“Hola, Señor A! Me llamo Sunny, soy … umm … una doctora. Como se siente?” As I introduced myself haltingly, with the only Spanish I knew, I smiled awkwardly.
“I’m OK,” the patient replied.
I pulled out my cell phone and dialed the number for the phone interpreter who would be able to bridge our language gap. As the interpreter introduced himself, I could see the patient relax.
Señor A was a patient with limited English proficiency (LEP) whose primary language was Spanish. He was in his 40s, didn’t have a medical history (at least not one I could access), and had had few interactions with the American medical system. I was the resident on the infectious disease team taking care of him. Señor A had endocarditis and was already receiving the appropriate antibiotic treatment, but was persistently febrile. My team was asked to figure out why.
When I met Señor A for the first time, I wanted to hear his story from his perspective, though I had already read the initial note that his primary cardiology team had written. The EMR had described his chronic bilateral hip pain, noting that he had also recently received intra-articular steroid injections for the hip pain. But when Señor A told me his story in Spanish through the phone interpreter, I was surprised to discover that he had actually never experienced hip pain until this hospital admission. He further clarified that though he had received intramuscular injections, it had been for nausea, not hip pain.
In possession of this new information, my team and I changed the way we approached his care. Instead of viewing the hip pain as a chronic condition (which we’d likely have set aside), it raised some red flags. Why did Señor A have new hip pain? Was it related to his fevers? Because of what we uncovered, the trajectory of his care changed. We ordered multiple imaging studies of his hip, including X-rays, CTs, MRIs, and even a joint aspiration to exonerate his hip as a source of infection. We also involved other specialists like neurologists and rheumatologists. In the end, we discovered that Señor A had a hip joint infection — a diagnosis that, if it had been missed, would have been catastrophic.
In retrospect, I can’t help but think that the language barrier between Señor A and his medical team was the cause of the misinformation in his chart. Would the miscommunication have occurred if Señor A were fluent in English? It takes time to parse the details of someone’s story, especially in another language. I understand the exhaustion of night shifts, yearning to go home, yet carrying the responsibility of admitting sick patients into the hospital. It is scary how easy it is to skip clarifying small but important details, especially if the patient has LEP. It can take almost twice as long to translate the patient’s history, especially if the barrier is cultural as well as linguistic.
Luckily, with respect to Señor A, I was a member of the consulting team, so I had the luxury of time not always afforded to the primary team — and I felt privileged that he felt comfortable enough to share his story with me. I found out that Señor A had emigrated from Central America and lived alone with no family in the U.S. He worked in the produce department of a grocery store in a nearby city and when he was admitted to our hospital, he had no medical insurance. In fact, he had never seen a dentist before, despite having poor dentition, which we ultimately concluded was the source of his heart valve infection.
Massachusetts, where I practice, insures all of its citizens with basic medical coverage; several questions popped up in my mind: Why didn’t Señor A have insurance? Was it due to fear of deportation? Lack of knowledge or access? Was his employer taking advantage of him? The care managers at the hospital helped him apply for medical insurance, but I still worried about his status. Because of his hip pain, he needed acute care at a rehabilitation center for physical therapy, which are known to provide inconsistent care depending on the facility. Would he be able to get the care that he needed despite being underinsured? I feared that if he had lower quality insurance, he wouldn’t be accepted by the higher quality rehabs.
Linguistic inequities are abundant in medicine. As the child of immigrants who have LEP, I remember encounters in which language barriers undermined my parents’ care because there was no Mandarin-speaking clinician or interpreter available. Now, as a doctor, I’ve seen medical teams spend less time with patients who do not speak English, likely because it takes effort to correctly time an in-person interpreter with the busy schedule of the clinical team. It takes effort to call the phone interpreter. It takes time to have your words translated into another language, and to have the patient’s words translated back into English. It is standard of care to use an in-person interpreter, but with the chaos of morning rounds and the millions of tasks that need to be done, arranging for an in-person interpreter often falls to the wayside on a clinician’s to-do list.
Indeed, patients with LEP experience higher rates of medical errors and have worse clinical outcomes compared to English-proficient patients. Señor A ended up being lucky enough to be accepted for physical therapy at one of the best centers in the country despite his insurance — but that isn’t always the case. Our medical system is not conducive to linguistic equity. Often, due to time and resource constraints, we resort to using cobbled English, hand gestures, and whatever words we know in the native language, to ask patients about important things like pain or tell them about their upcoming CT scan.
Language is one of the most important tools that a clinician has and, clearly, we cannot rely on individual clinicians to remember to schedule interpreters to secure accurate daily medical assessments. The medical system itself must be revolutionized. Simple things such as hiring more in-person interpreters, or having iPads available in every room for instant video interpretation are only stopgap solutions. The culture of caring for patients with LEP must shift. We must prioritize our most vulnerable patients and rectify the linguistic inequities that pervade through our institutions.
What especially struck me about Señor A was that he was so grateful for the care he received. Every day after I spoke with him, he would thank me for my time. During his inpatient stay, he was interviewed by My Life, My Story, a project that my hospital adopted from the VA system, which interviews patients and then provides a written summation of their life story to the clinical care team. I received Señor A's story, which was written in both English and Spanish, and, after reading it, I cried. When we counseled him about his fatty liver disease, a result of binge drinking on the weekends, he expressed remorse about his alcohol use and vowed to quit. I was impressed with how seriously he took to heart our recommendations. I also learned that his favorite type of music is merengue, and that his son and brother are still living in Central America. After his inpatient stay, Señor A wanted to go on TV and tell others about how good his care was. He told me he wanted to say: “I am an immigrant, but they saw beyond that.” In my mind, though, the medical system is failing patients like Señor A, and it has miles to go before care is equitable.
What has your experience with medical interpretation services been like? Have you found medical interpretation sufficient or lacking? Share your stories and your patients’ in the comments.
Sunny Kung is an addiction medicine fellow at Massachusetts General Hospital. She completed her internal medicine residency at Brigham and Women's Hospital and medical school at the Pritzker School of Medicine University of Chicago. Originally from California, she is a Taiwanese first-generation immigrant interested in caring for minoritized populations, immigrants, patients with substance use disorders, and those experiencing homelessness. Sunny is a 2021–2022 Doximity Op-Med Fellow.
All names and identifying information have been modified to protect patient privacy.
Illustration by Jennifer Bogartz
