Language Justice: Demanding More From Our Institutions

Author: Shane Solger MD

Peer Editor: Nicole Anthony MD, Alec Feuerbach MD

As emergency physicians, we pride ourselves on being resourceful, but communicating with patients in a language they understand should not require the same “MacGyver” skillset as “creative ways to remove a foreign body from the ear.” As discussed previously, there are federal and state laws that guarantee qualified interpreter services for our Limited English Proficiency (LEP) patients, and ultimately, the available modalities and quality of our interpretation and translation services fall squarely on the shoulders of our hospital administrators. 

Below, we’ll delve into the evidence behind two responsibilities that hospitals owe both to our colleagues and our patients to ensure safe care: appropriate interpreter services and translated documentation.

Quality Care During the Visit: The Need for Access to Video and In-person Interpreter Services

Providers and patients prefer in-person and video interpretation to telephone interpreters.[1-4] In-person and video interpreters facilitate smoother and more efficient physical exams and they support culturally competent care as body language can be assessed in addition to spoken word.[3,4] These services have been shown to improve communication with patients relative to interpretation telephones, making it more likely for patients to understand their diagnoses and with fewer interruptions in interpretation services.[1,4]

The importance of quality, readily available video-interpreters was illustrated in my ED recently, as I was concluding an encounter with a Punjabi-speaking woman. When I asked her in which language she preferred the discharge instructions, she told me it didn’t matter because she didn’t know how to read. Ultimately, the interpreter was the only way for the patient to understand what transpired during our clinical interaction, and it served as the only way for her to know the reasons for returning.

Unfortunately, this encounter is not an outlier. My hospital in Brooklyn, NY serves a large Haitian immigrant population, a country with an adult literacy rate of ~61%.[5] In addition, we must contend with the fact that 33% of the Kings County population can only read simple text or are illiterate in English, and 65% of the community we serve is not considered proficient at reading.[6] Having our patients rely on a subpar interpretation and documents they cannot read is setting them up for failure. 

To investigate the benefits of improved access to video interpreters, one hospital added 165 video interpreter devices to areas such as the ED and found that it improved access of interpreters to their staff, decreased reliance on phone use, and reduced wait times for interpreter services. In addition, it allowed their in-person interpreters to be better utilized for more complex clinical interviews.[7]

When discussing the need for in-person interpreters, I often think about a Spanish-speaking family that brought their four-year-old daughter to the ED. She was bradycardic, cold, and clammy. Each side of her pediatric assessment triangle was compromised as we worked to treat the myocarditis that had caused her cardiopulmonary failure. Her case was scary, but we had a native Spanish-speaking attending with us that night. Suppose we had to communicate via a series of telephone calls each time we needed to clarify parts of the history or update her parents: the consequences of a dropped call or muffled interpretation could have been disastrous. Our attending could respond to the parents’ body language and interact with the patient and her family in a way that an interpreter from a tablet or a telephone could not. It was only by chance that we could meet the standards of the American Academy of Medical Colleges and the Robert Wood Johnson Foundation: in-person interpreters should be available for serious or complex cases.[8,9]

Quality Care After the Visit: The Need For Culturally Competent and Translated Discharge Materials

Discharging a patient is often one of the more fulfilling moments of the encounter. You’ve fixed them (or excluded an emergency condition), developed a plan, and now you’ll hand them written instructions on what to do next or when to return to the ED. But what happens when you try to print out the discharge paperwork for your patient and their language isn’t available? 

You can try to write it into Google Translate, but the accuracy may fall anywhere between 55% to 94% depending on the language you need. Some of these errors, especially if you misspell a word or your English grammar ain’t perfect, have the potential for harm.[10-12]  In one review, the authors discussed the potential for life-threatening harm using the example of the English instruction “hold the medication.” Google translates it into “keep the medication” in Spanish, and “keep taking the medication” in Chinese.[13] In another example, I copied and pasted chest pain discharge instructions from Haitian Creole into English, only to find that I was being warned regarding the symptoms of an “erotic dissection.”

Ultimately, you won’t know what is being translated for sure unless you’re proficient in reading and speaking your patient’s language. Using Chinese as an example, it would be important to clarify if your institution is providing discharge instructions that have been directly translated into Chinese, or are the available instructions actually written in Chinese with the phrases and idioms understood by the people who speak the language? Is your Chinese patient going to follow the discharge instructions and hold the medication that’s hurting them or keep taking it?

Each of these shortcomings in the provision of appropriate communication act as one more hole in your block of swiss-cheese, and this also may be why LEP patients are more likely to return to the ED within 72 hours of discharge.[14]

Quality Care for the Future: The Need For Change and a Pathway Forward

We have established that equitable and quality care for our LEP patients involves the use of in-person interpreters and video-interpreters. We know that Google Translate has the potential for harm and that our institutions need to invest in culturally competent discharge instructions. 

So what now?

Maybe your shop doesn’t cater to a large LEP population, and it would be impractical to have an in-person interpreter on staff 24/7 to cater to a once-in-a-blue-moon phenomenon. For others in more urban practice settings where 94% of the population has LEP, these stories and limitations in services may resonate with you, and the services available to you may not have improved or expanded to keep up with the growing number of LEP patients in your community.[15] 

Below we’ll discuss tangible steps to improve interpreter and translation services in your emergency department:

