Accompanied by her son, a 75-year-old Pakistani woman entered her new primary care physician’s office due to her son’s concerns of Alzheimer disease. The woman did not speak English, and, to the physician’s surprise, a translation service was not available in Urdu to complete a cognitive exam. Anxious about the health of his mother, the son offered to translate the encounter himself.
The examination was rocky from the start. When asked to spell the name “Mr. Johnson,” the son struggled to find a comparable phrase in Urdu. And, when assessing her memory, instead of asking his mother to recall the three words she was asked to remember, he said the words aloud himself and had her repeat. The physician, believing that too many questions were left unanswered or even inaccurate, prematurely concluded the examination and asked the patient to come back in two weeks when a trained interpreter would be available.
Regardless of insurance, employment or social status, language barriers are correlated with poor patient and provider satisfaction, quality of care and, in the case of Angelina Diaz-Ramirez, a California farm worker who unknowingly consented for the implantation of a pacemaker, a violation of medical ethics. In order to help limit this disparity, the U.S. Department of Health and Human Services (HHS) issued a revised National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. These revised guidelines included a 15-point outline to assist in providing “effective, equitable, understandable, and respectful quality care and services,” to all cultures and languages represented in the United States.
Trained interpreters are necessary, and the use of improvised or informal sign language, or family members as interpreters to “get by,” is not enough. As Alicia Fernandez, an expert in medical interpretation, laments, “’Getting by’ leads to mistakes, and mistakes can be tragic for both patient and the physician.” As a result, providers are now required to inform those with limited English proficiency or other communication barriers (e.g., deaf patients) of the availability and efficacy of language assistance services.
According to the 2011 census, 60 million Americans reported speaking a language other than English at home. Meanwhile, a 2013 survey of over 4,500 hospitals across the country found that only 69% of hospitals offered language services to their patients. Unfortunately, areas with the greatest need for translation services (poorer socioeconomic settings, areas of first generation immigrants, etc.) were often behind in the language services available to their patients — with some having long waits (in the hours) for a patient to be able to be accompanied by a translator.
The two most common forms of services are in-house translators or an outsourced telephone service, both of which have limitations. In an ideal world, there would be an in-house translator for every patient that needs the service — the translator would enter the room with the physician, inform the patient that they are a translator and that they will repeat the questions of the provider exactly and relay the patients back to the provider without altering the patient’s answers. The translator would speak slowly, maintain empathetic eye contact, build rapport, pause when appropriate and make the service seamless.
However, nowadays, having a trained, readily available translator for all languages and dialects is a rarity. Instead, medical offices often rely on an outsourced telephone service. While better than having no translator at all, this service removes the one-on-one experience between patient and provider. Furthermore, the system fails for more unusual languages. This has become a crisis in Fresno, CA, an area made of tens of thousands of migrant farmworkers, many of whom require interpreters knowledgeable in the over 68 indigenous languages and 364 linguistic variants spoken in Mexico.
If a provider cannot understand their patient, they are unable to treat them. Likewise, if a patient cannot understand their provider, how can they possibly adhere to their medical advice? “Getting by” is not enough; patients are entitled to someone who speaks their language, no matter how rare.
So what’s the fix? Prepare. Prior to their visit, patients must be asked if they need a translator and, if so, what language and dialect is needed. The appropriate steps must then be taken to ensure that a trained interpreter is ready either in person or by phone upon the patients arrival. Fortunately, the demand for trained interpreters is recognized. The U.S. Bureau of Labor Statistics anticipates the number of interpreters and translators to grow by 18% by 2026. Furthermore, programs like the Bridging the Gap are providing 40-hour courses that teach interpreters not just language but also “interpreter roles, ethics, medical terminology, culture and an overview of the U.S. healthcare system.”
Trained health care professionals must also be trained in the art of conducting an interview and medical examination with an interpreter. While it is important that we call a translator when needed; physicians should not forget the power of eye contact and appropriate touch in building rapport. After all, all of these factor into the trust that a patient develops and the ability to obtain a proper history and physical exam that may drastically change the outlook of a patient’s health. We should not just rely on translation services; we should still make the effort to talk to our patients.
I have experienced this firsthand from a patient of mine while volunteering at a local free clinic. While I do have some medical Spanish training, I needed a translator just in case there were questions that I was unable to answer; however, I made it a point to introduce myself as a student-doctor in Spanish, with a disclaimer that I am still learning Spanish and medicine, and used Spanish when appropriate. The results were favorable. After the visit, the patient disclosed to my translator how happy and impressed she was that I made the effort to speak to her in her language. To her, it felt like I cared. As providers, we should make the effort to try to fully listen and talk to our patients.