Conversations surrounding patient autonomy have been at the crux of conversations on doctor-patient relationships for decades. Though existing conversations question and focus on the paternalistic model to view the way medical providers control their patients’ autonomy, this essay shifts focus on the ways language barriers remove autonomy. Whether intentional or not, language barriers have been used to exert control over minoritized communities and remove the opportunity for self-advocacy.
The U.S. economy was built on the exploitation of racial and ethnic minorities and “race” as a concept was invented to reinforce boundaries that would benefit the U.S. economically. The crushing weight of the economy remains on the backs of many immigrants, especially those from minoritized groups. Though limited English proficient (LEP) communities are not necessarily limited to racial minorities, they are often associated with racially minoritized groups. LEP is one of many factors that contribute to the acculturation, or the perceived assimilation of an immigrant into the norms of another country, of a patient (Saha, par. 6). Then, a “less noticeable accent” is a signifier for a greater degree of acculturation, lifting the ranking of a patient higher in the hidden curriculum. In American healthcare, those who are more valued within “the hidden curriculum” are afforded more authority over their own treatments. Subsequently, LEP individuals are valued less because of the astonishing rates at which they experience worse treatments and worse health outcomes.
In accordance with Jay Katz’ ideas on sharing authority between patients and doctors in his book, The Silent World of Doctor and Patient, many of those who have experiences with LEP communities in healthcare emphasize the importance of maintaining a patients’ authority (Katz, 85-103). While this framework has been widely adopted in medical communities, it has been actively withheld against LEP communities, especially in racial minorities.
Ysaura Rodriguez, who provides perspective as a LEP patient and a Spanish-speaking certified nursing assistant for CommWell Health, emphasized, in a recorded interview, how she came to trust her doctor. She speaks on the clear communication between them, “She’s given me choices, which, it is very important for us to have choices. And if I said I want to try this home remedy, and she said, “Let me know if it works. But think about your medicine. Take your medicine. But let me know if it works.” (Ramirez with Ysaura, 25:14 – 26:30). In this interaction, Rodriguez’ doctor clearly respects Rodriguez’ autonomy as a patient, while still providing advice based on her medical expertise. Because having an open, non-judgemental conversation is ideal for any provider and patient relationship, it’s important to have qualified interpreters to be a medium for these conversations.
Alexandra Lightfoot and her colleagues conducted a study to highlight barriers in healthcare to Latine communities. Many of the Latine youth that particulates described interpreters as potential sources of error. One example involved a youth who corrected an interpreter who misrepresented a school administrator’s message to his mother. His concerns were immediately dismissed, despite being a native Spanish speaker, and the circular reasoning that the interpreter was a “professional” was used to insist on the accuracy of the translation (Lightfoot et al.). Here, the youth was denied any type of self-advocacy, alienating him from authority. Unfortunately, the alienation of youth surrounded by LEP communities (especially for healthcare authorities) has consequences for long-term health outcomes, future doctor-patient interactions and trust, etc.
While Lightfoot’s work highlights issues that arise with the use of interpreters, the issue of access to interpreters or other language access services remains, in spite of the Affordable Care Act (ACA). Melody Schiffiano and her colleagues compared the language services available in hospitals with the demand for those services and found major disparities in the proportions of hospitals that offered language services across ownership (private for-profit, private non-profit, and government-owned hospitals). Private, not-for-profit hospitals offered language services in the highest proportion at 70.2% in areas of low need, but decreased down to 62.5% in areas of high need. Then, only 18.2% of private, for-profit hospitals and government hospitals offered language services (Schiffiano et al.). While the rates are astonishingly low on an ethical level, since it guarantees that large proportions of BIPOC communities will be receiving subpar treatment, it also blatantly violates federal regulations. Section 1557 of the ACA specifically mentions that hospitals need to hire “qualified” interpreters, effectively differentiating “qualified” interpreters from (more commonly used) “competent” and untrained bilingual staff (United Language Group). While there are certainly issues with the current standards of language services, as shown by Lightfoot’s studies, having a complete lack of language services shows disregard for the LEP communities seeking healthcare.
