Most medical care takes place outside of the physician-patient encounter. Phlebotomy in the lab, “clean catch” urines, EKG’s, colonoscopy preps, mammography, and nasopharyngeal swabbing all happen when the physician is busy elsewhere. If there is a delay between the order and the completion of this task then the interpreter for that encounter has often moved on to the next encounter. Each site (i.e. the lab, the MA, radiology) then calls an interpreter for very routine tasks that are discrete, quick, and often require some demonstration.
Worse than calling and waiting is not calling, and instead pantomiming the task or worse yet, simply proceeding without explanation or warning. The time it takes to call an interpreter, register for the encounter, wait for an interpreter, then describe a concrete task over the phone creates delays, unequal access to care, and bottlenecks for technicians. The financial cost of time and repeated calls is also significant. Nowhere was this more evident than during symptoms screening and viral testing for LEP patients during the Covid-19 pandemic.
What might help is immediately available high quality interpretation and demonstration of the task at hand in the language of that patient using actors from their community. This communicates very clearly the key information, and provides a demonstration that can be readily played repeatedly in many simultaneous locations. If there is an option to opt out and ask for an interpreter then this also siphons off the group who are anxious, have additional questions, and are willing to wait for an interpreter to get care.
By linking language specific videos on a YouTube channel to QR codes, a library of linguistically appropriate demonstrations becomes immediately available for a number or specific, simple, but potentially confusing tasks – like FIT testing or spirometry. The QR code can be available online, in a book, or printed on an AVS (after visit summary), making the video available to view on iPads in labs or screening stations or on smartphones that the patient themselves may carry.
We have attached an example and “proof of concept”. This is the example of nasopharyngeal swabbing, a routine that created a great deal of anxiety and avoidance for some during the 2020 pandemic.
These videos are not intended to replace in-person or telephonic interpreters in clinical care, but to provide better access to care by making sure interpreted instructions are given. This also avoids the delays in written translation of information, and the fact that children and many visually impaired or marginally literate people prefer not to read. Translations are invariably flawed, expensive, soon obsolete, and frequently lost. These videos were made in minutes on an iPhone, using available hospital interpreters.
An interesting observation made by the British sociologist Anthony Giddens is that cultures and social structures are comprised of routine behaviors. Routines like dressing, greetings, conversational rules, the use of utensils, worship and driving patterns all vary by culture and are the concrete building blocks of a culture. These are the things we teach our children and young adults that perpetuate a culture and a society.
As these routines are modified and change a culture evolves and adapts. This is very evident in medical culture which is comprised of endless routinized practices that are repeated, occasionally modified, standardized across settings, and then measured. “Code Blue,” BP measurements, immunization, the use of glucometers, ventilator care – each of these are routinized practices that we standardize and teach the next generation to carry on the practices of medical care. These routines are the building blocks of medical culture. The subtle variations in the manner these routines are conducted can create the palpable differences experienced between clinical settings exercising very similar clinical or administrative routines with small variations.
When we expertly translate and demonstrate key clinical routines that we need patients to cooperate with, we provide them equitable access to the culture of medicine and its routines. We also take a step toward removing some disparities in care, as we improve the potential inequities in outcomes which result when we fail to communicate well. These kinds of innovations are efficient and inexpensive, but much more importantly they are inclusive and move toward equity.