3–3–3–3– dialing tune plays, then pickup– “You’ve reached–” 2– beep– “Press one for–” 1– beep– “Please hold for your Portuguese interpreter.” Dialing tune plays again.
Holding the desk phone just enough away from my ear that I can still hear it ringing, I ask the woman in front of me her name.
“Qual su nomi?” I ask, my voice uncertain. I don’t speak Portuguese, but I know enough to ask someone’s name. If possible, I’ll start checking her in to her appointment while waiting for a phone interpreter.
Scrolling down the day’s schedule, I find her name. The phone line picks up at the same time, so I point to the second handset and ask, “Celia, can you pick up the telephone?” I have no translation, but “telephone” is close to the Portuguese pronunciation. She picks up the phone.
“This is Ana, Portuguese interpreter. My ID number is 4-1-6-3-7-4. Please be aware that everything said in this call will be interpreted and remain confidential. Please speak slowly and in short sentences so that everything can be interpreted accurately. Is the customer with you or would you like me to dial them?”
I hear variations of this introduction no less than 30 times a day. Last spring, I decided to take leave from university. During my year off, I’m working as a Medical Practice Receptionist at Cambridge Health Alliance (“CHA”)’s Obstetrics and Gynecology (OB/GYN) Clinic. After a few months, I got the hang of things and had learned about health insurance, pregnancy, and even a touch of Brazilian Portuguese. Interpreters assist around half of my interactions with patients. CHA serves a diverse subpopulation of the greater Boston-Cambridge area. According to their website, 42% of primary care patients have limited English proficiency. [1] I’d bet that percentage is higher in our OB/GYN clinic.[1]
CHA makes interpretive services readily available. Primarily, patient-facing employees dial 3333 for phone interpreters. In-person interpreters are available, when needed, by immediate dispatch or advance scheduling. CHA also provides translation service for ten pages of medical records per patient. Everything published by CHA is available in English and the three most common languages our patients prefer: Brazilian Portuguese, Spanish, and Haitian Creole. Our patient app is available in English, Spanish, and as of a few months ago, Portuguese. When registering a new patient, I always ask for their preferred oral and written languages. I offer an interpreter to any patient upon request, at any sign of struggle, or if I see the “interpreter needed” flag after finding a patient’s chart. Like with Celia, I may try to continue the conversation while dialing the interpreter to respect the patient’s time, but I never want to imply that getting an interpreter is an inconvenience or burden.
I never want to imply that getting an interpreter is an inconvenience or burden.
To illustrate the danger of unmet language needs, take another encounter. I’m talking to a caller who’s trying to make an appointment for her friend, Luciana.
“I’m sorry, but I can’t speak with you about another patient’s health. Can you have her call us directly?” Even if it seems to be out of kindness, patient confidentiality comes first.
“I’m just trying to help her out. Luciana was seen in another E.D. and she didn’t understand the outcome since she doesn’t speak English and I wasn’t with her. It was very scary for her and she’s worried. Can’t she talk to someone?”
The image of lying on a stretcher in the Emergency Department with no idea what anyone is saying sends a chill through me. Then being sent on my way with a stack of unintelligible papers. As frightening as the situation sounds, it’s hard to imagine since English is so ubiquitous across the world.
“I’m sorry to hear about her experience at the other hospital; that sounds really hard. I can definitely have a nurse speak with her and schedule an appointment if she needs to come in, but I can’t do anything until I talk to Luciana directly. We do have interpreters available, so you can let her know to just ask for an interpreter when she calls and we’ll be happy to help.”
The conversation got me thinking about how accessible interpretive services are outside of CHA. Before working here, I hadn’t thought about how low-English or non-English speakers navigate, or try to navigate, the healthcare system. It had occurred to me that many people do not seek routine care or health treatment due to prohibitive costs and lack of health insurance. I knew, too, that healthcare inequity is pervasive and minority groups are at higher risk of harm from being overlooked or not being taken seriously. I hadn’t thought specifically about linguistic accessibility until taking this job, where I became familiar with the medical interpreting services.
I recognized that since CHA prides itself on diversity and champions health equity, the widespread use of medical interpreters was likely not commonplace. I would have guessed that small or rural hospitals, or less diversely populated areas, likely had no such interpretive services, and patients might have to rely on friends or family members. But hearing from this patient still surprised me: I assumed, based on my experience at CHA, any relatively progressive hospital—certainly any in the Boston-Cambridge area—would have interpreters available. Perhaps other hospitals utilize these services less; perhaps they only provide interpreters if requested, or they offer fewer languages. Maybe routine care clinics like OB/GYN can get by without interpretive services, assuming non-English-speaking patients can seek care elsewhere. But an Emergency Department near Cambridge, I certainly thought, should be able to adequately serve a Spanish-speaking patient. Isn’t it essentially malpractice to not communicate with the patient? There are emergencies when a patient may be unconscious or severely mentally disabled and the provider needs to act quickly, but the idea that a person could be admitted and discharged from the E.D. before any Spanish-speaker could be reached, not even by phone? It was unfathomable, and it was dangerous.
Isn’t it essentially malpractice to not communicate with the patient?
