Language Justice: Stop Using the Clerk as an Interpreter

Author: Shane Solger, MD

Editor: Nicole Anthony, MD

When patients come to us for help, they put themselves in a position of vulnerability. They need something from us that they cannot provide for themselves. 

If a person with limited English proficiency (LEP) comes into the ED, they are disempowered for an additional reason: they cannot communicate to us in the language they use to joke, argue, or express love. Our LEP patients are tasked with telling their story to an iPad or iPhone app, with a small, unfamiliar face on the screen, or they may find themselves with a phone speaker shoved near their ear, straining to hear over the beeping and bustle of the ED. They may be asked to speak to a staff member without interpretation training, or they may turn to their family member, who, in addition to being marginalized as a first or second-generation immigrant with a sick or injured relative, must now act as the free interpreter service. 

A large body of evidence paints the picture of a healthcare system that does not use interpreters as frequently as it should.[2,4,8,10,13,19] But, we don’t need RCTs or observational studies to be convinced. Many of us see it firsthand in the hospital nearly every day. 

Neither we nor our hospital administrators should be surprised by the need for interpreter services given that when asked how well they would rate their English in the 2013 census, 25 percent of Kings County residents responded “less than very well.”[3] Our Arabic-, Haitian Creole-, Spanish-, or Bengali-speaking patients who visit Kings County Hospital are coming from communities where 50 percent or more do not feel comfortable speaking English – a number which is likely an underestimate, including among only those willing to fill out the census. [3,11]

I have seen nurses hand LEP patients cups filled with pills and tell them both the name and indication solely in English. I have watched a surgery resident try to obtain consent from an elderly Haitian patient in English despite her request for an interpreter. Although her English was very good, it was not adequate to discuss the nuances of surgery. After telling the resident he was obligated to use an interpreter, the resident protested that “the patient can speak English!”

One of our own, Dr. Allen, wrote about the communication challenges his wife faced during childbirth vis-à-vis a hospital’s poor infrastructure and training surrounding language accommodations.[1] He made the poignant observation that even their medical training didn’t save them from the confusion and frustration of not being able to communicate, noting how those feelings must be magnified for someone outside of the medical profession.

The kicker is that qualified interpreter use is required by law and has been for nearly 60 years. New York State has 76 statutes and regulations surrounding language needs in healthcare.[12,16,17,20]

Interpreter use is ingrained in our professional ethos and has been integrated into most medical school curricula.[9] We know it is the right thing to do. It is even reflected in the mandatory training we complete for credentialing:

Start by stopping the use of ad hoc interpreters

Stop using any nearby warm body that speaks the same language as your patient to interpret. A patient’s son at the bedside or the clerk that knows Creole will seem like the convenient option when you start doing the “time math” in your head. You know “time math”… like:

• -It will take 10 minutes between the time you pick up your phone and the time that the interpreter introduces themselves to the patient. 
• -There’s an additional 3-5 minutes added each time the call drops and you have to reconnect. 
• -Add on an extra 5-10 minutes for all the times that the interpreter, yourself, or the patient needs to repeat themselves because of the background noise in the ED.
• -If using the video-interpreter, add on 2-4 minutes to hunt down an iPad (as long as you find it on the first lap around the department).

I have been guilty of running these equations as are most residents, however, when using “time” as a variable for properly communicating with an LEP patient, you’re more likely to do harm than good.[4]

Ad hoc interpreters have been found to make twice as many errors as qualified medical interpreters, errors that may fundamentally change the physician’s understanding of their patient’s symptoms with devastating downstream clinical consequences.[14,15] An ad hoc interpreter’s lack of professional training makes their interpretations unreliable as cultural nuances may go unrecognized. Further, ad hoc interpreters are not neutral parties and are not guaranteed to translate everything to your patient.[5,6,7,14,15] One might imagine a situation whereby an elderly LEP patient does not want invasive interventions such as central lines, intubations, or surgery, but their child may find it hard to accept their parent’s decision to withhold care. One might also understand that a patient may not be especially truthful about sensitive topics (such as sex or infidelity) when their children are interpreting for them. 

When translations were analyzed for accuracy, studies have found that ad hoc interpreters often times omitted important information, substituted words, added words, or were simply inaccurate with their translations (e.g. providing incorrect dosage frequency for medications).[15] LEP patients are at an intrinsically higher risk of adverse events related to their language barrier; by using a lower quality of interpretation, you are only adding to the likelihood of a mistake.[7]

Finally, disregarding the use of professional interpreters makes us vulnerable to lawsuits. In one review of 35 cases that occurred over a four-year period, malpractice cases involving inappropriate interpreter use have cost insurance providers, hospitals, and doctors more than $5,000,000. This does not compare to the life and limb lost and children in some instances, due to avoidable errors in communication.[18]

On your next shift

You can find steps that you can take on your next shift to actively improve the care of our LEP patients. (This is written from the standpoint of working at an institution where there are zero qualified interpreters on staff):

• 1) Avoid using ad hoc interpreters. Use your smartphone or video tablet to get a professional medical interpreter. 
• 2) Intervene when you hear a colleague or a consultant attempting to use unqualified staff members for LEP interpretations. Our patients’ safety outweighs the convenience of an ad hoc interpreter.
• 3) When feasible, keep the video interpreting devices near your LEP patients to be a physical reminder that they need an interpreter. 
• 4) Ask your patients if they need an interpreter at any sign that they might be uneasy answering questions or understanding medical lingo in English, irrespective of what Epic says. You can change their language preference in Epic (I certainly have) as it is frequently entered as English by default.
• 5) Report instances of unsafe care related to interpretation and failures of our smartphone/video-tablet devices.