1. 1) Speak with others and build a coalition of like-minded residents and faculty who are concerned about interpreter access. 
2. 2) Find out who handles interpretation services or patient relations at your hospital. They may have attempted to fix this in the past, may be non-clinicians that need guidance on how best to help your patients, may be unaware of the issues faced by our patients, or may be apathetic to the needs of this population. 
3. 3) Your hospital may have a language access committee that can report ongoing projects for you get a feel for the momentum to get better language services for your patients.
4. 4) If correctly translated documentation is an issue, you may have an informatics officer to help provide those services to your patients through your EMR vendor. This individual may also be able to provide insight into barriers they are facing to give patients appropriately translated documents.
5. 5) Continue to climb the ladder. Keep going above people’s heads. If the director of patient relations or the hospital committee on language access is not responsive to your patient’s needs, then speak with your hospital’s Chief Medical Officer. If she cannot assist you, your hospital has a Chief Executive Officer. These individuals are ultimately accountable for ensuring the civil rights of your LEP patients.
6. 6) Engage with your local government. Your hospital serves your community, and the community elects your representatives. Your hospital district’s local City Councilmember or State Senator can be powerful allies when communicating with hospital administration, as they may be responsible for providing funds to your hospital. 
7. 7) Reach out to community groups and coalitions from the affected patient groups. They may also have relationships with your local representatives, and they can act as a way to obtain real patient stories about the harm that has been done due to poor interpretation access. 
8. 8) Engage with your State Department of Health. They are also vested in health equity for everyone in your State, including LEP patients. New York State has Language Access and Health Equity & Human Rights offices.[16,17] 
9. 9) Speak with other prominent medical groups that are affected by poor interpretation services: this may include groups from your hospital’s affiliate medical school (i.e., American Medical Student Association), resident unions that may represent multiple subspecialty groups (i.e., Committee of Interns and Residents), or nursing unions (i.e., New York State Nursing Association).
10. 10) Work towards creating a Language Justice-oriented culture within your residency. This may include lectures at your weekly conferences, M&M’s due to poor interpreter access, or journal clubs.[18] 

References Cited

[1] 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 

[2]Schulz TR, Leder K, Akinci I, Biggs BA. Improvements in patient care: videoconferencing to improve access to interpreters during clinical consultations for refugee and immigrant patients. Aust Health Rev. 2015;39(4):395-399.doi:10.1071/AH14124

[3]Locatis C, Williamson D, Gould-Kabler C, et al. Comparing in-person, video, and telephonic medical interpretation. J Gen Intern Med. 2010;25(4):345-350. doi:10.1007/s11606-009-1236-x

[4]Lion KC, Brown JC, Ebel BE, et al. Effect of Telephone vs Video Interpretation on Parent Comprehension, Communication, and Utilization in the Pediatric Emergency Department: A Randomized Clinical Trial. JAMA Pediatr. 2015;169(12):1117-1125. doi:10.1001/jamapediatrics.2015.2630

[5]Literacy rate, adult total (% of people ages 15 and above) – haiti (no date) Data. Available at: https://data.worldbank.org/indicator/SE.ADT.LITR.ZS?locations=HT

[6]U.S. PIAAC Skills Map (no date) National Center for Education Statistics (NCES) Home Page, a part of the U.S. Department of Education. Available at: https://nces.ed.gov/surveys/piaac/skillsmap/

[7] Marshall LC, Zaki A, Duarte M, et al. Promoting Effective Communication with Limited English Proficient Families: Implementation of Video Remote Interpreting as Part of a Comprehensive Language Services Program in a Children’s Hospital. Jt Comm J Qual Patient Saf. 2019;45(7):509-516. doi:10.1016/j.jcjq.2019.04.001

[8]Speaking Together Toolkit (2008) shorturl.at/bgitQ. Robert Wood Johnson Foundation. Available at: shorturl.at/bgitQ.

[9] Guidelines for use of Medical Interpreter Services – AAMC. https://www.aamc.org/media/24801/download.

[10]Taira BR, Kreger V, Orue A, Diamond LC. A Pragmatic Assessment of Google Translate for Emergency Department Instructions. J Gen Intern Med. 2021;36(11):3361-3365. doi:10.1007/s11606-021-06666-z

[11] Patil S, Davies P. Use of Google Translate in medical communication: evaluation of accuracy BMJ 2014;349 :g7392 doi:10.1136/bmj.g7392 https://www.bmj.com/content/349/bmj.g7392

[12] Patil S, Davies P. Use of Google Translate in medical communication: evaluation of accuracy. BMJ. 2014;349:g7392. Published 2014 Dec 15. doi:10.1136/bmj.g7392

[13] Khoong EC, Steinbrook E, Brown C, Fernandez A. Assessing the Use of Google Translate for Spanish and Chinese Translations of Emergency Department Discharge Instructions. JAMA Intern Med. 2019;179(4):580-582. doi:10.1001/jamainternmed.2018.7653

[14] Ngai KM, Grudzen CR, Lee R, Tong VY, Richardson LD, Fernandez A. The Association Between Limited English Proficiency and Unplanned Emergency Department Revisit Within 72 Hours. Ann Emerg Med. 2016;68(2):213-221. doi:10.1016/j.annemergmed.2016.02.042

[15] Jeanne Batalova Monica Whatley JB. Limited English proficient population of the United States in 2011. migrationpolicy.org. https://www.migrationpolicy.org/article/limited-english-proficient-population-united-states-2011#:~:text=The%20number%20of%20LEP%20individuals,residents%20in%20California%20was%20LEP. Published July 20, 2020.

[16] Department of Health. State Department of Health Announces Reorganization and Emphasis On Health Equity, Aging & Emergency Preparedness to Advance Public Health Protections In New York. https://www.health.ny.gov/press/releases/2022/2022-07-29_doh_reorganization.htm. Published July 29, 2022. Accessed April 16, 2023.

[17] Office of Language Access. Office of General Services. https://ogs.ny.gov/office-language-access. Accessed April 16, 2023.

[18] Desel T, Barrett E. Humility is One Case Away: Patient With Difficulty Accessing Care in His Native Language. University of New Mexico. https://vimeo.com/681692990.