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Lost in Translation: The Negative Impact of Linguistic Barriers, Lack of
Cultural Competence, and Low Health Literacy Among Limited English-
Speaking Proficiency (LEP) Patients in U.S. Hospitals and the American
Healthcare Industry
By: Jillian N. McHenry
Imagine that your doctor asks your 9 year-old daughter to tell you that you have
just been diagnosed with life-threatening cancer; or the friendly Hispanic custodian to
interpret your routine pap smear and pelvic exam; or your roommate behind the curtain
to weigh-in on your end of life care meeting where you make critical decisions regarding
your final wishes and care. Unfortunately, these situations and many similar are not
merely hypothetical, in fact, they happen on a daily basis in hospitals throughout
America. It is a commonly known fact that the linguistic and cultural diversity of the
United States has grown significantly in recent years, and in the medical community,
this growth comes along with the problem of bridging this linguistic barrier and
overcoming a lack of cultural competence in order to provide quality and accessible
healthcare to patients who have limited english-speaking proficiency and low health
literacy skills. Being a bilingual healthcare worker myself, this is a problem that I am
faced with on a daily basis, and oftentimes, I am the equivalent of the “friendly Hispanic
custodian” who is brought in to “interpret your routine pap smear and pelvic exam.”
Through my own experiences and through interviews I have conducted with multilingual,
bilingual, and unilingual hospital staff, I have come to realize that the current status quo
and translation services infrastructure is not effective, and have, in turn, resorted to
strategizing, brainstorming, and researching solutions to improve this rapidly evolving
problem. It is my belief that in today’s day and age, providing quality healthcare in
communities goes hand-in-hand with providing quality translation services and
resources.
Let me first begin by outlining the problem at hand: The rapid growth of multiple
diverse languages and cultures - mainly brought on through the recent surge in
immigration - in the United States has given rise to a greater population of non-English
speaking patients in hospitals. This, coupled with a lack of cultural competence on
behalf of hospitals and low health literacy among limited English-speaking proficiency
(LEP) patients, has ignited a decline in the quality of healthcare delivered to LEP
patients. “Low health literacy, cultural barriers, and limited English proficiency have
been coined the ‘triple threat’ to effective health communication by The Joint
Commission,” reports Kate Singleton, MSW, LCSW in an article published in Nursing
World. With the American Medical Association (AMA) Journal of Ethics reporting that for
as many as ninety million English proficient Americans “the skills required to
comprehend typical health information exceed their abilities, according to The Joint
Commission on Accreditation of Healthcare Organizations (JCAHO)”, it is no surprise
that health literacy is even more a struggle for the 1 in 5 people living in the United
States (approximately 60.6 million) who have limited english-speaking proficiency. In
hospitals nationwide, this linguistic barrier and lack of health literacy can cause
potentially fatal consequences including medication errors, missed signs and
symptoms, longer hospital stays, higher rates of readmission within 30 days of
discharge, non-compliance with medications and discharge instructions, and in some
circumstances, even death. The AMA Journal of Ethics outlines that, “Too often we

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learn of life-and-death drama in local newspapers - reminders of the potential affects of
communication failure on patients with limited English proficiency; the young Savannah
mother of two, unable to speak English, who died after being treated for a possible
stomach infection in the emergency department and told to leave; or the 41-year old
native of Haiti who died of tuberculosis after giving birth to a son, never mentioning her
coughing fits during regular visits to her obstetrician during pregnancy. These cases
bring attention to the extreme outcomes, but, while language and cultural differences
are markers for variability that require attention, they can serve as reminders of the
importance of effective communication in all clinical encounters.”
In order to be considered health literate, one must posses a mastery of several
skills that they can utilize in application towards health-related tasks and decisions.
These skills include: the ability to read and write in English; to speak, listen, and
understand in English; to compute numerics; to think critically; and to make decisions.
