Keywords

Introduction

Approximately 60 million people in the United States speak a language other than English at home. Half of these individuals report that they speak English less than “very well.” These individuals are considered to have limited English proficiency (LEP). Linguistic barriers can lead to patient misunderstanding of treatment, misdiagnosis, significant delays in treatment, patient’s poor decision-making, ethical compromises (e.g., difficulty obtaining informed consent, medical errors, and patients not being given all available options of care), and rise in the cost of medical care. Overall, linguistic barriers have been associated with lower healthcare access and poorer physical and mental health. Providing medical interpreter services is vital to promoting equitable healthcare and in overcoming the stigma and prejudice that can be associated with being a patient with LEP.

Effective communication is achieved not only by addressing linguistic barriers but also by better understanding the various cultural beliefs patients hold in relation to healthcare. When learning about a patient’s culture, healthcare providers can become aware of their patient’s (as well as their own) prejudices and biases. This awareness can help healthcare providers think about ways of providing culturally sensitive services.

Providing culturally appropriate services can improve communication, access to healthcare, and eventually health outcomes. In the following chapter, the authors will discuss the role of the medical interpreter, the importance of effective communication, the benefits of partnering with medical interpreters in meeting hospital-wide quality and safety requirements, how partnering with medical interpreters helps to reduce the overall cost of delivering healthcare, and how healthcare providers can partner with medical interpreters to improve the quality of care and health outcomes in LEP patients. Medical interpreters are instrumental in bridging the communication gap when there are language and cultural differences. The goal of this chapter is to make the reader aware of both the established and innovative ways in which working with medical interpreters can help in overcoming the stigma and prejudice that can be associated with being a patient with LEP.

The authors would like make note that in this book chapter, the term “healthcare provider” refers to clinicians, researchers, and healthcare educators. Patient cases will be presented to help illustrate several of the topics discussed. Some of these cases are well known in the medical literature, and others will be blended cases shared by colleagues from various institutions.

Who Is the Medical Interpreter?

Gricelda Zamora, a 13-year-old daughter of Spanish-speaking parents, often served as the interpreter whenever the parents needed to communicate with English-speaking persons. When Gricelda herself got sick with severe abdominal pain and was rushed to the hospital, no interpreter was provided for the parents. After a pregnancy test, she was discharged with a diagnosis of gastritis. The parents were told to bring her back if symptoms worsened, otherwise to follow up with a doctor in 3 days [1]. Without a medical interpreter, what the parents understood was to follow up with a doctor in 3 days. After 2 days however, Gricelda got sicker and the parents brought her back. By then it was too late and Gricelda died from a ruptured appendix.

There is no question that effective communication is essential to deliver quality and safe care, contributing to overall good outcomes; that it is critical to ensure that patients are able to follow instructions and adhere to treatment plans; and that this can be accomplished by partnering with professional medical interpreters.

Medical interpreters are professionals who are fluent in at least two languages, one of which is English, who are trained and proficient in the skills and ethics of medical interpretation and have extensive knowledge in medical terminology and concepts in both languages to be able to facilitate accurate, complete, and impartial medical interpretation between a healthcare provider and a non-English or limited English-proficient (LEP) patient or family. The work of the professional medical interpreter is to foster the therapeutic relationship between patient and healthcare provider by facilitating direct and effective communication. The authors would like to point out that research has not been consistent, and several papers have used the term bilingual (i.e., speaks two languages) to refer to interpreters who speak more than two languages. For the sake of this chapter, the authors will use the term bilingual, taking into consideration that there are medical interpreters who speak more than two languages.

Medical interpreters have different roles within the medical encounter, and they move between these roles seamlessly as necessary to ensure good communication and understanding. The roles of the medical interpreter are conduit, clarifier, cultural broker, and advocate [2]. Often, these roles are depicted as a pyramid to show the more predominant role at the base of the pyramid; and the roles less often assumed as the pyramid reaches its apex (Table 14.1). As a conduit the medical interpreter renders a message from one language into another, without adding or omitting information and without changing the message. Medical interpreters are skilled in managing the flow of communication, they have participants speak in turns and allow for each speaker to finish, including the medical interpreter, before speaking. This is by far the role which medical interpreters assume most of the time.

Table 14.1 The roles of the professional medical interpreter
Full size table

As message clarifiers, medical interpreters pay close attention to terminology or concepts that may be difficult to understand by the patient, by the healthcare provider, and by the medical interpreter. In order for medical interpreters to be effective conduits, they must first fully understand the original message. If the message and the intended meaning are not clear, then medical interpreters will ask the healthcare provider or the patient to explain terminology or concepts.

Medical interpreters at times must also provide cultural context while interpreting when they feel that there may be confusion due to cultural misunderstandings. Cultural values vary greatly among individuals. Each person experiences culture based on a variety of factors, such as socioeconomic status, education, and life experiences. In an encounter you may have various cultures at play, and cultures play a part in how you interpret information. In a medical encounter, you have the healthcare provider’s culture, the patient’s culture, the medical interpreter’s culture, and the Western healthcare culture. Although the medical interpreters are by no means cultural experts, they can offer healthcare providers and patients cultural context as needed to promote understanding and effective communication.

