The Importance of Addressing Language Barriers in the US Health System - Duke Personalized Health Care

Language Barriers and Poorer Health Outcomes

“I’m sorry to say this but we’ve found evidence of myocardial ischemia in your aortic valve. Now, we can either start you on a regimen of isosorbide or discuss plans for an angioplasty but we want to make sure you pick the option that best suits your needs.” Beyond the shock of hearing that the doctor has discovered a problem, most people would struggle to even comprehend a medical situation like this with all of the jargon woven into the diagnosis. To some, it might feel as if the physician is speaking an entirely different language. For the millions of people in the United States who don’t speak English, that feeling of confusion is a constant when seeking medical care. Language barriers play a large role in limiting access to quality healthcare, often creating a distinct public health divide between those who do and do not speak English.

It wasn’t until the Civil Rights Act of 1964 that translation needs were codified as a necessity for healthcare; stemming from the principles and verbiage of the act, the Department of Health and Human Services Office for Civil Rights declared inadequate interpretation as a form of discrimination. Consequently, the office required government-funded programs to provide equal services to non-English or limited English speakers. Despite this, many problems with the legislation constrained its execution, namely, how vaguely it defined “interpretation,” and how it aimed to enforce these rules.

Language Spoken at Home | American Community Survey | U.S. Census Bureau
US Census, language spoken at home in the United States. (Census.gov)

Since 1964, a number of federal regulations have been created to reinforce the essential nature of translation services such as Executive Order 13166 in 2000 and Section 1557 of the Affordable Care Act in 2010. Both mandated translator services in healthcare. This uptick in the availability of interpreter services hasn’t been unique to the medical field. Between 1990 and 2010, the United States Government spent 4.5 billion dollars on outsourced translation services indicating a trend toward understanding the necessity of having these services available in all areas of life.

As recently as the 1990s, however, professional translator services were essentially non-existent across most of the United States.[1] Physicians who encountered a patient who didn’t speak English had three communication channels available: make use of their own language skills, ask family or friends to translate, or attempt to recruit ad hoc interpreters. An ad hoc interpreter is any bilingual individual who is pulled away from their regular responsibility to provide impromptu translation service. In hospitals, this could be anyone from clerks, custodians, or patients in the waiting room awaiting medical services or their friends and families.

There are many ways to critique this arrangement. Physicians are often not adequately trained to practice bilingually. Involving friends and family can expose personal information and breach physician-patient confidentiality, while involving ad hoc interpreters may lead to poor translations. In these cases, interpretations may be inadequate due to difficulty in fully translating medical terminology.

Furthermore, under the current legislation, there are no mandatory interpreter services required for emergency medical services (EMS) personnel and private clinics. This makes 911 calls and urgent care visits difficult for those with limited English proficiency (LEPs). These difficulties are also present in pharmacies, which makes obtaining medication a hassle as well. Other common barriers include an inability to complete intake paperwork, poor patient-physician communication, and a failure to understand diagnoses, treatment options, risks, and costs. Some provide inaccurate histories or avoid medical practices out of fear of deportation. Together, these factors can result in misdiagnoses, adverse reactions to certain medications, and even psychological stress. Consequently, this leaves LEPs with in-person hospital visits as the only real method for multilingual treatment.

Interpreter services have become nearly ubiquitous in hospitals providing translation assistance for millions of Americans with limited English proficiency. In-person services may be offered for more commonly spoken languages in large hospitals, but for the most part, phone interpreter services have taken over the role of connecting patients and physicians to a trained interpreter. Legislation has been passed since 1964, mostly at the state level, ensuring that all patients are provided quick access to an interpreter if needed. For example, in New York State, all hospitals must “provide interpreters within 10 minutes in the emergency room and 20 minutes elsewhere in the hospital.” Still, this only goes as far as providing services for languages that are registered with the city or for which they have bilingual employees.

The situation becomes more complex for major metropolitan areas. Queens County, in New York State, is the most linguistically diverse county in the world with more than 360 languages spoken. To have in-person translation services for every language in every hospital would be a logistical impossibility. As such, individuals who speak a less common language or dialect slip through the cracks, leading to extremely poor communication between the physician and patient and possibly misdiagnosis.

Although numerous studies have found a direct correlation between the impact of communication between patients and physicians and better patient outcomes as well as decreased overall healthcare costs, the logistics of ensuring a bilingual physician for every language spoken in a region for every specialty in every state of the nation is currently impossible. A 2017 study about the most common languages spoken by multilingual physicians in metro areas across the United States found that languages like Swahili and Burmese are extremely underrepresented. The most commonly spoken language by multilingual physicians is Spanish at 36.2 percent. The number may seem high but it pales in comparison to the 61.5 percent of patients who need Spanish-speaking physicians. Training in medical Spanish is seldom offered, even as an elective, in many U.S. medical schools, not to mention any other languages.

To begin creating more linguistic diversity among physicians, several changes have to be made to medical school curriculums. By having specially trained, professional interpreters on hand in a larger number of medical encounters and by increasing and standardizing the languages offered, LEPs will be able to have as near equal access to healthcare as can be provided by our current healthcare system. The federal government should mandate translator services in order to provide all Americans equal access to quality medical care. Congress, however, is extremely slow at enacting anything as a law, especially anything related to healthcare. There are a number of plausible interim measures to take but each has its benefits and drawbacks. New legislation can be enacted at the state level or addendums to current laws can be implemented, however, any changes made at the state level will leave Americans in less cooperative states stranded. One solution may be to create a governmental organization to run interpreter services as currently, most interpreter services are sourced from third-party companies. However, as previously mentioned, the federal government is slow at implementing large changes and it may take decades before patients see benefits.

In the best-case scenario with regards to having more bilingual physicians, all medical schools would require basic medical Spanish and offer other languages as electives. This would drastically reduce mortality by increasing the speed at which patients receive the treatment they need. Realistically, we can aim higher to have more linguistically diverse physicians, nurses, and other medical personnel able to personally deliver relevant medical information without the need for a third party, but until then, we must focus on ensuring the availability and accessibility of interpreter services to limited English proficient individuals.

  1. Steven Woloshin, “Language Barriers in Medicine in the United States” JAMA: The Journal of the American Medical Association 273, no. 9 (1995): 724.

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