Therefore, it is no surprise that culture and language can have an impact on how
patients both learn and apply these skills in healthcare settings. Furthermore, when so
many non-English speaking patients are not even literate - never mind health literate - in
their native languages, barriers arise in terms of providing/acquiring adequate
healthcare. However, these barriers are not only linguistic in nature, but they also lie in
lack of cultural competence. Providing quality medical care is about understanding the
idiosyncrasies of a patient’s culture equally as much as it is about providing quality
translation services. One of the doctors from my own hospital touched upon this point
while chatting with me one day when she said that people need to realize that, “it’s not
only cultural like language, it’s cultural also beliefs and religion and all of that. For
example, you have patients who have different religions and different beliefs. For
example, I had a patient the other day who was a Jehovah’s Witness with a very, very
low hematocrit and he refused blood transfusions. I cannot force that on them, I need to
respect their beliefs and values, and we need to work around it.” By understanding the
problem that we face and using this knowledge as a tool to improve our own cultural
competence and provide more targeted resources, we can make adjustments to the
status quo, essentially heightening the quality of care that is delivered to LEP patients.
This is a problem that we not only face on a national scale, but on a local level as
well. Through my work at a not-for-profit, community-based hospital in Southcoast,
Massachusetts, I have come to witness firsthand several situations similar to those
outlined by Singleton, the AMA Journal of Ethics, and JCAHO. Southcoast
Massachusetts has a heavy Portuguese and Brazilian population, and in recent years,
Hispanics have been added into the melting pot. Working at a community-based
hospital, I treat patients from all walks of life; from the poorest of the poor - homeless,
disabled veterans, prisoners, drug dealers, immigrants - to the middle class and the rich
- doctors, professors, businessmen and businesswomen. Our scope stretches from the
projects and jails of New Bedford to the affluent communities of Nonquitt and
Mattapoisett Neck. With that being said, on a daily basis we are exposed to a wide
variety of languages and culture. From what I have seen through my own work, my
internship with speech therapy, and my research with the some of the doctors is that on
an average day, at least 25% of a provider’s patients will be Portuguese or Spanish
speaking, sometimes up to 50%. If I listen closely enough while walking through the
halls, I can almost always hear Spanish and Portuguese being spoken, and I sometimes

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come across rarer languages such as Hatian Creole, French, Italian, Chinese,
Japanese, Mandarin, Cantonese, and Arabic. Translators are always part of the hospital
shuffle - including nurses, doctors, dietary, housekeeping, pharmacy, social workers,
therapists, rehab, and more - and many of the patient rooms contain a blue translation
telephone for those times when a translator is not available. But, even with the high
traffic of non-english speaking patients and the strong presence of translators and blue
phones, we are not exempt from problems concerning cultural competence and health
literacy.
In order to fully understand the inherent problems of language-discordant
communication, allow me to outline the current translation infrastructure that is in place,
its methods and modes of translation, and the pros and cons that surface as a result. In
my hospital, translation services works on a call-for-consult, first-come-first-serve basis.
From my understanding, there are an average of 3-4 translators on staff per day, with
1.5 on the weekend, and someone working on-call from home during the night. In my
experience, having only 3-4 translators at most for a 400+ bed hospital in a community
heavily populated by Portuguese and Spanish speaking people is not enough. While
completing my undergraduate internship in Speech and Language Pathology this past
semester, I spent a considerable about of time waiting for translators to become
available. The system works as such: When we need a translator, we call or page
translation services, giving our location and the language needed. They then tell us
approximately how long the wait currently is. Sometimes a translator is readily available,
sometimes we need to wait 10, 20, 30+ minutes at a time. Naturally, waiting awhile for a
translator slows down hospital operations significantly. I have seen staff be slowed
down and less productive due to waiting, discharges get pushed back by even a whole
day, and subpar translations provided by family members of staff with a limited-working
knowledge of the language as a quick substitute when time is of the essence. I have
seen patients receive fish when they ordered chicken, labs and tests ordered
incorrectly, symptoms misunderstood, discharge instructions not followed, medications
not complied with, and frequent readmission to the hospital due to these hinderances.
