I’m a proud Canadian, but I was mortified and ashamed when I learned the full story of the tasering of Robert Dziekanski by police officers at the Vancouver International Airport in 2007 that led to his tragic death. A Polish newcomer who spoke no English, he was unable to navigate customs and immigration upon arriving in Canada, and after hours of frustration he became agitated enough to draw attention. Rather than being provided an interpreter and some help, police arrived—and the result was heartbreaking.
I was critical then of the airport’s seeming inability to support a traveller who did not speak English, yet on duty in the emergency department (ED) I sometimes have to take a deep breath and make do with a patient or their relative whose English is poor. Luckily, whenever I have resorted to our “language line” service it has gone relatively smoothly.
In this guest blog by one of our emergency medicine fellows, Dr. Gaibrie Stephen, I learned a lot about the evidence supporting a more rigorous and professional approach to language translation services. I also learned about some options available to me that I’ve not yet tried. I’m not a big fan of legislated solutions for practice issues (as Dr. Stephen suggests), but if a lack of translation can have tragic consequences at an airport, the obligation of an ED to set a new and better standard of care for communicating with patients is now painfully clear to me.
—Dr. Howard Ovens, October 2019
Equitable health care starts with communication
Imagine you are in a country where you do not speak the language. You’re wrapped in a culture that isn’t known to you. You’re living there with your partner. You’ve raised your children in this country. You’ve grown old there. One day there is a conflict in your home, and police officers send you to the hospital. People are yelling at you, but you do not understand them. They’re holding you down, you’re trying to get out … “What’s happening to me?” Suddenly, you’re placed in restraints, and two people approach you wearing masks with holding needles. You feel a jab in each thigh. “Five and two: haloperidol, lorazepam.”
This isn’t fiction; this was the experience of my patient who was admitted to hospital for “bizarre behaviour not yet diagnosed” after an altercation at home with her partner. She was elderly, and we questioned whether this was an early presentation of dementia. The next day the geriatric psychiatry resident used a language interpretation service and discovered the patient had been a victim of domestic abuse for years and had finally lashed out physically. She was fully competent. This discovery was made after she had been admitted and restrained, using both chemical and physical means. This was truly a traumatizing event for this patient—all because of a fundamental gap in our system.
“Language line” is a colloquial term for telephone interpretation services. Asking for a language line in medicine is often not a straight-forward process. At some hospitals, a request for a language line is met with a 30-minute wait, after which a dusty two-way telephone device will appear after being unearthed somewhere in the hospital basement. Then you can expect to wait for four or five minutes on hold until you’re connected with the operator, and another four or five minutes until you are connected with the appropriate translator. Language lines aren’t always easy to access, but in a country as diverse as Canada they should be.
Poor access to language services presents barriers to first contact for most health services, decreases participation in prevention programs, and ultimately delays presentation for care.  Language minority communities identify lack of language access as the greatest barrier to seeking health services. Patients who face language barriers have a greater risk of misdiagnosis, lower adherence to treatment, lower satisfaction, and differences in prescribed treatments. These patients are often under-treated for pain, are less likely to provide informed consent for therapies, and often have their privacy compromised with regard to their medical information.[2,3] In these encounters the patient’s family members (including children) are often used as surrogate translators, which jeopardizes not only the well-being of the patient but also that of the family as a whole.
Language interpretation services provide an effective way to address language barriers in clinical settings, and interpretation allows providers to mitigate the negative health barriers faced by language minority communities. In fact, a review from the Wellesley Institute in Toronto, Canada, found that the use of interpretation services was associated with an increased uptake of preventative care, reduced re-admission rates, and fewer clinically significant errors compared with care provided without the use of interpreters or with untrained interpreters.
Understand the lay of the land
While health care organizations in Canada are mandated to deliver American Sign Language and French language services by law, this does not apply to other languages. The current system does not prioritize language interpretation services, and as a result we see significant variability across Canadian jurisdictions in the way health care is delivered to language minority communities.
For example, British Columbia and Alberta each has a single, centrally coordinated telephone interpretation system. Meanwhile, the rest of the provinces and territories in Canada have no coordinated interpretation services and instead rely on individual organizations and health authorities to deliver this service. This is especially alarming in Ontario, considering one in 25 people in the Greater Toronto Area alone speak neither English nor French.
Canada could learn something from our southern neighbour in terms of the appropriateness of relying on patients’ family members as interpreters. In 2016 the United States explicitly prohibited using ad-hoc interpreters—including family members and untrained bilingual individuals, barring extreme circumstances—as part of the Affordable Care Act within Section 1557. The United States, unlike Canada, has made several steps to tie hospital financing to quality metrics as it relates to language.
