How do we ensure that patients receive care in their own languages?
I met Anton* earlier this year, shortly after starting my residency training to become a family physician. A Ukrainian gentleman in his 80s, Anton had been living largely independently with his son, spending his days cooking, cleaning and keeping up with sports on TV. Then, without warning, he had developed vision loss and a severe headache. A CT scan showed a bleed into his brain that couldn’t be surgically removed. My job was to evaluate the progress of his symptoms, monitor his pain and coordinate his plan for discharge with his son.
Anton reminded me of my grandfather. They had a similar sparsely toothed smile, dark eyes that crinkled at the corners, salt-and-pepper whiskers and a penchant for reading the newspaper at all hours of the day. Crucially, they shared another commonality: neither spoke any English.
Because of this, when it came time for me to see Anton, I would resort to a number of strategies to communicate with him: wait for his bilingual son to visit, find the Ukrainian-speaking nurse on our floor, or, at worst, mime and Google-translate my way through our interactions. Somehow, I wasn’t aware of the language services available at the hospital; they were not discussed at our orientation nor suggested by any staff. And while Anton always greeted me with the same benevolent smile, I couldn’t help but wonder how much of a disservice I was doing him by not speaking a language he could understand.
Training in a city as diverse as Toronto has afforded me the privilege of caring for patients from many nationalities. Concurrent with this diversity is a rapidly evolving linguistic landscape—25 percent of Ontarians have a mother tongue that is not one of Canada’s two official languages and 80 percent of them live in Toronto. As immigration continues to drive Canada’s population growth, Ontario’s proportion of limited English proficiency (LEP) speakers is expected to grow.
Health care organizations have attempted to meet this need by employing language services ranging from in-person and over-the-phone live interpretation to using newly developed mobile interpretation apps.
In exploring Ontario’s current landscape of language services, I wondered how accessible our current system is to patients and providers. Is there a more effective way forward?
Language interpretation services in Ontario
Receiving care in a language you don’t understand leads to poorer health outcomes. According to a 2017 review by the Wellesley Institute, these include a higher risk of receiving inappropriate medical testing, an increased risk of hospitalization and adverse medication reactions, and decreased patient satisfaction with the provider and encounter.
Even if patients have a family physician who speaks their language, they will inevitably encounter health care professionals who do not. To fill this gap, many providers turn to untrained interpreters, including the patient’s family, friends, or bilingual hospital staff.
When I tell Joanna Fine-Schwebel, director of interpretation services at the Sinai Health System in Toronto, that I once tried to explain appendicitis in Cantonese (my first language) with minimal success, she laughs: “Well, where did you get your training in Cantonese medical terminology?”
She points me to the evidence against the use of untrained interpreters; namely, that they incur a higher rate of omissions and clinically significant errors when compared to professional interpreters. Untrained family and friends may feel uncomfortable discussing intimate or sensitive issues with their loved ones and instead give unsolicited advice or use euphemisms in their translations. Using relatives or friends as interpreters can lead to inappropriate interpretation because of their lack of understanding of medical terminology and disease concepts, and it can also subject them to moral or emotional distress over the illness of their relative or friend.
In Ontario, “Each hospital contracts with its own interpreters and runs its own language services program,” says Fine-Schwebel. “They might run a little differently, but most, if not all [language interpretation service] agencies adhere to the National Standard Guide for Community Interpretation Services in Canada.”
Up until six years ago, this decentralized model was largely the only one available in Ontario. Then, in 2012, the Toronto Central Local Health Integration Network (one of the 14 regional health authorities in Ontario) recognized that language was a “systematic and avoidable” barrier to equitable health care access and subsequently launched Language Services Toronto (LST), a bulk-buy program whereby 19 hospitals and 14 community agencies within the TCLHIN signed on to access centralized, over-the-phone interpretation in 170 languages at any hour of every day. Providers at participating institutions simply dial a number, key in their access code, and select their language, and then they are transferred to Remote Interpretation Ontario, a provincial interpretation services collaborative. If a RIO interpreter is unavailable, the caller is transferred to a backup agency.
This bulk purchasing of services resulted in clear cost savings: In the first year of implementation, the volume of use had driven costs down to the lowest pricing tier (around $1.50 per minute). An evaluation of LST found high levels of satisfaction among both patients and providers: 76 to 90 percent for patients and 83 to 95 percent for providers. Sixty-nine percent of providers reported that they used LST each time a patient required interpretation.
