“So, how are we doing today?” Dr. N walked into the exam room and sat on her stool as the accompanying registered nurse followed her and shut the door.
The nurse waited for the patient to finish speaking in Japanese, then turned back to the physician. “The patient said she’s experiencing chest pain.”
“Okay, let’s see what we can do.” Dr. N began a full body examination on the patient, lightly pressing into different areas of the patient’s chest and abdomen. When she reached the lower right area of the abdomen, the patient winced and recoiled.
“Ma’am, this is not your chest,” the physician said, pointing to the area she was examining. “Why did you say that you were having chest pain?” The patient turned back to the nurse with a puzzled expression. The patient was treated for appendicitis later that day.
Language and communication are important elements of healthcare that are often overlooked. Physicians who encounter language barriers when treating their patients should make better use of trained health care providers, but several obstacles stand in the way. Extra costs to the provider and patient, as well as administrative issues in organizing interpreter services, are the most common reasons that many medical practices fail to fully utilize these services (Brandl et al., 2019). Considering the reported high demand for medical interpreters, interpreter agencies and services should be made more accessible to address linguistic and cultural barriers between providers and non-native patient populations.
Despite the need presented by immigrant and multilingual patient populations, physicians do not use professional interpreting services enough in their standard care plans. As globalization has caused populations across the world to become increasingly interconnected, it is imperative that those seeking healthcare in countries foreign to them are accommodated with regard to their language. Misinterpretation and limited communication could have detrimental outcomes for the patient and physician. For example, an article discussing the use of medical interpreters in American outpatient practices found that one out of forty medical malpractice lawsuits were at least partly related to lack of proper medical interpreter services (Jacobs et al., 2018). Had the right personnel been present to facilitate discussions between the provider and patient, clinical mistakes would have been better resolved or may not have occurred at all. So why are physicians not making better use of the medical interpretation services in their practices?
In an online cross-sectional questionnaire-based study, 599 primary care physicians were asked to identify the main barriers obstructing them from using interpreter services in their practice (Jaeger et al, 2019). The main barriers identified were (1) absent or limited financial coverage, (2) organization of interpreter services and (3) a lack of knowledge on how to arrange interpreter services.
With these barriers present, it is not surprising that physicians fail to incorporate more interpreter services into their practice. Physicians often have crammed schedules that leave little time for organizing these services or lengthening the time of visits to accommodate for interpretation. Furthermore, patients who are treated in trauma centers or emergency rooms often do not have the time to wait for an interpreter to be requested. The previously discussed study shows that doctors recognize that these barriers exist and that they require addressing, but there still remains a significant gap between understanding and taking action.
Current policies and pilot initiatives to improve access to medical interpretation in the United States healthcare system have either been unsuccessful or only temporarily beneficial in providing patients and physicians with services as needed (Jaeger et al., 2019). The lack of nationwide provisions is partly due to the large state-to-state variations in policies and how funds and administrative assistance for these services are chosen to be distributed, if that. As of 2018, only fourteen states and the District of Columbia had policies in place to reimburse medical practices that used interpreter services for patients who used federally-funded insurance (Jacobs et al.,2018). These policies are a step in the right direction, but are available in less than 30% of the states and limited to patients who are enrolled in Medicare or CHIP programs.
One of these fourteen states is Kansas, which was the focus of research conducted by Showstack et al. in 2019 to look at the state’s policies and support for medical interpretation services, given its rapidly growing Latino population. Despite financial coverage and reimbursement for providers, the reviewed policies did not list any competency requirements for the interpreters that are provided, leaving interpreter agencies to make their own guidelines. In order to be of great benefit to the patients and physicians, states must provide interpreters that are fully competent in medical terminology and also aware of cultural differences between patient and provider.
To improve relationships between patients, interpreters, and physicians, it is imperative that translator diversity, access to interpreters, and holistic training for both physicians and interpreters increase. Making these revisions to the current medical interpreter system would positively impact non-native patients’ treatment and health outcomes. A review that examined the different outcomes of using trained medical interpreters found that a majority of studies showed an improvement in care and that additional costs are minimal compared to other healthcare expenses (Brandl et al., 2019). Patients whose care was enhanced by proper medical interpretation made fewer future trips to emergency rooms and long-term costs for the patient were reduced. To have these outcomes be true for all patient populations, increased government funding and insurance reimbursement for training interpreters should be better implemented into the healthcare system.
