Last spring, Lourdes Cerna, a fifty-eight-year-old medical interpreter, received a phone call from a hospital in Texas. In Cerna’s home, in Los Angeles, the audio crackled to life; on the other end of the line, she could hear a woman struggling to breathe. A doctor at the woman’s bedside wasted no time. “Please tell her that if she does not agree to go on the ventilator, she will not survive the day,” she said.
Cerna translated the physician’s plea into Spanish. When the woman didn’t respond, the doctor asked Cerna to try speaking in her own words, clearing them in English with the medical team first to insure that there were no contradictions. In Spanish, Cerna and the patient started a conversation. They talked about the woman’s grandchildren and about how she might see them if she made it out of the hospital. But Cerna could detect an unmistakable determination in the patient’s voice; she had already made up her mind. “This is the end,” the woman said. “I know I’m not coming back.”
The physician offered pain medication to ease the woman’s suffering, and she agreed to take it, with Cerna translating all the while. The doctor thanked Cerna for her time, and the conversation ended. Fifteen hundred miles away, Cerna sat at her computer, waiting for the next call.
By November of 2020, when we first spoke, Cerna had grown accustomed to such conversations. Since the start of the pandemic, she had been receiving many COVID-related calls. Often, they involved end-of-life discussions with patients whose lungs were faltering. At other times, she spoke to relatives in faraway countries, delivering the worst possible news. Some conversations were leisurely and thoughtful; others were brusque and hurried, with the medical team rushing from item to item on an interminable list of tasks. Each time, when the call ended, Cerna was left alone to absorb the experience. “I’d have one after the other after the other after the other, and I would feel just sad and drained,” she said. “Many times, I would cry by myself in my home alone, because there would be nobody to talk to.”
A Guatemalan immigrant, Cerna is part of a burgeoning profession that has assumed a critical role during the pandemic. The spread of the virus has been especially brutal in immigrant communities, where more people have had to work outside the home despite the risk, and in which health-care resources are scarce. Interpreters must help patients with limited English skills navigate their treatment and the health-care system more broadly. The job is taxing both practically and emotionally. For many patients, meanwhile, an interpreter is the last person they will speak to who understands what they are saying.
Cerna’s interpreting career began in the nineteen-eighties. She was a laundry worker at the Los Angeles County and U.S.C. Medical Center; when doctors and nurses discovered that she was proficient in English, they began calling her to interpret for Spanish-speaking patients. There were no staff interpreters at that time—for most patients, interpreting was either ad hoc or nonexistent. Cerna had no training in medical interpreting and no access to education for the job. “I was interpreting for AIDS patients, the burn unit, the emergency department—you name it—all without proper training, without proper medical terminology,” she said. “I was studying on my own just to try to get a grasp on different medical terms.”
A decade after starting as a medical interpreter, Cerna attended a training program. She has since become an instructor in her own right. Her level of formal education is unusual in the field. Today, two national bodies have certification exams, but only a fraction of working interpreters have taken them. Although health-care organizations or private interpreting companies may have their own proprietary tests, interpreters aren’t always required to take them. The low barriers to entry belie the intensity and complexity of the job.
For decades, federal law has guaranteed access to medical interpretation for any patient with difficulty communicating in English. But the reality is more fraught. Lax regulation, a lack of reimbursement, and variations in skills and procedures mean that many patients go without interpreting services. Researchers have found that, when patients do not have access to an interpreter, they are more likely to stay in the hospital longer and to be readmitted later on. A survey of malpractice cases paints a grim picture. In one landmark case, from the nineteen-eighties, a misinterpretation of Spanish led physicians to assume that an eighteen-year-old patient had suffered a drug overdose. In reality, he had a brain bleed; by the time they realized their mistake, it was too late. He became paralyzed from the neck down.
Even before the pandemic, medical interpretation was a difficult job. An interpreter must grapple with a range of dialects: Cerna told me that the verb “tragar,” which she uses to mean “swallow” when speaking to a Guatemalan Spanish speaker, can be an insult to someone speaking Mexican Spanish. Filigata Paitomaleifi Peneueta-Samuelu, a Samoan interpreter, explained that her native language does not have single, clear words for some common medical terms, such as “dialysis” and “vaccination,” or even for some body parts, such as “colon” and “bladder.” “For our language, you have to explain what the meanings of those words are,” she said.
