Commentary
Language barriers: challenges to quality healthcare Michael M. Wolz, BMBCH, JD Department of Dermatology, Mayo Clinic, Rochester, MN, USA E-mail: [email protected] Funding sources: None. Conflicts of interest: None. doi: 10.1111/ijd.12663
248
Language barriers pose significant challenges to providing effective and high-quality healthcare. Of 291.5 million Americans 5 years of age and over, 60.6 million people (21%) speak a language other than English at home.1 In the United States, federal and state laws provide a framework to ensure healthcare access for individuals unable to speak English.2,3 Many larger healthcare institutions have access to interpreter services, and the availability of professional translators has been associated with improvements in patient satisfaction, communication, and healthcare access.4–6 However, it is not only the availability of professional translators that helps ensure quality healthcare; it is also the individual healthcare provider’s cultural competence that is a cornerstone in reducing ethnic and racial disparities.7 An in-depth survey of 39 immigrant Somali women at a London obstetric center showed that the availability of translators alone is insufficient to overcome cultural barriers. Trust, accessibility, and quality of translation were other important factors.8 In addition to the logistical problem of providing adequate translation service, healthcare providers face individual ethical and epistemological predicaments in approaching patients with language barriers. These challenges can be divided into three main categories: space, time, and interpretation. Failure to recognize these challenges can lead to compromises in the quality of care. First, the presence of a translator can complicate the healthcare encounter as the interpreter may quite literally interpose between the healthcare provider and the patient. For example, if the interpreter stands between the healthcare provider and the patient, the latter two focus their attention on the interpreter rather than each other. This leads to the loss of important components of communication, including body language. In the most extreme of cases, the healthcare provider may even miss important clues to the diagnosis, such as constant lip-licking by the patient who presents for a perioral rash. Moreover, it leads to the loss of an opportunity of the healthcare provider and the patient to connect on a level beyond the spoken words, where smiles and warm gestures can establish trust and rapport. International Journal of Dermatology 2015, 54, 248–250
The physical presence of a translator leads to even more complexities when the translator is not a professional interpreter but a family member of the patient. In such scenarios, conflicts of interest and patient confidentiality come into play. Institutional guidelines often state that, whenever possible, translations should be performed by professional interpreters. In practice, professional translators are not always readily available, and the presence of bilingual family members can expedite and promote highquality healthcare. However, the principle of autonomy dictates that each patient should have a choice whether family members are present. Healthcare providers should also be open to alternative solutions the patient provides, such as mobile translators or other electronic devices. The patient and healthcare provider have a mutual interest and, as such, both may contribute to overcoming any language barrier. In many parts of the world, it is mandatory for healthcare providers to speak more than one language. Appropriate comfort with medical terms in different languages becomes a natural part of such a requirement. Ultimately, both the healthcare provider and patient should be comfortable with the translation services provided. Second, time is a critical factor in communication. The temporality of listening allows recourse to memory and interpretation in the listener. In the setting of healthcare, this often helps in reaching a diagnosis by recognizing patterns in the perceived communication. The words used by the patient may remind the healthcare provider of similar cases. However, it is not only the words used but also the time for interpretation that matter. Translation, even when real-time, stretches the time factor of communication and, thus, alters the healthcare provider’s usual method of working. For example, the healthcare provider might use the time necessary for translation to review the patient’s record or, more worryingly, pursue a different, unrelated task. The provider’s attention is therefore diverted from the communication with the patient. Similarly, the time needed to explain a diagnosis is also a time of interpretation of the patient’s reaction. Because of this interpretation, the healthcare provider can create an individualized management plan. If the patient’s reaction is ª 2014 The International Society of Dermatology
Commentary
lost in translation because the healthcare provider’s attention is elsewhere, the opportunity for patient-centered and individualized care is limited. Third and most importantly, language is humankind’s fundamental way of relating to the world. This has two implications for healthcare in the setting of language barriers. On the one hand, the meaning of a word depends on its use in language.9 Many linguists and philosophers have argued that differences in language lead to differences in experience and thought. The literal translation of a word can result in a very different meaning in the translated language than in the original text. Some foreign language words also have no direct English equivalent. On the other hand, our perception of another’s language fundamentally influences our impression of that individual. In the healthcare setting, the perception of the patient’s language influences