Tumor. Cancer. Surgery. Disorder. Disease. Treatment. Doctors have the responsibility to tell their patients “bad news” all the time. The “news” is not some abstract story that can be simply watched out of boredom or skimmed over with glazed eyes. The “news” is about one’s future of living or dying. Far more difficult to swallow than prescribed pills is the fear of dying and suffering. Doctors possess special vocabulary reserved for delivering “news” beyond medical terms. “Best”, “try”, “everything”, “understand”, “support”, “sorry”. They aren’t big words, but they somehow take on greater importance in the context of a fluorescent, sterile, Purell-scented doctor’s office.
Doctors are the communicators of truth about bodies and well-being. Clear patient-directed communication is a way to restore some control in the midst of what could be a dehumanizing and undignified circumstance. A patient being examined in a gown that exposes their imperfect nakedness to the whims and waits of the healthcare system—it is an experience that could be forever ingrained in memory. Paul Kalanithi, a neurosurgery resident at Stanford who became a patient and passed away before finishing his book, When Breath Becomes Air, learned the true role of a physician after he lost the power of the role.
He learned “something not found in Hippocrates, Maimonides, or Osler: the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence” (Kalanithi 166).
Kalanithi eloquently characterizes the patient-physician relationship. It is inherently unbalanced. The physician’s job is to enter into the patient’s existence and personal life. The physician is the safeguard of sensitive, HIPAA-sheltered information. Doctors communicate advice on how to live better. They ask very personal questions about our lives, prescribe medications, write directives and tell us what to eat and how much to move. All of these actions require clear and compassionate communication.
Health literacy is the term given to describe the ability to acquire and make sense of information and resources regarding health. A displaced immigrant or refugee may be familiar with different foods and traditions; they may come from a different culture with its set of medical practices and beliefs; they will almost definitely not speak the same language or have the same mannerisms as their providers in the United States. In these situations, health literacy is not just a matter of knowledge and implementation as language and culture become major barriers to access.
The Center for Immigration Studies gathered information regarding the prevalence of foreign languages spoken in the United States in 2018 (1). The representation of almost all languages has steadily increased. The most prevalent languages spoken in the U.S. following English are Spanish, Chinese and Tagalog.
While much energy is wasted on debating whether or not healthcare is a right, no energy is needed to realize the fact that all people need access to healthcare services. Title VI of the Civil Rights Act of 1964 ensures that federal money given to hospitals must not discriminate on the basis of race, color or national origin (2). This means that healthcare providers that receive federal funding must provide equal access to healthcare for all of its patients by providing professional medical interpretation. Even with policy protection, the reality for non-native English speakers is bleak. In order to receive federal funds, hospitals must comply with the law and “provide adequate language services, but virtually everyone agrees that too many cases slip through the cracks” (3). There are many gaps in communication and a lack of enforcement, and medical professionals are often unprepared. Politics of healthcare aside, more needs to be done to ensure that patients from all backgrounds are included, represented and advocated for in the healthcare system. While most hospitals have free translation services for multilingual or non-native English speaking patients, the demand will continue to surpass the available resources given the upward trajectory of the prevalence of other languages.
Jose Salinas Valdivia, a Hispanic Studies Ph.D. candidate at Washington University in St. Louis, volunteers at Casa de Salud where he serves as a qualified Spanish medical interpreter to the mostly uninsured patient population, most of whom are immigrants or refugees. Jose came to St. Louis for his academic pursuits, and while he had always been involved with culture-related volunteer work at home in Peru, medical interpreting was not an activity he had sought out. It started with curiosity and the desire to do something meaningful.
Jose is one of many interpreters who represent a variety of experiences. Many older medical interpreters immigrate to the United States from places of war or persecution. They come to the United States with years of field experience as engineers, physicians and professors. But given the near impossibility of validating their degrees to match U.S. standards, these individuals provide their language skills in the humble profession of medical interpreting to serve people with the shared experience of living in a foreign country.
The effectiveness of medical interpreting is contingent on the invisibility of the interpreter. The medical interpreter’s job is to be the two-way street for the non-native English-speaking patient and the English-speaking physician. The interpreter’s own voice has no place in the medical office unless there are cases of abuse or mismanagement. Jose conveyed the challenge of sitting behind the patient and minimizing his presence even when he notices something unfair. Jose argues that the patient has the right to know if the physician is racist, for example. For Jose, medical interpreting is volunteer work, but it is a matter of life and death for some patients.
In Medical Spanish class, an undergraduate introductory course at Washington University in St. Louis, we practice medical interpretation, and we role play the doctor, the patient and the interpreter. The only correct positions for the medical interpreter are to the side or behind either the doctor or the patient. Medical interpretation provides the basics of healthcare for non-native English speaking patients.
Medical interpreting is a self-effacing profession, but as Jose shares, “it’s so important to be able to help the communication between the patient and the doctor that otherwise wouldn’t be there.”
While Jose has been interpreting at Casa de Salud for only a little over two years for a few hours every other week, he already has gained enough experience and exposure to know that there is an overwhelming need for and undeniable meaning to his work. Medical interpreting is rewarding. Success is measured on the individual patient level.
Jose knows he has done a good job when “a patient walks out of the clinic feeling calmer and more hopeful than when they walked in.”
As a medical interpreter, his job is to be the bridge that allows the patient to know that they are being cared for and that they can have hope. This volunteer work has become one of Jose’s major focuses during his time in St. Louis. He has been working on a project proposal to the Gephardt Institute to establish a network to connect students with medical interpreting positions.
Medical interpreting reminds us that healthcare relies on much more than what the white coat embodies. Brittany Jones, a Community Referral Coordinator with the St. Louis Integrated Health Network, understands the power of the white coat. She strongly voices for greater participation and integration of social workers and community health workers into healthcare, especially for displaced and at-risk patients. Physicians have a lot of influence that can be leveraged for good, but many times the burden is too great. This is where the coordination of care is crucial for the follow-through and continuity of healthcare access. Hospitals would collapse without the support of janitorial services, technicians, social workers, administrative workers, etc. We may see medical interpreting as another non-essential administrative role, but without these dedicated professionals who faithfully do their jobs behind the scenes, the physician’s ability to speak to patients would be utterly broken. Patients would be left stranded on a one-way street.
My conversation with Jose ended with him telling me about his favorite specialty to interpret: physical therapy. The minor movements and posture adjustments that physical therapists impart to patients with occupational pains and chronic suffering can be life-changing. Small changes that will not make the patient wealthy or give the patient a better job, instead, these changes improve quality of life little by little. Small changes can make all the difference. The less glorified roles in healthcare are integral to the functioning of the entire system and the delivery of services.
Jose concludes, “it’s about going back to the basics.”
Written by: Alicia Yang
Edited by: Daniel Berkovich
Illustrated by: Lucy Chen