Beyond the task of translation itself, there’s the nebulous work of cultural brokerage. The journalist Anne Fadiman’s nonfiction book “The Spirit Catches You and You Fall Down” is often assigned in medical schools; it follows a Hmong child with a severe form of epilepsy as she and her family navigate the American medical system. Fadiman shows how a deficiency of trained interpreters plagues the partnership between the family and their physicians, compounding cultural mistrust and misunderstanding on both sides. (The mistrust can run deep: Gleb Velikanov, a Russian medical interpreter I spoke with, told me that he has had to explain to patients that they don’t have to bribe or beg their doctor for treatment.) But, while interpreters can provide important cultural context, their code of ethics is also clear: they are there to translate, not editorialize. The interpreters I spoke with said that they took this code seriously, but not all do. Meanwhile, it is next to impossible for a health-care provider to verify the accuracy of interpretation for a language they don’t understand.
I am an emergency-medicine resident, and, two years ago, my cohort conducted a simulation that highlighted the degree to which bad interpretation can interfere with medical care. A resident who spoke Gujarati played the patient, and our team used our hospital’s telephone service to contact a real Gujarati interpreter. It took several minutes of back-and-forth between the resident and the interpreter before we arrived at the right diagnosis: carbon-monoxide poisoning. Only after the simulation ended did the resident explain what had happened. She had tried repeatedly to tell us, through the interpreter, that she had been cooking on a makeshift stove in her apartment when she began feeling lightheaded. In translating this for the rest of us, the interpreter had repeatedly left out the part about the stove. When the “patient” insisted, the interpreter told her, “Shut your mouth—the doctors don’t want to hear about the stove.”
As a practicing emergency-room physician during the pandemic, I’ve encountered other problems with interpretation. I’ve sometimes waited for more than an hour to get an interpreter on the phone or lost interpreter calls because of poor reception. Even when the process works smoothly, interpreting inevitably eats up time; it’s tempting to take shortcuts in the face of crushing pressure. One might rely on a patient’s family members for interpretation, but it’s hard to know whether the family member is translating technical or emotionally fraught sentences correctly. (A child, for instance, might try to shield a parent from a frightening diagnosis.) Alternatively, a doctor can try to use his or her own language skills. This is risky, too. In 2019, a few of my colleagues asked fifty clinicians to take a test measuring their proficiency in medical Spanish; afterward, the study participants took a survey. Of the thirty-two who’d failed the test, forty-four per cent reported that they enlisted professional Spanish interpreters “some of the time,” “rarely,” or “never.” (After receiving their test results, half of those thirty-two said they’d be “more likely” to consult with an interpreter in the future.)
In 2014, a team of Harvard researchers interviewed medical and nursing students, and found that they all reported having worked with physicians who expressed frustration with the difficulties of communicating with patients who have limited English proficiency. Some of the behaviors reported reflect clear prejudice. One physician dismissed a patient’s symptoms as “Haitian chest pain,” while claiming that Haitian patients have “a different perception of pain than other people.” Others saw language access as a low priority—a hindrance to getting things done. Amid a deluge of COVID-19 cases, even clinicians who are deeply committed to language access may find the additional burden of getting interpreters prohibitive. “The concern is that people are reverting to just getting by,” Leah Karliner, a physician at U.C.S.F. who studies language access, said, when I spoke to her last October. This kind of laxity was especially bad during surges in case numbers, Karliner added.
A few decades ago, hospitals still struggled to enforce hand-washing rules. Poor hand hygiene among doctors made patients sick. Still, the practical and cultural barriers to making hand washing more widespread seemed strangely insurmountable. Eventually, health-care leaders focussed on the problem, directing funding toward efforts to solve it. These efforts included the adoption of easier-to-use alcohol-based hand sanitizer, the installation of sinks in more convenient locations, and electronic sensors that track hand-washing compliance. The federal government also began assessing penalties for high numbers of hospital-acquired infections. Hand hygiene remains a challenge in health care, but organizations that implemented these changes have experienced dramatic improvements.
“We should treat this the same way we now treat hand washing,” Alexander Green, an internist at Massachusetts General Hospital and the Family Health Center of Worcester, who has written extensively on language barriers in health care, told me, referring to medical interpreting. “That used to be optional, and our systems didn’t make it easy to do. Then we learned doctors weren’t washing their hands and it was killing people, so we changed course. This is no different.”
There are technological innovations that could make interpreting easier. I used to call interpreters using my cell phone; I’d place it on speaker, then huddle next to the patient so that we could both hear and be heard. But, last year, one of the hospitals I work in began deploying more mobile video-interpreting stations—essentially, iPads on rolling platforms—which have speakers that can play audio louder than the din of the emergency room and allow the patient and interpreter to see each other. These sorts of improvements cost money, and, outside of a handful of state Medicaid and children’s insurance programs, reimbursement for medical interpreting is virtually nonexistent. Interpretation is what policy experts call an “unfunded mandate”: providers are required by law to offer language services but aren’t paid to provide them. Hospitals or clinics that serve mainly patients with limited English proficiency are already underfunded compared with those serving primarily English speakers.