The other option we provide for translation services is the blue telephones that
connect you instantly to a translator at a remote call-center facility. I have used these
blue phones several times, and have actually found them to be more of a hinderance
than a helper. Yes, they are convenient in the sense that you do not need to wait for a
translator and that virtually any language is readily available, but I have used and
observed them enough to see through to the problems that still remain. Many
physicians agree that these phones are a time-saving convenience and a good
alternative, but I still remain skeptical. One of the doctors I work with shared with me her
thoughts and experiences on using the telephone translation service. She described this
alternative as being “very helpful. For example, the other day I had an Arabic-speaking
patient, which is very unusual for us, but with the phone it was great. That’s what I used
during residency a lot as well- the hospital where I trained there was a lot of Asian
languages spoken like Vietnamese. So we used the phone translators a lot as well,
especially overnight. It works well, but it’s hard with elderly patients because they don’t
get the concept that the phone is there to translate me speaking but with younger
patients it’s great, I like the phone. You don’t need to wait for anyone to come. I think
that it’s a good alternative, you need to remember that we cannot have all the

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languages translated in the hospital so there are a lot of limitations. You usually have
translators for Spanish in any single hospital that you go to and the second most spoken
language, but that’s pretty much it.”
Personally, I find the translation telephones to be rather cold. More often than
not, the patient does not understand how this system works - that we are both supposed
to pick up a receiver and use the phone together. It also takes a very long time.
However, my biggest issue is that I feel that all of the unspoken communication such as
facial expressions, body language, hand gestures, etc. are not able to be
communicated, whereas a translator who is physically present can rely these additional
forms of communication. To me, this barrier signifies that there is an aspect of the
translation that is missing, essentially lowering the quality of translation received.
Furthermore, in order to be culturally competent and take into account the patient’s
cultural views and norms, one needs to be able to “read the patient,” in essence
capturing and conveying the patient’s unspoken communication. This is generally the
job of the translator - to bridge the gap that is both linguistic and cultural. By not being
able to be physically present with the patient and myself, the phone translator is unable
to pick up on the context of these subtle unspoken nuances and idiosyncrasies that are
so important in establishing cultural competence.
When I reflect back upon my own experiences, research, and the thoughts and
opinions that others have shared with me, it becomes shockingly apparent that the
status quo of translation infrastructure is less than ideal. To use my own community-
based hospital as an example, the current set-up is not sufficient. It is nearly impossible
to provide quality healthcare without providing quality translation services; and in order
to keep up with the rapidly growing population of non-English speakers, to establish
cultural competency, and to identify and overcome the needs and struggles of LEP
patients, the current translation infrastructure needs to be seriously reconsidered and
adapted to meet these new standards of care.
The AMA Journal of Ethics outlines three main problems that lie within the
current translation infrastructure: “(1) language and culture are inextricably linked; (2)
relationship building is hindered with interpreter-mediated communication; and (3)
cultural competency and effective communication are interdependent.” I, myself, would
like to add a fourth problem: Translators and hospital staff are not adequately trained to
meet a proficient level of cultural competence in order to provide quality patient care.
When Ludwig Wittgenstein said, “if we spoke a different language, we would
perceive a somewhat different world,” he was correct. The AMA Journal of Ethics
outlined that “language professionals tell us that words have no meaning until meaning
is assigned; that is, as we learn new words we associate them with concepts that give
them meaning. Comprehension, then, is based on our ability to link experience and
knowledge of the world to the words we hear.” Naturally, if we are hearing the same
word but in different languages, the assigned meanings and their respective concepts
will differ, causing comprehension to vary between the languages. This is established
through the concept of Scenes-and-Frames Semantics: “Common experiences lead to
common “frames of reference.” Speaking a language other than English in the U.S.
obviously means that one’s lived experience are likely to be quite different than those of
English speakers. The greater the difference between our lived experiences and those
of others, the more likely our frames of reference will be different.”

