Language Barrier


Article Author:
Sam Slade


Article Editor:
Shane Sergent


Editors In Chief:
Sherry Gossman


Managing Editors:
Carrie Smith
Abdul Waheed
Frank Smeeks
Benjamin Eovaldi
Scott Dulebohn
Sobhan Daneshfar
William Gossman
Pritesh Sheth
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Richard Ciresi
Phillip Hynes


Updated:
1/19/2019 5:22:45 PM

Introduction

A language or communication barrier generally occurs between patients and medical personnel when a difference in the native language is present or the patient is hearing impaired. Misinterpretation of patient complaints or presentation is a growing problem in the United States when English is not the native language of patients. Physicians, nurses, and admitting and laboratory personnel along with many others are involved with patient care through the patient's stay. Potentially, language or communication barriers may negatively impact medical care as well as any ongoing relationship between patient, providers, and facilities. Ongoing relationships include, but are not limited to, ethical and legal implications that may occur over time. Historically, three different types of medical interpretation have been utilized by providers to overcome language barriers, each with advantages and disadvantages. Despite the proven advantages and increasing ease of video interpretation services, medical personnel are reluctant to regularly utilize this solution to improve the language barrier. Although the cost is high, further research and implementation of positive practices could benefit and improve language barriers in the medical field.

Issues of Concern

Language or communication barriers between patient and health professionals may negatively impact medical care. It has been reported that up to a quarter of all interpretation from family members or untrained personnel is incorrectly translated. This is due to the precision of vocabulary used in the interpretation. Studies show trained personal demonstrated increased precision and decreased errors.

There are a number of concerns when family members do the initial interpretation, and there can be cumulative issues that may have a detrimental effect on patient care. First, there is a lack of confidentiality. Typically, family members have not had HIPPA training and may unintentionally discover the information regarding the patient that may not be beneficial to the treatment plan and detrimental to their relationship with the patient. The depth of information may be limited due to the sensitive nature of several subjects including sexual activity and substance use. Another concern includes the lack of medical knowledge required to interpret medical information correctly; this may lead to misunderstandings and errors in the translation, which is also the primary reason a patient’s child should be used as an interpreter only in medical emergencies. Finally, untrained interpreters and family members may have their own notions regarding medicine, evaluation, and treatment. These thoughts may be conveyed during translation possibly causing an error and medical information to be skewed.

Some see the lack of adequate interpretation during medical care as discrimination. Federally funded programs are required to provide adequate interpretation for patients with limited English skills in Title VI of the Civil Rights Act, except if they are Medicare Part B. In fact, several past legal decisions considered lack of appropriate interpretation as negligence. One such case involved the incorrect interpretation of the word “intoxicado” by office staff to mean “intoxicated.” The misinterpretation resulted in a fruitless dialog of drug and alcohol use. In reality, the meaning of the word in this situation was meant to be translated as “inadvertent toxicity,” and an intracranial hemorrhage was overlooked resulting in a 71 million dollar lawsuit. Due to this case, as well as other rulings, some states in the United States instituted laws requiring adequate interpretation for medical encounters. Currently, adequate interpretation is not funded in all states, and the exact meaning of adequate interpretation is unclear.

Patients with a language barrier are more likely to receive larger workups including labs, intravenous fluids, longer emergency department stays, more hospital admissions, and increased medical charges. Poor interpretation may lead to negative relationships with providers and interpreters as well as decreased compliance with treatment. Thus, patients who require medical interpretation are typically less likely to be satisfied with their care from medical providers. The lack of appropriate medical interpretation has been a cause of increased anxiety for patients. Patients with a language barrier spend less time in an INR therapeutic window at Coumadin clinics, have more vision impairment with type II diabetes, and have increased medical errors. Patients with language barriers and cultural differences are also less likely to seek mental health care. These are just a few of the many problems that may possibly be avoided with appropriate medical interpretation.

Clinical Significance

There are three ways to provide adequate medical language interpretation during patient evaluation.

