The dramatic rise in the U.S.' immigrant population is only expected to accelerate. Approximately 47 million people in this country, or 18% of the population over 5 years old, speak a language other than English at home, a 46% increase since 1990. Yet less than one-fourth of American hospitals employ professional interpreters, and those that do often fail to formally train them.
Clear communication is essential to quality healthcare. As the number of patients with limited English continues to grow, the potential exists for declining quality of care and increasing costs. Addressing language barriers must be a key component of how we as a nation of immigrants work to improve our healthcare system.
Several studies have shown that language barriers can negatively affect health outcomes, patient satisfaction, efficient use of resources and quality of care. For example, explaining the proper dosage and mode of administering medication often can be challenging even with English-proficient patients; a language barrier presents more substantial difficulties.
A report by the Center for Community Health Research and Action at Brandeis University revealed that more than one-fourth of limited-English patients without interpreters did not understand medication instructions.
Research by one of this article's authors, reported in the journal Pediatrics, found that errors in medical interpretation frequently have clinical consequences. Ad hoc interpreters (untrained bilingual employees, family members, friends or strangers pulled from the waiting room) were found to be significantly more likely to commit errors of potential clinical consequence than professional hospital interpreters.
Professional interpreters are not only better able to communicate medical terms but also to help reduce the ever-present risk of breaching patient privacy and confidentiality. This risk occurs when calling upon family members or volunteers to serve as the go-between for doctor and patient. Not surprisingly, patients often will not provide their doctor with sensitive information through relatives.
Additionally, the filtering of information through family or friends can be detrimental to patients and medical staff alike, and can lead to public health problems. For example, we know of a situation where a Spanish-speaking pregnant woman entered a hospital emergency room. In triage, a family member who spoke limited English assisted her; he didn't repeat all the questions asked by the nurse. It was later learned the woman suffered from active tuberculosis, but only after several hospital staff members were exposed. A trained medical interpreter could have circumvented such a problem.
Healthcare providers have not only an ethical obligation to use appropriately trained medical interpreters; they have a legal one. HHS' Office of Civil Rights has clarified that under Title VI of the 1964 Civil Rights Act recipients of federal assistance must provide language-assistance services at no cost to limited-English patients. Additionally, all vital documents must be translated into the language of any limited-English population that comprises 5% or more of the total population in a hospital's service area. Hospitals can be fined or lose federal funding for failing to comply with these regulations.
Equally compelling in our litigious society is the prevalence of groups willing to take the local hospital to court over perceived inequalities in care. And rare is the risk manager who doesn't have nightmares from the possibility of lawsuits resulting from a misdiagnosis caused by a language barrier.
Not only are clinical outcomes improved and risks minimized with proper professional interpretation, costs are better managed as well. A study reported in the Archives of Pediatrics and Adolescent Medicine, found what the authors call a "language barrier premium" caused by a systematic "up-triaging" of low-urgency patients with a language barrier.
When a language barrier existed, they found physicians typically performed more extensive diagnostic testing and offered more conservative treatment. When a professional interpreter was used, however, treatment protocols and costs were similar to those for English- proficient patients.
Most hospital administrators recognize that in addition to positive medical outcomes, cost savings and risk abatement, patient satisfaction is an equally important factor. Culturally sensitive, high-quality language assistance services are vital to ensure proper understanding on both sides of the medical equation.
Doctors can't be expected to provide top quality treatment if they can't communicate effectively with their patients. Patients can't be expected to follow instructions given in a language not their own. Whether they are on-site or contacted by telephone, professional interpreters provide accurate and culturally competent language assistance.
Study after study shows that optimal communication enhances patient satisfaction, improves outcomes and provides greater patient safety. Addressing language barriers must be an integral part of our ongoing efforts to improve our medical system. Without addressing language barriers, we cannot achieve a healthcare system that provides the highest quality of care for all Americans.
Michael Greenbaum, left, is chief executive officer of Tucson, Ariz.-based CyraCom International, and Glenn Flores is associate professor of pediatrics, epidemiology and health policy at the Medical College of Wisconsin and the Children's Hospital of Wisconsin, Milwaukee.