"I am sorry. Don't speak English. Spanish?"
I had just entered the room to speak with a mother whose daughter was admitted to the hospital.
I quickly returned with a video translator, and we were able to discuss in detail what was going on with her 5-year-old daughter whose asthma had flared.
When I left the room, I let her nurse know the patient's mother felt most comfortable speaking Spanish.
"Are you sure? She seemed to understand what I was saying when I talked to her earlier," the nurse replied.
This scenario is not uncommon in the children's hospital. When a child's caretakers speak little to no English, the decision is simple: a translator is necessary. When their caretakers' English fluency spans from basic to conversant but they do not request a translator, a decision is forced -- because no one asks if they need a translator. This approach to assessing translator needs must change.
More than in the U.S. have limited comfort with English as their primary language. This number may be an underestimate. Making a bad situation worse, the language used in medical history taking includes vocabulary regarding anatomy, medications, and diagnoses that are not always part of fluent English speakers' vocabulary, let alone the vocabulary of people with less proficiency.
In , Mary Pilarz, MD, and colleagues assessed translator use in a children's hospital. They found over 91% of residents and nurses reported communication with families with limited English proficiency without translators. This is unsurprising at face value.
I previously believed appropriate translator service usage was a matter of health equity to ensure all children and families, regardless of background, ethnicity, or immigration status understood what was happening with their child's health. I realize now it goes beyond only equity -- it is equally a matter of patient safety for hospitalized children.
In , Jennifer White, PhD, and colleagues found that patients with limited comfort with English were less informed of their care. These patients were more likely to receive larger volumes of information over a shorter time period, likely due to their consistent need for interpreters. This resulted in fewer total interactions with medical teams during their hospitalization. While this study analyzed adult patient encounters, the findings forced me to reflect on my experience caring for children. I am guilty of having chunked information into one conversation rather than utilizing a translator multiple times. In my drive for efficiency, what costs did my patients bear?
In , Alisa Khan, MD, MPH, and colleagues found that hospitalized children whose families had limited comfort with English were twice as likely to experience medical errors during their stay. While there is no singular reason explaining this risk, less thorough and inconsistent communication with these families was a common theme.
Our current approach to assessing the need for translator use for hospitalized children and their caretakers is insufficient. It forces families to advocate for their child's needs in situations where families are less informed of their child's hospital course and at greater risk for experiencing medical error.
Addressing this shortcoming requires a consistent approach whereby the provider explicitly asks every patient or family about their language needs.
Healthcare workers should ask, "In what language would you be most comfortable talking about your child's health?" This question is not, "Do you speak English?" or "Can you understand me?" The first question centers on the child and caretakers' abilities to communicate, while the second two focus on the healthcare workers' needs. The onus to initiate this process should fall on the healthcare worker.
Normalizing active assessment of patient language preference is necessary and possible. It requires changes in medical school curricula, patient-provider interactions, and hospital administration policy.
All students, regardless of their chosen specialty, will need to be able to effectively communicate using in-person, phone, and video translators. Through standardized patient encounters and clinical skills sessions, students must gain the ability to identify needs and effectively communicate with translators prior to starting residency.
Residents and nurses serve as the healthcare team members who communicate most frequently with patients and their families. They may be the first to assess the patient's language preferences and may be responsible for communicating translator needs to the rest of the team. Incorporating this step into each new admission will normalize this patient safety measure. In the from Pilarz et al., participants who were familiar with poor outcomes for patients less comfortable with English were more likely to use interpreters in the future. By making it clear to nurses and doctors that interpreter use can improve patient outcomes, we can better motivate behavior change among providers.
Attendings too should advocate for appropriate translator use and ensure non-English speaking families receive equal amounts of facetime on rounds. As leaders of medical teams, they can warmly "call-in" others, as an act to encourage patient safety. Similarly to how proper PPE use and handwashing became a collective responsibility, appropriate communication using the patient's preferred language must follow the same principles.
Hospitals and administrators play a role too -- they will need to increase the availability of translators. Hiring in-person translators and investing in reliable video technology are actionable changes. With a medical community that is already stretched thin, it is unfair to simply ask healthcare workers to do more without equipping them with the necessary support. Additionally, hospitals are increasingly recognizing the need to commit to diversity and health equity. Ensuring patients who speak all languages have reliable and prompt access to translator services through proper staffing and investment in technology are tangible actions leadership can take to meet their stated goals.
All it takes is for healthcare workers to ask each child and family admitted to the hospital just one easy question. The gain is more equitable and safe care.
Patients should never have to apologize for the language they feel most comfortable speaking. And we, as a medical community, can easily avoid having to apologize for underserving their needs by giving them the appropriate resources up front.
is a PGY-2 pediatrics resident at Yale Children's Hospital.