P. Y. Chan, a new immigrant with limited English, sought cancer treatment in Toronto in April 2021. Her doctor said in English they would be “taking samples” from her vagina and it would hurt a bit.
She lay on the operating table without anesthesia, not knowing what the process will be like.
The doctor scrapped tissues from her.
Chan said in Cantonese that she later discovered the process was a biopsy.
She is one of the 20 per cent of Canadians who have a mother tongue other than English or French, and they are exposed to the potential for language discordance in medical settings.
The Canadian government’s Job Bank forecasts a growing labour demand for translators and interpreters in the next decade, raising concerns about language accessibility in healthcare.
An August 2016 study by the Canadian Paediatric Surveillance Program (CPSP) revealed that out of the 856 valid responses, only 87 per cent of Syrian refugee clinicians had access to interpretative services. And only 67 per cent of the interpreters were professionally trained, the survey showed.
The language barriers and need for interpretative services also made the identification and care of mental health disorders challenging, the report shows.
Ontario will be one of the provinces that need interpreters the most, the forecast suggested.
Chan said the anesthetist for her tumour removal surgery told her she had the right to apply for interpreters, but she decided to proceed without an interpreter’s help. She said the long waiting time for interpreting services discouraged her to seek help from them.
She learnt from the medical staff that patients phoned in to see if there were any interpreters available on the day of surgery, it’s a game of luck, she said.
Patients never know how long they have to wait, and whether or not it will affect their scheduled appointment with the physician, Chan said.
Chan said she would rather proceed with no interpreters because there were too many uncertainties. Patients may have to reschedule and delay their treatment to fit interpreters’ packed schedules.
Italian medical interpreter and manager at University Health Network, Maria Anna Calamia said medical interpreters are important as they break the language barrier in patient-provider relationships.
MARIA ANNA CALAMIA
Calamia has been working in the field for decades, and she witnessed how influx of immigrants has impacted the need for Toronto medical interpreters.
Medical interpreters also consider cultural contexts when interpreting, and the tiniest difference can make a huge impact, she said.
“If the care provider said, ‘how would you pick up a glass,’” Calamia said. “In my culture, cups don’t have handles; they are just round. You have to say the interpreter needs clarification. Do you mean something made of glass? And with no handle?”
The Canadian government responded to the language accessibility loophole with extra funding on May 23, 2023.
Minister of Health Jean-Yves Duclos announced more than $15.4 million will be given to four institutions to bridge the language barrier faced by Francophones who live in Northern Ontario.
The projects aim at improving access to health services for French speakers and promoting healthcare services in French, he said.
“When it comes to healthcare, language should never be a barrier because it can lead to a life-or-death situation,” he said. “This is why we are supporting projects by these four organizations who will improve access to health services for Francophones living in minority communities in Northern Ontario.”
Sudbury Liberal MP Viviane Lapointe said the funding “will directly support the increase of capacity to train additional bilingual nurses and personal support workers right here in Sudbury.”
But language barrier is a multilingual matter that extends beyond bilingualism.
Calamia said the shortage of specific interpreters depends on the emigration trends, and Ukrainian medical interpreters were needed the most in the Greater Toronto Area in 2023.
Canadian Paediatric Society Dr. Charles Hui also said in his research paper in August 2016 that war, healthcare, and immigration are closely related.
UNIVERSITY OF OTTAWA
Dr. Charles Hui studied the correlation between war, immigration and health in his research paper in August 2016.
“Canada resettled over 40,000 refugees from Syria from November 2015 to February 2017; 50 per cent of those welcomed were children,” he said. “The health of migrant children has been shown to be at risk.”
Hui said their situations include malnutrition, psychosocial disorders including post-traumatic stress disorder, depression, anxiety, and other infectious diseases.
Calamia said Spanish, Cantonese, Mandarin, Portuguese, Vietnamese, Arabic, Russian, and Hindi were also languages which needed more staffing.
“There’s a shortage in language interpreters, but there’s an even bigger shortage of American Sign Language (ASL) interpreters,” Calamia said. “There’s something like 50 American Sign Language interpreters for all of Toronto, so it’s absolutely crazy.”
Unfortunately, patients are the ones to suffer when medical services are not linguistically accessible.
Dr. Don Thiwanka Wijeratne, an assistant professor in internal medicine at Queen’s University, compared and analyzed the frequencies of Canadian residents, language-proficient immigrants, and non-language-proficient immigrants undergoing unplanned hospital visits.