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The second problem identified in the AMA Journal of Ethics is that “relationship
building is hindered by interpreter-mediated communication.” It does make sense that
“when patient and doctor do not speak the same language, there is less opportunity to
develop rapport or use “small talk” to obtain a comprehensive patient history, learn
relevant clinical information, or increase emotional engagement in treatment.” It is
difficult to develop rapport between doctor and patient when both speak the same
language, never mind when a language barrier and interpreter are introduced into the
conversation. Since patient and doctor are essentially speaking through an interpreter
and not directly to each other, it becomes very difficult for this rapport to develop.
I once had a Portuguese-speaking woman as a patient who I bonded with simply
over the fact that we both spoke Portuguese. I remember her telling me that I was the
only person she really connected with. I wrote about her in my clinical journal that I kept
to document my experiences: “She told me that none of her nurses, doctors, therapists,
or other providers spoke Portuguese. She told me that I was the only one who spoke
Portuguese with her. I asked her if a translator was called for the times when a doctor,
nurse, therapist, or other provider needed to speak with her. Her answer was no. She
then said, “I like you a lot. You speak my language to me. You try to help me
understand. No one else does that for me. I am going to miss you.” This made me
think… I wondered why translators were not being called. Are there not enough of
them? Also, shouldn’t health care providers speak at least one other language so that
they can communicate more effectively with a larger percentile of their patients? In this
rapidly evolving melting pot of language and culture, shouldn’t it be a requirement for a
healthcare provider to be bilingual in at least one other language besides English? Is
foreign language not taught in school as much as it should be? I became frustrated by
this woman’s dilemma, especially when she asked me, “I don’t know what is wrong with
me. I don’t understand what is happening. Can you tell me what is wrong? Can you tell
me when I can go home?” I was bothered by the fact that this woman had no idea what
was wrong with her and how she was being medically treated. Does this violate the
policy of informed consent? Regardless, it is an issue and I feel I should do something
to help solve it.”
However, as many times as I have seen and experienced how interpreter-
mediated communication and interpreter-absent communication can hinder quality of
care, I have also seen the stark opposite. During my internship, I spent some time
shadowing and working with a bilingual doctor, a native of Brazil, who speaks both
Portuguese and English (and some Spanish that she describes as “broken”) who is well
versed in both languages and cultures and therefore able to easily establish rapport with
LEP patients. Over the course of a day, I accompanied her on clinical rounds. She
visited and examined patients; spoke at length with them and their families; taught me a
great deal about patient interaction, diagnostic processes, treatment, and medicine in
general; and even was kind enough to share her experiences in relation to working with
LEP patients from the unique perspective of being a proficient bilingual healthcare
provider.
Out of all the patients that we visited together, there was one patient in particular
with whom she developed a beautiful relationship. He was an older Portuguese widower
who had recently lost his wife to an aggressive and rapidly progressing brain cancer. He
and his wife never had any children and any family he had left was living back home, in

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Portugal. I watched and was actually quite moved as she sat down next to him, held his
hand, looked at him with genuine care and concern, and spoke to him in his own
language, Portuguese. She was attentive to the smallest of details - even his gripe
about hospital food - just simply smiling and nodding her head in acknowledgement to
show she cared and was listening. As she got up to leave, he kissed her hands, hugged
her, and kissed her on the cheek. I was surprised to see that she obliged, as I never
would have.
Later that day, when we sat down to speak, I brought this patient to her attention.