The role of advocate is the more controversial role and one that medical interpreters may choose to take on only if those actions support better clinical outcomes and only if the patient’s health, well-being, and dignity are compromised; and no other interventions have resolved the issue [3]. The reason is that one of the fundamental tenets of the professional code of ethics for medical interpreters is the need for impartiality and professional distance. Being impartial ensures that the communication is accurate and objective. Both patients and healthcare providers can trust the objectivity of the interpretation when the medical interpreter is not seen as taking anyone’s side. The professional medical interpreter could easily be perceived as having greater power within an encounter due to the understanding of both languages. Therefore, medical interpreters must skillfully navigate the role of advocate in order to ensure objective, quality interpretation.

When Should You Request a Medical Interpreter?

The United States is becoming increasingly more diverse, and the number of LEP individuals continues to grow. According to the US Census data, the Hispanic population grew by 43 % between 2000 and 2010 [4]. Additionally, according to the 2011 American Community Survey Report, approximately 21 % of the US population speaks a language other than English at home. That’s approximately 60 million people. And of those about 25 million have self-identified as speaking English less than very well [4]. Furthermore, it is anticipated that the Affordable Care Act will allow more diverse populations to enter the healthcare system. In a report published by the Kaiser Family Foundation, of the 24 million projected new enrollees of private health insurance, about 23 % will speak a language other than English at home [5]. Providing medical interpreter services is critical to effective communication between healthcare providers and patients. Healthcare institutions and staff should gather information on the patients’ preferred language to communicate healthcare information with healthcare professionals. Given the changing demographics and the need to provide culturally sensitive care, it is necessary to partner with professional medical interpreters.

Having an organization that reflects the diverse population it serves is also necessary to improve interactions and create a more culturally and linguistically sensitive organization. This will increase access by minorities, promote research in new areas, and enable leadership to address the needs of the diverse groups. However, workforce diversity has not kept pace with the changing demographics. This requires creating pipelines to increase enrollment in schools that feed these professions, a process that will take time [6].

How Healthcare Providers Can Contribute in Supporting Effective Communication

Providing professional medical interpreters when caring for patients who are LEP is a matter of quality and safety. Language barriers have been shown to be the cause of medical errors in LEP patients. Evidence shows that LEP patients are more likely to suffer from adverse events in hospitals resulting in harm or death, as compared to their English counterparts [7]. There is also evidence that working with untrained ad hoc interpreters results in a significantly higher number of errors with clinical consequences [8]. Ad hoc interpreters are untrained individuals who are bilingual and who are asked to interpret. These can include family members, staff members, bystanders, or anyone else who volunteers or is asked to provide interpretation and has not been trained as a professional medical interpreter.

In a study conducted in 2003 by Glen Flores, M.D., transcripts of interpreted pediatric encounters were analyzed. The study compared the errors in interpretation between encounters that were facilitated by medical interpreters and encounters facilitated by untrained or ad hoc interpreters. Ad hoc interpreters included bilingual healthcare providers and siblings of patients. It was concluded that the frequency of errors and the clinical significance of those errors were much greater when ad hoc interpreters were used [8]. Untrained bilingual individuals, whether they are family members or bilingual staff, may not know medical terminology and do not have the confidence to clarify terms unfamiliar to them. Patients may also not feel comfortable disclosing private healthcare information in front of family or individuals who may happen to live in the same communities as the patients. This can be a breach of confidentiality and privacy for the patient [9].

Asking untrained bilingual staff to serve as interpreters, in addition to risking poor communication, breach of confidentiality, and violating the law, also puts this staff in a difficult position [10–12]. Sometimes, if these individuals have support roles, or roles that report to the more senior staff asking them to do this, they do not feel empowered to admit that they don’t feel comfortable doing this. They may fear for their job security. Also, they may be concerned with the perception that they don’t want to be helpful and feel embarrassed to admit when they don’t know certain terminology. Furthermore, calling on colleagues to interpret is taking them away from their primary job responsibilities and asking them to do something that falls outside of their scope of practice. This can result in poor job performance. It can also create resentment among other colleagues who may have to cover the responsibilities of those being pulled in to interpret.

It’s important to note that different institutions have different systems in place to provide medical interpretation. Requirements may differ between a medical center and a research institution, for example. Some research institutions may have to follow strict IRB requirements pertaining to the enrollment of limited English-proficient (LEP) subjects. These requirements may dictate the need to have specific materials available in other languages, such as translated consent forms, as well as requirements for having interpreters available during the enrollment process when subjects speak another language. These requirements may vary from institution to institution. In some healthcare facilities, medical interpretation is provided by bilingual employees who have been trained as medical interpreters and are hired as dual-role employees. Others may have medical interpreters available only remotely, by telephone or by video or both.

