Medical Interpreters: Necessity, Not an Option

“I sometimes wish I could skip these dialysis sessions. I don’t even feel human here. They don’t smile at me or talk to me like they do with other patients”.

As this patient’s medical interpreter, I was jolted by her revelation. How alienated, devalued, and neglected must this elderly woman have felt at this dialysis center to even think about forgoing life-saving treatment for her end-stage renal disease? She further explained that she was often not provided with interpreter accommodation–­– interpreters were reserved only for “important” days, such as when a physician or nutritionist was visiting. How could “they”, the very same members of the care team who take sincere oaths of doing no harm, and medical center administrators, who proudly point to mission statements vouching to provide equitable care to all patients, not recognize the harm and distress they were bringing upon this patient?

Unfortunately, this is not an uncommon experience for patients with limited English proficiency (LEP). Gaining access to a trained medical interpreter is only the first obstacle to cross. The next barriers may present themselves in the exam room itself. Whether it is the indisputable expression of hurriedness (and maybe even annoyance) on the provider’s face at “how long” appointments with interpreters take, or the provider’s bias about the patient’s understanding abilities leading them to omit information that they would otherwise give to their English-speaking patients, receiving high-quality and dignified care as a patient with LEP is no simple task. It is no surprise then, that, patients with LEP experience multiple health disparities including reduced access to preventative services, poorer health outcomes, and decreased satisfaction with care [1].

In addition to the use of professional interpreters to address language barriers, patients with LEP may benefit from services centered around healthcare system navigation, cultural mediation and brokering, and care coordination. These needs for patients with LEP have not been just newly discovered. The stark disparities in care for patients with LEP have inspired the genesis of some state-of-the-art programs such as the Harborview Medical Center Community House Calls [2]. This program utilizes caseworker-cultural mediators (CCMs) to not only provide language interpretation, but also advocacy, navigation, and culturally-sensitive care management to improve the quality of care for immigrant and refugee patients, including LEP patients who speak Amharic, Cambodian, Somali, Spanish, or Vietnamese.

However, sincerely acknowledging these gaps in care and committing to devoting resources and revising institutional policies to optimize interpreter services for LEP patients has not been the natural course of action at all medical care facilities. Instead, ad-hoc or non-professional interpreters such as family members are often used, who may not be well-versed in medical terminology, placing LEP patients at risk for avoidable adverse events. Or patients may be judged to know just enough English to “get by” without an interpreter. Dr. Ben Danielson, a revered Seattle-area pediatrician who resigned in protest from the Seattle Children’s Hospital, describes his experience: “Amid a national reckoning with racism, the hospital’s executives would offer symbolic overtures to equity, but take little action toward righting its own wrongs and those of the broader medical system, he said — particularly around a lack of translation services and the frequency with which security was being called on patients of color” [3].

Symbolic overtures to equity and social justice can be found commonly in today’s time– the routine solidarity statement emails, adding “diversity, equity, and inclusion” to institutional websites, holding diversity seminars. But will these gestures ensure that all LEP patients will be accompanied by a qualified interpreter at every single interaction with the healthcare system, whether it is as “simple” as getting lab tests done or something more complex as seeing a cardiologist? Structural determinism, an integral theme of Critical Race Theory, encourages us to consider systems of power and how they often preserve themselves in the interest of the dominant group [4]. It is hard not to wonder how circumstances may change if, instead of mainly BIPOC immigrants and refugees, it were white patients who needed medical interpretation. Would more institutions be willing to dedicate financial resources to interpreter programs or would we see the development of robust legal policies to hold medical institutions accountable for not upholding standards of interpreter accommodation?

Prioritizing access to interpreters and other cultural caseworkers for patients with LEP can be viewed as one test of how much medical institutions are willing to invest in concrete, impactful actions for marginalized patients and truly live up to their declarations of equity and inclusion.

References

[1] Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007). Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health services research, 42(2), 727–754. https://doi.org/10.1111/j.1475-6773.2006.00629.x

[2] EthnoMed. (2020, October 20). Community House Calls Program | EthnoMed. https://ethnomed.org/about/community-house-calls-program/#patient-services-

[3] Kroman, D. (2020, December 31). Revered doctor steps down, accusing Seattle Children’s Hospital of racism. Crosscut. https://crosscut.com/equity/2020/12/revered-doctor-steps-down-accusing-seattle-childrens-hospital-racism

[4] Ford, C. L., & Airhihenbuwa, C. O. (2018). Commentary: Just What is Critical Race Theory and What’s it Doing in a Progressive Field like Public Health?. Ethnicity & disease, 28(Suppl 1), 223–230. https://doi.org/10.18865/ed.28.S1.223