Lightfoot’s findings underline the issues that many non-native interpreters cause: imprecise and inaccurate translations. Claudia Garrett, who was interviewed as a part of the Southern Oral History Program, works as an interpreter for CommHealth, describes the need for native-Spanish speakers well. Because the majority of doctors she worked with had some understanding of Spanish, they were able to advocate for themselves when they heard an inaccurate translation of their words (Ramirez with Claudia, 19:35-20:00). The crucial distinction between a patient’s (or Latine youth’s) and a doctor’s relationship to the interpreter is the default authority provided to doctors. The inconsistent standards for interpreters that the ACA attempted to correct are demonstrated and patched by the doctor’s ability to understand the interpreted language, but is an unreliable solution.
Jacqui Laukaitis’ experiences as a volunteer medical interpreter reiterate the consequences of having no language accessibility services. As an immigrant from Chile, she volunteers and works at Open Door Clinic and a hospital, where she’s seen patients being completely disregarded because of their LEP. The reliance on one or two volunteer medical interpreters meant that LEP patients were pushed to the back of the line, waiting for a medical interpreter to arrive. Even with access to language interpretation services, some doctors she interacted with refused to call interpreters to the room and would not talk to a LEP patient. She says “doctors figure if they can’t communicate, they just won’t communicate,” combining ideas about patient worthiness and acculturation, consequently removing the patient’s autonomy and power of self-advocacy (Moore with Jacqui, 52:30-55:00). Instances like these and even in more innocent interactions, where doctors attempt to communicate over language barriers lend itself to worse health outcomes for LEP communities.
According to a study conducted by Chandrika Divi and her colleagues, on correlations between language proficient and adverse events, defined as any unintentional harm done to the patient not resulting from an underlying disease or condition). Leaving language barriers unaddressed inevitably resulting misunderstandings, issues with informed consent, all leading to preventable issues with morbidity and mortality. These issues would occur even from well meaning doctors, just by nature of communicating over a language barrier. When considering implicit biases surrounding perspectives of acculturation, patient mistreatment can originate from more nefarious motivation from doctors being unnecessarily dismissive (Divi et al.). These negative experiences with mainstream American healthcare isolates LEP communities, making them less likely to return, and subjects them to worse health outcomes.
While cultural competence has been a popular framework to view the treatment of BIPOC patients, it does not emphasize the structures that force symptoms out of certain communities in a helpful way. Jonathan Metzl and Helena Hansen outline “structural competency”, in a research article to highlight the forces that affect health outcomes at levels higher than individual interactions. They emphasize that issues at structural issues are main causes for non-compliance within many BIPOC communities. Structural conditions like living in food deserts, neighborhoods with no gyms or parks, etc. would prevent many communities from following advice like to eat healthier or increase exercise (Metzl & Hansen). Lack of access to grocery stores and parks or sidewalks represses autonomy at a structural level, far beyond the control of any individual doctor or patient. While there is very little to be done at an individual level, recognizing the issue at a structural level and developing the language to describe the way these issues prevent patient autonomy in LEP communities is key to implementing structural interventions.
References
Katz, Jay. The Silent World of Doctor and Patient. Johns Hopkins University Press, 2002.
Lightfoot, Alexandra F et al. “”What I wish my doctor knew about my life”: Using photovoice with immigrant Latino adolescents to explore barriers to healthcare.” Qualitative social work : QSW : research and practice vol. 18,1 (2019): 60-80. doi:10.1177/1473325017704034
Metzl, Jonathan M, and Helena Hansen. “Structural competency: theorizing a new medical engagement with stigma and inequality.” Social science & medicine (1982) vol. 103 (2014): 126-133. doi:10.1016/j.socscimed.2013.06.032
Moore, Isabell. Interview with Jacqui Laukaitis. 2 April 2019 (Y-0108). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Saha, Somnath et al. “Reducing language barriers and racial/ethnic disparities in health care: an investment in our future.” Journal of general internal medicine vol. 22 Suppl 2,Suppl 2 (2007): 371-2. doi:10.1007/s11606-007-0372-4
Ramirez, Joanna. Interview with Claudia Garrett. 25 June 2018 (Y-0023). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Ramirez, Joanna. Interview with Ysaura Rodriguez. 29 June 2018 (Y-0044). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
United Language Group. “The Affordable Care Act and Language Access.” United Language Group, United Language Group, 27 June 2022, https://www.unitedlanguagegroup.com/blog/the-affordable-care-act-and-language-access.