She shared her thoughts with me, saying: “Unfortunately he is a patient who went
through a lot in his life. You will learn also a lot about interactions with patients and
there’s no one that can teach you that, but you know the patient that you need to be a
little bit more reserved, the patients who hold your hands and kiss your hands and are
very approachable to you, and those who you need to set the limits, and this just comes
with time and experience on rounding on patients and seeing different scenarios and
things like that. But I think that with that specific patient, it’s because he is alone, all he
has was his wife to whom he was married for 50 years, she died of a brain cancer and it
was something that happened very fast. They never had any kids so his entire family is
in Portugal , and he doesn’t have anyone to talk to him. It’s a sad story but it’s true. So
he doesn’t like the nurse that comes in and out, he likes the other one who goes in and
spends an hour with him in the room, listening to every single complaint, to his entire
life, then he shows the picture of his wife again to her and just like he did with me a
couple of days ago.”
I reflect back on this encounter and cannot help but think that as healthcare
professionals, we should all strive to be able to achieve the level of cultural competence
and effective communication as she did, whether we need to use an interpreter or not.
This is not something that would have happened if it were another doctor in the room
with him accompanied by an interpreter. This is what quality patient care and
communication should be. This very talented doctor has an invaluable skill set,
something every healthcare worker should strive to cultivate through the use of self-
assessment, professional development, and continuing education in order to help solve
the problem of rapport-building in interpreter-mediated communication and interpreter-
absent communication.
The final problem brought forth by the AMA Journal of Ethics is that “cultural
competency and and effective communication are interdependent.” Therefore, it is
important for us as healthcare providers to understand that we need to not only speak to
our patients in their language, but we also need to consider their culture as well. For
example, in some cultures it is improper for a man to speak to a female doctor. Other
cultures believe that medications poison the body which leads them to the belief that
side effects that they are feeling from what we have diagnosed as their illnesses are
actually from the very medications upon which their lives depend. While others, as my
colleague previously touched upon, may have beliefs prohibiting them from receiving
blood and organs, even if their life were to depend on it. According to the National
Health Institute: “One’s culture affects one’s understanding of a world or sentence and
even one’s perception of the world. To learn a language is not the same as
understanding a culture - even those who share a common native language may not
share a common culture.”

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My own experience has proven this to be inexplicably true. There have been
times where my Portuguese language skills have been on par, but there was a cultural
disconnect between my patient and I, simply because we come from different cultures
and therefore have different perceptions of the world. For example, one day my clinical
instructor and I were doing a routine speech and swallowing screen on a young mother
of three who was suffering from end-stage metastatic breast cancer with mets on the
liver, kidneys, and brain (she has since passed away). During our examination of her
mouth, we noticed that she had thrush, essentially, a yeast infection of the mouth. When
we told her what we had found, she became very agitated. She kept telling us that she
had been in this bed alone, that no one had been in bed with her, that she had not
performed any sexual acts, so how could she possibly have yeast infection? It became
apparent to me that culturally, this woman had associated yeast infections with sexually
promiscuous behavior. In essence, telling her that she had a yeast infection was
accusing her of inappropriate sexual conduct while in reality, her yeast infection was
from chemotherapy and strong antibiotics. In this situation, my language was
understood, it was the cultural intent that was misconstrued due to the fact that this
woman and I did not share a common culture. From that day on, I became more aware
of the cultural implications that were so closely married to my words. I realized that even
though a patient can hear the exact words and phrases that I intend for them to hear,
that does not mean they will understand it the way I expect them to .
Through my own reading and research I came across a fantastic quote that I
believe sums up this problem quite well. The Association of Asian Pacific Community
Health Organizations (AAPCHO) wrote: “Just as syringes are need for drawing blood,
communication between providers and patients is critical for discussing issues such as
diagnoses, treatment plans, medication adherence, and disease management
technique.” Unfortunately, oftentimes this communication is hindered by lack of cultural
competence, the equivalent of “operating with a rusty scalpel,” proving the point that
reform to the existing translation infrastructure is vital.
