Editorial
Healing starts with understanding: Addressing language barriers in patient care through medical student interpreters

Xinyu Ji BSc1, Kenzy Abdelhamid1, Darya Naumova MSc1, Ellen Chow BCom1, Juan-Carlos Chirgwin MD CCFP2
Published online: 23 May 2020
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1Faculty of Medicine, McGill University, Montreal, Canada
2Department of Family Medicine, Faculty of Medicine, McGill University, Montreal, Canada

Corresponding Author: Juan-Carlos Chirgwin, email juan.chirgwin@mcgill.ca

Tags: language barriers, medical interpretation, medical students


As the most ethnically diverse metropolitan of the most multicultural country in the world, Montreal’s 2016 census profile found its immigrant population to be at a staggering rate of 23.4%, which does not include its second and third generation immigrant population (1). While this diversity undoubtedly gives Montreal its unique charm, it can create social, political, as well as healthcare challenges. Indeed, a majority of our most vulnerable patients include immigrants and refugees.

Dr. Juan-Carlos Chirgwin is a name you can mention in any community centre or school in the Parc-Extension neighbourhood of Montreal and expect people to recognize with a smile. Over the past years, Dr. Chrigwin has done extensive work reaching out to the local residents, comprised mostly of asylum seekers and new immigrants. In fact, a demographics analysis shows that this small neighbourhood of 1.6 km2 hosts 32.9% of Montreal’s visible minorities (1). In collaboration with medical student interpreter volunteers from McGill University, Dr. Chirgwin’s advocacy includes making effort to break the language barrier he faced with his patients from the Parc-Extension community

Language barriers in healthcare services are common, but unfortunately, professional medical interpreters are often unavailable. This problem is not just limited to the Parc-Extension community. In a city as diverse as Montreal, this issue impacts all healthcare institutions, including hospitals and medical clinics. In 2018 alone, at just 4 of the McGill University Health Centre (MUHC) sites, over 500 layman interpreter requests were made through overhead intercom announcements. In fact, as medical students completing clerkship rotations, we have the privilege of circulating through various specialties and institutions, which provides us with an overview of the healthcare network. In every rotation, without fail, there would be at least one allophone (non-English and non-French speaking) patient for which the healthcare provider struggles to find an interpreter

It is the elephant in the room: interpreters can be just as essential to patient care as a stethoscope, if not more. These barriers, unaddressed, impede the physician’s ability to fulfill the Hippocratic Oath. As Dr. Chirgwin so candidly explains:

“History is everything,” we are told in medical school, and yet a glaring blind spot in our medical system is the lack of trained interpreters in large cities with inhabitants from different regions of the world. We are asked to be “patient-centered” in our interview style yet are given no tools to address a patient who cannot understand either French or English. Quality control in our hospitals would frown upon any type of practice that represented an avoidable risk for a patient; however, it is customary to hear hospital overhead announcements requesting any person who speaks such and such a language to assist for interpretation in the emergency room. We are asked to depend upon friends or relatives of patients to gather details of medical complaints, which may be embarrassing to describe or simply “taboo” subjects. The assumption is that it is the patient’s responsibility to provide an interpreter, although we are not asking them to bring a stethoscope, gauze or an IV bag.

Where communication is a cornerstone of the relationship and therapeutic alliance between the patient and the healthcare provider, language barriers are a serious obstacle in a medical setting.

Ample evidence in the literature speaks for the importance of linguistic concordance in provider-patient communication and the negative consequence of language barriers in healthcare: increased diagnostic testing, decreased quality of management, increased medical errors, etc. (2-5). Further evidence suggests that medical errors with potential consequences are highest when an untrained, ad hoc interpreter is utilized for medical interpretation—as compared to no interpreter intervention at all (6). Currently, in the context of urgent care, communication between the health professional and the allophone patient relies largely on layperson interpretation through a friend or family member, or a volunteer recruited through the hospital intercom. In these circumstances, the layperson, often untrained in interpretation and inexperienced with medical terminology, does not transmit fully or accurately all the necessary information. In the context of scheduled appointments, interpretation services are occasionally requested from professional agencies, which are often costly ($45-$150/hour), scarce, and complicated to arrange. As expressed by the hospital administration, major current barriers to accessing professional medical interpreters include cost, time availability, variety of languages requested, coordination with interpretation services, and quality of interpretation

The need for more adequate and more accessible interpretation services is, however, ever so significant. To reiterate, barrier to quality communication increases chances of misunderstanding, negatively impacts the thoroughness of health investigations, and can undoubtedly lead patients to lose control of their health. These issues are mainly due to poor patient education, poor compliance, lower patient satisfaction, lack of safety, and negative clinical experiences (7, 8). Consequently, there is a stark increase in health disparities, and this already marginalized population is at a heightened level of vulnerability. With this in mind, healthcare workers and administrators must strive to meet the need. We must be reminded that the need to provide adequate interpretation is reinforced by provincial regulations: Quebec’s Act Respecting Health Services and Social Services establishes a structure “to foster, to the extent allowed by the resources, access to health services and social services in their own languages for members of the various cultural communities of Québec (9).”