  1. The first is to provide an on-site, live well trained medical interpreter. This is expensive and limits the variety of languages provided.
  2. The second is the use of trained ad hoc hospital personnel including nurses, technicians, or other hospital employees who have been specifically trained to be medical interpreters in a language they speak fluently. 
  3. The last option is the use of a language line or video interpretation that provides many languages but is expensive. Large hospitals equipped with on-site interpreters often utilize off-site interpreters for languages in which they are not themselves proficient.

Bilingual hospital employees are a valuable resource for providing one-on-one medical interpretation. However, it has been proven that one out of every five hospital employee interpreters has inadequate language skills. When feasible, these employees should be tested for their language ability before acting as an interpreter. One validated assessment companies may consider is the Clinical Cultural and Linguistic Assessment that is administered via telephone. Some large organizations increase pay for employees who are trained and have passed proficiency examinations to expand the number of medical interpreters available.

Video interpretation ensues with a tablet or computer mounted on a mobile stand. The device is connected to a wireless internet network, and companies who provide video interpretation services may then connect to their interpreters. Video interpretation has been shown to improve use and communication over telephone interpretation.

Other Issues

In general, hospital discharge instructions are often misunderstood by patients, and patients with limited English proficiency tend to misinterpret this information to a greater extent. This has proven true for follow up and medication information, even when language interpretation was provided for the patient. Therefore, in an attempt to minimize misunderstandings during hospital discharge, instructions should be printed in the patient’s proficient language as well as a detailed explanation from an interpreter.

The use of in-hospital professional interpreters has decreased the use of hospital assessments including but not limited to laboratory tests, imaging, and medications. Use of in-house interpreters is also the most cost-prohibitive mode to provide medical interpretation because it involves hiring a full-time employee. In addition, another source of medical interpretation needs to be purchased and readily available when the hospital interpreter is not present or is not fluent in a respective language.

Physicians and nurses with limited interpretation skills continue to utilize ad hoc interpreters or other nearby people with poor language skills for important conversations which include patient consent and medicine administration. Family members and guests of the patient should be used sparingly for ad hoc medical interpretation due to the reasons mentioned above.

The use of video interpretation can decrease the use of laboratory tests, radiology, EKG, ECHO, and hospital admissions. These savings can not offset the cost to provide in-house professional interpretation at most institutions.

Physicians and medical staff should be trained regarding the use of available medical interpretation services. Despite its obvious necessity, tele-interpreter services are underutilized in many situations due to lack of knowledge regarding availability, the misunderstanding regarding the length of time for use, difficulty in training a rotating workforce, and the different procedures for activation of services at different times of the day.

Despite all of this information, language barriers persist for many patients seeking medical care.


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Language Barrier - Questions

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A 17-year-old female presents to the emergency department with her parents. During the evaluation, the provider observes bruising around her neck. The patient and family speak Spanish exclusively, and therefore, the evaluation is interpreted by a technician who speaks a little Spanish. During the interpretation, the word “ropa” was misinterpreted to mean rope, and a suicide attempt workup was started. This included an inpatient psychiatry consult for intentional hanging. Later, it was determined the word “ropa” correctly translated means “clothes,” and her clothing got caught on a hook when she fell. What type of interpretation could have been used to avoid this situation?



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A 17-year-old Hispanic female, with limited English proficiency, enters the emergency department for a sexual assault examination. She appears in distress and is accompanied by her English speaking sister and friend. A patient advocate who is fluent in Spanish is present, and a professional interpreter is available on site. Who would be the best choice to provide translation?



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A 17-year-old female presents to the emergency department with her parents. During the evaluation, the provider observes bruising around her neck. The patient and family speak Spanish exclusively, and therefore the evaluation is interpreted by a technician who speaks a little Spanish. During the interpretation, the word “ropa” was misinterpreted to mean rope, and a suicide attempt workup was started. This included an inpatient psychiatry consult for intentional hanging. Later, it was determined the word “ropa” correctly translated meant “clothes,” and her clothing caught on a hook when she fell. Which statement regarding the misinterpretation is true?



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Language interpretation services are required during patient care for federally funded hospitals due to what law?



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Up to what percent decrease in interpretation errors can a professional interpreter achieve over a non-trained ad hoc family member interpreter?