There are also several reasons why a family member should not be asked to interpret for a patient. When allowed to interpret, English-speaking family members often end up speaking for the patients and not interpreting; they often answer healthcare provider’s questions right away in English without interpreting for the patient and leaving the patient out of their healthcare discussion [13]. Family members may withhold information from healthcare providers or from the patient themselves [14]. This prevents patients from being active participants in their healthcare, healthcare discussions, and treatment plans. These types of encounters can make it difficult for the patient to feel connected to their healthcare provider. When a patient does not feel connected to their healthcare provider, they are less likely to communicate their concerns which can lead to negative treatment outcomes.

Thus, healthcare providers should encourage families to be present in the healthcare encounter, if the patient so chooses, as caregivers and supporters for the patients, but advocate for effective communication by having a medical interpreter facilitate the communication. The evidence supports that partnering with professional medical interpreters improves clinical outcomes and contributes to the decrease in healthcare disparities in LEP patients, compared to patients without language barriers [15]. One study demonstrated shorter lengths of stay and lower readmissions for LEP patients who had professional medical interpreters at admission and at discharge [16]. Another study that analyzed transcripts of appointments, some facilitated by ad hoc interpreters and others by professional medical interpreters, found that the errors committed by ad hoc interpreters were “significantly more likely to have potential clinical consequences” [8].

For example, a 50-year-old Vietnamese woman arrived for her appointment. At the desk she was asked for her name and date of birth, which she was able to give with her limited English. Upon checking in, the staff at the front desk said to her “you don’t need an interpreter, right?” She felt embarrassed for not knowing English. She did not want to cause more work for the staff person and did not want to make someone go out of their way to provide her with a medical interpreter. The patient timidly shook her head and sat down.

Some healthcare providers also have limited language skills and may attempt to conduct appointments without the help of a professional medical interpreter, even when interpreter services are readily available. Some even welcome the opportunity to “practice” their second language with patients [17]. While healthcare providers can certainly use their limited second-language skills to chat with patients, this should not happen when discussing medical care. Patients are often embarrassed to let their healthcare providers know they do not understand them. Often, patients may speak some English. In fact they may be able to check in for an appointment without an interpreter. However, medical conversations, even with English speakers, can be complex. When you add a language barrier to that encounter, it adds to the complexity and to the risk of misunderstanding and miscommunication. Many fear being stigmatized and worry about how they may be perceived due to their limited English language ability.In many cultures, this inability to communicate for themselves in the dominant language can create a form of social disability, particularly in elders, which can have an impact on their self-esteem and their perceived authority and status within the family unit [18].Had the staff instead said “I’m going to call now for a medical interpreter for your appointment,” the patient would have kindly accepted the offer knowing that she would need the help in order to effectively communicate with her healthcare provider. This case example serves as a reminder that best practice is to preemptively offer a medical interpreter to prevent this stigma.

Another example is that of a 48-year-old Haitian woman who was accompanied by her 18-year-old son to her primary care appointment. Because her son spoke English, he was asked to interpret for his mother. He did not want to appear rude or unhelpful and agreed. His mother, embarrassed to reject his help, didn’t advocate for herself. During the encounter questions of sexual history were left uninterpreted and unanswered due to the embarrassment between mother and son.

Quality and Safety

Partnering with professional medical interpreters is a matter of quality and safety. There is no question that language barriers contribute to poor outcomes and adverse events. Patients who are limited English proficient are twice as likely to suffer from adverse events in the hospital, as compared to English-speaking patients. Those events experienced by LEP patients are also more likely to result in harm or even death [7]. Communication is at the heart of the patient-healthcare provider encounter. Not being able to communicate effectively creates a greater risk for medical errors and other conditions, such as infections, falls, and pressure ulcers [19].The six aims of the Institute of Medicine’s (IOM) Crossing the Quality Chasm that healthcare institutions must fulfill in order to deliver high-quality care strongly apply to patient populations who are LEP. According to the IOM, healthcare should be safe, effective, efficient, timely, patient centered, and equitable [20]. Providing safe care ensures that the healthcare provider can be alerted to a medication allergy.

In one case for example, a 56-year-old Filipina patient was unable to accurately convey to her healthcare provider what medications she was allergic to due to a language barrier [21]. In the emergency room, the treating healthcare provider prescribed a medication the patient was allergic to.

Effective healthcare is care that is evidence based; however, inability to understand a patient’s symptoms and history renders the healthcare provider unable to provide the best effective care in that situation. Efficient care refers to removing waste and providing care that is cost effective. One can argue that if a healthcare provider isn’t able to communicate with his or her LEP patient, then unnecessary tests may be ordered, resulting in higher cost of care that does not benefit the patient. If the patient who was scheduled for a colonoscopy arrives for his procedure without having prepared correctly and has to be rescheduled because the instructions given to the patient were in English instead of his native Haitian Creole, then the patient is being delayed; in other words, appropriate care is not being delivered in a timely manner.

