By Ami Bhatt
April 11, 2019
Alba desperately wanted to get better. However, she could not consent to surgery. She didn’t understand either of the two languages being used in the room.
Alba (not her real name) was 24 years old and had come to the US to visit family. After experiencing a transient ischemic attack, she was found to have a large atrial septal defect that required surgical closure. There was not an Albanian interpreter available in short order; therefore, phone interpreter services were utilized. As she and her family conversed with the team in the room, looks passed between the patient, her mother, and her aunt with almost every sentence being translated. When the conversation was complete, and all others had left, the cardiac attending asked Alba about the interpreter. She smiled and delicately conveyed that it was a completely different dialect than hers, and therefore, much of the conversation entailed two languages (English and this other dialect) that she and her family did not comprehend. There was laughter (albeit sheepishly on the team’s part) as they appropriately decided to wait for both her English-speaking family members and the correct in-person interpreter before signing consent for surgery. For Alba, the signs around the hospital in several common non-English languages (Spanish, French, and recently added, Arabic and Mandarin) were not useful to her specific language barrier. The interpreter, however, was meant to be a safe haven. Unfortunately, in many institutions, interpreter services can no longer accommodate the volume of people with limited English proficiency (particularly for foreign languages less commonly spoken in the world).
Recently, a study of nearly 20,000 inpatient admissions revealed that in patients who were identified as needing and requesting an interpreter, one was provided only 4% of the time. Studies in outpatient interpreter services are sparse. The rationale for deferring language assistance has been well studied, and ranges from issues of convenience to those of conformity. As we face increased language diversity, there is an opportunity to fundamentally change infrastructure to support language diversity and create an equitable outpatient medical practice.
Currently, many institutions have an interpreter, but one that is not used efficiently or effectively. Interpreter services can be engaged when needed, but are not pre-planned, and therefore, unexpected surges in the need for a specific language, long waits that result in visits without the interpreter or in cancelled appointments, or perhaps a provider trying to find the mobile translation device, becomes an added logistical burden during limited outpatient clinic time. However, most of outpatient care is pre-planned, providing ample opportunity to deliver interpreter services by making them part of the clinic infrastructure and practice workflow. Addressing three facets of language diversity can improve the patient experience, and ultimately, patient care. These include weaving interpreter services into the outpatient infrastructure, leveraging technology for interpreter services, and designing mechanisms for rapid educational translation.
A systematized approach to addressing these three facets includes several key structure and process adaptations: 1) assessment of native language distribution in the practice to create an effective “supply chain” of interpreter services, 2) interpreter service scheduling (live, televised, phone, or artificial intelligence at the time of visit scheduling, 3) arrival alerts when a patient enters the clinic to optimize coordinated care, 4) post-visit confirmation of comprehension (phone calls or televisits with interpretation), and 5) rapid or real-time translation of educational material and FAQs (handouts, video or mobile app) to the most common languages, as assessed in step 1. Although there may be hesitation to create such an infrastructure for a minority of patients, this methodology would improve communication, and thereby serve all clinic patients, once established.
The mechanism to achieve language equity in outpatient care exists today. By doing the hard work of process and structure innovation, we can establish effective, comprehensive interpreter services, and prioritize equity in the outpatient realm. It is up to us to prioritize this goal, even if it may seem to serve a minority of the patient base in some institutions. Language equity will enable these patient populations to become part of the majority receiving quality health care in the future.
- Blay N. et al. Healthcare interpreter utilisation: analysis of health administrative data BMC Health Serv Res. 2018; 18: 348. Published online 2018 May 10. doi: 10.1186/s12913-018-3135-5
Dr. Ami Bhatt is the director of outpatient cardiology as well as adult congenital heart disease at the Massachusetts General Hospital Heart Center where she leads initiatives to provide state-of-the-art subspecialty cardiac care, runs her own Telemedicine Clinic for Adults with Congenital Heart Disease, and creates platforms for virtual cardiovascular care. Her research centers on using medical and patient-reported data to create prediction algorithms for risk stratification and optimal resource utilization.
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