Communicating in a language you understand regarding your healthcare is a right guaranteed by our Federal and State governments, and we need to hold ourselves, our colleagues, and our institutions accountable for ensuring our patients’ civil liberties are not infringed upon.

For Reference:

Total Persons from Each Population Stating They Speak English “Less than very well” [3]

References:

1. 1. Allen R. Communication During the COVID Pandemic: Unmasking the Problem. Blog.clinicalmonster.com. http://blog.clinicalmonster.com/2022/01/20/communication-during-the-covid-pandemic-unmasking-the-problem/. Published January 20, 2022. 
2. 2. Baker DW, Pitkin K, Coates WC, Williams MV, Parker RM. Use and effectiveness of interpreters in an emergency department. JAMA: The Journal of the American Medical Association. 1996;275(10):783. doi:10.1001/jama.1996.03530340047028 
3. 3. Bureau USC. Detailed languages spoken at home and ability to speak English for the population 5 years and over: 2009-2013. Census.gov. https://www.census.gov/data/tables/2013/demo/2009-2013-lang-tables.html. Published December 16, 2021. 
4. 4. Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: Underuse of interpreters by resident physicians. Journal of General Internal Medicine. 2008;24(2):256-262. doi:10.1007/s11606-008-0875-7 
5. 5. Elderkin-Thompson V, Cohen Silver R, Waitzkin H. When nurses double as interpreters: A study of Spanish-speaking patients in a US primary care setting. Social Science & Medicine. 2001;52(9):1343-1358. doi:10.1016/s0277-9536(00)00234-3 
6. 6. Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111(1):6-14. doi:10.1542/peds.111.1.6 
7. 7. George Washington University School of Public Health & Health Services Center for Health Policy Research. Speaking together toolkit. Speaking Together Toolkit. https://www.rwjf.org/en/library/research/2008/06/speaking-together-toolkit0.html. Published June 6, 2008. 
8. 8. Ginde AA, Sullivan AF, Corel B, Caceres JA, Camargo CA. Reevaluation of the effect of mandatory interpreter legislation on use of professional interpreters for ED patients with language barriers. Patient Education and Counseling. 2010;81(2):204-206. doi:10.1016/j.pec.2010.01.023 
9. 9. Himmelstein J, Wright WS, Wiederman MW. U.S. medical school curricula on working with medical interpreters and/or patients with limited English proficiency. Advances in Medical Education and Practice. 2018;Volume 9:729-733. doi:10.2147/amep.s176028 
10. 10. Lee KC, Winickoff JP, Kim MK, et al. Resident physicians’ use of professional and nonprofessional interpreters: A national survey. JAMA. 2006;296(9):1049. doi:10.1001/jama.296.9.1050 
11. 11. Lehman Held M. Why undocumented immigrants still fear the 2020 census. The Conversation. https://theconversation.com/why-undocumented-immigrants-still-fear-the-2020-census-132842. Published July 20, 2020. 
12. 12. Limited English proficiency (LEP). HHS.gov. https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/index.html. Published August 10, 2021. 
13. 13. Lion KC, Gritton J, Scannell J, et al. Patterns and predictors of professional interpreter use in the Pediatric Emergency Department. Pediatrics. 2021;147(2). doi:10.1542/peds.2019-3312 
14. 14. Moreno MR, Otero-Sabogal R, Newman J. Assessing dual-role staff-interpreter linguistic competency in an Integrated Healthcare System. Journal of General Internal Medicine. 2007;22(S2):331-335. doi:10.1007/s11606-007-0344-8 
15. 15. Nápoles AM, Santoyo-Olsson J, Karliner LS, Gregorich SE, Pérez-Stable EJ. Inaccurate language interpretation and its clinical significance in the medical encounters of Spanish-speaking Latinos. Medical Care. 2015;53(11):940-947. doi:10.1097/mlr.0000000000000422 
16. 16.Office of the Secretary. Vol 45. No. 244 ed. Washington, D.C.: Office of the Federal Register, National Archives and Records Service, General Services Administration; :82972-82973. https://tile.loc.gov/storage-services/service/ll/fedreg/fr045/fr045244/fr045244.pdf. 
17. 17. Office of the Secretary. Vol 91. No. 96 ed. Washington, D.C.: Office of the Federal Register, National Archives and Records Service, General Services Administration; https://www.govinfo.gov/content/pkg/FR-2016-05-18/pdf/2016-11458.pdf
18. 18. Quan K. National Health Law Program; 2013. https://healthlaw.org/resource/the-high-costs-of-language-barriers-in-medical-malpractice/. 
19. 19. Tsuruta H, Karim D, Sawada T, Mori R. Trained medical interpreters in a face-to-face clinical setting for patients with low proficiency in the local language. Cochrane Database of Systematic Reviews. 2013. doi:10.1002/14651858.cd010421 
20. 20. Youdelman M. Summary of state law requirements addressing language needs in health care. National Health Law Program. https://healthlaw.org/resource/summary-of-state-law-requirements-addressing-language-needs-in-health-care-2/#:~:text=For%20the%20purposes%20of%20health,LEP%20individual%20to%20ensure%20access. Published August 11, 2021.

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