These delays in care can be prevented by addressing the language needs proactively and having material available in the patient’s language or going over the instructions with a medical interpreter. Providing care that is patient centered is one of the aims of quality healthcare. This is care that revolves around the patient and considers the patient’s preferences, including cultural beliefs, and in which the patient has the authority to make informed decisions [22]. As the authors have already illustrated, LEP patients are at a disadvantage when ad hoc interpreters facilitate the communication. Untrained interpreters tend to omit information they deem irrelevant or editorialize what needs to be interpreted. Rather than empowering patients with information, patients are left on the periphery of their care. Finally, the last IOM aim is equitable care [20]. If care to LEP patients is not the same as care for an English-speaking patient, when access is different and when delays in receiving care are experienced, then care is not equitable.

Cost Considerations

The case for medical interpreters does not only impact quality and safety, it can also have an impact on cost. When LEP patients are not provided with professional medical interpreters, they experience longer lengths of stay and are at greater risk of being readmitted [16, 23]. Patients who experience language barriers may not fully understand postdischarge care and medication instructions. Therefore, they are more likely to be readmitted for the same condition. In addition, as the authors have already discussed, the inability to communicate effectively can result in getting unnecessary tests which adds to the cost of caring for that patient.

Furthermore, failure to provide competent interpreter services is a violation of Title VI of the Civil Rights Act of 1964. It is considered discrimination based on national origin. When the authors speak of competent interpreters, in addition to the spoken languages, the authors also refer to American Sign Language (ASL) interpreters. Patients who need ASL interpreters are also covered under the Americans with Disabilities Act (ADA) of 1990, which prohibits discrimination based on disabilities [11].

This federal law ensures equal access to services provided by institutions that receive federal funding, such as Medicare and Medicaid. Violations of this law are investigated and enforced by the Department of Justice and the Department of Health and Human Services and can carry hefty penalties. A study of medical malpractice cases from a carrier that covers four states in the United States found that in 2.5 % of all the cases covered through that insurance carrier, language barriers had a direct or indirect impact in the patient’s outcomes. This resulted in the carrier paying approximately $5 M in damages and legal fees [21].

However, it is important to note that violation of both Title VI and ADA does not always involve malpractice, and when that happens, penalties may come out of a healthcare provider’s own pocket. This was the case of a physician in New Jersey who treated a patient who was deaf for over a year, but never provided the patient with a sign language interpreter, despite the patient asking for one repeatedly. The physician argued that the cost of providing an interpreter (approximately $200/visit) far exceeded the reimbursement rate of $49 per visit. They communicated by writing back and forth and by relying on family members, including the patient’s child. Although the care provided was adequate, the patient sued the physician for not providing a competent interpreter, under the ADA. The malpractice carrier did not cover the penalty since there was no allegation of malpractice. The physician had to pay $400 K out of his own pocket [24].

The Informed Patient

Healthcare organizations have unique obligations. They are expected to, in an ethical manner, meet the healthcare needs of the communities they serve while being considerate of profitability [25–27]. This expectation creates a social covenant between healthcare organizations and their communities. One tool that healthcare organizations use to fulfill their social covenants and meet their ethical obligations is patient-centered communication [22].

Patient-centered communication is communication that is respectful of and responsive to the patients’ preferences, needs, and values [22]. Any communication that affects patients can be patient-centered including oral, written, and nonverbal communication between patients and healthcare providers, between patients and healthcare organizations, and between and among healthcare providers and healthcare organizations [22]. It is important to remember that on a daily basis, patients in the United States, from diverse backgrounds, who hold various beliefs about healthcare, are asked to make important decisions about their medical care. In order for a patient to be able to make important decisions about their medical care, healthcare providers must share with their patient information such as what their diagnosis is, what the medical treatment options are, and what are the risks involved with each of the presented treatment options (if there are more than one). The goal is to provide the patient all the information they will need to be able to make an informed decision about their medical care.

Individuals from Western cultures believe in the value of autonomy, and within the medical field, it is believed that the patient should be in control when making decisions about their medical care. Without patient-centered communication, patients would be taken out of the loop, leaving the healthcare providers to assume or guess the patient’s needs and preferences. In such a situation, autonomy would be denied. Thus, patient-centered communication is vital for healthcare organizations to provide ethical, high-quality care.

The use of patient-centered communication can also expose areas where communication-vulnerable groups receive lower-quality care and allow healthcare providers to find ways to improve care [22]. For example, it is important to remember that although Western cultures value autonomy and individualism, other cultures value collectivism. In some cultures (and in some families in every culture), healthcare decisions are made not just by the individual but by the individual and their family. LEP patients may have cultural beliefs and traditions that can influence the medical encounter and subsequent health outcomes in subtle and often invisible ways. These include minimizing reports of pain, respecting authority, and adhering to specific gender roles, as well as class biases [19]. Healthcare providers should be aware that these differences exist and should talk to their patients about their preferences.

