Adriana sat quietly looking at the floor with her young son, Pablo, beside her. She looked tired. The two had come in for a follow-up appointment for advice on Pablo’s autism medication. The clinician in the room did not speak Spanish, this family’s mother tongue, so they waited in a polite, mildly uncomfortable silence as a translator dialed in over the phone. The visit commenced. Questions were asked, answered in monosyllables; rinse, repeat. Finally, the young patient lifted his head: “Where’s Pilar?”

Dr. Pilar Trelles, a child and adolescent psychiatrist at the Icahn School of Mount Sinai, is a physician whose native language is shared by many of her patients. Born and raised in Peru, she immigrated to the United States after medical school to begin clinical practice. Twice a week, she leads the psychiatric service in a developmental disability clinic that treats patients on Medicaid. The majority of patients who come to this clinic are newly minted immigrants, many of whom speak little, if any, English, with Spanish and Bengali featuring as two of the most commonly spoken languages among families. Although translation services are readily available, they are not always ideal.

Translation in medical settings has long been problematic. Elderly patients can get confused by the presence of a third party via phone or video device, while other individuals cannot hear very well. In one unfortunate incident, an interpreter mistranslated one word, leading doctors to choose an incorrect treatment plan, ultimately leaving the patient quadriplegic. Even beyond these concerns, there’s the base element of connection. “Families are inviting us into their lives, to share intimate details and troubles that they go through,” Trelles says. “There has to be a trust component, and sometimes it’s very difficult to have that when you cannot speak directly to someone.”

Around 24 million people in the United States have a primary language other than English and have limited English proficiency. During the pandemic, there has been a rise in the use of translators who “dial in” over the phone, but many nuanced forms of language, including expressions and body language, are missed. As a result, mistranslation runs rampant—though it is severely underreported. Not only does this hurt the quality of medical care that patients who do not speak English receive, but it also reinforces a barrier between clinician and patient, as many people do not feel comfortable sharing more than the bare minimum for fear of being misunderstood or stereotyped.

Patients with limited English proficiency have often immigrated to the United States from other countries to get specialized medical attention. Many of them have already been failed by the US system—a child with autism denied proper services, another with emotional disability brought to the emergency room in handcuffs—so when a doctor comes in who relies on a third party to understand the patient, they shut down. The spread of coronavirus has exacerbated these issues of trust and translation, since the virus has ravaged immigrant communities in particular, where more people have had to work outside of the home despite risk and where health care resources may be more scarce.

But as the pandemic continues to prevent the presence of in-person translators, what can be done? “I have a lot of families that I treat where I do not speak the same language as they do and will [be forced to] use an interpreter,” Trelles answers. “But then I make it a point to get to know them. I will spend time hearing about their lives and about their families and where they come from, opening those doors even through an interpreter.”

Yet working in the health care system makes it hard. “There’s so much pressure to be fast and treat only what has to be treated, but this requires more time and effort. I just don’t know if the health care system recognizes that. We try, but we need more support.”

While immigrants are disproportionately affected by subpar translation services, those from small communities who speak particular dialects suffer the most. “We have a family who comes to the clinic from a region in Africa where the official language is French but the language that this family speaks is a dialect that is particular to their area, and there are very few people who speak it,” says Trelles. In fact, no interpreters were readily available to translate. “In the beginning, it was so hard, we actually had to track down the social worker that was working with this family and have them come to the clinic to translate.” While this social worker was kind enough to accommodate the situation, this is not always feasible.

Ultimately, medical mistranslation and the lack of appropriate interpretation services further systemic racist and classist practices in hospital settings, with underrepresented patients bearing the brunt of poor outcomes. While this is particularly relevant during the coronavirus pandemic, inadequate medical care and stunted trust at the hands of improper translation will remain important for years to come.

“When I’m translating, I make an effort to not just speak directly with the families while excluding everyone else in the room,” Trelles says. “I talk to the provider as well, to make sure everyone’s on the same page and understands what’s going on, which makes a difference. It may feel a little broken but taking that extra time does help, because then when I’m not around, the other provider will still have that relationship with the patient.”

Since in-person translators are not always an option, the same effort can be made by video translators. Both providers and interpreters have expressed a preference for video translators over dial-in ones, with patients agreeing that it is important that interpreters see them and vice versa. Of note, doctor visits that use interpreters over the phone are correlated with the shortest visit times. Perhaps a solution, though an imperfect one, is to emphasize the use of video by dial-in translators. Video interpretation has been shown to facilitate and enable patient confidentiality more than over-the-phone translators. While this may not be the cornerstone of trust, it can certainly be a foundation to build on.

Finally the door opened and Trelles entered. She beamed as she saw Pablo and greeted him affectionately, embracing both him and his mother. “Pablito, you’re so big now! Did you know you’ve gotten so big? Mom, how are you? You look good!” Adriana smiled faintly but uncrossed her legs and began to speak, sharing what had been happening in her life, her son’s, their extended family’s, and Trelles kept up, firing back questions about other family members not present at the visit. Meanwhile, Pablo ran over to Trelles and hugged her tightly, with no appearance of letting go. The clinical air faded at last and warmth flooded in.