Hospital patients in Canada lacking English need access to interpreters, study says
Risks include missed diagnoses, medical errors, research finds
Waking up with worsening pain had Surjit Garcha worried, but the red blisters on her stomach were so alarming that she went to her neighbour's home to try to explain, in her limited English, that she needed help.
Garcha, who lives alone, doesn't have the English skills to call her doctor's office and felt more comfortable going to someone she trusts.
Her neighbour took her to the emergency department in Delta, B.C., where Garcha learned she had shingles, a viral infection that can include complications such as scarring and vision and hearing loss in older adults.
Garcha, now 82, said the intense pain was bad enough, but not being able to understand what was wrong with her made her feel even more vulnerable.
"The employees who bring food to patients would leave it outside the door, because they could catch what I had and no visitors could come in my room,'' she said in Punjabi about her experience three years ago.
Garcha's only solace was that a nurse spoke Punjabi, but it wasn't until her daughter arrived from Seattle the next day that she had any contact with a family member.
Interpreters trained in medical terminology are more often provided for patients in Canada's larger centres, but a researcher from the University of Toronto said lack of access to interpretation could potentially result in unsafe health care through missed diagnoses and medical errors, suggesting language services should be a priority.
Dr. Shail Rawal, lead author of a study that includes data from Toronto General and Toronto Western hospitals, said patients with a chronic disease and limited English are more likely to return to the emergency room or be readmitted to hospital because of poorer understanding of discharge instructions and not taking medication as required, compared with those who are proficient in the language and were discharged with similar health concerns.
The study was published recently in the Journal of the American Medical Association and includes data for all patients discharged from the two hospitals with acute conditions, pneumonia and hip fracture, and chronic conditions heart failure and chronic obstructive pulmonary disease, between January 2008 and March 2016, amounting to 9,881 patients.
"We saw that if you had heart failure and limited English proficiency you were more likely to come back to the emergency room to be reassessed in 30 days after you were discharged,'' said Rawal, an assistant professor in the University of Toronto's department of medicine and a staff physician at the University Health Network, which includes the two hospitals.
"Patients who had limited English proficiency and heart failure or chronic obstructive lung disease were more likely to be readmitted to hospital in the 30 or 90 days after discharge,'' she said.
The quality of care or the level of access to interpretation ... should not vary based on which hospital you happen to present at with your illness.- Dr. Shail Rawal
For those with pneumonia or hip fracture, the data showed no difference in return to hospital regardless of patients' ability to speak English, Rawal said.
"Our thinking is that those are acute conditions that have a pretty standard treatment, whether it be surgery and then rehabilitation or a course of antibiotics, whereas the two chronic conditions require a lot of patient-centred counselling and patient management plans.''
Of the 9,881 patients:
- 2,336 had limited proficiency in English.
- Nearly 36 per cent spoke Portuguese.
- Just over 23 per cent spoke Italian.
- Cantonese, Mandarin and Chinese were the primary languages for about 14 per cent of patients.
- Greek and Spanish were the least spoken languages.
- 18.5 per cent of the study subjects' languages were listed as "other.''
Rawal said patients at the two hospitals have around-the-clock access to interpretation in various languages by phone and in-person interpretation is also available but must be pre-booked and is typically offered during business hours.
"The quality of care or the level of access to interpretation, in my view, should not vary based on which hospital you happen to present at with your illness,'' she said.
"Currently, that is the case, that depending on what hospital you go to in our city, in our province or across the country, you will have varying levels of access to professional interpretation services and I think that in a linguistically diverse country the language needs of patients and families should be met by institutions.''
Family members often step in to interpret and alleviate a patient's anxiety but may end up having to rearrange their schedules while waiting for nurses, doctors or specialists to show up at the bedside, Rawal said.
However, she said previous research studies have shown that families are less accurate in their interpretation than professionals and sometimes may not wish to translate what a clinician is saying, perhaps to lessen the impact if the prognosis would be too upsetting.
Kiran Malli, director of provincial language services for the Provincial Health Services Authority in British Columbia, said patients in Vancouver and the surrounding area have access to 180 languages through interpreters who work at hospitals and publicly funded long-term care homes.
The top three languages are Cantonese, Mandarin and Punjabi, Malli said.
In-person and phone interpretation is provided without a pre-booked appointment. The health authority started a pilot project last year to provide services by phone to family doctors' offices, she said.
Another pilot on video-remote interpreting at hospitals, which Malli said would greatly benefit patients needing sign language — which is already being provided — will also start soon and benefit those living in isolated parts of the province.
A few scattered grassroots programs were available in B.C. in the 1990s but the current standardized one didn't start until 2003, she said.
"It was getting pretty evident that we needed to do something a little more than just pulling up any bilingual person or calling on the overhead paging [system] to say 'If anybody speaks Cantonese could you please come to emergency,''' Malli said of the current program's genesis.
"Research shows us that as people get older, even if you know English when you're younger, you tend to revert back to your mother tongue as you age,'' she said, adding elderly people in medical distress tend to forget the English skills they have.
"I do think we are seeing more elderly patients for that reason,'' she said.
It's unfair for health-care staff to expect family members to act as interpreters because, just like English-speaking patients' relatives, their role should be to support their loved ones and not to be burdened further, Malli said.
"If we are looking at equity, as family I should just be there to support my family member through whatever it might be rather than act as their language conduit," she said.