Effective communication between patients and providers is essential in improving health outcomes, addressing healthcare costs, and achieving health equity goals. As the US experiences soaring growth in people who don't use English as a primary language, qualified medical interpreters are increasingly critical in filling this important patient need.
Serious harm can arise from medical communication fails
Adverse medical events more frequently impact people with limited English proficiency, according to a guide from the Agency for Healthcare Research and Quality. Serious harm can arise from basic communication failures, underscoring the necessity of patients having ready access to qualified medical interpreters in provider settings.
In the US, that need is pressing. More than 20% of US residents now speak a language other than English at home, a number than has tripled since 1980, according to the US Census Bureau. About 8% of US residents surveyed reported speaking English less than “very well." In addition to language challenges, patients with hearing loss or those with limited health literacy may also require interpretation services.
Why are medical interpreters necessary?
Imagine this scenario: A senior-aged female with limited English visits the emergency room, suffering from abdominal pain and vomiting. Her medical team needs to know her past medical history, any allergies, past surgeries, and current medications. In the exam room, the provider will ask when the symptoms started, their severity, the specific location of the pain, and relevant details, such as whether there's blood in the vomit. The patient's answers could influence whether the medical team may order a CAT scan, blood work, or urine tests. If the patient has a diagnosis, such as appendicitis, they'll need to discuss surgery options.
Every step of that process could be rife for miscommunication and misunderstandings that could adversely impact her quality of care and health outcomes. This is one of many examples of how relevant and important medical interpreters can be to patient well-being.
What is a medical interpreter?
A medical interpreter can offer patients language translation help in person, over the phone, or through a videoconferencing service.
A professional medical interpreter's skills exceed language fluency and a thorough understanding of medical terminology, points out Lisa Morris, the director of Cross Cultural Initiatives at the Massachusetts Area Health Education Center in a UMass Chan Medical School post. Medical interpreters are also trained to “read the moment" so they can determine when to translate word-for-word and when to ask a follow-up clarification. They're familiar with laws and regulations surrounding privacy and reimbursement.
Bringing cultural sensitivity to their work
“But perhaps the essential skill for a professional medical interpreter is the high degree of cultural knowledge and sensitivity they bring to their work," she writes. “The interpreter's ability to accurately read non-verbal communication and cues—gestures, posture, energy rooted in culture or nationality—is crucial to helping the patient and provider fully understand each other. And, in this way, reduces the risks associated with misunderstanding a diagnosis or a treatment plan."
In healthcare, communication is key
Effective communication in medical settings is vital, research has found. People who are at higher risk for miscommunication are also more likely to experience medical errors. In an issues report updated in 2021, The Joint Commission outlines key inequities facing patients with Limited English Proficiency (LEP) when compared to English-proficient patients. Among the findings, patients with LEP:
- Have longer hospital stays when professional interpreters were not used at admissions and/or discharge
- Have greater risk of surgical infections, falls, and pressure ulcers
- Have a greater risk of surgical delays due to difficulty understanding instructions, including how to prepare for a procedure
- Have a greater chance of readmissions for certain chronic conditions due to difficulty understanding how to manage their conditions and take their medications, as well as which symptoms should prompt a return to care or when to follow up
Government provisions address patient rights
As part of the Civil Rights Act of 1964, providers who receive federal funds must take reasonable steps to make their programs and services accessible for eligible people with LEP. This “meaningful access" is required so that people can make informed choices about healthcare treatment.
More recently, the Department of Health and Human Services published the National Cultural and Linguistically Appropriate Service Standards (CLAS) with the intent of improving health equity goals. The CLAS standards provide “a blueprint" for healthcare organizations to provide culturally and linguistically appropriate care. Care and services should be “responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs," the guidelines state.
Professional medical interpretation leads to wide-ranging benefits
The American Academy of Family Physicians points to research documenting the benefits of professional medical interpreters, ranging from fewer errors in communication and improved patient satisfaction to shorter hospital stays and lower malpractice risk. Ad hoc interpreters, such as family, friends, or untrained staff are more likely to "make errors, violate confidentiality, and increase the risk of poor outcomes," the document says. In addition, the guidance advises against using children as interpreters except in emergencies.
In some situations, the patient might feel more comfortable using a trusted family member or friend as an interpreter, federal guidance points out. In those cases, though, the individual should be made aware that he or she has the option of having a professional interpreter without a charge. Before involving a family member, the provider should also ensure that the patient wants this individual involved and aware of confidential medical information, advise experts in a 2020 article in The BMJ.