The problem that I notice through my daily work and observation is that
translators and bilingual staff are not provided with adequate training, education, and
resources in order to overcome linguistic barriers, lack of cultural competence, and low
health literacy in their LEP patients. The AMA Journal of Ethics has found that:
“Unfortunately, most interpreters learn their trade through on-the-job training. Their
language proficiency and how accurately intended meaning is conveyed from one party
to the other is often not known. Using untrained interpreters or family members who are
less skilled in being transparent can result in incomplete patient assessments.”
One of the biggest problems that I face with translator-mediated communication
is that often I receive a summary when what I really want is a translation. I do believe
that in large part, this problem can be linked to improper/inadequate training and an
overall lack of continuing education and professional development programs. This is not
to say that the translators from my hospital are incompetent, in fact, they are wonderful!
They are kind, caring, fluent in multiple languages, and try so very hard to bridge
linguistic and cultural gaps between patient and provider. Rather, it is my observation
that many of them often summarize what a patient is saying instead of translating as
close to word-for-word as is possible. From my perspective, a bilingual healthcare
worker who has watched several interpreter-mediated communication encounters,

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these summaries often leave out information that I would deem to be crucial to both
patient and provider. In my opinion, this would essentially lower the quality of translation
and negatively impact the quality of patient care.
When I sat down to chat one day with the doctor that I was following, the topic of
translators and summaries arose. Here is an excerpt from our (recorded) conversation:
MD: “You talk like a ten second paragraph - then the person translates
into blah blah blah. Or the opposite, right? The patient is speaking in their
language for like ten seconds and then the lady looks at you and says
“Yes.” And I’m like that cannot be “Yes.” That does not! Like, ten seconds
of speaking does not translate into “Yes.” But what did the person say?
“No, he said yes.” I was like, He didn’t say yes. Like he was talking for ten
seconds! What did he say? “Oh no, he just said yes.” And I was like your
yes is quite long if you have to say all the time, right? Ten seconds for
every single yes! But it’s hard, it’s different because you don’t know what
they're saying. And sometimes they might have questions and even
though the translator is not supposed to give their opinion or answer
anything, they are supposed to just translate back to us, you don’t know
what’s being said. But, you expect the best.
Me: “I find it interesting when I do it with Portuguese because I feel like I
kind of get a unique perspective because I can understand everything
that’s going on, whereas my advisor won’t, and I’ll understand my advisor,
then I’ll understand the patient and the translator, so it’s kind of like- and
I’ll say to my advisor, “wow that was a really bad translation.” And she’ll
ask me why and I’ll just say “I really don’t feel comfortable with that.”
Some of them, not all of them, but one of them just summarized. And I feel
like…
MD: It’s not your job!
ME: …with something medical you need to…
MD: It’s not your job to summarize.
Me: …be as specific as possible.
MD: And I’m not asking you to summarize, I’m asking you to translate. Not
to give me a summary of what the patient said. And that’s exactly what I
was saying, so the patient will talk for like ten seconds and then where
was it? “Yes.” No. It was not yes! The patient said a bunch of different
things and probably asking questions that you answered for him and you
gave me a yes.
ME: Or they’ll have a little side conversation about something and then
they’ll come back to you and you’re like well what did I miss? And is it
relevant? And they’ll be like oh no, no, no it’s not relevant, but then you’re
kind of like well let me be the judge of that.”
Contributing to this problem is the fact that less than one in four hospitals in the
United States currently provides training for medical interpreters. Additionally, the
majority of hospital staff are not trained to work with interpreters and have little or no
education in the linguistic or cultural issues related to clinical care. In recent years, the
federal government has required that all hospitals provide patients with interpreters,
however, they have failed to set formal standards for interpreter services, and do not

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require routine quality assessment of these services. When JCAHO “developed
standards that required an organization to address the language needs of patients, in
was in the context of the patient’s right to be fully informed about his or her care. Later,
the need to communicate effectively was recognized as an element of the quality of
patient care. Today, effective communication is seen as a prerequisite to safe health
care.” Therefore, as the linguistic and cultural diversity of the United States continued to
grow, the standards of care rose in order to accommodate the influx in immigration.
