FOREWORD: Lost in Translation: Spanish Language Communication in the Emergency Department

In 1964, Title VI of the Civil Rights Act was enacted to prohibit discrimination based on a person’s race, color, or national origin in programs that receive federal funding. This was a major milestone in United States history and gave hope to many for equal treatment and respect. One of the most important aspects of Title VI is that it extends to Medicaid and other health care and human services; one cannot be denied or have unequal medical assistance based on those factors. After this policy was enacted, changes had to be made nationwide from small clinics to major hospitals in order to best serve their surrounding communities. In order to comply with Title VI, heath care entities must “provide free oral and written language assistance to patients who have limited English proficiency” (Health care, human services, and title VI of the Civil Rights Act of 1964, n.d.) The Supreme Court officially ruled that discriminating against individuals with limited English proficiency is discrimination against national origin. Because of Title VI, it is the expectation that all hospitals and health care facilities hire qualified translators to work with patients. Unfortunately, although federal law requires sufficient translation services, most hospitals lack properly trained, around-the-clock translators for the large Spanish-speaking population in the United States.

More than one in five citizens of the United States live in a non-English primary language household, and nine percent of Americans have limited English proficiency (Flores, 2014, p. 1261). One would expect that hospitals have extensive services that not only reflect this national diversity, but cater specifically their local populations. Reuters Health (Cohen, 2016) reported on a study published in the Annals of Emergency Medicine in 2015 that measured that one-third of hospitals do not offer in-house interpreters. To follow the law or to provide services with a limited budget, many hospitals have telephone-based interpreter systems, but no matter how efficient, nothing is more effective than a qualified, on-site professional. Only thirteen states reimburse for language services through Medicaid and the Children’s Health Insurance Program (Flores, 2014, p. 1263). The federal government has attempted to bridge this gap my committing to reimburse 50 to 70 percent of states’ Medicaid costs and 70 to 86 percent of Children’s Health Insurance Program costs (Flores, 2014, p. 1263). Although this support system exists, it seems as though hospitals are not taking advantage of this opportunity to offer better experiences for their patients. Many studies have shown that language barriers are associated with prolonged hospital stays, serious medical events during hospitalizations, decreased patient satisfaction, and an increase in nonessential resource utilization (Chan, Alagappan, et al, 2010, 135). The process of being seen, understood, and treated effectively is much more drawn out for non-English speakers. Doctors need detail to work effectively and efficiently, but one small miscommunication or oversimplification due to improper translation could have large repercussions. Perhaps a translator was not there and a non-bilingual doctor had to use hand signals and limited vocabulary to assess problems; it is almost impossible to make an on-the-spot diagnosis from hand signals and sometimes even pointing at diagrams. One of the departments with the most need for translators is the emergency department, where communication can be the difference between life and death. The emergency room is not for check-ups, it is for people who feel they are having a serious problem that may need immediate attention; there is little to no time for delays and redoes.

From the moment non-English speakers enter the emergency room, they can encounter problems. The first step in the emergency department is triage, assigning urgency of a patient’s medical problem. If nurses and patients cannot effectively discuss symptoms, pains, injuries, or events, how can proper urgency be assigned? In a survey conducted of patients between 18 and 65 requiring triages in emergency departments, it was found that nurses tended to overestimate patients’ speaking skills and Spanish-speaking patients felt less understood and less satisfied by their triage nurse (Cossey, 2012, p. S113). An important part of health care and the goal of many doctors is to provide an environment that is helpful, informative, and safe for the patient. Miscommunications and misunderstandings are frustrating and can even be terrifying, and it is clear than many Spanish-speaking patients can encounter these emotions within minutes of stepping into the emergency room. So, just how many problems occur with translators on a daily basis in an emergency department? In a study conducted in two large pediatric emergency departments in Massachusetts, researchers recorded 1,884 translation errors, and eighteen percent of those had “potential clinical consequences” (Andrews, 2012). Although eighteen percent may look small, eighteen percent is a large number when it comes to a child’s health and safety. In pediatric units especially, communication is done through the parents, and even if a child speaks English, they cannot be expected to understand and translate all of the serious and confusing information provided by medical professionals. Aside from the errors with clinical consequences, these minor miscommunications just add more stress, discomfort, and time into the process. These problems affect not only the patients, but worried families who may also not speak English.

It is important not only to look at issues from the patient’s side, but also difficulties from the translator’s perspective. Some people that end up translating did not even sign up to do so. In many hospitals, bilingual nurses and other faculty are used as ad hoc interpreters with the dangerous assumption that they will accurately provide information. An ad hoc interpreter is an untrained person who has other duties but can be called upon to translate in the emergency department. They can be bilingual family members, doctors, nurses, or other faculty members that may be available before a professional translator. All these interim translators can do is try their best; they cannot be blamed for not being proficient in a job for which they are not equipped. Even hospitals with official translators lack proper education structures and educational experiences for their translators; a translator trained outside of a hospital may be able to carry a conversation in Spanish fluently, but may not know the medical vocabulary necessary for an emergency department. Researchers Prince and Nelson studied the effectiveness of a forty-five-hour medical Spanish training course for emergency medicine residents, and despite the seemingly extensive training, major errors occurred in 14% of encounters with Spanish-speaking patients, and minor errors occurred in over 50% of interactions (Chan, Alagappan, et al, 2010, p.135). Similar problems and frustrations exist on both ends and there has been extensive research to prove the inefficiencies caused by translation errors. The reliance on bilingual faculty members is too risky to be dependent on; the cost of one miscommunication in the emergency department is too high to ignore its effects. There cannot be better experiences for Spanish speakers without sufficient training so that they can do their jobs to the fullest extent.

