A Matter of Interpretation

Amelia K. Barwise, MB, BCh, PhD

Language barriers present significant challenges for patients in their interactions with the health care system. Research conducted in hospital intensive care unit (ICU) and other critical care settings has shown that language barriers contribute to worse outcomes, including longer hospital stays and greater risk of dying in the ICU. Across many types of health care settings, access to professional interpreter services has a positive impact on quality of care and patient satisfaction.^1,2 The federal government mandates that patients are entitled to a qualified professional interpreter during health care encounters.  Despite this, such services are greatly underutilized, even in settings where interpreters are readily available.

In caring for patients in your community who may have language barriers, here are four key rules of thumb to keep in mind:

1. Try not to rely on family members, except in an emergency

While some patients do prefer family interpretation, there are risks to relying on a family member.  Most guidelines suggest that children under age 18, in particular, should not be relied upon to convey information accurately or to understand medical issues. Even adult family members may themselves have poor health literacy or may not fully understand what the doctor says, leading to inaccuracies or misinformation being conveyed to the patient.  They may withhold information from the doctor or from their relative, even subconsciously, because they feel it is embarrassing or might be difficult for the other person to hear. This can add to the confusion about whether the patient has truly made an informed consent, for example.

2. Where possible, choose professional over ad hoc interpretation

Many medical offices utilize ad hoc interpretation, pulling in a staff member to help when a patient’s understanding of English seems to be limited.  That may be alright if the ad hoc interpreter has a strong command of both languages, but in most cases, ad hoc interpretation is less than ideal.  The individuals who are helping on an ad hoc basis are pulled away from other presumably important tasks in the practice.  Depending on the staffer’s role, they may not have the same understanding of patient confidentiality that medical professionals have, so you may be inadvertently violating patient privacy by inviting someone else into the exam room.  And if the individual who is asked to help out isn’t truly fluent—perhaps they had a couple years of high school Spanish, for example—they may be conveying the doctor or patient’s intent incorrectly.

3. For routine situations or where in-person interpretation is not available, technology can help

Remote interpretation services via telephone or video chat, such as LanguageLine, CyraCom, BoostLingo, and many others, are available by subscription.  Increasingly, artificial intelligence (AI) is also making it possible for people who don’t speak the same language to quickly and efficiently communicate. There are many new AI interpretation tools, including some that are being developed specifically for the health care setting, such as Jaide and the Instant Language Assistant from TranslateLive. Smart phone applications that can quickly translate written information or interpret an instruction in another language on the fly can be helpful.  Keep in mind, however, that AI lacks human intuition; it can go off on tangents or “hallucinate” incorrect information when it does not have a clearly correct answer. Remote interpretation services are better, but they can still miss nonverbal cues and other information in the room that they cannot see or hear.

4. Prioritize by complexity and severity

When resources are scarce, it is most important to prioritize in-person interpretation for patients who are very sick, have a complex medical condition, or are being asked to make a major decision about their health.  We have studied this issue at the Mayo Clinic,³ but even in a primary care optometry office, there are ways to triage based on the type of case.  When a patient has a very worrying symptom, such as pain or loss of vision, for example, it is important to use an interpreter to make sure you are asking the right questions to accurately diagnose and make clinical decisions. Similarly, when referring a patient with a serious or sight-threatening condition to a specialist, you will want to make very sure the patient understands the urgency and the potential consequences of not following through with the referral appointment.

I encourage all clinicians to explore the options for interpreter services, both in-person and remote or AI-assisted, to improve understanding and access to care for patients.

For more information:

References:

1. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007;42(2):727-754.
2. Flores G. The impact of medical interpreter services on the quality of health care: A systematic review. Med Care Res Rev 2005;62(30:255-299.
3. Barwise AK, Curtis S, Diedrich DA, Pickering BW. Using artificial intelligence to promote equitable care for inpatients with language barriers and complex medical needs: Clinical stakeholder perspectives. J Am Med Inform Assoc 2024;31(3):611-621.

Amelia K. Barwise, MB, BCh, PhD, is Associate Professor of Medicine and Biomedical Ethics at the Mayo Clinic in Rochester, MN.  She has published extensively on the role of medical interpreters and how language barriers can impact health care.

Disclosure: Dr. Barwise has no relevant financial interests to report.

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