However, because of the government’s lack of formal standards and educational
programs, studies have shown that many doctors and healthcare workers who say they
are proficient in another language, really aren’t as proficient as they think they are, in
essence causing the language barrier to be underestimated by both patient and
provider. As JCAHO stated, this truly has become an issue that is much larger than
solely patient rights and quality healthcare, it has become an issue of safe medical
practice.
In order to overcome these problems and barriers, I suggest that a new
infrastructure be implemented. This infrastructure should consist of three parts: (1)
federal and board regulations, (2) video translating services, and (3) professional
development and continuing education opportunities for all hospital staff.
ABC News reported that “with the absence of guidelines and a formal certification
process to demonstrate interpreter competence, many health care facilities across the
country may not be providing the best possible care to all patients.” Ideally, the system
would benefit from having a federally guided program with established standards of care
in the form of board and an interdisciplinary learning collaborative. The auspices of the
board and the collaborative would be similar to those of a medical board, such as the
American Board of Internal Medicine, whose activities include “conducting or
commissioning research to determine whether an emerging trend in medical practice
requires the attention of its members; developing and updating policy guidelines to
reflect the impact of scientific advances, new technologies and changing cultural
attitudes; helping members carry out their duties as regulators of the medical profession
through educational meetings, programs, and seminars; representing its members in a
growing number of collaborations as new medical knowledge and new technologies
demand work across old boundaries; serving as a national and international
spokesperson on issues related to medical regulation and discipline; and conducting
outreach to the public around new initiatives and responding to calls from the media,
editors and concerned citizens.” Therefore, not only would this board be responsible for
accrediting educational institutions and professionals, but for acting as a resource for
translators and all healthcare workers. Keeping in similarity with medical boards,
translators would need to “sit for boards” before being authorized to practice (as is
required of doctors, nurses, and other personnel), and would need to remain in good
standing with the board by means of ethical practice and continuing education for the
entirety of their careers.
The Massachusetts Commonwealth Fund believes that “interpreters should be
cross trained in cultural competence and health literacy in addition to medical
interpretation training. Hospitals are providing medical interpretation in a variety of
ways, but they are doing so without federal guidance, uniform standards or agreed-upon
systems for assessing the quality of the language services they provide to patients.

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There is a clear link between the overall quality of care a patient receives and the
quality of the medical interpretation they were provided - and that is why we want to
better understand how hospitals can provide consistent, effective, and timely
interpretive services.” Thus, a federally-implemented board would be an ideal solution.
By creating and enforcing national standards, this problem can be virtually eliminated.
Secondly, within hospitals, the translation telephones should be replaced with
video translation. Of course, it remains ideal to physically have a translator present, but
in their absence, a translator present via video feed is more effective than a telephone.
With this system of video translation, unlike the telephones, the nuances and
idiosyncrasies of unspoken communication can still be relayed. A company called
Stratus who is “dedicated to eliminating language barriers throughout the US, offers an
advanced system that connects healthcare facilities with a cloud-based network of
certified spoken language interpreters with the ability to translate over 175 different
spoken and sign languages. Stratus’ interpreting service is an application that can be
loaded onto any PC, Mac, Smartphone, or Tablet; the technology can even be applied
to Polycom and Cisco systems. Through a virtual private network, an encrypted call is
placed to one of Stratus’ 33 video call centers across the US, and the next available
interpreter in that language is found and connected.” All of the rooms have televisions
and most have computers, it would just be a matter of removing the old technology and
replacing it with the new technology. In a world where telephone calls have been
upgraded to Skype and FaceTime, why not allow translation services to do the same?
