Reflections on the value of Canadian multiculturalism in health care delivery

Improving access to formal interpretation services

Professional interpreters are scarce in community settings where family physicians have limited funding.² Physicians often rely on translation software (eg, Google translate) to facilitate medical conversations with patients who speak different languages. Policy-makers must be aware of higher costs associated with language-discordant care (ie, longer appointments, interpreter services, increased patient navigation assistance) and the higher value of providing language-concordant care (through improved end-of-life care conversations, equitable access to health care services, and a reduction in overall health care costs by addressing preventative care in community settings rather than in hospitals).^5-7

The criterion standard solution to language discordance is professional interpretation.^7-9 Yet, without sufficient public funding to offer this in all health care settings, there is an opportunity for AI to fill the gap. Though AI offers exciting promises—low cost, no wait times, and fast interpretation—it also raises many questions, such as interpretative accuracy, provider liability, and patient consent and privacy concerns. The limitations of AI in health care have been widely discussed in recent studies.^10-13 In the language and culture context, there remain issues to consider at the interaction level, especially in end-of-life care settings where sensitive conversations are frequent and can be substantially impacted by language discordance.¹⁴

First, goals of care discussions, an important part of serious illness care, are complex due to the emotional nature of the conversations as well as language and cultural nuances around end-of-life care.¹⁵ Breaking bad news and discussing serious illness is a delicate art for which most physicians require years of practice to achieve competence. Current research on AI interpreters is mainly focused on improving accuracy of language models instead of delivery of interpreted information including tone and connotation of the translation.^14,16,17

Second, each language is rich with different dialects.¹⁸ This raises issues about the risks of miscommunication from miswording during sensitive conversations. Any AI translation tool must account for this language diversity to be successful in end-of-life care. Finally, patient-physician interactions can often include a component of emotional therapy. Whether an AI interpreter can ever be sufficiently trained to be the right messenger for sensitive clinical information and counselling requires deep consideration. Are patients ready to have emotional conversations facilitated by AI? Would interacting with an AI interpreter be better than waiting in queue for a human interpreter?^13,17,19

Considering today’s technology, it is hard to imagine a dying patient could find ease or comfort receiving a toneless, emotionless translation from an AI machine—even if it did help patients better understand their conditions and choices. Patient concerns regarding data privacy may also hinder acceptance of AI, especially if there is lack of transparency about how sensitive, emotionally charged information is being handled by corporations.²⁰ However, there is an opportunity for more sophisticated AI to play a larger role in end-of-life care. In fact, any form of interpretation should be presented as a crucial treatment, just as essential as a prescribed medication, to emphasize to physicians and administrators the negative health consequences of language discordance. This presents the need for more high-quality research on both AI and non-AI interpretation services examining clinically important outcomes. This can help make interpretation an institutional standard and assist in finding new technologies to overcome existing patient-provider communication barriers.^7,21

Developing cultural humility

In 2020, the death of Joyce Echaquan, an Atikamekw woman who recorded hospital staff making racist remarks while she sought medical care, ignited a widespread discussion on the continued existence of racism in the Canadian health care system.²² Mitigating racism is a priority in most corners of Canadian society, yet formal training regarding cultural humility and its connection to equitable health care delivery remains insufficient and inconsistent.^23,24 While cultural competency is gaining knowledge about different cultures (which has risks of stereotyping social groups), cultural humility is admitting one does not know and is willing to learn from patient experiences. Humility is the preventive measure to racism in health care, bolstered by empathy, awareness of personal biases, respect for a patient’s culture, and individualized goals of care.²⁵

Medical education is a critically sensitive period to foster cultural humility in future physicians. Embedding equity, diversity, and inclusivity (EDI) objectives across all curricular components, including examinations, would help medical students be better prepared to provide culturally appropriate care. One recommendation is to ensure standardized patients in simulated clinical evaluations are ethnically diverse, or have scripts containing elements of cultural information students must recognize; students can be rewarded for eliciting information on complementary or alternative medication use (eg, turmeric, Chinese medicine), or inquiring about the patient’s cultural beliefs on end-of-life care. However, applying the EDI lens across other curricular components, such as lectures, small-group sessions, and rotations in underserved communities, are equally important for heightening students’ sensitivities toward language and cultural diversity.

It is challenging to teach cultural humility in a way beyond increasing awareness of the negative impacts of language- and cultural-discordant care. In some cases, cultural humility can be learned on the job, though this type of experiential learning can vary depending on training location, access to appropriate mentors, and a care providers’ own language and cultural positionality. If we are to prioritize the provision of culturally appropriate care across institutions, it must start with leadership levels promoting ethnically diverse teams with lived experience of diversity who are ready to engage with new learners as role models.²⁶ Health care professionals with unique cultural experiences and understanding of non-Western cultures are well-positioned to lead an inclusive workplace culture.^21,23 They can also play a key role in developing and updating guidelines on specific cultural sensitivities, enabling providers to navigate cultural nuances with greater confidence, similar to relying on standardized guidelines for medical treatments.^27,28 Acknowledging and respecting diversity is essential for fostering a health care culture that prioritizes equitable and compassionate care. It is a systemic imperative as much as it is an individual responsibility.