The main reasons for using ad hoc interpreters and phone services is typically convenience and perceived financial benefit, however, studies indicate that using a professional interpreter can lower the costs of a patients visit. Researchers Hampers and McNulty (2010, p.138) concluded that limited English-speaking patients who do not have a translator have increased utilization of and cost for testing, and are more likely to be both admitted and receive intravenous hydration (Chan, Alagappan, et al, 2010, p. 138). These procedures all cost money, and the more unnecessary tests conducted due to miscommunications, the higher the cost of the visit. The researchers also discovered that doctors were making decisions more cautiously without a translator, thus these visits are more expensive (Chan, Alagappan, et al, 2010, p. 138). Using professional translators would allow doctors to pinpoint the patient’s issue better from the beginning and mitigate the time and money spent. Thus, it is more financially beneficial to keep official, trained translators on staff based on the needs of the hospital’s community because it decreases both the time and money spent on testing and other medical procedures that may not be deemed necessary if the doctor were to understand immediately what the patient is feeling. If that is not convincing enough, Doctor Glenn Flores (2014, p. 1261) suggests national third-party funding for translation services. She found through her research that a budget report to Congress estimated that it would cost around $4.04 more per patient with limited English proficiency, 0.5% of the cost of each visit, to provide language services for the emergency department (Flores, 2014, p. 1263). She also estimates that hospitals making use of state third-party funding for interpreting services results in more professionals and better overall translating experiences (Flores, 2014, p. 1263). If hospitals are aware of and put effort into implementing these funding opportunities, Spanish-speaking patients will have much more comfortable experiences in the emergency department.

Many solutions that address mitigating translation errors in the emergency department have been proposed by researchers and doctors dealing with the problems on a day-to-day basis. The financial benefits of having professional translators may push hospitals towards the solutions that many researchers suggest: having a proportional number of translators that reflect the Spanish-speaking population of the surrounding area. Bilingual staff, telephone interpretation services, and other new technologies should be used to complement and give support to the professionals (Chan, Alagappan, et al, 2010, p. 138). In a life-or-death situation in the emergency room, one cannot make a phone call to a translating service; there must be an in-person professional who can best serve both the doctor and the patient. Emergency department visits always require immediate, on-site care that can only be successful with the help of trained translators. Part of a successful visit is making patients feel comfortable and cared for to the fullest extent. Spanish-speaking patients statistically feel less understood and are less satisfied with their emergency department visits than their English-speaking counterparts (Cossey, 2012, p. S113). Providing translation services from triage until release from the emergency room is crucial to providing not only a positive experience, but a guarantee of safety for Spanish speakers.

If hospitals are to have ‘professional’ translators, what training must they go through? Medical interpreting is especially difficult as it requires not only the knowledge of two or more languages, but also medical vocabulary for both. There also standards of practice that must be followed on the job. Many institutions require a bachelor’s degree in interpretation as a prerequisite to medical interpreting, then one must take a specialized training course that is a minimum of 40 hours held by an accredited agency (How to Become a Qualified Medical Interpreter, 2018). Getting into this training course is difficult; there is an oral exam to prove proficiency and some programs even ask for evidence of your language education through transcripts or other documentation (“How to Become a Qualified Medical Interpreter, 2018). After the course, there are two ways to become a certified medical interpreter: one can take an accreditation exam, with both oral and written parts, with the National Board of Certification for Medical Interpreters or one can take a similar exam given by the Certification Commission for Healthcare Interpreters (“How to Become a Qualified Medical Interpreter, 2018). This process is rightly extensive as the job of a medical translator could come down to life or death, especially is one works in the emergency department. This training is necessary for the safety and care of patients across the country.

The following articles by Willis, Piekarski, Campbell, and Roberts highlight the necessity of Spanish translation services in the emergency department and how their implementation leads to more comfortable and more efficient visits. Since the Civil Rights Act was enacted in 1964, translation services in emergency departments and hospitals have been lacking in many communities. Not having enough qualified professionals has led to hundreds of daily errors, some minor and a few with potential detrimental consequences. Insufficient translation services pose a health and safety risk; thus, it is imperative that we put pressure on hospitals to both train and hire enough translators to serve their communities. This is a civil rights issue; it is not fair that our emergency departments do not cater to the true demographics of this country and that some are better served than others due to the languages they speak. There are many options that are financially feasible, if not beneficial, for hospitals to adopt. It will take advocacy from both doctors and the general population, English and Spanish-speaking alike, to make these changes. There are only benefits to providing better translation services in the emergency room, doctors want them; it is time to push past bureaucracy and excuses and to make easy changes. Translators can help to save lives and to foster trust and equality within communities.