Additionally, it would be helpful to make small changes throughout the hospital to
make translation more easily accessibly. One of these changes involves indicating a
patient’s language through sing placed above their bed. This is standard when we need
to indicate skin, clostridium difficile, neutropenic, droplet, and airborne precautions. In
these cases, a sign sign is placed outside the patient’s door so that all hospital
personnel and visitors who enter know which precautions need to be taken (gown,
gloves, hair net, shoe coverings, surgical mask, respirator, hand washing techniques,
etc). This is a system that is already established and we know it works, so why not
include linguistic preference? This system would provide a clear indication of the
patient’s language preference to any healthcare provider that enters the room,
eliminating any guesswork or confusion. Furthermore, interpreter rounds should be
initiated. Similar as to how doctors round on their patients, interpreters should round on
the LEP patients in the hospital. This would provide an opportunity to communicate with
them, check in, see if they need anything, if have any questions, etc. Since interpreters
are a vital part of the treatment team, and other members of the treatment team (namely
doctors) round on patients, it would only make sense for interpreters to do so, too.
Finally, each floor should be assigned a resident interpreter to provide services for that
floor alone. Just as each floor has their own nurses, resource nurse, attending nurse,
dietitian, rehabilitation aides, dietary aides, social workers, caseworkers, nurse
managers, etc., they should have their own interpreter. That way, instead of having to
page/call for interpreter when one is needed, there is already one who is on the floor
and assigned to the floor. These simple changes would make translation services so
much more accessible within a hospital setting.
Thirdly, in accordance with the standards and resources set forth by the board,
hospitals should provide their staff with professional development and continuing

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education opportunities. Hospitals could even pair with a local adult learning center or
community college to provide classes and training. Most hospitals have a continuing
education and professional development department, mine does, and they could
provide inservices and CBLs (Computer-Based-Learning Modules), a weekly part of job
training and continuing education. By developing these classes and establishing
connections with learning centers in the community, all hospital staff can be trained on
how to effectively work with translators on issues of cultural competence and health
literacy.
Currently, 97% of U.S. hospitals see LEP patients on a daily basis. The best of
them brag about being able to interpret for 90% of them. Jonathan Hirsch of Holy Name
Medical Center asks what they plan to do about the other 10%. “Charades?” he asks.
Even the doctor I have partnered with reflects that “it gets complicated especially when
you don’t know the language that they speak, right? If someone is brought by an
ambulance and they are speaking a language and you have no idea which language it
is- it’s easy here when it’s Portuguese, but what if it’s not? What if they are speaking
Russian and you don’t know what he is saying. You don’t know which language he is
speaking. You don’t know where he comes from. And, what to do in that situation? But, I
guess, it’s a situation that could happen anywhere in the world, not only here in
America, it could happen anywhere that you have someone who is an immigrant who
goes to the hospital and doesn’t speak the language and cannot communicate at all.
What do you do? Well, you need to do your best! You do what’s best for the patient.
You try to get labs, you try to get an interpreter, you try to use signs, you do your best.”
There is no question that everyone - doctors, nurses, therapists, social workers,
dietitians and dietary aides, PT, OT, speech therapy, translators - do their best. But, due
to linguistic barriers, lack of cultural competence, and low health literacy among LEP
patients, our best is not always enough.
Adjusting the translation infrastructure within hospitals and implementing new
standards will allow us all to do what we entered the medical profession to do: to save
lives, to help people, to treat patients, to make a difference in people’s lives, to provide
a service that is as rewarding as it is heart-wrenching, as exhilarating as it is humbling,
to inspire, to provide, to heal both the body and the soul. Today, there are so many
barriers in the way. But tomorrow, that’s not the way it has to be. Tomorrow, through the
implementation of a new infrastructure, we can transcend these boundaries and
practice medicine in a setting that is understanding, that harbors no judgment, and that
has virtually eliminated any barriers of language and culture. Because essentially, what
it comes down to is that the healthcare industry is fast-paced and ever-changing. In this
industry, seconds count. And you don’t want those seconds to be lost in translation.