No matter how carefully the post-operative discharge instructions were worked out, I was concerned about how my Spanish-speaking patient would refer to the English-language “warning signs” if questions arose at home. And I was right to worry: your arrival at the emergency room eight days later with a severe but preventable infection highlighted the challenges more than 25 million Americans face when interacting with our English-speaking healthcare system. While this system aims to provide the best possible care for all patients, it is often inadequate for non-English speakers.
Language discordance – the situation in which providers and patients speak different languages - are all too common in the United States. Impaired English proficiency affects patient, doctor, and system interaction by undermining communication, trust, and health literacy. This miscommunication leads to sub-optimal care, decreased understanding of diseases and treatments, difficulty making decisions together, and decreased satisfaction with care. The discordance between patient and provider is linked to poorer chronic disease management, longer hospital stays, and increased hospital readmission rates.
Even in Massachusetts, where there is a high rate of insured residents, patients with limited English proficiency tend to be at higher risk of being uninsured or underinsured, leading to poorer access to health and poorer outcomes. With the increasing exposure of medical inequalities in the face of COVID-19, it is important that we improve communication between the health system and non-English speakers.
Medical interpreters have been shown to improve care and are our best way to resolve differences that arise from disagreements between patients and providers. Executive Order 13166 and the Affordable Care Act Section 1557 mandate the use of an interpreter for patients who do not speak English well. Title VI of the Civil Rights Act states that this language support must be free of charge. However, because insurance companies rarely pay for interpreting services, providers and hospital systems have to pay for the services themselves, resulting in poor compliance by only 65 to 75 percent of US hospitals that provide language services. State advocacy for the reimbursement of legal insurance for this essential service would improve hospital compliance and effective patient care while driving innovation and reducing overall costs.
In addition to changes in reimbursements, local and regional investment in newer technology that enables instant and easy interpretation from a smartphone can encourage more frequent and consistent use of interpreters. In the hospital or clinic, using a personal or telephone interpreter can take valuable minutes, which can lead to long waiting times or delays in emergency care. COVID has created a market for the further development of telehealth technologies, in which patients and providers make communication via video more convenient. Novel and low-cost applications on the ubiquitous smartphones of patients offer instant access to a certified medical interpreter. This may be better than relying on a family member to come with you or the provider calling in a medical interpreter as a preventive measure.
Written discharge instructions in Spanish may have prevented my patient from returning to the hospital. This example of misunderstanding is sadly just one of many in Massachusetts and across the country. The automatic and medically valid translation of all patient instructions should be a legal requirement so that patients can read and understand their instructions at home, not just with an interpreter at the clinic appointment or discharge from the hospital. Granted, there are some barriers to these solutions, but we believe that these barriers will be removed. Ensuring better compliance with the legal requirements for interpreters would lead to increased surveillance as well as consequences and regulations for non-compliant companies. The adjustment of the reimbursement structures affects the financial health system and the payment structures of health insurance companies, which can lead to higher premiums.
Although the workforce is growing and paid well above the minimum wage, greater efforts must be made to expand the interpreter workforce, particularly in areas of greatest need. Despite these costs, investments in translation services through improved communication will save health care resources and lives. Failure to invest in those resources that promote clear understanding can increase future patient safety risks. A translator saves nine on time.
Hospitals and healthcare systems in the United States should take advantage of the technological advances and novel telemedicine environment created by the COVID-19 pandemic to reevaluate their interpreting services. Improving access to timely medical interpretation is a moral imperative in a society that seeks a more equitable system in and outside of health care.
The opinions expressed in this article are solely those of the authors and do not reflect the views and opinions of Brigham and the Women’s Hospital.
This is an opinion and analysis article.