He said in his 2021 research paper that non-language-proficient immigrants had a smaller likelihood to make “unplanned emergency healthcare visits” when compared to their language-proficient counterparts.
“Language challenges can reinforce systemic and social-cultural barriers to accessing healthcare services and further, prolonged language barriers have been strongly associated with poor health outcomes,” Wijeratne said.
Chan’s journey to recovery reflected his findings.
She sought medical help six months after she realized she had a frequent and unusually large amount of vaginal bleeding, she said.
Chan said she had doubts about whether or not she could communicate with the healthcare providers and had in her brain every scenario of how things could go wrong, she said.
She said she only presented herself to the doctors when the excessive loss of blood affected her daily life, where she had to sit in the washroom for hours, couldn’t eat, and started to experience body malfunctions.
A July 2022 study in the Canadian Medical Association Journal also suggested it was “hypothesized that patients receiving language-concordant care would have better outcomes than those receiving language-discordant care.”
Physicians who cannot communicate effectively with patients are prone to perform unnecessary tests, which may lead to increased risks of unideal events and prolonged hospitalization, the report showed.
For Chan, she had been reliant on her ex-wife’s assistance in translating and interpreting the papers and conversations, she said.
But return visits were not as smooth ever since they parted ways, Chan said. That was her first time having a consultation with a doctor in Canada.
She said she vaguely remembered a nurse saying in English that they would be conducting a test that is something “virginal.” So, she assumed it was a vaginal test.
But it turned out to be an anal examination, Chan said.
“That’s not expected,” she said.
Wijeratne said the lack of linguistic accessibility is worrying.
“These findings are significant because they highlight potential shortcomings in our healthcare system that, if left unfixed, could threaten the lives of a large portion of our population,” Wijeratne said.
A research paper on BMC Health Services Research dated July 2021 said language barriers prevented clients from “to explain their health conditions adequately” and “understand treatment instructions.”
One healthcare provider featured in the research said there were instances of clients misunderstanding the treatment instructions, which gave rise to “a couple of disastrous cases,” including medication that was to be taken orally ‘but they thought it was to be installed in the ears.”
The study also said the language barrier made clients uncomfortable to ask for clarifications.
“They get very embarrassed and they get very frustrated,” it said.
Patients and care providers had to get creative to overcome language barriers and the shortage of medical interpreters.
Chan said she and her ex-wife watched 18 seasons of Grey’s Anatomy, an American medical drama television series, to make sure to acquire medical knowledge and language, and they searched on Google for words that they didn’t know during the consultations.
They asked the physicians to jot down all the words and medical jargon and sought dictionaries once they got back home if time was running short, she said.
She said all was done just to keep up with the conversations and better understand what care providers were saying.
Calamia however had a different take on using translation software like Google Translate in medical settings.
“It’s just not 100 per cent reliable and it hasn’t been tested enough for us to able to say ‘yes, the patient understood that,’” Calamia said.
She said the problem with using translation aids is that it makes communication one-way.
An example will be a speaker asking the other if they want coffee or tea with Google Translate, but chances are the person answers something outside of the two options, like lactose-free milk in my coffee, she said.
“I think right now, because it’s not two-way communication, I would say there could be legal issues,” she said. “It’s not just about you know, getting coffee or tea wrong.
“I feel like Google Translate gives the false impression to the person using it actually speaks their language,” Calamia said. “And sometimes, they could divulge things to you, like medical information.”
Hui said in a position statement dated June 22, 2023, that using untrained or ad-hoc interpreters, including family members, raised concerns about medical safety.
A correlation was shown between the use of untrained interpreters and distorted meanings, which may increase the chances for miscommunication and medical errors, he said.
“Using a family member or an untrained stranger to interpret on behalf of a vulnerable adolescent makes it difficult for a health professional to respect and maintain the patient’s autonomy and confidentiality,” Hui said.
Chan said she was thankful for all the medical staff who had been accommodating to her by using language that matched her lingual abilities.
Chan, who has Nosocomephobia, a phobia of hospitals and medical settings, said she told the nurses at Toronto General Hospital that she was extremely anxious about the upcoming tests because of the environment.
But the nurses there patiently explained in almost “baby talk” how the blood tests would be conducted, Chan said. They even offered her several options and let her choose one she would feel comfortable with, she said.
