When Samia Ali worked as a medical scribe in Rhode Island—assisting doctors by writing down what happened during patient visits—she saw everything there is to see about the intimacies of a patient-physician relationship.
Many times, Ali told Splinter in an interview, she saw efficient and thoughtful care. But there was also neglect, mismanagement and, in some cases, open xenophobia.
“One dynamic that struck me was working with providers who did two things: express impatience when [patients were] not understanding English and [ignore] that most elder immigrants like bringing another person, usually one of their kids, to talk to the provider directly as a translator,” she said.
On more than one occasion, Ali, who was meant to be an impassive observer, had to act as a translator for patients who could not speak English.
During one visit, a Nepali patient came into the clinic where Ali worked. No Nepali translators were available at the time. Ali speaks Hindi, which is similar to Nepali, so she was brought into the exam room to translate for both the patient and physician. At the end of the appointment, the patient told Ali that it was the first time she could remember feeling really involved in her own care.
The pitfalls Ali was dealing with are ones which plague caregivers every day.
While some may be overtly bigoted, most medical caregivers are victim to their circumstance. They are impaired by a few obstacles when it comes to treating patients who can’t speak English: lack of satisfactory translation sources, limited time to spend with each patient, and inadequate cultural training. And patients in turn become distrustful and frustrated in medical environments, potentially complicating their care further. As Ali said, they can even feel locked out of their own treatment. When nearly 20 per cent of those living in America don’t speak English, multilingual care is vital.
Medicine tends to reflect issues we engage with all the time, and doctors and medical professionals are susceptible to the same forces as the rest of us. A 2017 study published by Chloë FitzGerald and Samia Hurst, researchers at the University of Geneva, found that there was a direct relationship between implicit bias and low quality of care. They concluded that prejudice, bigotry, and assumptions about patients based on their ethnicity, weight, or appearance can harm their care. FitzGerald and Hurst went on to show that implicit bias among health care professionals is exhibited at the same level as the wider population.
So when something as basic as a language barrier pops up, all of these biases can be triggered.
“If you’re in a setting where you’re time-limited, resource-limited, and you and your patient fundamentally do not speak the same language, there is absolutely is an increased risk for all of the things that already plague medicine like the propensity for mistreatment of marginalized people to then be increased, often just on the back of not understanding what the other person has going on,” Sameera Mokkarala, a obstetrician and gynecologist at Kaiser Permanente in California, told Splinter.
Frustrations over communication are amplified in the high-stakes medical environment, where one word or phrase could hold the missing link for proper diagnoses, Mokkarala said. A 2010 study from UC Berkeley’s School of Public Health and National Health Law Program found that 35 of 1,373 malpractice claims were connected to lack of adequate language access. Five of these cases resulted in patient death.
Having access to translation services is vital. The Center for Studying Health System Change released a survey in 2008 which concluded that 97 percent of physicians see at least one patient that requires translation services. But translation is still not widely available. The American Hospital Association published a survey in 2016 looking at 4,586 hospitals. Only 56 percent of the hospitals surveyed provided their patients with linguistic and translation services.
For nurses and doctors to administer the right care, they need to have a detailed medical history for the patient. They need to know about things like previous illnesses, drugs taken, and family histories. All of these items go into the formulation of a diagnosis. But if the patient and physician have trouble communicating with each other, obtaining a medical history can be extremely challenging and doctors might find themselves shooting in the dark trying to figure out what’s wrong with their patients. Or, worse, doctors might be operating with a “false premise,” as Mokkarala calls it.
Mokkarala said that on one occasion when she was working, a sick Spanish-speaking teenager came into the ER saying “estoy intoxicado.” Mokkarala’s colleagues believed he was drunk but “intoxicado” translates to “dizzy,” not “intoxicated.” It turned out that he had meningitis. (This exact linguistic confusion is unfortunately a very common one.) Translation can be tricky, even when you speak the language.
“Even little things like that can muck up a diagnosis,” Mokkarala said. “And then we explain stuff back to the patient, whether it’s a diagnosis or a care plan. Consents, that kind of thing. Even in English those things can be tough to explain adequately and to mutual satisfaction. So translation and communication issues make that worse.”
Because of Title IV of the Civil Rights Act, which bans discrimination based on race, color, or nation of origin, medical providers who receive Medicare and Medicaid have to provide an interpreter and cover the cost. If they refuse to do so, the government could pull federal funding, though there are no reports of this ever happening. (A 2007 study found that 43 states have some version of compliance laws around medical translation, but that the laws have not been consistently enforced.)
But this opens up a whole other range of possible issues. While Spanish speakers might be widely available, for example, other languages may not be. Which means if the single translator in your area who can speak Marshallese isn’t available, you’re stuck. So you either wait for a translator, all while the patient could be getting worse, or try to solve the issue yourself, which could also go very wrong. And, if the patient brings in family members or there’s a medical student on the floor who does speak the language, the patient might be reticent to be honest in conversation with them about their concerns. A medical setting can be a harrowing scene for some people of color, who feel as if their issues are ignored or downplayed. Those fears are worsened when there isn’t a clear line of communication between the patient and their provider.
When Sandy Sanchez takes her mother Rosa to the doctor in Dallas, she has to fill out her mother’s forms herself since they’re often in English. She told Splinter she’s been doing this, as well as translating what doctors said for her mom, since she was seven years old.
“I’d be there filling out her paperwork while the other kids played with the toys in the waiting room,” Sandy said. “Afterwards, I’d help her Google symptoms, and I’d help her understand medicine and how to read instructions.”