Learn from success stories
A 2018 Wellesley Institute report identified a few hospitals in the Greater Toronto Area as positive case studies in addressing language needs, and these examples have a few things in common:
- They have invested in a centralized language services program with clear criteria for in-person and telephone services.
- When appointments are booked, patients are asked what their primary language is and whether they require access to interpretation services.
- Staff are trained on how to access interpretation services and how to use these services efficiently.
Perhaps the largest challenge in establishing a robust interpretation service is generating buy-in among front-line staff members. Given the lack of federal and provincial guidance when it comes to using interpretation services, it rests on senior hospital officials to establish these programs in their facilities.
Senior front-line staff need to champion interpretation service use and demonstrate its effectiveness, and administrative officials must arrange convenient training opportunities for staff on how to use these services. The interpretation service selected at an institution must be tried and tested and continually evaluated using a quality improvement framework.
Address fears about inefficiencies
Perhaps most relevant to emergency medicine, a reason front-line staff commonly cite for not accessing interpretation services is a fear that it will reduce efficiency and unnecessarily increase the length of the encounter. The only review to my knowledge of the impact of language lines suggests that—based on three studies—interpretation services do increase the length of the appointment (with telephone services increasing this time more than in-person services). However, these studies were not conducted in the ED setting, and it is unclear if the extra time is due to the interpretation process or because more clinical information is being exchanged.
From an ED perspective it is unclear, based on the current body of evidence, whether the total length of stay in the ED might differ with the use of language services. If these services were used and a better first assessment were obtained, it is unclear whether this would affect the kinds of tests ordered and ED flow.
Despite the potential of longer patient encounters, the evidence suggests that using interpretation services increases diagnostic accuracy, decreases clinically significant medical errors, provides higher rates of pain control, and decreases re-admission/admission rates. [2,3] These are all relevant metrics in emergency medicine. The study that found longer appointment times occurred when telephone interpretation was used suggested a 28 per cent increase in the length of the encounter. Is the additional 28 per cent increase in consultation time worth the potential 10 per cent reduction in 30-day readmission rate? Perhaps at this time the answer to this isn’t clear, this is likely a topic that may require further research moving forward.
Consider alternative language translation tools
Figure 1: The google translate application’s main page menu. Note the option to change your spoken language and translated language. You have to option to click “conversation” which then allows you to converse in this language directly.
Google Translate: In the current climate many providers may find themselves at an institution that has not prioritized language services, and in these situations there are some tools that may help bridge the language gap. Google Translate is a free app available through the App Store and Google Play. When put in conversation mode this application can be a powerful way to communicate with your patient in a clinical encounter. But be careful about using this tool for sensitive conversations, such as goals of care.
Also, be aware that the translation provided is not perfect. A 2019 study evaluated Google Translate in Spanish and Chinese translations for ER discharge instructions and identified 2 per cent of Spanish and 8 percent of Chinese sentence translations had a potential for harm to the patient due to inaccuracy. Clinicians can reduce potential harm when using Google Translate by having patients read translations (handouts) while also receiving verbal instructions, and by avoiding complicated grammar, medical jargon, and colloquial language.
Step 1: Open the Google Translate application and select your desired language for translation. In Figure 1 I have selected Malayalam (my mother tongue).
Step 2: Click “Conversation” mode. Using this mode you can either click English or your desired translated language, and the app will translate in real time. Place your phone between you and your patient and converse as you normally would.
Figure 2: The Canopy application’s primary menu. Choose your speciality to open up an extensive menu of common phrases. The green circle indicates the language option which can be changed.
Canopy: Canopy is a free application that tries to eliminate the shortcomings of Google Translate. It allows the provider to communicate in 15 languages with pre-set phrases based on specialty. While the application does not allow for nuanced discussions and it does not interpret what the patients is saying, it does a fairly good job with the most commonly used phrases in emergency medicine. For example, there are phrases available specifically for the incision and drainage of abscesses, such as, “I will probe the abscess cavity to break up any inner cavities, identify foreign bodies, and ensure proper drainage.”
Note that in the image of the Canopy home page, the area circled in yellow shows your selected language. You can choose from 15 languages.
Handheld devices: There are several examples of handheld devices on the market that translate languages in real time. The cost of these devices ranges from $45 to $360 and up, depending on the device’s features. One example of such a device is the JoneR, which supports the translation of 53 languages and 73 regional accents. The company claims its two-way translation between English and Chinese has a 97 per cent accuracy rate. To my knowledge there are no studies that assess the efficacy of such a gadget in the clinical setting. Whether these tools are safe to use in a clinical setting is unclear but likely warrants future research.