It is important to remember that when there are differences between the healthcare provider’s decision-making beliefs and that of the patient’s, the differences should be respected. To do so is not to deny patient autonomy. On the contrary, when a patient feels their values are respected, they gain more trust in their healthcare provider. This helps to further open the lines of communication allowing the patient to feel more comfortable to talk to their healthcare provider about their doubts and concerns regarding treatment without the fear of being judged or dismissed. When this happens, medical healthcare providers should actively listen to their patients. Healthcare providers should learn from their patients about their healthcare practices and should also learn about their patient’s cultural and personal preferences. If healthcare providers do not have the general awareness of cultural traditions or beliefs of their patients, these cultural nuances can be easily overlooked and can impact healthcare outcomes [19, 22]. The authors remind the healthcare providers that they are ultimately responsible for ensuring safe and effective communication with their patients [9].

The Importance of Cultural Sensitivity

Culturally sensitive healthcare has been described as care in which healthcare providers offer services in a manner that is relevant to patients’ needs and expectations [28]. Studies have shown that the level of cultural sensitivity in the healthcare that patients perceive experiencing positively influences their adherence to treatment and ultimately their health outcomes [29, 30]. When a healthcare provider is aware of their patient’s healthcare practices, they are better able to work with their patient on identifying appropriate health and mental health interventions. When a healthcare provider is responsive to their patient’s preferences and cultural needs, the patient feels heard and understood. This patient is therefore more likely to stay in treatment with this healthcare provider. However, if a patient does not feel heard by their healthcare provider and instead feels stigmatized because their practices are thought to be foolish, this patient will likely not return to treatment. As a result this patient does not receive equitable care.

Beliefs around healthcare practices vary greatly. To illustrate this point, the authors will now provide examples of diverse beliefs that can be held by individuals from China, Cambodia, Southeast Asia, Haiti, and Latin American countries. For example, some Latinos believe that a woman should not leave the house for 40 days after having a baby. This is called “quarentena.” This belief is likely to be held by individuals from rural parts of various countries in Latin America (e.g., Mexico). In addition, some Latinos believe that after surgery (even if it’s minor surgery), one should not get out of bed too soon and should rest for several days as one’s body has been “traumatizado” (traumatized). Thus, it can be shocking for some Latino patients to hear the physical therapist tell them they need to get up and walk around a day after surgery.

In China, ginseng is widely used to help with conditions such as anemia, depression, digestion, rheumatism, and many others [31]. Other individuals believe in traditional forms of healing such as cupping, practiced in Cambodia and other Southeast Asian countries. Cupping consists of placing cups on the skin surface, usually the back, and creating a vacuum by suctioning the air from the cups, usually with heat. This is believed to cleanse the body of harmful toxins [32]. The marks left on the body from cupping can easily be interpreted as abuse. It is vital for healthcare providers to be sensitive to these practices in order to gain their patient’s trust. Healthcare providers should do their best to not misunderstand their patient’s cultural practices as doing so can lead to the patient feeling shamed and/or alienated.

In other countries, members from the community believe in spiritual rituals for the treatment of the sick (e.g., individuals from Cambodia or Haiti). For example, in Haiti the practice of voodoo as a way to treat and cure illness is widespread. This stems from the belief that many illness are caused by spirits or “demons” [33]. These general examples presented here are meant to provide a brief glimpse of some of the beliefs patients can hold. However, patients may not tell their healthcare providers about these remedies out of fear that their healthcare providers will not understand their practices and will negatively judge them. In some communities there is stigma associated with mental illness and as such patients may conceal their symptoms. Therefore, it is important for the healthcare provider to actively involve their patients in sharing information about their healthcare practices and their understanding of their health condition.

The various beliefs about healthcare practices around the world are infinite. The best way to start learning about them is by asking each patient, in a nonjudgmental and inquisitive fashion, what their beliefs are. This goes for individuals from the United States as well as outside the United States [19]. Healthcare providers should do their best to not make assumptions and instead to learn from each of their patients. There is so much richness in diversity, and when a healthcare provider shows cultural humility and a genuine interest in learning about their patients, they are better able to communicate with their patients and gain their trust. Healthcare providers should listen closely to the language patients use to describe their symptoms and to the ways in which they conceptualize their condition. Healthcare providers should then work with the patient, using their framework, on developing a plan for treatment. When needed, healthcare providers should also educate the patient using language that makes the information accessible to their patient. This open communication leads to trust. When a patient is able to trust their healthcare provider, they are more likely to try interventions they may have refused otherwise.

When a patient feels heard and not judged, they are more likely to listen to what their healthcare provider has to say about treatment options, which leads to the patient actually being “informed.” [22] Now the patient can make decisions about treatment on their own or with the support of family, friends, or a spiritual leader. Through this patient-centered approach to managing health and mental health, healthcare providers open the lines of communication. This can lead to the patient feeling more comfortable asking honest questions about treatment options. Through this process of open communication, the healthcare provider can empower their patients to try interventions they would have otherwise refused due to fear or distrust. The goal of open communication is to improve healthcare outcomes.