Of the 31 percent of providers who did not consistently use LST, over half described “convenience of alternate methods” including using untrained interpreters, gestures or miming as proxies; while the majority of remaining respondents noted patient preference (for instance, for a family member or friend to interpret, or to avoid the dialing and connection process) as reasons for inconsistent use. Other providers mentioned a shortage of technical equipment (speakerphones, phone jacks and dual handsets), or patients becoming frustrated by the amount of time the calling-in process took, as significant impediments.
Anjum Sultana, co-author of the Wellesley review, talks about another challenge of the TCLHIN’s bulk-buy model: geography. “In Toronto, the boundaries of the LHINs don’t perfectly align with the borough boundaries, but the greatest diversity of languages in the city lie in areas like Scarborough or Etobicoke, which are separate LHINs,” she says. “It’s nice to see the TCLHIN take this forward, but it would be ideal to have further centralized language services planning to be able to address those areas of greatest need.”
Sultana, like a number of other stakeholders I spoke to, advocates for centralized administration of language services across the city, if not the province. She describes British Columbia’s Provincial Language Service, which is funded by the province and services all five BC health authorities (the equivalent of LHINs in Ontario), in addition to private physicians’ offices, as a model to emulate. One barrier to the uptake of the TCLHIN’s centralized model is cost: While community health care agencies receive funding from the LHIN to access LST, hospitals are required to pay independently for access.
Apps: The new frontier in health care language interpretation?
More recently, language interpretation has seen the introduction of an alternative service delivery model: mobile interpretation apps. Two main categories exist: the first connect the health care provider directly to a live interpreter through an app housed on the provider’s phone or at the patient’s bedside computer station. The app is usually developed by the same service provider that the hospital already acquires language services through, and the costs incurred are paid by the hospital. The major benefits of this model are ease of use and elimination of additional hardware needed to facilitate connection to an interpreter.
The second model works similarly to a phrase dictionary: the apps host a repository of searchable common medical phrases sorted by language and affected body part, whose spoken-on-command and written translations are pre-reviewed by trained interpreters. For instance, if providers are interviewing patients about back pain, they would search “back pain,” and the app would return a list of uni-directional questions such as, “Where does it hurt?” and “Have you started new medications recently?”
Although neither of these services have yet been widely adopted in Ontario, some institutions appear on the verge of implementing some form of them. Fine-Schwebel reported that Sinai Health System was planning to offer an app on hospital computer desktops or mobile phones that would facilitate immediate access to over-the-phone interpretation. At St. Joseph’s Healthcare Hamilton, Phil Valvasori, manager of medical affairs, has been approached by vendors of the phrase-dictionary-style apps which would be hosted on providers’ personal mobile phones.
An additional advantage of the phrase-dictionary-style apps is their ability to generate substantial clinical and demographic information with minimal additional effort beyond routine use. Jerrit Tan, former CEO of Canopy Apps, describes a pilot in a New York hospital where 30 percent of patients had limited English proficiency. In the pilot, Canopy was given to all health care providers in the emergency department, and over a few months of use, the data stored on the apps revealed that Cantonese-speaking patients were frequently presenting to the emergency department with non-emergent issues (determined by rolling up the phrases commonly searched by the provider) between 4–10 p.m. on weekends. Chinese-speaking staff were then placed in clinic at those times and were able to redirect patients from the waiting room to make an appointment with another outpatient clinic.
These results highlight the potential for mobile phrase-dictionary apps not only to provide interpretation services but also to generate practice-changing data in a way that is easy to extract and unambiguous.
As to the quality of the conversation afforded by phrase-dictionary apps, Grace Egan, manager of business development for Access Alliance Language Services, remains skeptical. “Any repository that is validated is one step better [than non-validated services like Google translate]. [These apps] can be a tool, a static resource, but we would still only recommend these when you don’t have access to a qualified interpreter.”
Ensuring providers know about language interpretation services
In Ontario’s current system, each institution is independently responsible for ensuring their staff are aware of what language services are available. Fine-Shwebel remarks that, although it’s a priority to ensure that everyone routinely receives the appropriate information, the quick turnover of medical trainees makes this difficult.
I was not aware of the hospital’s interpretation services when I cared for Anton, but the problem was not unique to our situation. One of my resident colleagues from another Toronto teaching hospital, Stephanie Zhou, reflects: “[Learning about language services] was not part of our one-hour orientation to the unit—that was much more focused on logistics like how to admit a patient.”
Providers must be aware of the language services offered at their institution (and advocate for better ones if necessary), because in-language care improves health outcomes. As Zhou says, “When you speak the same language as the patient… they can see themselves or someone they love in you, which can give them hope.”
*Names and identifying details have been changed to protect patient privacy