Too often, language and cultural barriers prevent diverse immigrant patients from receiving the quality treatment they deserve. Hospitals frequently fail to provide basic translation services that are efficient and culturally complementary for immigrant patients or fail to train health care professionals on how to incorporate these services into treatments. This lack of proper care for immigrant patients is a discriminatory, biomedical issue that robs them of their voice and rights.
Imagine: It’s 1 a.m. on Monday morning. Workstations in the ED are peaceful. Patients who’ve been treated rest comfortably on stretchers while nurses review files, check emails, and chat about their weekend. Suddenly, a monitor flatlines, followed by a high-pitched “beeeeeeeeeee” sound. Spines straighten and everyone rushes toward a 42-year-old Odia-speaking patient. Doors fly open and the doctor rushes toward the unconscious patient.
“Can you hear me?” asked the nurse gently.
The entire team crowds around to assess his condition.
“He’s nonverbal and has a slow breath.”
The tapping continues and the patient starts coughing several seconds later.
“He doesn’t speak English, the chart shows,” exclaimed the nurse.
“Sir, are you OK?” asked the physician. “Where is the translator?!”
The physician raises his voice in frustration as the patient tries to regain his breath. After a few seconds, the monitor and sounds return to “stable.” The moment of terror passes, but how do we placate a patient’s fears and explain the situation without a medical translator? How do we include them in their own treatment plan if they can’t even understand what’s going on?
In the U.S., over 46 million people primarily speak a language other than English. Studies show that patients with limited English proficiency are less likely to receive preventive care and are at higher risk of experiencing medical errors. In 2012, recordings from EDs in Massachusetts revealed thousands of professional interpreters’ mistakes, including word omissions, adding personal perspectives, or using phrases that didn’t exist in the patient’s language. Of these incidents, 18 percent had potential clinical consequences, such as mistaking teaspoons for tablespoons in medication.
Expanded training for interpreters in both health care and culture will greatly affect the patient’s overall health. Interpreters should expand their training from analyzing morbidity and mortality to include psychological and social factors, such as housing and working conditions. It is essential for the interpreters to attend to patients’ mental, emotional, social, and spiritual states and relay that information to the health care providers. Interpreters must respect the patient’s cultural uniqueness and regard them as active and responsible partners in, rather than recipients of, their health care. Bridging the gap in (mis)communication requires expanded training for medical interpreters. Currently, national certification requires only 40 hours of training; raising the standard to at least 100 hours with supplemental training in medical terminology and cultural competency will ensure holistic care, greater knowledge, and effective communication between all parties.
Training in medical terminology should go above the required vocabulary skills to incorporate cultural awareness training to improve cultural competency and sensitivity. In addition to having a basic understanding of anatomy and physiology, medical interpreters should be able to relay accurate, culturally competent explanations to the patient. While Western cultures often use direct forms of communication, many cultures rely on indirect forms of communication—body language, tone of voice, and other interactive cues, which the interpreters should be cognizant of. As of now, the interpreters’ exam has two components: written and oral, which test for accuracy and fluidity in the target language. They focus on text and dialogue, and thus, rely on surface-level translation. The oral exam should be restructured to include role-playing scenarios with actors to include indirect forms of communication to test for cultural competency and non-verbal cues. For instance, the lack of eye-to-eye contact in Western cultures is often perceived negatively. As such, if a patient refuses to maintain eye contact, a physician may interpret the gesture as insecurity, lack of interest, embarrassment, or depression. Examining the same situation through a cultural lens creates a large difference. A Navajo patient prevents eye contact to prevent soul loss or theft. The only way to differentiate possible feelings of shyness, insecurity, and depression from purposeful gestures of respect and self-protection would be through the necessary cultural knowledge that should be instilled. Lack of understanding of cultural differences like this can create a cloud of mistrust on the end of the patient, potentially creating doubt and insecurity in medicine.
In addition to expanding the training level of the interpreter, there is a critical need for all health care facilities that serve the underserved to have access to these health care advocates. In 2016, the American Hospital Association surveyed approximately 4,500 hospitals and found that only 56 percent offered linguistic and translation programs. Hospitals must identify which languages are most commonly spoken in their communities so they can offer on-site interpreters to pick up culture-specific non-verbal cues as well as written services. Studies also show that over half of physicians can’t navigate interpretation services because they’ve never been trained. Going forward, all medical professionals—once employed—should undergo mandatory training workshops regarding hospital policies, procedures, and legal requirements surrounding interpretation. What use is improving interpretation services if health care workers don’t even know how to use them?
Of course, this bioethical issue is not one that’s easily remedied. However, adequate training for health care professionals and more rigorous, comprehensive training for interpreters is a step in the right direction toward providing competent care and advocating for patients. Translators can work together with health care advocates to educate families and help them navigate the health care system that can oftentimes be confusing. Together, these solutions will help create a more holistic approach to encompass the mental, emotional, and social aspects of culture that are often ignored. Language and cultural barriers further the gap between the patients and the providers—especially during the growing diverse populations in the United States. Therefore, translation services must be tailored to mitigate language and cultural barriers to accommodate the diverse population and to improve health care outcomes.
Asma Asghar is an incoming medical student.