diagnosis, investigations, and management. This introduces an element of subjectivity or, more accurately, intentionality. In his work on aesthetic interpretation, Jean-Paul Satre describes how meaning depends on acts of consciousness.10 The healthcare provider directs his conscious attention to the words of the interpreter. This harbors the danger of transference, in which the healthcare provider, consciously or subconsciously, uses the interpreter (rather than the interpreter’s words) to form an impression of the patient. Although the extent of linguistic differences is subject to debate, there is clearly something lost in translation. On the one hand, the meaning of the words as used in the original language is subject to alteration by the meaning of the words used in the translated language. On the other hand, the healthcare provider is deprived of his or her direct perception of the patient’s communication. In clinical practice, the three problems can be minimized by awareness of the complexities of translation and by addressing them individually. First, unnecessary space between the patient and physician should be eliminated. While the interpreter is a necessary contributor, whose services should be respected and acknowledged, it is important that the interpreter does not stand between the healthcare provider and the patient. In some settings, it may even be appropriate for the interpreter to stand behind a curtain while providing translation services. Similarly, the healthcare provider and the patient should always address each other directly. Second, the time delay imposed by the translation should be reduced by using short, easily comprehensible sentences. This simplifies the task of the interpreter and allows less room of misinterpretation and miscommunication. It also reduces the temptation to engage in other tasks while translation is in progress. Both healthcare provider and patient should keep their focus on each other, even while both of them are silent and the interpreter speaks. Finally, the healthª 2014 The International Society of Dermatology
care provider must keep an open mind. Jumping to conclusions is likely a recipe for misinterpretation. This applies also in cases when the healthcare provider is familiar with but not fluent in the patient’s language because important nuances could be missed or misinterpreted. If a translator is present, the center of attention should always be the patient, and transference to the interpreter must be carefully avoided by both healthcare provider and patient. The healthcare provider should not hesitate to repeat or clarify questions. Almost inevitably, something will be lost in translation. Thus, at the end of each component of the encounter, the healthcare provider should ask whether the patient has anything to add and whether the patient’s concerns were adequately addressed. Institutional approaches to language barriers also involve multiple steps: identifying language barriers, providing language services, and ensuring cultural competence among healthcare providers. Awareness of language barriers is a first, easily achievable step. Within a 3-month period, a hospital in Switzerland managed to add language data to nearly 100% of its patients by altering data collection at registration.11 The next step is providing adequate interpreter services. A systematic review demonstrated that professional interpreters could raise the quality of clinical care for patients with language barriers to approach or equal that for patients without language barriers.6 Finally, on an institutional level, cultural competence training programs may help increase awareness among healthcare providers and facilitate good quality care for patients from all backgrounds. Studies have demonstrated that short, focused educational events can significantly increase cultural competency scores.12
References 1 United States Census Bureau. Language Use in the United States: 201. Retrieved November 1, 2013 from the United States Census Bureau Web. 2 Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: title VI and beyond. J Gen Intern Med 2007; 22(Suppl. 2): 362–367. 3 Zuniga GC, Seol YH, Dadig B, et al. Progression in understanding and implementing the cultural and linguistic appropriate services standards: five-year follow-up at an academic center. Health Care Manag 2013; 32: 167–172. 4 Moreno G, Morales LS. Hablamos Juntos (Together We Speak): interpreters, provider communication, and satisfaction with care. J Gen Intern Med 2010; 25: 1282– 1288. 5 Ramirez D, Engel KG, Tang TS. Language interpreter utilization in the emergency department setting: a clinical review. J Health Care Poor Underserved 2008; 19: 352– 362. International Journal of Dermatology 2015, 54, 248–250
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6 Karliner LS, Jacobs EA, Chen AH, et al. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007; 42: 727–754. 7 Anderson LM, Scrimshaw SC, Fullilove MT, et al. Culturally competent healthcare systems. A systematic review. Am J Prev Med 2003; 24(3 Suppl): 68–79. 8 Binder P, Borne Y, Johnsdotter S, et al. Shared language is essential: communication in a multiethnic obstetric care setting. J Health Commun 2012; 17: 1171–1186. 9 Wittgenstein L. Philosophical Investigations/ Philosophische Untersuchungen. Anscombe
International Journal of Dermatology 2015, 54, 248–250
GEM (transl.), 2nd edn. Oxford: Blackwell, 1997. 10 Satre JP. What is Literature. Frechtman B. (transl). London: Methuen, 1967: 26. 11 Hudelson P, Dominice Dao M, Durieux-Paillard S. Quality in practice: integrating routine collection of patient language data into hospital practice. Int J Qual Health Care 2013; 25: 437–442. 12 Hawala-Druy S, Hill MH. Interdisciplinary: cultural competency and culturally congruent education for millennials in health professions. Nurse Educ Today 2012; 32: 772–778.