In order to gain a better sense of how medical interpretation works and the implications it can have today, we interviewed Dr. N, an internist with over 25 years of experience. During the interview, Dr. N explained that she now often turns to Google Translate in her practice, since her nurse-interpreter was transferred from her private practice to the main hospital. Although the hospital she works for provides trained medical interpreters, Dr. N prefers the ease of using this software and the endless selections of languages, which meets the needs of her diverse patient population. Google Translate is the most accessible form of language translation since it is available on the internet, in hundreds of languages. If this and equivalent online translators were utilized in medical settings, there would be no need to hire and train interpreters in multiple languages. Furthermore, the cited financial barriers and funding issues would be eliminated since the software is free.
Similar to Dr. N, many physicians began turning to Google Translate when trying to deliver care in the presence of communication barriers. An algorithm update in 2017 to Google Translate proved to be promising as instructions for patients after emergency department visits were 92% accurate when translated to Spanish and 81% accurate when translated to Chinese (Khoong et al., 2019). As long as sentences and instructions between the patient and provider are kept simple, there should be minimal issues in the translation program and clinically significant errors can be avoided (Miller, 2018).
Despite technological advancements, Google Translate’s accuracy continues to be questioned. Miller et al. found that Google Translate is accurate about 9 out of 10 times in a medical setting, but that 10% of situations where mistakes occurred would be otherwise avoidable and at the expense of the patient (2018). Moreover, medical care cannot always be delivered in a few short sentences. Explaining complicated topics such as cancer diagnoses, therapy regimens, or medication names would not align with the simple-sentence model expected to be followed when using Google Translate. Words and phrases may not translate accurately, leading to further inaccuracies in the care delivered to the patient or the issues communicated to the physician. In these scenarios, physicians would have to use a medical interpreter or use other methods to communicate, such as writing instructions out or using pictures to describe treatment plans. Even studies as recent as 2019, which account for the aforementioned 2017 software update, recommend that Google Translate be used as a supplement to traditional medical interpretation and a warning about inaccurate translations be provided (Khoong et al., 2019).
Translation software may be convenient and free, but it is also missing one of the most important elements of medicine: human connection. Dr. N frequently cited the importance of making patients feel comfortable and heard, despite language and cultural barriers that may be present. In fact, she stated “[as long as] you make them feel comfortable and relaxed, somehow you can communicate with them.”
Medical interpreters serve a crucial role in the healthcare system by bridging language and cultural gaps between patients and providers. Software programs could translate a doctor’s instructions verbatim, but doing so would lose the personalization required to communicate emergencies and instructions and empathize with the patient. Unlike trained interpreters, Google Translate and similar technologies do not see puzzled expressions, hear the pain in people’s voices, or ask if there are any more questions.
The medical and healthcare industries must work to create a space with palpable, comfortable forms of communication for patients who are non-native speakers. Whether it be through providing more funding for training and employing interpreters or starting programs similar to those of translating softwares, properly understanding the needs of a patient is a start to reaping more fruitful connections between the patient and physician, creating better interactions and outcomes for both groups of people.
Andreae, M. H., White, R. S., Chen, K. Y., Nair, S., Hall, C., Shaparin, N. (2017). The Effect of Initiatives to Overcome Language Barriers and Improve Attendance: A Cross- Sectional Analysis of Adherence in an Inner City Chronic Pain Clinic. Pain Medicine, 18(2), 265–274.
Jacobs, E.A., Shepard, D. S., Suaya, J. A., and Stone E. (2004). Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. American Journal of Public Health. 94, 866–869.
Jaeger, F.N., Pellaud, N., Laville, B. et al. (2019). Barriers to and solutions for addressing insufficient professional interpreter use in primary healthcare. BMC Health Serv Res, 19, 753.
Miller, J. M., Harvey, E. M., Bedrick, S., Mohan, P., Calhoun, E. (2018). Simple Patient Care Instructions Translate Best: Safety Guidelines for Physician Use of Google Translate. MDedge Journal of Clinical Outcomes Management, 25, 1.
Showstack RE, Guzman K, Chesser AK, Woods NK. (2019). Improving Latino Health Equity Through Spanish Language Interpreter Advocacy in Kansas. Hispanic Health Care International, 17(1), 18–22.