Current alternative “leading practices” to on-site professional medical interpretation services can be found in Manitoba and Toronto, where remote professional interpreter services in over 200 languages are available by phone 24/7. However, many of these companies are US-based and interpret only to English as the reference language. In Quebec, where both French and English are regularly used in our working environment, the necessity to provide an additional service in French translates to a greater budget need. The use of mobile translation applications, such as Google Translate, is another avenue that is already widely used. However, this practice has its own caveats, such as user friendliness and patient familiarity with the technology. Importantly, there are dangers associated with inaccurate application translations, which can be particularly inappropriate during medico-legal discussions, such as obtaining informed consent (10).

Dr. Chrigwin is not alone in his frustration: “This issue is not restricted to one hospital or even to one city. It is a phenomenon being played across the country and across borders.” A brief survey of physicians in any MUHC hospital site would reveal a dearth of interpreters to meet their patients’ language needs. This is of course also shared by all healthcare professionals, including nurses who are in most contact with patients, as well medical trainees who may have their teaching inhibited by those language barriers. Fortunately, the cultural and linguistic diversity of Montreal is not only reflected in the patient population but also in the cohorts of medical students. In McGill’s Class of 2021, for example, 35.36% of the students declared having a mother tongue other than English or French. This begs the question, what role can multilingual medical students play in breaking the language barrier in the healthcare setting? A simple call to action for medical student volunteers showed over 100 students that expressed interest in offering their interpretation services. As such, with appropriate medical training etiquette, there is, in fact, a potentially important role for multilingual medical students to facilitate both clinical encounters as well as community outreach events—introducing MedComm.

MedComm is a student-founded and student-led outreach initiative that aims to 1) train medical student volunteers who speak different languages in medical interpretation, and 2) develop an online platform to connect volunteering interpreters with healthcare professionals requesting interpretation services across the MUHC network. MedComm believes that medical students are in a unique position to bridge this gap for medical interpretation. Students have sufficient medical training to communicate the nuances in history taking with professionalism, and they carry an innate cultural competence to respectfully build patient rapport. To optimally harvest this potential resource (multilingual medical students), it needs to be collectively recognized and training needs to be organized through the curriculum. It is only with faculty support and physician recognition of the potential that this change can be in effect. Medical student interpreters can play an important role and significantly benefit countless families in our ever so diverse community.

It is the responsibility of physicians and students in training to provide the highest quality of care for patients, which means breaking the language barrier. To achieve this, action must be made at an institutional level. With an urban population as diverse as the one in Montreal, interpretation services should always be available and easily accessible, and all healthcare providers, including allied health professionals, should be comfortable in requesting, booking and interacting with interpreters.

To support the initiative and learn more about MedComm, visit our Facebook page: https://www.facebook.com/MedComm-Medical-Interpretation-107488790739458/


References

  1. Statistics Canada. (2017). Montréal [Census metropolitan area], Quebec and Canada [Country] (table). Census Profile, 2016 - Montréal.
  2. Jackson C. Medical Interpretation. In: Loue S, editor. Handbook of Immigrant Health. Boston, MA: Springer US; 1998. p. 61-79.
  3. Bowen S. (2015). The Impact of Language Barriers on Patient Safety and Quality of Care. In: Canada H, editor. Société Santé en français.
  4. Bowen S. (2001). Language barriers in access to healthcare. In: Canada H, editor. Ottawa.
  5. Jacobs E. The Need for More Research on Language Barriers in Health Care: A Proposed Research Agenda. The Milbank Quarterly. 2006;84(1):111-33.
  6. Flores, G., Abreu, M., Barone, C. P., Bachur, R., & Lin, H. (2012). Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Annals of Emergency Medicine. https://doi.org/10.1016/j.annemergmed.2012.01.025
  7. Karliner, L. (2019). When Patients and Providers Speak Different Languages. AORN Patient Safety Network. https://doi.org/10.1002/aorn.12757
  8. Vargas Pelaez, A. F., Ramirez, S. I., Valdes Sanchez, C., Piedra Abusharar, S., Romeu, J. C., Carmichael, C., … Silveyra, P. (2018). Implementing a medical student interpreter training program as a strategy to developing humanism. BMC Medical Education. https://doi.org/10.1186/s12909-018-1254-7
  9. Act Respecting Health Services and Social Services (1991, c.42, s.2; 2002, c.71, s.1). Retrieved from Legis Quebec website: http://legisquebec.gouv.qc.ca/en/showdoc/cs/s-4.2#se:2
  10. Chen, X., Acosta, S., & Barry, A. E. (2017). Machine or Human? Evaluating the Quality of a Language Translation Mobile App for Diabetes Education Material. JMIR Diabetes, 2(1), e13. https://doi.org/10.2196/diabetes.7446

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