ª 2014 The International Society of Dermatology
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
Language barriers: challenges to quality healthcare Michael M. Wolz, BMBCH, JD Department of Dermatology, Mayo Clinic, Rochester, MN, USA E-mail: [email protected] Funding sources: None. Conflicts of interest: None. doi: 10.1111/ijd.12663
248
Language barriers pose significant challenges to providing effective and high-quality healthcare. Of 291.5 million Americans 5 years of age and over, 60.6 million people (21%) speak a language other than English at home.1 In the United States, federal and state laws provide a framework to ensure healthcare access for individuals unable to speak English.2,3 Many larger healthcare institutions have access to interpreter services, and the availability of professional translators has been associated with improvements in patient satisfaction, communication, and healthcare access.4–6 However, it is not only the availability of professional translators that helps ensure quality healthcare; it is also the individual healthcare provider’s cultural competence that is a cornerstone in reducing ethnic and racial disparities.7 An in-depth survey of 39 immigrant Somali women at a London obstetric center showed that the availability of translators alone is insufficient to overcome cultural barriers. Trust, accessibility, and quality of translation were other important factors.8 In addition to the logistical problem of providing adequate translation service, healthcare providers face individual ethical and epistemological predicaments in approaching patients with language barriers. These challenges can be divided into three main categories: space, time, and interpretation. Failure to recognize these challenges can lead to compromises in the quality of care. First, the presence of a translator can complicate the healthcare encounter as the interpreter may quite literally interpose between the healthcare provider and the patient. For example, if the interpreter stands between the healthcare provider and the patient, the latter two focus their attention on the interpreter rather than each other. This leads to the loss of important components of communication, including body language. In the most extreme of cases, the healthcare provider may even miss important clues to the diagnosis, such as constant lip-licking by the patient who presents for a perioral rash. Moreover, it leads to the loss of an opportunity of the healthcare provider and the patient to connect on a level beyond the spoken words, where smiles and warm gestures can establish trust and rapport. International Journal of Dermatology 2015, 54, 248–250
The physical presence of a translator leads to even more complexities when the translator is not a professional interpreter but a family member of the patient. In such scenarios, conflicts of interest and patient confidentiality come into play. Institutional guidelines often state that, whenever possible, translations should be performed by professional interpreters. In practice, professional translators are not always readily available, and the presence of bilingual family members can expedite and promote highquality healthcare. However, the principle of autonomy dictates that each patient should have a choice whether family members are present. Healthcare providers should also be open to alternative solutions the patient provides, such as mobile translators or other electronic devices. The patient and healthcare provider have a mutual interest and, as such, both may contribute to overcoming any language barrier. In many parts of the world, it is mandatory for healthcare providers to speak more than one language. Appropriate comfort with medical terms in different languages becomes a natural part of such a requirement. Ultimately, both the healthcare provider and patient should be comfortable with the translation services provided. Second, time is a critical factor in communication. The temporality of listening allows recourse to memory and interpretation in the listener. In the setting of healthcare, this often helps in reaching a diagnosis by recognizing patterns in the perceived communication. The words used by the patient may remind the healthcare provider of similar cases. However, it is not only the words used but also the time for interpretation that matter. Translation, even when real-time, stretches the time factor of communication and, thus, alters the healthcare provider’s usual method of working. For example, the healthcare provider might use the time necessary for translation to review the patient’s record or, more worryingly, pursue a different, unrelated task. The provider’s attention is therefore diverted from the communication with the patient. Similarly, the time needed to explain a diagnosis is also a time of interpretation of the patient’s reaction. Because of this interpretation, the healthcare provider can create an individualized management plan. If the patient’s reaction is ª 2014 The International Society of Dermatology
Commentary
lost in translation because the healthcare provider’s attention is elsewhere, the opportunity for patient-centered and individualized care is limited. Third and most importantly, language is humankind’s fundamental way of relating to the world. This has two implications for healthcare in the setting of language barriers. On the one hand, the meaning of a word depends on its use in language.9 Many linguists and philosophers have argued that differences in language lead to differences in experience and thought. The literal translation of a word can result in a very different meaning in the translated language than in the original text. Some foreign language words also have no direct English equivalent. On the other hand, our perception of another’s language fundamentally influences our impression of that individual. In the healthcare setting, the perception of the patient’s language influences