Ultimately, the decision to use a family member should be noted in the patient's medical chart, states the American Academy of Family Physicians.
Research finds low utilization of medical interpreter services
Despite the clear advantages, medical interpreter services are underused especially in outpatient settings, research shows. In a large, national study, researchers found fewer than 1/3 of outpatient physicians reported regularly using a trained professional interpreter when communicating with LEP patients. About 40% reported never using professional interpreters, according to the results published in 2020 in the Journal of General Internal Medicine.
“Our findings demonstrate that despite clinical evidence and legal requirements, professional interpreters remain greatly underused," the authors wrote.
Report: informal system can impact patient care
Similarly, an in-depth NPR story summarized the frequent occurrences taking place as facilities across the country fall short of these access goals:
“And yet, despite the law, and despite the obvious benefits, thousands of hospitals and other medical facilities continue to fall short, leaving patients—if they are lucky—relying on family members and friends to be ad hoc interpreters of maladies and medical care. It's an informal and imperfect form of triage that unfolds in clinics across the country every day, with potentially harrowing consequences should something be lost in translation."
Real-world challenges to using professional medical interpreters
While the evidence strongly supports professional medical interpretation uses, myriad real-world challenges can influence implementation. For example, in fast-paced emergency settings, it can be difficult to quickly arrange an in-person interpreter. Video conferencing technology is a common solution, but that can present challenges in the form of poor interfaces or sound and visual quality. Providers also report being unaware of interpretation resources, and, when they are aware, cite lack of training on how and when to use medical interpretation.
Even when in-person medical interpretation is available, difficulties can still arise, points out a review of published journal articles on the topic, published in 2021 in the Journal of Legal, Ethical and Regulatory Issues. These include struggles to translate medical language and different dialects within a language.
Other interpersonal influences can impact the patient experiences and communication, too. Medical interpreters might disagree with providers' protocols and adjust the narration in a way that influences content.
The connection with health access
Navigating these challenges is vital in ensuring health equity goals. Research has found a link between adults with limited English proficiency and less healthcare utilization, according to results published in 2021 in Health Affairs.
“These language-based gaps in spending and use raise concern that language barriers may be obstructing access to care, resulting in underuse of medical services by adults with limited English proficiency," authors wrote.
Raising readmission risks
Healthcare costs are impacted as well because communication gaps can lead to higher readmission rates. A 2022 study published in the International Journal of Nursing Studies compared 30-day hospital readmission risk from home healthcare based on language use. They found that patients who had a non-English preference had a higher risk for readmission.
That new study builds on prior research that found constant access to interpreters makes financial sense, too. A 2017 study found that using professional interpreters led to hospital cost savings by reducing readmissions.
How to address the care gaps
While expanding use of these interpretation services is critical, it's also important to increase uptake in a way that doesn't penalize hospitals that care for higher populations of people who need these services. That's the message from authors of the underutilization study published in the Journal of General Internal Medicine.
While enforcement of government requirements might increase uptake when applicable, this must be done in a mindful way that doesn't “further burden clinical settings that disproportionately care for LEP and other underserved populations," the study's authors caution.
Other observers have advocated for national certification standards and standardized policy guidelines for medical interpreters, similar to the way these services are used in federal courts.
Language concordant care can help
While professional medical interpretation has significant benefits, there is another approach: language-concordant care. This happens when patients and providers speak the same language.
“Language-concordant care has been demonstrated to improve patient outcomes, lower healthcare costs, increase satisfaction, and reduce medical errors," write the authors of a 2021 piece published in The Journal of Immigrant and Minority Health.
Using technology to bridge gaps
Another way to expand medical interpreter usage could arise through technology advancements. In a 2022 piece published in The Philadelphia Sun, Daniel Sanchez describes the benefit of remote interpretation service that can put care teams in touch with medical interpreters 24/7 in 250 languages. That's an important stride in advancing health equity while addressing costs.
“Enabling language access and being able to reach limited English proficient and deaf or hard of hearing populations with telehealth is the future of healthcare and helps continue to keep communities safe, healthy, and well informed."
RTI can help you advance health equity
At RTI Health Advance, we focus on helping clients eliminate barriers like these and create better patient experiences for everyone. Let us help you create practical and effective solutions that improve care, reduce costs, and advance health equity.