The two-year-old Latina girl arrived at a Massachusetts emergency room in 1999 with intense shoulder pain. “Se pegó, se pegó,” her Spanish-speaking mother cried.
To the attending resident, the phrase sounded like “she was hit,” as in, she was struck by another person. X-rays revealed a fractured collarbone. Then the physician saw discharge papers from a previous hospital admission, which indicated the girl had broken her collarbone just two months earlier. Suspecting child abuse, the hospital contacted the Department of Social Services (DSS).
After questioning the family without an interpreter, the DSS caseworker concluded that the child was not safe at home. The little girl and her four-year-old brother were taken from their mother on the spot and placed in DSS custody. Two hours later, the team interviewed the mother with the help of a trained Spanish interpreter and discovered that the child fell off her tricycle and accidentally struck her shoulder. After several days of red tape, the mother regained custody of her children.
This young girl's story is just one example of a growing problem across the United States, as the national health care system has struggled to adapt to the growing number of people who do not speak English as their primary language. According to U.S. Census data released earlier this month, over 63 million Americans speak a language other than English at home, and over 25 million self-identify as having limited English proficiency.
Rampant miscommunication compromises patient safety and quality of care while widening existing health disparities. Some technological solutions are on the rise, from videoconferencing sessions with interpreters to smartphone applications that act as digital translators, but these innovations have a ways to go before they can stand in for medically trained in-person aid.
“Good communication is essential for every medical encounter, whether you are talking about a visit for a rash or someone who is in the ICU,” says Glenn Flores, the distinguished chair of health policy research at the Medica Research Institute in Minneapolis.
“We know from extensive literature that language barriers affect access to care, health status, use of health services, patient/physician communication, satisfaction with care, quality and safety—it really spans the spectrum in terms of the impact,” he says.
Unbeknownst to many patients and physicians, individuals with limited English proficiency have been guaranteed language services under federal law for decades. Title VI of the Civil Rights Act of 1964 prevents discrimination based on race, color, religion, sex or national origin by any organization receiving federal funding. And in Lau v. Nicols (1974), the Supreme Court set the precedent that language can be used as a proxy for national origin, specifically saying that schoolchildren who do not speak English as a first language must be given equal educational opportunities.
Because virtually all healthcare providers accept Medicare, Medicaid or some other form of federal funding, the rulings imply that providers cannot discriminate based on language and must supply an interpreter for limited English proficiency patients. These rights were reaffirmed in 2000, when President Bill Clinton issued an executive order that reiterated the requirements of Title VI and outlined expectations for healthcare providers.
“If you have someone who is limited English proficient who comes in for services, you need to ensure that they have meaningful access to your programs,” says Mara Youdelman, managing attorney at the National Health Law Program in Washington, D.C. “You can’t turn them away because they don’t speak English. You can’t say, 'Come back next Wednesday when my bilingual staff person is here.' You can’t make them bring their own interpreters. These patients should have the same access as an English speaking patient does.”
The trouble is that Title VI did not come with associated funding. “There is no requirement that either the federal government or the state pay for the language services in the providers' offices,” says Youdelman.
Only 13 states and Washington, D.C. have elected to specifically reimburse the costs of medical interpreters through Medicaid. The remaining states—including those with the largest non-English speaking populations, such as California and Florida—argue that the costs of language services are factored into existing reimbursement rates. As a result, providers who are responsible for a higher percentage of the limited English proficiency population are forced to bear the costs of supplying interpreters on their own, which cuts into operating costs and puts the communities they serve at a disadvantage, Youdelman adds.
Meanwhile, Medicare and many private insurers refuse to pay for interpreters, despite the efforts of many policymakers to get Medicare reimbursement in the Affordable Care Act.
That was not the first time language issues had failed to get priority in health care policy. In 2000, the groundbreaking report “To Err is Human” highlighted many patient safety issues resulting from physician errors. But it failed to include language barriers as a significant threat to patient safety, despite the thousands of language-related cases that have been filed with the Department of Health and Human Services.
Without loud and clear announcements of the law, many health care providers remain unaware of their responsibilities, and enforcement of Title VI has been difficult.
“The way this is currently enforced is through administrative complaints,” says Youdelman. “So if a patient thinks that he or she was discriminated against, they can file a complaint with the Office for Civil Rights at the Department of Health and Human Services.” But many of these individuals are likely to be unaware of their rights, or they might erroneously think that filing a complaint could affect their immigration status, says Youdelman. As a result, many remain silent.
If an incident is reported and the provider is found to be intentionally or unintentionally discriminating against someone, the consequences are rather feeble. Generally, the provider and the Office for Civil Rights simply come to an agreement as to what processes need to be fixed and what policies need to be implemented. In theory, the government could punish offenders by withdrawing federal funding, but that has never happened.
“There are two ways to get healthcare providers to follow the mandates,” says Francesca Gany, director of the Center for Immigrant Health and Cancer Disparities at Memorial Sloan Kettering Cancer Center. “One is to provide incentives to adhere, and the other is punishment if they don’t. And neither of those, the carrot or the stick, have seen much attention.”
Even in hospitals that have implemented language interpretation programs, many doctors elect to use their own skills or an ad hoc interpreter to save time. “Doctors often don’t call interpreters when they need to,” says Gany. “Given the time constraints that providers are under, if it takes one extra iota of time to use an interpreter, they will try and get by with their own rudimentary language skills.”