Shortages in medical interpreting have been a longstanding problem.
Stefanie Cassidy, a professor in the Language Interpreter Training course at Humber College, said the enrolment figures for community interpreters were “healthy,” but students chose not to pursue medical interpretation upon graduation.
Lesley Abad, Interpreter Educator for University Health Network, said the requirements needed to work as a freelance interpreter with them included:
• Completed interpreter language examinations, ILSAT or CILSAT
• Have thorough knowledge of and adhere to the Code of Conduct for interpreters.
• Experience interpreting in a healthcare setting.
• Medical Terminology courses
Cassidy said education costs pile up, which can be discouraging to candidates who aspire to be medical interpreters.
Cassidy said language interpreter training courses itself were affordable, and were around $250 for a course, with six courses in total.
But medical terminology courses can come in a range of very different prices, she said.
Another reason behind the labour shortage was the difference in pay, Cassidy said.
Legal interpreting, which also required advanced education like medical interpretation gives a higher pay, she said.
Calamia said the University Health Network was lucky to have seven to eight staff interpreters, meaning they worked Monday to Friday, with fixed salaries, fixed hours, and pension benefits.
But that wasn’t the case for freelance medical interpreters, she said.
“So basically, as a freelance interpreter, it means that from 8 a.m. to 9 a.m., I could be at St. Joe’s from 11 a.m. to 12 a.m.I’m at, you know, St. Michael’s from 1 p.m. to 3 p.m., I’m at UHN, and then from 5 p.m. to 7 p.m., I’m somewhere else,” she said.
“But I don’t get paid from 8 a.m. to 7 p.m., I only get paid the hours I worked,” Calamia said.
She said medical interpreters’ travelling and time costs were not covered.
“It’s very hard to maintain yourself, let alone a family doing this,” she said.
Another reason behind the shortage was that interpretation has not been treated as a profession, Calamia said.
“This profession is like 99 per cent women,” she said. “And a lot of times, it’s seen as, ‘oh, that’s the housewife doing something in her spare time.’”
When Calamia first started her career 15 years ago, she was mistaken as being a volunteer, she said.
“I’m professional, I work here,” she said. “I have a PhD, like what are you talking about?”
Calamia said the lack of recognition of medical interpreters also led to the current understaffing situation because talents were drawn to other professions.
She said the solution to the labour shortage was to “give people a full-time job” which will hopefully “make them want to stay.”
Toronto healthcare can mimic what she did to alleviate the shortage of ASL language interpreters about five years ago, she said. Calamia initiated the “Shared American Sign Language Programme,” which is a contract where hospitals pay a few dollars more to share interpreters with other hospitals.
Cassidy said another way to encourage more interpreters to specialize in the medical field is through subsidy.
STEFANIE CASSIDY
Cassidy explored the possibility of recruiting more medical interpreters with government subsidy, which has been done in the past for other interpretation fields.
“I know that has been done in the past, through certain agencies, where they did get help from the government, and they were able to pay for [around] 25 students,” she said. “We did classes just for that course that was subsidized.
“Again, if healthcare needs certain languages, they can just subsidize the whole fee for them,” she said.
Additionally, Wijeratne said improving the representation of a diversified spectrum of ethnicities among healthcare workers can be a way to remedy the lack of linguistic accessibility.
He said this can “facilitate communication in multiple languages and offer more culturally attuned service provision, catering to cultural diversity.”
Hui said a systematic solution can be “establishing free 24-hour interpretation services [which] should be a priority for all provinces and territories.
“Interpretation services should be part of hospital accreditation standards,” he said. “Organizations that represent health professionals, and agencies responsible for accreditation should work with the interpretation community to develop and implement a national standard for interpretive services.”
But most importantly, people should not refrain from seeking medical help merely because of the potential language barriers.
Chan said new immigrants should not hesitate to sign up for a family doctor accepting new clients, regardless of the language they speak. One never knows when they’ll be sick, or how bad it can be so, people should not be afraid of the language barrier because technology is getting handy and can assist, she said.
Immigrants were so used to doubting themselves that it could sometimes upset their best treatment times, Chan said.
And because it’s Canada, most medical staff are patient and willing to address any concerns you may have, Chan said.
Language barriers exist but finding a family doctor should be the first thing an immigrant who is settling in Canada does, she said.
Don’t be afraid to seek medical help, Chan said.
Krystal H W Yeung 
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