Her mother historically has looked for Spanish-speaking nurses and doctors after experiencing difficulties in communicating with other caregivers. And she has more or less found a few. Recently, Sandy said, Rosa has been experiencing pre-menopausal insomnia and depression and as a result her health has become impacted. But she has had trouble consistently finding caregivers who speak Spanish (one person she hired didn’t work out).
“I don’t live at home and there’s no one to help her out so if she didn’t have a caregiver who speaks Spanish, she wouldn’t be able to communicate what’s going on with her or get the proper healthcare,” Sandy said. “She’s very in tune with her wellbeing and health and goes to doctors a lot, so if she didn’t find doctors who speak Spanish, she wouldn’t be able to get the care she needs because of the language barrier.”
Not finding a pathway to communication can make adequate care impossible to give. And it can make patients uncomfortable with those trying to help them, frustrating care even more. Multilingual physicians are crucial but relatively rare even in high-density areas. Even interpreters in Dallas, where the Sanchez family was looking, are in high demand. At the city’s Parkland Hospital, translators are needed for approximately 1,000 visits a day and almost half the patients admitted need translation services.
Doximity, an online network for American health care professionals, found that at least ten major metro areas in the country face major language gaps where spoken languages by medical providers don’t match up to the most common non-English languages spoken by their patients. Washington, D.C. was at the top of this list, which also included Baltimore and Boston. The need for multilingual caregivers dwarfs the current supply.
According to a study from New American Economy, despite the fact that language skills are in demand across industries and ranks, the rate of Americans taking language classes in college is actually dropping. In 2013, only seven percent of registered American university students were enrolled in a language class. In 2014, the study found, only about 21 percent of Americans spoke a language other than English at home. Multilingual language requirements are largely being filled by foreign-born workers. In the healthcare industry specifically, just five roles—registered nurses, medical assistants, medical and health services managers, licensed practical and vocational nurses, and medical secretaries—accounted for 7.6 per cent of the bilingual jobs listed in 2015, the study said.
Anna N., who did not want to use her last name to protect the privacy of the patients she worked with, was a Russian-to-English translator in the Sacramento, CA area from 2013-2015. And though she was hired out by her interpreting company to translate for medical visits on behalf of a medical insurance company, she says she was never formally trained in medical translation.
“It was a ‘fly by the seat of your pants’ and ‘do the best you can’ sort of situation,” she told Splinter. “I did have a lot of experience translating for my family, which came very much in handy. I was not there to advise, merely to facilitate understanding, though it was at times a bit frustrating not to be able to intervene when I saw a deeper level of cultural or personal miscommunication that it would have been unprofessional for me to get involved in.”
Anna also saw patients dismiss their providers, maintaining they could use their own remedies for conditions they did not seem to understand. This could have been due to their confusion around their diagnosis, which wasn’t communicated to them effectively or in a culturally-appropriate way, and their distrust and discomfort in medical settings. Even severe conditions like skin cancer, one patient claimed, could “just smooth down” with a “nice herbal tincture.” Patients were confused or dismissive about what they were being told, and providers grew frustrated.
Even if caregivers had excellent translation services handy, they may not have enough time with their patients to tease out all the information they need. Doctors have on average 15 to 20 minutes to spend with each of their patients before their hospital or clinic hurries them on. This is often not enough time to explain complicated medical matters in English, let alone again in another language. Many of the medical workers I spoke to voiced frustration with both taking care of non-English speakers and themselves for being irritated by the situation. The shortcomings are there, they’re aware, but almost impossible to fix. And in the meanwhile, patients aren’t getting adequate care and medical workers don’t have enough time in the day to help them.
“It’s tougher to build rapport without common language, and using an interpreter on speakerphone causes this feeling of separation through technology,” Elicia Fox Chaney, a nurse practitioner in Neuro and Body Interventional Radiology at UCSF Medical Center in San Francisco, told Splinter. “And if I know that it’s going to take 10 minutes to call an English speaking patient, or 35 minutes to call a non-English speaking patient, at the end of the day when I’m tired and late and have a long commute ahead of me, I am more likely to call the English speaking patient and wait until the next day to contact the non-English speaker.”
For Capri Kasai, who uses they/them pronouns and previously worked as an opthalmic technician at Weill Cornell Medical Center in New York, time was a major factor in how well they could care for their patients.
“Unfortunately, I am sometimes impatient with non-English speakers,” Kasai told Splinter. “My patience and compassion are at maximum on days where our clinic volume is low enough to afford me more time to spend with them and less pressure to expedite their care so I can see the next patient.”
“These days are infrequent, however,” they continued. “Normally, our clinic volume is close to or exceeds 500 patients a day. On these days, I find myself rushing not just non-English speaking patients, but all patients because if I am slow my manager will reprimand me for not reaching the daily patient benchmark or for spending too much time with one patient.”
Cultural competency also becomes an obstacle to care. As Ali said, many non-English speaking patients like to bring family members into the examining room with them. Providers who don’t understand this and become frustrated may in turn stress their patients out. This lack of culturally open-minded bedside manner might begin in medical school. As recently as 2017, a standard American nursing textbook, Nursing: A Concept-Based Approach for Learning, offered up a ham-fisted approach to navigating the different cultural expectations of potential patients. For instance, the book said that “Arabs/Muslims” might thank Allah for pain, that Jews may be demanding, Asians may be stoic in the face of pain, along with other offensive stereotypes. (The book’s publisher said that the textbook would be revised.)
These gaps in medical care are a byproduct of a failing medical infrastructure and societal disregard for the “other.” It’s a vicious cycle: frustration and impatience combine with a lack of resources, an unforgiving schedule, and, at times, outright prejudice in a toxic combination. And because of it, patients are falling through the cracks every day.
Nadya Agrawal is a Brooklyn-based writer. She edits the print and digital magazine Kajal and co-hosts the Cardamom Pod.