Disparities and Improving Health Outcomes

Through language, healthcare providers of different disciplines and specialties are able to communicate with their patients, and through communication they are able to learn about their patient’s concerns so they can then provide appropriate care. Effective communication is necessary in order for the healthcare provider to achieve an empathic connection with their patient. To communicate effectively with LEP patients, healthcare providers should make sure to ask their patients about their symptoms and ask them why they believe they are experiencing these symptoms. Once a healthcare provider has a sense of what their patient’s beliefs are, they can take the time to share with the patient facts about their condition and clear up any misconceptions using clear and simple language.

Communication barriers, whether literacy related, language related, or culture related, can impact healthcare outcomes. For example, language barriers can impact patients’ ability to relay information about their symptoms to physicians; importantly, this can influence treatment and overall healthcare experience. Still, there are healthcare providers who may choose to conduct an interview with LEP patients without the support of interpreter services. One possible rationale may include the perception that the encounter will take too long [34, 35]. Yes, healthcare providers have a very tight schedule, but the consequences of not having an interpreter could be dire. Other healthcare providers may choose to use their limited language skills in hopes of conducting an “adequate” medical interview [36, 37]. The risk taken by these healthcare providers is ineffective communication at best and poor health outcomes at worse. Studies have found that LEP patients experience more adverse events, such as medical errors and drug side effects, when compared to English speakers [38]. In the next section cases will be discussed where healthcare providers did not work with a trained medical interpreter and patients suffered the consequences of their decision.

It is important to recognize that when a patient is not able to effectively communicate with their healthcare provider, they are being put at a disadvantage which might result in the patient receiving a lower quality of care than those from less linguistically vulnerable groups. Language barriers have been evidenced to impact healthcare utilization, patient-physician trust, treatment adherence, satisfaction with healthcare, and screening practices [39, 40]. Studies conducted with LEP patients repeatedly reveal that patients don’t fully understand what is being discussed during a given encounter and feel dissatisfied with the care they receive [37, 41, 42].

In addition, if a patient can’t understand what is being said during a particular encounter, they will be less likely to adhere to treatment [15]. This can lead to a frustrating dynamic where the healthcare provider does not understand why the patient is not following their treatment. These patients are usually referred to as “noncompliant.” Meanwhile, the patient may be frustrated because they don’t know how to tell the healthcare provider they don’t understand what is being said to them. Some patients may in fact be reluctant to say anything to their healthcare provider because they don’t want to be disrespectful to them.

It is well established that language barriers contribute to health disparities for LEP patients [43]. Studies have also revealed that medical care is improved when healthcare providers work with professional medical interpreters [44]. Studies revealed that when healthcare providers partner with professional medical interpreters, interpretation errors are less likely to occur [8, 45], greater patient comprehension is achieved [46], and increased patient satisfaction with communication is reported [47]. In addition studies have found an association of higher satisfaction among patients and/or healthcare providers working with professional medical interpreters than with ad hoc interpreters [34, 48–50]. Overall, study findings suggest that medical interpreters are associated with an overall improvement of care for LEP patients.

It is likely that the improved utilization and clinical outcomes are mediated by the ability of professional medical interpreters to overcome health communication barriers [15]. Professional medical interpreters, through their experience, training, and knowledge of both medical and lay terminology, are better able to communicate patients’ symptoms and questions to healthcare professionals and healthcare professionals’ rationale for treatment and explanations of proper use of therapy to patients [15].

Additional Cases and Stories

The literature on adverse events and medical errors when caring for LEP patients is extensive. A few cases stand out as examples to illustrate the risks involved when steps aren’t taken to ensure effective communication. Cases run the spectrum of patients not adhering to treatment plans or becoming “noncompliant” to the full out malpractice as a result of poor communication.

One of the most widely known cases of poor outcomes based on language barriers is the case of an 18-year-old Cuban young man, Willie Ramirez, who was brought to a South Florida emergency room unconscious [51]. The family was Spanish speaking but no Spanish-speaking medical interpreter was available or requested. The only word the English-speaking healthcare provider could understand was “intoxicado”, which sounds much like the English word “intoxicated.” The staff began treating Ramirez for a drug overdose. However, the word “intoxicado” can have a significantly different meaning, such as nauseous or becoming ill from something a person ate or drank. The patient laid in a bed for 2 days with an untreated intracerebellar hemorrhage. By the time the healthcare providers realized the error in diagnosis, it was too late.

Willie became quadriplegic, an outcome that could have been avoided had the family and the doctors been able to communicate and understand each other effectively.This case also illustrates the stigma that patients and families feel when they face the need to request a medical interpreter. Immigrants want to be seen as making an effort to learn the dominant language and sometimes overestimate their own language skills or don’t want to appear “difficult” by requesting a medical interpreter. Additionally, in many cultures it is not considered polite to question figures of perceived authority, as doctors are seen in many cultures.