Although I don’t know the exact details of this patient’s experience, it made me wonder just how accessible interpretive services are. Especially in rural areas, it seems plausible that interpretive services are not provided, yet non-English speakers live throughout the U.S. As of 2016, only 56% of hospitals offered any kind of translation services, despite 97% of physicians seeing patients who struggled to understand English. [2] How many people experience terrifying Emergency Department stays like Luciana? In a 2011 study, medical interpreters assisted with only 17% of hospital admissions for patients with limited English proficiency. [3] Since the patient can’t tell the doctor, how much critical information is missed in these visits? How many people’s health concerns go unaddressed or misdiagnosed because of a language barrier? How many people don’t access healthcare due to this language barrier, who otherwise would?
Like Luciana, many patients rely on friends or family to translate. In the same 2011 study, around 28% of patients relied on a family member or friend to interpret during their hospital stay. [3] When non-English speakers rely on family members to interpret, does the extra person make sharing intimate details with a doctor harder? Even native English speakers sometimes hesitate to discuss sensitive topics with their doctors.
I recall a conversation I had with one of our doctors about a patient she referred to a specialty hospital for vulvar cancer treatment. I’d heard of ovarian cancer and cervical cancer, screened for by pap smears, but vulvar cancer was new to me. Apparently, it’s an external cancer, and this woman’s cancer had progressed severely over the past few years. The cancer had spread to her anal canal, meaning she will likely suffer further infections. Although vulvar cancer is highly treatable, intervention is limited at a late stage. It was a worrying thought—that such a severe cancer could worsen without a sign that anything was wrong. “There were symptoms,” she corrected me. “This poor woman had been in discomfort for years.” I sat with that for a moment, speechless. “‘You guys [gynecologists] scare me,’ she said.” The doctor repeated that last sentence in such a sad, timid voice. A yet more terrifying thought: the patient knew something was wrong, but was too scared to see a doctor, and now faces advanced, potentially incurable cancer. I don’t know if this patient spoke English or not. For those who don’t, does relying on family to interpret make it even less likely they will have the difficult, necessary conversations with their providers? How often does a situation like this, exacerbated by inability for privacy from family or communication at all, go untreated?
Without interpreters, I imagine we would lose patients to care, detect fewer medical issues, and sacrifice patient-provider trust.
In any situation with family members interpreting, how does the hospital ensure confidentiality and safety? Doctors ask about mental health, substance use, sex, and domestic safety, challenges that people often hide from loved ones. Providers, especially in an OB/GYN setting, rely on the privacy of the space to expect truthful responses. More than once, our clinic cared for a patient carrying the baby of a man who was horrible to her. In her TEDx Talk, Yasmin Mulji, PhD, relays an encounter with a postpartum woman who was seen by physicians throughout her pregnancy. Despite visible signs such as bruises and missing teeth, she wasn’t able to reveal the domestic violence she faced until a visit eight months after her baby’s birth. “The [family] translators often used with her were the perpetrators of her abuse.” [4] Over one in ten women report intimate partner violence when asked by a physician, and about 17% of those victims follow up with services directly as a result of that conversation. [5] How many women, I wonder, are kept from communicating with their doctors by their abusers, and without other interpreting options can’t even speak for themselves?
Not all of these questions have researched answers. What we do know is that low-English and non-English-speaking patients face much higher risks in U.S. healthcare due to linguistic inaccessibility. In just my role as a receptionist, interpretive services enabled me to connect patients with health insurance resources, make appointments work for patients, and relay their messages to providers. Without interpreters, I imagine we would lose patients to care, detect fewer medical issues, and sacrifice patient-provider trust. CHA’s strides towards health equity, though imperfect, make a dramatic difference. Raising the standard of interpretive services in healthcare is essential to better care—safe and humane care—for all patients.
Works Cited
- “Diversity at CHA.” Cambridge Health Alliance, under “Multilingual Services,” www.challiance.org/about-cha/advancing-equity-at-cha/diversity. Accessed 15 Mar. 2025.
- Eldred, Sheila Mulrooney. “With Scarce Access To Interpreters, Immigrants Struggle To Understand Doctors’ Orders.” NPR, 15 Aug. 2018, https://www.npr.org/sections/health-shots/2018/08/15/638913165/with-scarce-access-to-medical-interpreters-immigrant-patients-struggle-to-unders. Accessed 16 Mar. 2025.
- Schenker, Yael, et al. “Patterns of interpreter use for hospitalized patients with limited English proficiency.” Journal of general internal medicine vol. 26, no. 7 (2011): 712-7. doi:10.1007/s11606-010-1619-z
- Mulji, Yasmin. “How Language Barriers Undermine Healthcare Outcomes.” TEDxNHS, Sept. 2023, https://www.youtube.com/watch?v=wkfxEoEgozo.
- Miller, Christopher J., et al. “Screening for intimate partner violence in healthcare settings: An implementation-oriented systematic review.” Implementation research and practice vol. 2 (2021): 26334895211039894. doi:10.1177/26334895211039894
Footnotes
[1] Typically, patients need a referral from primary care to see CHA specialties such as gynecology. However, prenatal patients do not need a referral (a positive home pregnancy test counts). Many do not have a primary care provider before coming to us. Some set up primary care at our recommendation. Additionally, many patients come to us after a CHA Emergency Department visit (which similarly suffices in place of a formal referral). These patients frequently have no regular medical provider. Sometimes, such patients are brand new to Massachusetts; more often, they have foregone routine care.
