The language of medicine can prove terribly difficult for patients, particularly those considering complex surgical procedures or elaborate treatment protocols. A doctor's occasional slip into technical jargon may quickly leave patients confused about their diagnoses or uneasy about what happens next.
But what if the doctor and patient cannot understand each other at all -- if they do not share a common language?
This question has become increasingly important with the growing number of non-English speakers in the United States, many of whom frequently encounter severe language barriers within today's largely Anglocentric health care delivery system. Unsurprisingly, many of these patients often receive poorer medical treatment with worse outcomes than their English-speaking peers, effectively marginalizing all but those with access to family members or friends who can intermediate on their behalf.
In an attempt to address these problems, then-President Bill Clinton issued Executive Order 13166 in late August 2000, mandating that suitable translators and related language services be provided to all non-English-speaking Medicaid and Medicare patients, and within all health care facilities receiving federal support. Unfortunately, the executive order failed to provide matching government funding, leaving individual doctors or hospitals to foot the bill. The American Medical Association soon reacted, arguing that the mandate would cripple the nation's medical infrastructure if strictly enforced.
The Department of Health and Human Services subsequently relaxed the requirements in 2003, noting that the specific steps for providing adequate language interpretation were best considered a gray area, contingent upon the type of medical care in question, the density of non-English speakers in surrounding populations, the frequency of their visits and the available resources.
"Reasonable steps" are still minimally mandated, however, pursuant to Title VI of the 1964 Civil Rights Act banning "national origins" discrimination, culminating in a federal suit recently filed in San Diego by the Pacific Legal Foundation on behalf of the Association of American Physicians and Surgeons and other groups. The U.S. District Court for the Southern District of California has yet to rule on the matter.
Here at the Hospital of the University of Pennsylvania, like many other hospitals in large urban settings, the demand for interpreters is being partially met by volunteer Penn Medical and Nursing students -- though, without significant government backing, their training remains expensive and extremely limited. As a result, most physicians either make do without interpreters or get on the phone and call AT&T;, which gladly offers live translators for over 140 languages but at an average per-minute rate of $2.25 to $7.50. AT&T;'s Language Line does not provide, however, specialized medical interpreters, so the communication gap between doctors and non-English-speaking patients frequently persists. This is especially true at many smaller clinics, which may see few student volunteers and have difficulty affording pricey phone bills.
Clearly, the intent of EO 13166 and Title VI is on target, but in the absence of feasible financing options, their impact will remain remote at best, regardless of their legal defensibility. Rather than placing the burden on a select group of individuals and institutions, a better plan would build upon the piecemeal solutions mentioned above. Two immediate ideas spring to mind.
First, specialized federal grant programs could be expanded to further subsidize interpreter training at medical and nursing schools. Currently, only a handful of schools have student interpreter training programs, the success of which is more closely tied to budgetary constraints than lack of interested volunteers. Targeted federal aid would both increase the proximate pool of interpreters and ensure that more working health care professionals are bilingual in the future. Government aid could then be gradually reduced over time, as sufficient numbers of appropriately trained volunteers become available to teach the next crop of students.
Second, a government-sponsored medical interpreter hotline could be established, modeled on the private language services currently in use. A centralized call center would have the benefit of minimizing inequitable cash layouts by spreading the expense evenly among taxpayers. More importantly, however, it would provide the requisite regulation and oversight to ensure competent exchange of medical information while simultaneously protecting patient privacy.
These two relatively simple steps would go far toward improving the public health of the nation and reaffirming our commitment to the highest standards of clinical practice. Health care delivery should not hinge on the ability to speak English but must instead be ready and willing to embrace patient diversity.
Maintaining a medical system that offers anything less is surely a discredit to ourselves and a disservice to those who need help most.
Jason Lott is a first-year student in the School of Medicine from Anniston, Ala. Whole Lotta Love appears on alternate Mondays.
