By Sirajum Sandhi
My head was buried in integrals during high school calculus class when I felt my cell phone vibrate in my back pocket. I glanced to find the words Social Worker flash across the screen, setting my heart pounding in my ears. I excused myself to answer the call in the hallway.
“Sirajum, would you be able to come to the hospital? I brought your mom here after she had passed out in my office.”
I pictured the worst possibilities, as I explained to my guidance counselor that I needed to leave immediately for the hospital.
I found my way to my mom’s room to find her lying in the hospital bed. She looked pale and sedated, and I could barely make it to her bedside before a team of doctors approached me. They detailed her critical condition and their plan for an emergency cesarean delivery. She is only seven months pregnant, I thought to myself. As though the doctors could read the confusion and horror on my face, they began to explain how it was not safe for my mom or the baby to wait any longer. They urged me, an untrained translator and minor, to translate all the medical jargon to my mom, a native Bengali speaker.
I have found myself in this position many times before and following this incident. I interned at Maimonides Hospital during high school. The hospital, located in the heart of Brooklyn, serves one of the most diverse communities in the U.S. During the internship, my supervisors and colleagues would often ask me to informally translate for South Asian patients with limited English proficiency (LEP). However, there are 7099 living South Asian languages, and I only speak three of them. More importantly, I am not a trained medical interpreter. When asked to translate for an Urdu-speaking patient, I found myself jumping in to try and help the patient but also to impress the supervising surgeon. The experience left me feeling uncomfortable, as I was aware of potentially doing more harm than good. Afterward, I started making excuses whenever any South Asian patients were in the room, regardless of the language they spoke and suggested using a medical interpreter.
In our healthcare system, the use of trained medical interpreters is relatively lower than that of ad-hoc interpreters. Family members or other untrained individuals often step in as interpreters, increasing the potential for errors. Pressed for time, healthcare professionals often avoid using interpretation services if they “can get by with just a little bit of the language or using some other form of communication.” One study found that the “hidden curriculum” in medical education conveys implicit messages to students that good communication is valued much lower than clinical knowledge. Moreover, the study described that “supervisors role-modeled an indifferent, and sometimes negative, attitude towards care of patients with LEP.” Medical students share that the hidden curriculum presents a moral conflict for them. Their efforts to use interpreters when they recognized suboptimal care was not appreciated by supervisors.
This hidden curriculum also affects patients’ (and their families’) willingness in asking for interpreters and using their services during patient-provider interactions. According to a study focusing on LEP Latina mothers’ pediatric healthcare experiences, some parents chose to “get by” even if interpreter services were available. “They believed it was more efficient and polite, it did not increase the burden on providers, and they perceived less stigma and discrimination if they were able to get by.” The study asks what would happen if interpretation services were default and calls for more research into its effect on healthcare safety and quality.
I attempted to interpret for my mom that horrid day, but she was not interested in listening to me. Besides, I can only imagine that my limited medical vocabulary did not clear up any fogginess. She kept protesting that she did not want an emergency cesarean delivery, and wanted to go home instead. The rest is a blur. I only remember feeling like the weight of two lives was on my shoulders as I convinced my mom to stay for the surgery. That day at the hospital felt like the longest day of my life. As for my mom, who had four prior successful cesarean deliveries back in Bangladesh, she would go on to suffer from several postpartum complications and emotional distress.
Lack of appropriate language services is a symptom of larger systemic inequity. Today’s racial and ethnic inequality are direct results of structural racism: “the historical and contemporary policies, practices, and norms that create and maintain white supremacy.” Since the structures surrounding us were built to benefit those who are already privileged, and therefore are inherently racist and xenophobic, the healthcare system and individual caregivers are not immune from perpetuating such inequities. Patients and families have reported humiliation and discrimination due to language barriers when accessing care. Such discrimination and biases based on country of origin, immigrant status, cultural and ethnic background, in turn, further contribute to the linguistic inequality that LEP patients have to navigate.
Studies have shown that patients with LEP receive lower-quality care than their English-proficient counterparts due to communication barriers and associated cultural differences, clinician biases, and structural barriers. This gap in service raises concerns about informed consent and effective and dignified care delivery.