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Caring for a patient with a language barrier requires the implementation of some fundamental principles. What are essential elements in providing linguistically appropriate care? Select all that apply.



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Language Barrier - References

References

Language barriers in medicine in the United States., Woloshin S,Bickell NA,Schwartz LM,Gany F,Welch HG,, JAMA, 1995 Mar 1     [PubMed]
Limited English proficient Hmong- and Spanish-speaking patients' perceptions of the quality of interpreter services., Lor M,Xiong P,Schwei RJ,Bowers BJ,Jacobs EA,, International journal of nursing studies, 2016 Feb     [PubMed]
Language barrier and its relationship to diabetes and diabetic retinopathy., Zheng Y,Lamoureux EL,Chiang PC,Anuar AR,Ding J,Wang JJ,Mitchell P,Tai ES,Wong TY,, BMC public health, 2012 Sep 13     [PubMed]
Does a video-interpreting network improve delivery of care in the emergency department?, Jacobs EA,Fu PC Jr,Rathouz PJ,, Health services research, 2012 Feb     [PubMed]
The use of Spanish language skills by physicians and nurses: policy implications for teaching and testing., Diamond LC,Tuot DS,Karliner LS,, Journal of general internal medicine, 2012 Jan     [PubMed]
Reducing clinical errors in cancer education: interpreter training., Gany FM,Gonzalez CJ,Basu G,Hasan A,Mukherjee D,Datta M,Changrani J,, Journal of cancer education : the official journal of the American Association for Cancer Education, 2010 Dec     [PubMed]
Language access services for Latinos with limited English proficiency: lessons learned from Hablamos Juntos., Wu S,Ridgely MS,Escarce JJ,Morales LS,, Journal of general internal medicine, 2007 Nov     [PubMed]
Impact of interpretation method on clinic visit length., Fagan MJ,Diaz JA,Reinert SE,Sciamanna CN,Fagan DM,, Journal of general internal medicine, 2003 Aug     [PubMed]
Impact of interpreter services on delivery of health care to limited-English-proficient patients., Jacobs EA,Lauderdale DS,Meltzer D,Shorey JM,Levinson W,Thisted RA,, Journal of general internal medicine, 2001 Jul     [PubMed]
Effect of Telephone vs Video Interpretation on Parent Comprehension, Communication, and Utilization in the Pediatric Emergency Department: A Randomized Clinical Trial., Lion KC,Brown JC,Ebel BE,Klein EJ,Strelitz B,Gutman CK,Hencz P,Fernandez J,Mangione-Smith R,, JAMA pediatrics, 2015 Dec     [PubMed]
Assessing dual-role staff-interpreter linguistic competency in an integrated healthcare system., Moreno MR,Otero-Sabogal R,Newman J,, Journal of general internal medicine, 2007 Nov     [PubMed]
English language proficiency and lifetime mental health service utilization in a national representative sample of Asian Americans in the USA., Kang SY,Howard D,Kim J,Payne JS,Wilton L,Kim W,Maramba D,, Journal of public health (Oxford, England), 2010 Sep     [PubMed]
Limited English proficient patients and time spent in therapeutic range in a warfarin anticoagulation clinic., Rodriguez F,Hong C,Chang Y,Oertel LB,Singer DE,Green AR,López L,, Journal of the American Heart Association, 2013 Jul 5     [PubMed]
Impact of language barriers on patient satisfaction in an emergency department., Carrasquillo O,Orav EJ,Brennan TA,Burstin HR,, Journal of general internal medicine, 1999 Feb     [PubMed]
Language barriers and resource utilization in a pediatric emergency department., Hampers LC,Cha S,Gutglass DJ,Binns HJ,Krug SE,, Pediatrics, 1999 Jun     [PubMed]
Appropriate use of medical interpreters., Juckett G,Unger K,, American family physician, 2014 Oct 1     [PubMed]
Language barriers and understanding of hospital discharge instructions., Karliner LS,Auerbach A,Nápoles A,Schillinger D,Nickleach D,Pérez-Stable EJ,, Medical care, 2012 Apr     [PubMed]

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