Introduction

A language or communication barrier generally occurs between patients and medical personnel when a difference in the native language is present, or the patient is hearing-impaired. Misinterpretation of patient complaints or presentation is a growing problem in the United States when English is not the native language of patients. Physicians, nurses, and admitting and laboratory personnel, and many others are involved with patient care throughout the patient's stay. Potentially, language or communication barriers may negatively impact medical care as well as any ongoing relationship between patients, providers, and facilities. Ongoing relationships include but are not limited to ethical and legal implications that may occur over time. Historically, three different types of medical interpretation have been utilized by providers to overcome language barriers, each with advantages and disadvantages. Despite the proven advantages and increasing ease of video interpretation services, medical personnel is reluctant to regularly utilize this solution to improve the language barrier. Although the cost is high, further research and implementation of positive practices could improve the issues created by language barriers in the medical field.[1][2][3][4]

Issues of Concern

Language or communication barriers between patients and health professionals may negatively impact medical care. It has been reported that up to a quarter of all interpretation from family members or untrained personnel is incorrectly translated. This is due to the precision of the vocabulary used in the interpretation. Studies show trained personal demonstrated increased precision and decreased errors.[5][6][7]

There are several concerns when family members perform the initial interpretation, and there can be cumulative issues that may have a detrimental effect on patient care. First, there is a lack of confidentiality. Typically, family members have not had HIPPA training and may unintentionally discover information regarding the patient that may not be beneficial to the treatment plan and detrimental to their relationship with the patient. The depth of information may be limited due to the sensitive nature of several subjects, including sexual activity and substance use. Another concern includes the lack of medical knowledge required to interpret medical information correctly; this may lead to misunderstandings and errors in the translation, which is also the primary reason a patient’s child should be used as an interpreter only in medical emergencies. Finally, untrained interpreters and family members may have their own notions regarding medicine, evaluation, and treatment. These thoughts may be conveyed during translation, possibly causing an error and medical information to be skewed.[8][9]

Some see the lack of adequate interpretation during medical care as discrimination. Federally funded programs are required to provide adequate interpretation for patients with limited English skills in Title VI of the Civil Rights Act, except if they are Medicare Part B. In fact, several past legal decisions considered lack of appropriate interpretation as negligence. One such case involved the incorrect interpretation of the word “intoxicado” by office staff to mean “intoxicated.” The misinterpretation resulted in a fruitless dialog of drug and alcohol use. In reality, the meaning of the word in this situation was meant to be translated as “inadvertent toxicity,” and an intracranial hemorrhage was overlooked, resulting in a 71 million dollar lawsuit. Due to this case, as well as other rulings, some states in the United States instituted laws requiring adequate interpretation for medical encounters. Currently, adequate interpretation is not funded in all states, and the exact meaning of adequate interpretation is unclear.

Patients with a language barrier are more likely to receive larger workups, including labs, intravenous fluids, longer emergency department stays, more hospital admissions, and increased medical charges. Poor interpretation may lead to negative relationships with providers and interpreters as well as decreased compliance with treatment. Thus, patients who require medical interpretation are typically less likely to be satisfied with their care from medical providers. The lack of appropriate medical interpretation has been a cause of increased anxiety for patients. Patients with a language barrier spend less time in an INR therapeutic window at Coumadin clinics, have more vision impairment with type II diabetes, and have increased medical errors. Patients with language barriers and cultural differences are also less likely to seek mental health care. These are just a few of the many problems that may be avoided with appropriate medical interpretation.

Clinical Significance

There are three ways to provide adequate medical language interpretation during patient evaluation.

1. The first is to provide an on-site, live well trained medical interpreter. This is expensive and limits the variety of languages provided.
2. The second is the use of trained ad hoc hospital personnel, including nurses, technicians, or other hospital employees who have been specifically trained to be medical interpreters in a language they speak fluently. 
3. The last option is using a language line or video interpretation that provides many languages but is expensive. Large hospitals equipped with on-site interpreters often utilize off-site interpreters for languages in which they are not themselves proficient.

Bilingual hospital employees are a valuable resource for providing one-on-one medical interpretation. However, it has been proven that one out of every five hospital employee interpreters has inadequate language skills. When feasible, these employees should be tested for their language ability before acting as an interpreter. One validated assessment companies may consider is the Clinical Cultural and Linguistic Assessment that is administered via telephone. Some large organizations increase remuneration for employees who are trained and have passed proficiency examinations to expand the number of medical interpreters available.

Video interpretation ensues with a tablet or computer mounted on a mobile stand. The device is connected to a wireless internet network, and companies who provide video interpretation services may then connect to their interpreters. Video interpretation has been shown to improve use and communication over telephone-only interpretation.

Other Issues

In general, hospital discharge instructions are often misunderstood by patients, and patients with limited English proficiency tend to misinterpret this information to a greater extent. This had proven true for follow-up and medication information, even when language interpretation was provided for the patient. Therefore, in an attempt to minimize misunderstandings during hospital discharge, instructions should be printed in the patient’s proficient language, as well as a detailed explanation from an interpreter.

In-hospital professional interpreters have decreased the use of hospital assessments, including but not limited to laboratory tests, imaging, and medications. In-house interpreters are also the most cost-prohibitive mode to provide medical interpretation because it involves hiring a full-time employee. Another source of medical interpretation needs to be purchased and readily available when the hospital interpreter is not present or is not fluent in a respective language.

Physicians and nurses with limited interpretation skills continue to utilize ad hoc interpreters or other nearby people with poor language skills for important conversations, including patient consent and medicine administration. The patient's family members and guests should be used sparingly for ad hoc medical interpretation due to the reasons mentioned above.

The use of video interpretation can decrease the use of laboratory tests, radiology, EKG, ECHO, and hospital admissions. These savings can not offset the cost of providing in-house professional interpretation at most institutions.

Physicians and medical staff should be trained regarding the use of available medical interpretation services. Despite its obvious necessity, tele-interpreter services are underutilized in many situations due to lack of knowledge regarding availability, the misunderstanding regarding the length of time for use, difficulty training a rotating workforce, and the different procedures for activation of services at different times of the day.

Despite all of this information, language barriers persist for many patients seeking medical care.

Enhancing Healthcare Team Outcomes

When a patient presents with a language barrier, the responsibility falls on all interprofessional healthcare team members to find solutions to achieve proper communication as outlined above. This responsibility also falls on facility administrators, who should be tasked with providing solutions to this challenge as a matter of policy, as patient's lives may literally depend on clear communication. This can help optimize treatment and achieve the best patient outcomes; language barriers need to be eliminated, especially in this ever-increasing global community where healthcare plays an ever-increasing role. [Level 5]