Editor’s note: “Medical interpreter” generally refers to someone who interprets spoken language and “medical translator” generally refers to translating printed material, but people often use the terms interchangeably.
The woman was understandably overwhelmed. On top of her cancer diagnosis, she had been displaced by war, forced to flee her Middle Eastern country with her husband and young children. She’d left her older children and most of her belongings behind.
Now in the United States, the health system proved a terrible labyrinth. As if the fear and confusion surrounding her brain tumor weren’t stressful enough, she didn’t understand what doctors were saying and struggled to decipher paperwork.
It wasn’t until she visited Commonwealth Catholic Charities in Richmond, VA, that she received a sliver of good news: She had the right to an interpreter at no charge.
“She cried,” says Alexina Portyrata, supervisor of the charity’s interpreter services program. She still needed urgent treatment for a brain tumor, but the removal of the language barrier was a massive relief to both herself and her family.
Language Equity Is a Legal Right
The right to competent language translation in medical care is guaranteed by the Civil Rights Act of 1964, Affordable Care Act, and Americans with Disabilities Act.
In the U.S., where 1 in 5 people speak a language other than English at home, that’s a lot of translation.
The need varies immensely between states – from Montana, where just 4% of residents between ages 18-64 speak a language other than English, to New York, where 32% of residents speak more than 200 different languages. (The U.S. Census Bureau tracks 350 different languages, including sign languages.)
But the right to these services remains the same.
A lot of medical providers have excellent resources for people who speak languages other than English, including sign languages for the hearing impaired. But some providers, especially smaller ones, struggle to keep up. In addition, many people don’t realize that they have a right to competent translation in a medical setting.
Without good language services and a framework for delivering them, the resulting miscommunication can have tragic consequences, says Marin Allen, PhD, former National Institutes of Health director of public information and a health communications expert.
“When a health provider does not speak the same language as those being treated, relationships can quickly become strained, important pieces of information can be lost and gestures or turns of phrases can be misinterpreted. These lapses in language can change the course of someone’s life,” Allen and co-authors wrote in a 2020 paper on language and cultural issues in the medical setting.
A 9-year-old Vietnamese girl dies from a drug reaction. A Cuban teen is rendered paraplegic after his hemorrhage is misdiagnosed as an overdose. An elderly Russian stroke patient has her leg amputated after she was unable to describe the severity of her pain. All of these outcomes might have been averted with better available medical language services.
A 2013 study showed almost a third of U.S. hospitals failed to provide language services, while American Hospital Association figures show that more than 40% of the country’s 2,168 community hospitals had no such offering.
A 2020 study found that fewer than one-third of outpatient doctors regularly used a trained professional interpreter for patients with limited English, that 40% didn’t use professional interpreters at all, and most did not provide a translation of printed materials.
The National Institutes of Health says failure to provide adequate professional interpreters costs hospitals tens of thousands of dollars in readmissions alone. Lawsuits can cost medical centers and their insurers millions – in the case of the Cuban teen, $71 million.
What It Looks Like
Medical centers provide language services in a variety of frameworks. Hospitals often have staff interpreters for their community’s most commonly spoken languages.
While in-person interpretation is generally preferred, it’s not always an option in time-sensitive situations, especially in remote areas, or when a person speaks a less common language.
In those cases, hospitals provide interpretation over the phone or via video through networks such as Language Line Solutions, Health Care Interpreter Network, or Martti. The screen can be affixed to a robot or cart that is wheeled room to room if needed.
The doctor should be sure to speak directly to the patient, not the interpreter, says Allen. That’s to ensure the person is a full participant. And interpreters should pay close attention to any signs the patient or doctor is confused while also considering any gestures or cultural cues that come into play, she says.
More Than Language Skills
More than merely translating words, interpreters “create understanding” between two parties, says Tamas Farkas, language access programs director for the Seattle-based Cross Cultural Health Care Program.
This can be complex. Think of the simple matter of dialect. People of Berber descent from Morocco speak a very different version of Arabic than someone from Iraq or Egypt, for example. The aforementioned Cuban teen used the term “intoxicado,” which in his dialect can mean “nauseated,” rather than the more common translation of “intoxicated.”
Even gestures can vary widely between cultures. People from India, especially southern India, are known for a “head bobble” gesture that can mean a variety of things, including “yes” or “I understand,” depending on the context. A Bulgarian nodding her head may mean “no” instead of “yes,” Farkas says.
And even that’s not always consistent. “People are people, which I know seems super, super simple, but not every Bulgarian is going to nod that way,” Farkas says.
“Interpreting means always having this kind of incredible openness to what it could mean, knowing what it means in certain contexts, but also negotiating the space for someone to have their own meaning.”
A trained interpreter must also account for other aspects of culture that may not relate directly to language. In some cultures, it might be inappropriate for a young person to discuss certain matters with an elder, or for a woman to discuss trauma or reproductive health with a man (or vice versa).
Then there are the complexities of explaining complex medical jargon and even sometimes legal jargon (especially for informed consent in clinical trials and certain treatments) in a way the person is likely to understand. Certified medical interpreters get training on all of these aspects of communication.
Family Members and Translation Apps
Many patients bring a relative or, as so often is the case with recent immigrants, a child, to interpret for them, says Brenda Robles, who has managed the language services program at the National Institutes of Health Clinical Center for 16 years.
These patients and family members might also refer to translation apps like Google Translate when they don’t understand something. But this is not always the best solution.
Can a translation app be trusted to differentiate between dysphagia (trouble swallowing) and dysphasia (a brain injury)? Can a child hear the difference in the words or understand the medical complexities inherent in these conditions?
Is this the best way for a child to process a serious or frightening diagnosis about a loved one?
Robles recalls an incident in which a daughter who wanted to translate didn’t want the doctor to use the word “cancer” for fear of upsetting her elderly mother. That was untenable for both the doctor and the patient for any number of reasons, Robles says. That’s just one example of how simply being bilingual doesn’t make you a medical interpreter, she says.
Research shows that not only patients, but also family members, might struggle to absorb emotionally charged information. They may be embarrassed to ask questions, or they could be misled by ads or misinformation on the internet they don’t fully understand because of language and cultural barriers.
A trained interpreter with keen observation skills can help caregivers identify when a message isn’t received clearly and follow up in a sensitive and culturally appropriate way, Robles says.
What Works: ‘Teach Back’ Technique
It’s part of a doctor’s job to ensure the patient understands their diagnosis, treatment options, and any risks, says Allen from the National Institutes of Health. That’s where a skilled interpreter can make a huge difference, she says.
She and other experts tout the “teach-back” technique – in which patients are asked to immediately explain what they heard the doctor say. It improves communications, especially when the medical provider destigmatizes a patient’s confusion or embarrassment by conceding the information is complicated, Allen says.
It’s a technique, Allen says, that can be a great help to both doctor and patient whether there is a language barrier or not.