In another case, the wrong surgery was performed on a patient [52]. The patient spoke Spanish and the surgeon spoke Spanish. On the day of the surgery, the surgeon and the patient communicated directly during the preoperative procedures. In this case, the lack of a medical interpreter prevented the other English-speaking healthcare providers in the room from understanding the conversation between the surgeon and the patient. Had an interpreter been present, someone could have alerted the surgeon that the wrong procedure was about to take place. While much focus is placed on medical interpreters facilitating communication between English-speaking healthcare providers and LEP patients and families, it is also important to recognize the value and need of the medical interpreter in settings where other healthcare providers may be left out of the communication when a patient or family is able to communicate with a healthcare provider directly in another language.

In yet another case, a patient suffered an allegedly avoidable leg amputation due to ineffective communication. The patient, Mr. Hernandez, was admitted to the hospital due to a workplace leg injury. Mr. Hernandez spoke both English and Spanish but was more fluent in Spanish. His wife, who was born and educated in Mexico until she was 21 years of age, understood a little bit of English and was also more comfortable communicating in Spanish. The doctor and medical assistant who treated the patient reported that they spoke Spanish “well enough” to communicate with the Spanish-speaking patients [21]. Discharge instructions were provided to Mr. Hernandez in English. He was unable to effectively understand the instructions, which led to further medical complications. This case illustrates how sometimes healthcare providers and staff overestimate their own second-language fluency and may decide to not work with a medical interpreter. It also highlights that although patients may speak some level of English, they may feel more comfortable and understand their care if the communication, both oral and written, is done in their preferred language.The Tran case illustrates situations when children are English speaking but the parents (who must provide care, follow up with treatment plans at home, and give informed consent) are themselves limited English proficient and need professional medical interpreters to communicate effectively.

Tran, a 9-year-old Vietnamese girl, was brought to an emergency room, accompanied by her parents and 16-year-old brother. The medical staff in the emergency room asked the patient and her brother to interpret for the parents during the encounter. The patient was diagnosed with gastroenteritis. The emergency room medical staff told the family to bring their daughter back to the ER if side effects arose. However, the side effects were not discussed and the discharge paperwork was given to the family in English. At home, the patient began suffering from an aggressive infection, low blood volume, and ultimately suffered a heart attack, resulting in her death [21].

In this case, the patient had been misdiagnosed with gastroenteritis and died from a reaction to the inappropriate medication she had been prescribed.By not having a professional medical interpreter present, the patient’s family was denied the opportunity to effectively communicate with the healthcare providers. The patient’s parents were not able to understand how to care for their daughter, they were not able to provide informed consent, and they were not able to understand their daughter’s medical needs. Tran’s parents were not able to engage in a meaningful discussion with her healthcare providers, which resulted in a dire outcome. Having minors serve as interpreters, even when they are the patients, alienates the caregivers (the parents) from understanding their child’s medical condition, not to mention relying on the minor to convey their own complex medical conditions.

In the case of patient Chan, a 59-year-old Cantonese-speaking patient, the healthcare providers didn’t clearly identify the patient’s language. When checking in for his medical care, his language was sometimes documented as Vietnamese and other times as Cantonese. When it came to providing care for this patient, the healthcare providers consistently relied on the patient’s son as the interpreter. In this case, the patient died from an overdose of a chemotherapy drug because the son was not able to accurately interpret the given information [21].

In a third case, Sokolov, a 78-year-old Russian-speaking woman, was unable to communicate to her healthcare providers the type and intensity of leg pain she was experiencing. She did not have a medical interpreter. Upon examining the patient’s leg, her healthcare provider discovered her leg was cold and had been so for some time. This resulted in an amputation for that patient.

Unconscious Bias and How It Impacts Care of LEP Patients

The reality of unconscious bias in healthcare is not disputed. Since 2003 when the Institute of Medicine (IOM) first published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, this has been an area of focus for healthcare institutions and for healthcare providers committed to understanding these biases and learning how to address them in order to decrease and eliminate healthcare disparities. It is well documented, for example, that African Americans receive less cardiac catheterizations and that Hispanic Americans receive less pain medication in long bone fractures than patients who are White [53, 54].

As previously mentioned, studies have shown that patients who perceive their healthcare providers as being culturally sensitive are more likely to follow and adhere to treatment plans. They are also more likely to follow the doctor’s advice if they agree with or trust their doctor. Additionally, treatment plans or interventions that are inclusive of cultural behaviors and beliefs tend to be more effective [55]. However, the challenge lies in training healthcare providers to first recognize their own biases and stereotypes and, secondly, in identifying the skills needed to not let those conscious and unconscious biases affect the way in which they provide care to that particular patient.

One important aspect of this heightened sense of cultural sensitivity is to move the focus of healthcare provider training from cultural competence to cultural humility. Cultural competence infers an end point of obtaining mastery in cultural skills. However, culture is dynamic, evolving, and hardly ever the same for two individuals. Culture depends on a variety of factors, such as socioeconomic level, education, and life experiences. Focusing instead on the notion of cultural humility implies a concept of life-long learning and self-reflection by healthcare providers and creates a patient-centered environment of care that is less authoritative and more supportive of patients’ engagement and sharing of beliefs and personal perspectives on health and illness [56]. Exercising cultural humility and creating an environment that is patient centered, where patients’ cultural beliefs are accepted without judgment, reduce the risk of stigmatizing patients and contribute to their full participation in their care.

