The room is dark and cold. I sit in a makeshift clinic in southern Mexico as dry air blows in past the curtain and the sound of children’s laughter plays in my ears. The woman speaks the Mixtec language from Santa Maria Zacatepec. I listen quietly as her words are interpreted from Mixtec to Spanish. I know no Mixtec but speak Spanish and am here to help the physician understand the woman. It’s my turn. I interpret Spanish to English. “The woman says her uterus has fallen out of her body,” I say with a cringe. My pre-med mind swirls in confusion.

I am a medical student now. A mother and son sit next to each other; the boy looks about 10 years old. The physician tells the mother the mass in her breast is cancer. The woman sits with blank eyes, but it isn’t grief or disbelief. It is simply the look of not understanding — not understanding the language the physician is speaking. She has limited comfort with English. The son turns to his mother and speaks in her preferred language. What he says or doesn’t say the physician has no idea. Paralyzed, my short white coat hangs limply off my tense shoulders.

Iyo kuati chi’in pa’a se’i.

Hay un problema con mi nene.

There is a problem with my baby.

I am a pediatric intern on my first ward month. I’m given all the Spanish language patients. And if there are extra, I’m expected to interpret for my fellow interns. I follow the Chicago-accented, English-speaking intern into the room. I wonder what happens on the days I’m not here and pause. I decide to make paper signs for my patients that say, “I have the right to an interpreter.” They will hold up the signs on the days I’m off.

By the time I am a second-year pediatric resident, I have stopped using my Spanish. I know my limits and realize I can’t interpret well enough. I’m in the pediatric ICU, where any Spanish language speaker is called upon to interpret for the removal of life support and to discuss DNR status. I call a phone interpreter when given Spanish language patients.

Küuni ra kashi ndikai.

No quiere tomar mi pecho. She doesn’t want to nurse.

Limited comfort with English. Limited proficiency in English. You choose what to call it. Or should we call it, “misery with English”? Misery is the antonym to comfort. These patients have fewer comfort measure orders, longer hospital stays, and more adverse outcomes. More misery and less comfort simply for not being able to communicate as well in English.

These concerns cross all areas of medicine — adult and pediatric. Hospitalized children are two times more likely to be harmed from medical care if their parent has limited comfort with English. Two times just because their parent doesn’t speak English as well as another parent. This is unrelated to other factors including parent race, parent education, and the child’s complex chronic conditions.

Yakanva jatai mamila va ndi’i xu’in ta jakanai ra chin’in takui.

Por eso compré mamila pero se acabó el dinero entonces la mesclé con agua.

So I bought formula, but then my money ran out, so I diluted it with water.

It’s 2020, weeks before the pandemic hits in full force. I sit at a table surrounded by colleagues. We are the Diversity, Equity and Inclusion (DEI) Advisory Group. We work for an employer that values and advances DEI work. Bilingual primary care physicians certified in a language of need receive additional compensation. What started as an effort to ensure the appropriate use of certified interpreters led to the ability to identify certified language-concordant clinicians. These clinicians speak Spanish, Vietnamese, and Russian. They communicate with their patients in their preferred language and provide medical care in a meaningful way.

Now it’s 2021. The COVID-19 pandemic swirls around us. Families with limited English proficiency lack consistent access to interpreters in the pediatric ER. Interpreters are rarely used for procedures and medication administration, and are not always used for detailed medical histories, even at centers that report excellent interpreter services. The gold standard isn’t so gold. We use interpreters less if we don’t perceive communication is the goal of the interaction. Procedure — no need for an interpreter. Medication administration — no interpreter needed. These patients miss invaluable updates and inclusion in their care. And we miss invaluable information and mislabel patients as poor historians. Take this story of a Brazilian construction worker being labeled a "bad historian" simply because his doctor didn't speak his language.

Va ya’a nda’vi kuuni yi.

Pero se quedó muy triste.

But she is listless.

Imagine your loved ones. Imagine them having to communicate with their doctor across a language barrier. They are unable to receive meaningful access to care. They cannot communicate their medication's side effects nor discuss DNR status. They are harmed from medical care due to their inability to communicate.

It is our job as health care professionals to give the best possible care, even when that means caring across languages. Federal law mandates we provide meaningful access to limited English proficient persons. However, this doesn’t always happen. One in 11 patients has limited comfort with English, but a study found that interpreter services are used in only 36% of medical communication events in the pediatric ER. That means two out of three times, professional interpretation is not used. It matters not only if an interpreter is used but also that the interpreter is certified. Fluency in a language doesn’t beget an ability to interpret. I am fluent in Spanish but took myself out of that role when I realized my skill was insufficient. Interpreters should be professional interpreters and certified if we are to give our patients meaningful care.

Iyo kuati chi’in pa’a se’i.

Küuni ra kashi ndikai.

Yakanva jatai mamila va ndi’i xu’in ta jakanai ra chin’in takui.

Va ya’a nda’vi kuuni yi.

Patients are human and deserving of care, whether or not they are comfortable in English. They deserve to use their preferred language. We owe it to them. And for all of us (myself included) who work with persons with limited comfort in English, remember these tips: Avoid slang — you may have “hit the ball out of the park,” but consider saying the procedure or treatment was successful instead. And be respectful — lack of respect requires no interpretation.

Together, we can successfully communicate with our patients. We need to consider the language they prefer. We need to work with a professional, certified interpreter with every patient interaction — whether it is history gathering, during a procedure, administering medications, or as a consultant. Interpreters can help us understand cultural nuance, too. Because language is more than spoken words: it is culture, and place, and people.

What comes to mind when you hear the word "interpretation"? Share your thoughts below.

Joy Eberhardt De Master works as a pediatrician in Portland, OR. She considers herself to be an American-Mexican and is a highly sensitive person who values beauty and equity. She believes that all people deserve quality health care and that the stories of indigenous people need to be sung loudly. She is a 2020–2021 Doximity Op-Med Fellow. She offers her gratitude to Eva Romero for reviewing the Spanish in this article, and to Linda and Doug Towne for providing the Mixtec translations.