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.