Adriana sat quietly staring at the floor with her young son, Pablo, beside him. She looked tired. The two had come for a follow-up appointment for advice on Pablo’s autism medications. The clinician in the room didn’t speak Spanish, this family’s first language, so they waited in polite and slightly uncomfortable silence while a translator called on the phone. The visit has started. Questions were asked, answered in monosyllables; rinse, repeat. Finally, the young patient raised his head: “Where is Pilar?
Dr. Pilar Trelles, a child and adolescent psychiatrist at the Icahn School of Mount Sinai, is a physician whose native language is shared by many of her patients. Born and raised in Peru, she immigrated to the United States after medical school to begin clinical practice. Twice a week, she runs the psychiatric ward of a developmental disability clinic that treats patients on Medicaid. The majority of patients who come to this clinic are newly established immigrants, many of whom speak little or no language at all, with English, Spanish and Bengali being the two most commonly spoken languages in families. Although translation services are readily available, they are not always ideal.
Translation in the medical field has long been problematic. Elderly patients can get confused by the presence of a third party via a telephone or video device, while other people cannot hear very well. In unfortunate incident, an interpreter mistranslated a word, leading doctors to choose an incorrect treatment plan, ultimately leaving the patient a quadriplegic. Even beyond these concerns is the basic element of connection. “Families invite us into their lives, to share intimate details and issues they are going through,” says Trelles. “There has to be a component of trust, and sometimes it’s very hard to have that when you can’t talk to someone directly.”
About 24 million people in the United States have a primary language other than English and have limited English proficiency. During the pandemicthere has been an increase in the use of translators who “composeover the phone, but many nuanced forms of language, including expressions and body language, are missed. Consequently, a translation error rages– although it is severely under-reported. Not only that affect the quality of medical care received by patients who do not speak English, but there strengthen a barrier between clinician and patient, as many people do not feel comfortable sharing more than the bare minimum for fear of being misunderstood or stereotyped.
Patients with limited English proficiency have often immigrated to the United States from other countries to obtain specialized medical care. Many of them have already been rejected by the American system – an autistic child has been denied appropriate services, another with an emotional disability brought to the emergency room in handcuffs – so when a doctor shows up and relies on a third to understand the patient, close it. The spread of the coronavirus has exacerbated these trust and translation issues, as the virus has ravaged immigrant communities in particular, where more people have had to work outdoors despite the risks and where health care resources may be scarcer.
But as the pandemic continues to prevent the presence of in-person translators, what can be done? “I have a lot of families that I deal with where I don’t speak the same language as them and I will [be forced to] use an interpreter,” replies Trelles. “But then I make it a point to know them. I will spend time hearing about their lives, their families and where they come from, opening those doors even through an interpreter.
Yet working in the healthcare system makes it difficult. “There’s so much pressure to be quick and only deal with what needs to be done, but it takes more time and effort. I just don’t know if the health care system recognizes that. We are trying, but we need more support.
While immigrants are disproportionately affected by poor translation services, those in smaller communities who speak particular dialects suffer the most. “We have a family that comes to the clinic from a region of Africa where the official language is French but the language that this family speaks is a dialect particular to their region, and there are very few people who speak it. “, explains Trelles. In fact, no interpreter was readily available to translate. “At first it was so difficult that we actually had to track down the social worker who worked with this family and bring him to the clinic to translate.” Although this social worker was kind enough to adapt to the situation, it is not always possible.
Ultimately, medical translation errors and the lack of appropriate interpreting services compound systemic racist and classist practices in hospital settings, with underrepresented patients bearing the brunt of poor outcomes. While particularly relevant during the coronavirus pandemic, inadequate medical care and shaken trust at the hands of poor translation will remain important for years to come.
“When translating, I try not to just speak directly with the families while excluding everyone in the room,” says Trelles. “I also talk to the supplier to make sure everyone is on the same page and understands what’s going on, what makes the difference. It may seem a little broken, but taking that extra time helps because then when I’m not around, the other provider will still have that relationship with the patient.
Since in-person translators aren’t always an option, the same effort can be made by video translators. Providers and interpreters expressed a preference for video translators on incoming calls, with patients agree that it is important that the performers see them and vice versa. It should be noted that doctor visits that use telephone interpreters are correlated with shortest visit times. Perhaps one solution, albeit imperfect, is to emphasize the use of video by remote translators. It has been shown that video interpretation facilitate and enable patient confidentiality more than telephone translators. Although it’s not the cornerstone of trust, it can certainly be a foundation to build on.
Finally the door opened and Trelles entered. She was beaming when she saw Pablo and greeted him affectionately, kissing him and her mother. “Pablito, you are so big now! Did you know you’ve gotten so fat? Mom, how are you? You look good!” Adriana smiled slightly but uncrossed her legs and started talking, sharing what had happened in her life, her son’s life, their extended family’s life, and Trelles continued, deflecting questions about other family members not present during the visit. Meanwhile, Pablo ran to Trelles and hugged her without giving the impression of letting go. The clinical air finally faded and the heat engulfed.