking patients before the training.

That was common, said Michele Scott, the executive director of Connecticut's eastern Area Health Education Center, as health clinics were still learning about the new requirements under the Affordable Care Act.

"A lot of time the clinics were just using whoever on their staff that said they were bilingual, which is a legal nightmare and medical nightmare if something gets misinterpreted," she said.

Medical offices can also call a remote interpreter to listen in on the appointment and relay information between a medical provider and patient, but the services can cost an office $2 per minute and can feel impersonal, Scott said. So community health organizations and medical systems like Hartford HealthCare have increasingly sent their bilingual clinicians and staff — most of whom speak Spanish but also Polish, Chinese and Haitian Creole — to AHEC for the certification program.

Rivera, who completed the 48 hours of online and in-person training through the last year, said the training has helped patients feel more comfortable that they understand information about their health and doctors more confident that their questions and medical advice are coming across accurately.

Knowing the precise Spanish word for a medical term — and the best way to convey complex or uncomfortable information to people from a variety of different cultures — has made a difference for patients who she said are often thrilled to have her in the room, Rivera said.

"They leave feeling like they got their questions answered," she said.

Last weekend, the students in the interpreter program went to the St. Vincent de Paul soup kitchen in Norwich to fulfill the final requirement before they got their certification: putting what they had learned into practice.

Volunteer doctors, University of Connecticut medical and dental students and Three Rivers Community College nursing students were seeing patients at a free clinic there, evaluating them and giving references as needed.

Megan Fahey, a senior at Connecticut College, sat with a man at the clinic who has Type 2 diabetes. The man spoke nearly fluent English but his wife did not, so Fahey, armed with a paper reminder of the Spanish words for phrases like "vital signs," "ache" and "acute," translated information about her husband’s blood pressure and glucose levels and relayed it to her.

Fahey, who is majoring in biology and Spanish, said she plans to go to medical school after graduating. She sought out the medical interpreter program so she can one day communicate precisely with her Spanish-speaking patients, an ability she said could make or break a patient’s health.

"If you don’t understand the finer details of things, it can (affect) the level of health care," she said.

Fahey followed Rachel Shafer, a Three Rivers Community College nursing student, downstairs, where a crowd had gathered for St. Vincent de Paul’s Saturday lunch and where a woman wanted an appointment at the clinic but was still waiting in line. They sat with her at a table in the crowded room and Fahey joked with the woman as Shafer took the her blood pressure, then translated the numbers Shafer read to her.

Fahey said she also learned to be fluent in the cultural differences between a doctor and patient’s ideas about health care.

A Mexican patient may put faith in la limpia, for example — a ritual egg cleanse used in traditional medicine — before deciding to try pharmaceutical medicine, Fahey said. It’s the interpreter’s job to explain that to the nurse or doctor and, in turn, interpret the medical professional’s advice.

"Your main priority is to be the liaison for the patient," she said.

Edith Ouellet, the director of the Three Rivers nursing program, said at the St. Vincent de Paul clinic that in-person interpretation can help doctors and nurses feel more confident that their instructions and diagnoses are understood. The phone-based interpreter service can work well, she said, but having an interpreter in the room lowers the risk of a misunderstanding.

"The body language is huge," she said. "Did they finish talking? Did they actually say what I just said?" (If) we don’t understand or communicate with that patient, then we can’t close that loop."

m.shanahan@theday.com