My mom recalled that in the OR, she was extremely uncomfortable when she discovered the room teaming with medical students. “I don’t remember giving them my consent to probe around,” she complained. “The whole thing was off,” she insisted for weeks after the surgery. The events in the OR remain a mystery to me. Still, I cannot help but wonder if her experience would have been different if she was a native English speaker.
Obstetrics present a unique challenge in patient-provider communication due to the intimate and unpredictable nature of birth. Birthing people with LEP are at higher risk of birth-related trauma than their non-LEP counterparts. According to a 2015 study conducted in Hawaii, speaking a non-English language was associated with approximately two times the risk of having an obstetric trauma during a vaginal birth when other factors, including race and ethnicity, were controlled. Non-English speakers also had an increased rate of first-time cesarean deliveries and higher rates of potentially high-risk deliveries. In contrast, the study also found an increased rate of vaginal births after Caesarean among non-English speakers.
With rapidly changing demographics in the U.S., the demand for language services to access healthcare will increase. The Pew Research Center estimates by 2065, 24% of the U.S. population will be Hispanic, while 14% will be of Asian descent, compared with 18% and 6% as of 2015. Although healthcare organizations that receive federal funding are mandated by law to provide interpreters and written translated documents to LEP patients, they often fail to provide them. We cannot just rely on the good-will of the care provider to ensure that patients with LEP are getting quality healthcare. Administrative leadership is required to dismantle this systematic problem and facilitate equitable linguistic access for patients with LEP.
Following my mom’s cesarean delivery, she did not feel comfortable trusting the team with her newborn’s neonatal care. We transferred to another hospital, where my mom met a Bangladeshi medical resident. The resident was kind enough to provide my mom with guidance, emotional support, and interpretation services during my sibling’s stay at the hospital. The kind of holistic advocacy and care the resident provided, going out of her way to earn my mom’s trust, indicates that an alternate model for language services is needed. Moreover, it shows a lack of standardization in care delivery. Patients and their families cannot rely on coincidences that lead them to find native language speakers in the hospitals’ hallways.
Studies show that a lack of standardization in providing linguistic services leaves decisions to the individual provider for each interaction increasing the potential for errors. Currently, limited information is available on how health systems ensure interpreter use. Language-proficiency standards for health care providers who wish to use their non-English language skills is uncommon. Organizational commitment to standardize interpreter services and train all staff with an emphasis on the adverse health outcomes associated with inadequate language services is the first step to ensure linguistic equity. Additionally, if hospitals expand the roles of medical interpreters from on-call services to a more holistic patient-advocate, patients with LEP are more likely to receive improved services.
An example of such a holistic model is language-concordant doula services for LEP birthing people. The interpreter/doula model can bridge the communication gap with limited English proficient birthing people. Time is critical in obstetrics, and incorporating language-concordant doulas will sharply reduce average wait times. The use of an interpreter-doula also enhances cost -effectiveness for the hospital as a whole. This model may help guide the adoption of other specialty-specific interpreter services.
Based on Title VI of the Civil Rights Act, patients with LEP have a legal right to access healthcare in their preferred language. Language concordant care has been associated with improved patient experience, safer health care, and more efficient resource utilization. Adequate language services should not be seen as an extra service, rather understood as integral to patient care. There have been calls for medical schools to “increase opportunities for medical language courses” and health care policies to catch up with the evidence. At the same time, language concordant care for specialties like the obstetrics remain under-researched. Health care leaders and administrations need to invest in research and integrate evidence-based strategies in their curriculum to ensure equitable linguistic access for patients with limited English proficiency.
Sirajum Sandhi was a summer intern on the Delivery Decisions Initiative team at Ariadne Labs. They will graduate from Dartmouth College in Spring 2021 with a major in Women’s, Gender and Sexuality Studies and minors in Global Health and Religion. At Dartmouth, they have been a Race, Migration, and Sexuality Scholar, and an Eric Eichler Healthcare Leaders Fellow. Sirajum is also a student activist and community organizer. Their favorite leisure activity is dancing with their three-year-old sibling, whose birth inspired this article.