Being bilingual only gets you so far, says Youdelman. “Not many people who had high school or college language training or studied abroad would be able to translate specialized medical terminology like describing cancer treatment options. So there is definitely an overconfidence many providers have about their language skills.”
Part of the problem comes from a culture in medicine that says doctors should always have the answers, notes Wilma Alvarado-Little, a medical interpreter and former co-chair of the Board of the National Council on Interpreting in Health Care. “When physicians are constantly being put in situations where they need to know, saying 'I don't know' really isn’t the ideal response,” she says.
To assess physician language skills, Alvarado-Little often asks a series of pertinent questions: Who can respond to basic commands, who can navigate, who can joke in the language?
“But the last question, if they feel they are at the level that they can interpret, is ‘Do you feel your language skill can hold up in a court of law?’” she says. “Many people don’t realize that interpreters become part of the medical chart, which is a legal document. And so the communication has to be spot on.”
Having interpreters who are trained specifically for clinical settings is extremely important. In 2012, Flores led a study in emergency departments investigating the use of professional interpreters, untrained ad hoc interpreters or no interpreters. The study found that the use of trained interpreters resulted in 10 percent fewer errors with potential medical consequences than using untrained interpreters, and that using untrained interpreters could be just as dangerous as using no interpreters.
“When limited English proficiency patients do not have professional medical interpreters or bilingual providers available, they have to resort to the use of ad hoc interpreters, which are family members, friends, people from the waiting room or strangers pulled from the street,” says Flores. This can introduce a host of biases, such as when a family member withholds information to try and protect a loved one, or when a speaker uses slang or idioms unique to their country.
Such errors can lead to misdiagnoses, unnecessary tests and misinformed treatments that put a patient's health at risk.
In another high-profile case, a Florida teenager felt unwell while attending a high school sporting event. Before collapsing, he told his girlfriend, “Me siento intoxicado.” When the paramedics came, the girlfriend, who spoke limited English, repeated intoxicado, which the paramedics, who spoke minimal Spanish, interpreted as “intoxicated.”
They brought the teenager to the emergency room, where he was treated for drug abuse. But after the boy spent 48 hours in a coma, the hospital staff ordered a CT scan, which revealed that the teenager’s head had flooded with blood. It turns out that feeling intoxicado can also mean “sick to the stomach,” which is a symptom of a brain aneurysm. This communication breakdown led to a $71-million-dollar malpractice lawsuit.
So what can be done? Many experts believe that every aspect of the health care process—from initial appointment bookings to treatment protocols—needs to be reappraised to accommodate the language needs of the local population.
For example, a survey of pharmacies revealed that only half of them were able to print their prescriptions in a language other than English, while another study showed that limited English proficiency families were fundamentally unable to use hospital signage to navigate from the parking lot to the emergency department.
Advocates are calling for hospitals and other health care providers to begin routinely collecting data on the primary languages spoken by their patients and whether they have limited English proficiency, so that providers can be prepared with appropriate language services.
Hospitals could also screen doctors and nurses for non-English language skills to determine whether they are qualified to use those abilities in clinical interactions, and they should provide pay raises for suitably bilingual clinicians. “It is important to change the culture of the institution so that it is no longer OK for care providers to get by with rudimentary language skills,” adds Gany.
In the meantime, hospitals are beginning to use a variety of cost-effective technologies that can serve as alternatives to in-person interpretation.
“The technology is out there to connect well-trained interpreters with doctors, even if they are not in the same room,” says Gany. Many companies offer phone interpretation services, where you can pay for remote access to speakers of hundreds of languages.
In one popular option called remote simultaneous medical interpreting, the clinician and patient each use a headset that is connected to an interpreter at a remote location. This approach, modeled after the UN interpreting system, allows for fast, reliable communication in a variety of languages.
“More and more hospitals are starting to use these services. It is better than it used to be, but it is still not nearly enough,” says Gany.
Phone interpreters are sometimes limited because they cannot see non-verbal cues, so some care providers have also begun to incorporate videoconferencing with interpreters via tablets, laptops and smartphones—although these services can be expensive.
Other companies have engineered smartphone translation and interpretation applications that are specialized in common health care phrases and nomenclature. But such technologies are not perfect, and many physicians remain skeptical.
“Google Translate, Canopy and some of those phone apps are really dangerous, and they even have a disclaimer that they should not be used for safety-critical tasks,” says Flores. For instance, Google Translate says that me siento intoxicado means "I feel intoxicated" and so would not have been much help to the paramedics in the Florida case.
Flores believes that a smartphone application could be developed that adequately serves as a reliable interpreter, but this is a long way off. He would instead prefer to see basic—and affordable—change come from state policy makers and hospital executives.
A 2002 report from the Office of Management and Budget found that it would cost an additional $4.04 per visit to provide all limited English proficiency patients in the U.S. with the appropriate language services. And states could be reimbursed for over 50 percent of these Medicaid costs through the Federal Medical Assistance Percentages program.
Without such actions, though, millions of Americans will remain lost in translation.
“I have seen what happens before and after we have implemented interpreter services," says Gany. “Patients are so grateful that they jump up and give you a hug, because it is the first time that they have felt understood in a doctor’s office. And doctors have shared with me that it was the first time that they were able to diagnose depression in a patient or find out about their past history. It makes a huge difference.”