Navigating a Three Way Conversation

My parents constantly worried about my health when I was a child. They ensured that I attended annual checkups, received all my vaccines, and if anything seemed out of the  ordinary, they were quick to bring me to our pediatrician  as a walk-in patient by the end of the day. My mom was especially vigilant. I remember getting ready one morning for daycare  and complaining about a crick in my neck after sleeping on a new pillow. To the clinic we went.  None of this was because I was particularly sickly—I had chickenpox, strep throat, and other milestone illnesses that my playmates also caught—but rather because I was their first child and they were protective new parents. They were also first-generation immigrants with few friends and limited familial guidance to help navigate the American healthcare system.

The year I developed signs of a severe food allergy, my parents and I were seen by a handful of  specialists. The providers we saw were unfailingly patient and kind. During our last consult,  however, the physician breezed through the history-taking, walked us out of the room and  told us: “if possible, I suggest you bring a friend next time who can speak better English.” My  parents returned the remark with awkward chuckles. But on the drive home, they discussed  names of family friends and coworkers who could help translate for future visits. If it meant I  could receive what they believed to be the best treatment, their pride was but a drop in the  bucket.

I often think back to this encounter. At the time it did not strike me as odd to ask for help  translating. Occasionally, I would edit my dad’s emails and correct my mom’s pronunciation. Over the years, however, that perception has changed. I’ve realized that more could have been done to create a better experience for both my family and the allergist. I have since worked in various health systems and settings over the course of my undergraduate and medical education. One thing remains constant, the option of inviting a medical interpreter into the room.

In 2019, more than 25 million people living in the US self-reported that they spoke English less  than “very well” and were considered to have limited English proficiency (LEP). Studies show  that LEP patients have worse health outcomes compared to their English proficient  counterparts, likely due to a poor understanding of their condition and care.^[1] By addressing  health literacy, increasing patient satisfaction, improving patient adherence, and reducing  adverse events, a medical interpreter creates the foundation from which a patient-physician  relationship can be built.^[2]

Delivering the message, however, is not easy. Each word exchanged between patient and  physician is sensitive to cultural, environmental, and emotional interpretation. And what if  another family member in the room begins interjecting during the conversation, wanting to be  helpful? Or if a nurse entering the room supplies additional information about the patient? The  medical interpreter must navigate these elements, sometimes picking and choosing from  multiple voices to convey what they deem most pertinent to the receiver. Effective  communication thus requires an enormous amount of trust in all parties to be successful.

Medical interpreters come with their own set of headaches. As a medical scribe working in an  emergency department, I often overheard providers complain when a non-English speaker was  added to their list. “It’s the interpreting system,” one attending told me, almost sheepish. “It  just takes so much time”.

I could only agree. It was frustrating to watch. First, the patient would be roomed. Then an  order would be put in for an interpreter to arrive. During the day, this would usually be an in person experience. During peak hours or overnights, a video monitor on wheels would be sent  instead. Both options could take over an hour to become available. The video monitor needed  to be plugged in, set up, squeezed into a room already cluttered with wires, equipment and human bodies. If the wi-fi connection was poor, this took even longer.

But it was not just logistical issues. Conversations became long and exasperating for both  parties as physicians asked the same question in multiple different ways, sometimes due to  undetected issues with health literacy. Other times, they lacked trust in the interpreter. It was  not uncommon for me and the physician to exchange doubtful looks after an interpreter  transformed a robust explanation of a treatment plan into their own spark-notes version of a  few phrases. Even worse, patients could also mistakenly perceive the provider’s rising  annoyance and exhaustion as a personal attack.

I recently asked my mom about the experience with the allergist in my childhood. We hadn’t  followed up with him, choosing another specialist instead. “It’s not because he couldn’t  understand my accent. He just didn’t seem like he cared about us,” she said.

The patient’s ability to read the room does not require a proficiency in English. We all  understand this well. I remember the times as a medical student when I locked eyes with a  mother while the child in her lap giggled at the touch of my stethoscope on her belly. Another  time, when my attending grimly studied scans of a metastatic cancer in silence while the  patient’s wife shook her head. Those emotions easily penetrated our language barrier. As we  look to the future, improvements in technology as well as interpreter and physician training will  make visits more productive, user-friendly, and hopefully, more meaningful. However, more  than ever do we need to remind ourselves to cherish the time spent with patients and to treat  each other with compassion. This is how we can provide a truly patient-centered conversation.