Just recently Microsoft announced that its new audio Surface earbuds can seamlessly translates an individual’s spoken words into written text. That being said, it can only translate in a one-way direction. A technology like the audio Surface earbuds may potentially be a useful way to provide discharge instructions but points to technology’s place in improving our ability to interface translation into our regular conversation. Moving forward with advances in artificial intelligence technology, the use of devices such as earphones may allow real-time translation without the need for a third party phone call, such as language lines.
The bottom line
Ultimately this is a health policy issue where our leaders have dropped the ball. If you are arrested and don’t speak the language of the court, you have a right to assistance from a professional interpreter—yet somehow this legal standard doesn’t extend to how we offer health care.
The story I mentioned at the start of this post was not an isolated event. The lack of appropriate language services is a gap I’ve observed throughout my training. I’ve seen patients return to the ED time and time again with the same complaint that was inappropriately diagnosed due to a lack of language services. I’ve seen goals of care discussions happen with distant nephews in the United States while the patient’s wife was bedside, simply because she did not speak English.
What Canada ultimately needs is legislation that protects the rights of language minorities in accessing health care. In the interim it is important that we as emergency medicine providers reflect on our own practices as Canada continues to become increasingly diverse. Let’s not accept getting by without an interpreter when there is a growing number of options available that would allow us to do better.
—Dr. Gaibrie Stephen is a family medicine resident at St. Michael’s Hospital in Toronto, Ontario.
Dr. Stephen and Dr. Ovens have no conflicts of interest to declare.
- Bowen S. Language Barriers in Access to Health Care. Ottawa, ON: Health Canada; 2001. Available from: www.canada.ca/content/dam/hc-sc/migration/hc-sc/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2001-lang-acces/2001-lang-acces-eng.pdf. Accessed October 12, 2019.
- Laher N, Sultana A, Aery A, Kumar N. Access to Language Interpretation Services and Its Impact on Clinical and Patient Outcomes: A Scoping Review. Toronto, ON: Wellesley Institute; 2018. Available from: www.wellesleyinstitute.com/wp-content/uploads/2018/04/Language-Interpretation-Services-Scoping-Review.pdf. Accessed October 12, 2019.
- Sultana A, Aery A, Kumar N, Laher N. Language Interpretation Services in Health Care Settings in the GTA. Toronto, ON: Wellesley Institute; 2018, www.wellesleyinstitute.com/wp-content/uploads/2018/04/Language-Interpretation-Services-in-the-GTA.pdf. Accessed October 12, 2019.
- Youdelman M. Summary of State Law Requirements: Addressing Language Needs In Healthcare. Washington, DC: National Health Law Program; 2019. Available from: https://9kqpw4dcaw91s37kozm5jx17-wpengine.netdna-ssl.com/wp-content/uploads/2019/04/Language-Access-NHeLP-50StateSurvey.pdf. Accessed October 12, 2019.
- Department of Health and Human Services. Nondiscrimination in Health Programs and Activities; Final Rule. Office for Civil Rights. . 2016;81(96):31376-31473. https://www.govinfo.gov/content/pkg/FR-2016-05-18/pdf/2016-11458.pdf. Accessed October 12, 2019.
- Khoong EC, Steinbrook E, Brown C, Fernandez A. Assessing the Use of Google Translate for Spanish and Chinese Translations of Emergency Department Discharge Instructions. JAMA Intern Med. 2019;179(4):580-582.
- Beijing Babel Technology. Update: The World’s First WIFI-based Translator (JoneR Translator) Debuting in 2019 CES [news release]. Beijing, China: Beijing Babel Technology; 2010. Available from: https://www.globenewswire.com/news-release/2019/01/18/1701755/0/en/UPDATE-The-World-s-First-WIFI-based-Translator-JoneR-Translator-Debuting-in-2019-CES.html. Accessed October 12, 2019.
- Beijing Babel Technology. Babel Technology launches AI-based WiFi translator JoneR Pro worldwide [news release]. Beijing, China: Beijing Babel Technology; 2018. Available from: https://www.globenewswire.com/news-release/2019/01/18/1701755/0/en/UPDATE-The-World-s-First-WIFI-based-Translator-JoneR-Translator-Debuting-in-2019-CES.html. Accessed October 12, 2019.
- Hamid A. Microsoft Surface Earbuds Offer Real-Time Dictation & Translation. Android Headlines. 2019 Oct 12. Available from: https://www.androidheadlines.com/2019/10/microsoft-surface-earbuds-real-time-dictation.html. Accessed October 12, 2019.