Developing a Complete Culture of Interpretation

For years, healthcare institutions have struggled with how to serve their limited English proficient (LEP) patients. We know that LEP patients have (1) greater risks for line infections, surgical infections, falls, surgical delays/complications, and other adverse events; (2) increased hospital lengths of stay; (3) poor patient experiences; and (4) higher rates of readmission.

Of all the barriers preventing LEP patients from receiving better healthcare, one of the most important is an absence of language concordant care (receiving care in one’s own first language.) Even when there are ample Culturally and Linguistically Appropriate Services (CLAS) available, clinical staff often decide to conduct patient visits without appropriate language and interpretive services. This frequent practice is not supported by current regulations, which require medical institutions to provide interpretive services to all LEP patients free of charge.

As institutions scramble to ensure language concordance for all LEP patients, we have neglected an important aspect of the patient-provider conversation. Language concordant care is more than simply reiterating words in one language to another; it is being able to converse with a non-English speaking patient just as you would with an English-speaking one. For this to happen successfully, two things must occur:

1. The English speaker must understand how to best use the interpreter.

2. The interpreter must be trained to capture not just the words, but also the tone, cadence, and meaning of those for whom they are interpreting.

Interpreters are key tools for improving the care of LEP patients, but tools are only as useful as those who wield them. Physicians who are known for their bedside manner and bubbly personality turn into robots in the face of an LEP patient and interpreter, suddenly unsure of themselves. Their conversation becomes limited and technical, often devoid of emotion. They can no longer rely on small talk to keep a patient engaged as they push a needle through a wound in need of stitches. They can no longer tell their favorite joke or ask friendly questions about spouses, children, and birthday parties, which can help build trust between themselves and their patient. The patient-provider encounter is instead turned into a tentative exchange rather than a relationship built on trust.

It is no secret that bedside manner can be as important as the clinical team’s competence in obtaining a patient’s confidence, adherence, and partnership. Patients are more likely to adhere to treatment plans when they trust in their physicians. This is not to devalue the importance of having an interpreter in the room, but to say that having an interpreter alone is still not enough. Medical personnel must learn how to better work with and utilize an interpreter to be able to understand a patient’s responses, language, and emotions.

JHM Office of Diversity and Inclusion has conducted an unconscious bias exercise, where a largely English-speaking audience listens to an audio clip of a woman in her early twenties speaking Spanish. In this clip, she describes how much she loves food and enthusiastically lists the different types of food she likes. The audience is unable to see the woman, but is asked to describe her. The usual response will be that the woman sounds angry, stressed, and frustrated. Some will even go as far as to describe her as old or middle-aged, or a mother type. When this exercise is conducted repeatedly, results are consistently similar.

The English-speaking audience analyze other languages using the parameters and norms of the English language. If an individual is speaking loudly in a non-English language, the tone can be mistaken for anger instead of enthusiasm. If an individual speaks quickly, it can be mistaken for stress instead of a norm of the Spanish language.

This unconscious bias prevents us from truly understanding the needs of our LEP patients. For this reason, interpreters need to act as “culture brokers.” Their role should be to repeat not just words, but also the feelings around words. Interpreters should capture the fear in a mother’s voice, whose child has a fever that will not break. They must be alert to the hesitation in each syllable, as the physician asks if the patient has ever experienced abuse. Without these things, our providers will never treat the entire patient, just their symptoms.

There is no question that having an interpreter in the room is critical to reducing health disparities among our LEP patient population. We should do everything we can to ensure language concordance inside and outside of the clinic. Language concordance should occur at every step of the healthcare process, from scheduling appointments to reviewing medication information with pharmacists, to discussing payment plans with billing, as well as filing complaints with patient relations if necessary.

We must create a true “culture of interpretation,” one in which using an interpreter becomes so common and intrinsic to the nature of our clinics that there are no longer differences in patient experience due to language. We can do this by training our staff on the proper role of an interpreter and empowering interpreters to act as cultural brokers, training them not only in the interpretation of words, but also of emotion, tone, and culture.