Conclusions

The authors believe in cultural humility and equitable healthcare for LEP patients. Exercising cultural humility and creating an environment where patients’ cultural beliefs are accepted without judgment reduces the risk of stigmatizing LEP patients. Likewise, exercising cultural humility allows the healthcare provider to identify potential areas of prejudice that can negatively impact LEP patient care. Developing partnerships with medical interpreters helps promote equitable healthcare as medical interpreters are instrumental in bridging the communication gap when there are language and cultural differences.

Healthcare providers are responsible for delivering respectful and effective healthcare to the increasingly diverse population of the United States. By being proactive in providing medical interpreter services, healthcare providers can help LEP patients feel more comfortable accepting/asking for language interpretation without the fear of being criticized for needing this support. This simple action can help in overcoming the stigma and prejudice that can be associated with being a patient with LEP. This action is important today and will become even more important given the change in the cultural demographics and the increased access to healthcare that these groups now have as a result of the Affordable Care Act.

Through language, healthcare providers are able to communicate with their LEP patients, and through communication, healthcare providers are able to learn about their LEP patient’s concerns so they may be able to effectively care for them. Language barriers can impact LEP patients’ ability to relay information about their symptoms to healthcare providers; importantly, this can influence treatment and overall healthcare experience. An entire encounter, and LEP patient’s treatment, may suffer when a healthcare provider and a patient with LEP do not communicate effectively. The goal of medical interpretation is to facilitate effective communication between patient or family and a healthcare provider. When a healthcare provider partners with a medical interpreter, they can work together in providing appropriate care by promoting effective communication, maintaining confidentiality, and reducing bias in the transfer of information between parties. Working with professional medical interpreters bridges the gap in health inequities and helps to reduce healthcare disparities.

Healthcare providers need to recognize that language barriers place LEP patients at a disadvantage that can lead to healthcare inequality. Thus, working with professional medical interpreters is an essential step in ensuring quality of care to every patient regardless of their language proficiency. Better quality care leads to better outcomes which results in lowered healthcare costs. Consistently, studies have demonstrated that working with professional medical interpreters is associated with an overall improvement of care for LEP patients. Working with professional medical interpreters has also been associated with a decrease in communication errors, increase in patient comprehension, increase in patient satisfaction with communication, and improved health outcomes. When a healthcare provider works with a professional medical interpreter, they give their LEP patient the opportunity to effectively communicate their symptoms to them. This in turn, allows the healthcare provider to develop an appropriate plan for treatment that can then be communicated to their LEP patient.

When a patient with LEP is able to effectively communicate with their healthcare provider, they are able to work with their healthcare provider and make an informed decision about their health, which leads to treatment adherence and satisfaction with healthcare. When a patient with LEP does not understand the instructions they are given, they are likely to follow the instructions incorrectly which can result in the patient needing to come in for urgent care. Not only does this result in increased healthcare costs, it also jeopardizes the health and well-being of the patient. However, when a patient with LEP understands their healthcare provider’s recommendations, they become active participants in taking care of their health.

It is important for healthcare providers to learn about their LEP patient’s cultural healthcare practices. Healthcare providers should ask, in a nonjudgmental way, about their patient’s understanding of their health condition. When a healthcare provider shows cultural humility and a genuine interest in learning about their LEP patient, they are better able to earn their patient’s trust which leads to improved communication.

Everyone who seeks healthcare has the right to receive that care in a manner that they can understand. Providing the highest-quality and safe care to all patient populations is the responsibility of healthcare providers and healthcare institutions. Research suggests that vulnerable populations, such as patients who have limited English proficiency are at higher risk to suffer from adverse events in hospitals than those who speak English due to communication barriers. It has also been shown that LEP patients may feel embarrassed or intimidated by how they may be perceived by healthcare providers if they advocate for themselves to have a medical interpreter present. Healthcare providers also must address their own biases and other perceived barriers to working with medical interpreters when caring for LEP patients. The authors assert that it is a best practice not to ask family members or bilingual staff to interpreter for LEP patients, even if that option seems more readily available and faster than requesting a medical interpreter.

It is also not appropriate to have children serve as interpreters for their LEP parents. Nor is it adequate for healthcare providers to use limited second-language skills when caring for LEP patients. It is best to partner with a professional medical interpreter. Healthcare providers must also engage LEP patients in sharing their beliefs and cultural concepts about their illness and create an environment where LEP patients feel safe in doing so. Making assumptions about LEP patients’ particular belief system or practices can lead to creating barriers and mistrust, which in turn compromises LEP patients’ adherence to plans of care. Healthcare providers can empower themselves and their LEP patients by partnering and working with trained medical interpreters. By working together optimal communication can be achieved, treatment outcomes can be improved, and the overall health of our diverse population can be promoted.