diagnosis, investigations, and management. This introduces an element of subjectivity or, more accurately, intentionality. In his work on aesthetic interpretation, Jean-Paul Satre describes how meaning depends on acts of consciousness.10 The healthcare provider directs his conscious attention to the words of the interpreter. This harbors the danger of transference, in which the healthcare provider, consciously or subconsciously, uses the interpreter (rather than the interpreter’s words) to form an impression of the patient. Although the extent of linguistic differences is subject to debate, there is clearly something lost in translation. On the one hand, the meaning of the words as used in the original language is subject to alteration by the meaning of the words used in the translated language. On the other hand, the healthcare provider is deprived of his or her direct perception of the patient’s communication. In clinical practice, the three problems can be minimized by awareness of the complexities of translation and by addressing them individually. First, unnecessary space between the patient and physician should be eliminated. While the interpreter is a necessary contributor, whose services should be respected and acknowledged, it is important that the interpreter does not stand between the healthcare provider and the patient. In some settings, it may even be appropriate for the interpreter to stand behind a curtain while providing translation services. Similarly, the healthcare provider and the patient should always address each other directly. Second, the time delay imposed by the translation should be reduced by using short, easily comprehensible sentences. This simplifies the task of the interpreter and allows less room of misinterpretation and miscommunication. It also reduces the temptation to engage in other tasks while translation is in progress. Both healthcare provider and patient should keep their focus on each other, even while both of them are silent and the interpreter speaks. Finally, the healthª 2014 The International Society of Dermatology
care provider must keep an open mind. Jumping to conclusions is likely a recipe for misinterpretation. This applies also in cases when the healthcare provider is familiar with but not fluent in the patient’s language because important nuances could be missed or misinterpreted. If a translator is present, the center of attention should always be the patient, and transference to the interpreter must be carefully avoided by both healthcare provider and patient. The healthcare provider should not hesitate to repeat or clarify questions. Almost inevitably, something will be lost in translation. Thus, at the end of each component of the encounter, the healthcare provider should ask whether the patient has anything to add and whether the patient’s concerns were adequately addressed. Institutional approaches to language barriers also involve multiple steps: identifying language barriers, providing language services, and ensuring cultural competence among healthcare providers. Awareness of language barriers is a first, easily achievable step. Within a 3-month period, a hospital in Switzerland managed to add language data to nearly 100% of its patients by altering data collection at registration.11 The next step is providing adequate interpreter services. A systematic review demonstrated that professional interpreters could raise the quality of clinical care for patients with language barriers to approach or equal that for patients without language barriers.6 Finally, on an institutional level, cultural competence training programs may help increase awareness among healthcare providers and facilitate good quality care for patients from all backgrounds. Studies have demonstrated that short, focused educational events can significantly increase cultural competency scores.12
References 1 United States Census Bureau. Language Use in the United States: 201. Retrieved November 1, 2013 from the United States Census Bureau Web. 2 Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: title VI and beyond. J Gen Intern Med 2007; 22(Suppl. 2): 362–367. 3 Zuniga GC, Seol YH, Dadig B, et al. Progression in understanding and implementing the cultural and linguistic appropriate services standards: five-year follow-up at an academic center. Health Care Manag 2013; 32: 167–172. 4 Moreno G, Morales LS. Hablamos Juntos (Together We Speak): interpreters, provider communication, and satisfaction with care. J Gen Intern Med 2010; 25: 1282– 1288. 5 Ramirez D, Engel KG, Tang TS. Language interpreter utilization in the emergency department setting: a clinical review. J Health Care Poor Underserved 2008; 19: 352– 362. International Journal of Dermatology 2015, 54, 248–250
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6 Karliner LS, Jacobs EA, Chen AH, et al. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007; 42: 727–754. 7 Anderson LM, Scrimshaw SC, Fullilove MT, et al. Culturally competent healthcare systems. A systematic review. Am J Prev Med 2003; 24(3 Suppl): 68–79. 8 Binder P, Borne Y, Johnsdotter S, et al. Shared language is essential: communication in a multiethnic obstetric care setting. J Health Commun 2012; 17: 1171–1186. 9 Wittgenstein L. Philosophical Investigations/ Philosophische Untersuchungen. Anscombe
International Journal of Dermatology 2015, 54, 248–250
GEM (transl.), 2nd edn. Oxford: Blackwell, 1997. 10 Satre JP. What is Literature. Frechtman B. (transl). London: Methuen, 1967: 26. 11 Hudelson P, Dominice Dao M, Durieux-Paillard S. Quality in practice: integrating routine collection of patient language data into hospital practice. Int J Qual Health Care 2013; 25: 437–442. 12 Hawala-Druy S, Hill MH. Interdisciplinary: cultural competency and culturally congruent education for millennials in health professions. Nurse Educ Today 2012; 32: 772–778.
ª 2014 The International Society of Dermatology
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
