Seconds Count: Dr. Sam Frenkel's Frontline Perspectives on Language Barriers in Emergency Medicine

Eyal Heldenberg (00:10) Hi everyone, my name is Eyal Heldenberg. I'm the CEO of No Barrier, an AI medical interpreter for healthcare providers. I'm very pleased to have Dr. Sam Frenkel with us. Sam Frenkel, how are you today?

Sam Frenkel (00:24) I'm doing great, how are you?

Eyal Heldenberg (00:26) All good, all good. So just to be a full disclosure, so Sam has been with us. He's one of our first beta users for our AI medical interpreter, I think more than a year. And we had a chance to talk on many things, on many topics. So I'm truly excited about the opportunity to record this episode. So maybe Sam, just give us your career, your background, your location, etc.

Sam Frenkel (00:55) Yeah, this is San Francisco. I grew up in Washington DC or just outside. I went to Emory for undergrad in Atlanta, back to Georgetown in DC for a master's and then medical school. I did residency at UCSD in San Diego in emergency medicine. I finished in 2020. And since then I worked in San Diego for a few years. I worked in a pretty rural site in Virginia for about a year and then moved out here and I've here for almost two years now.

Eyal Heldenberg (01:28) All right, perfect. So you're coming kind of from the ER aspects of healthcare. So maybe just your kind of initial experience of the San Francisco area. We know this is a diverse population. just give us a taste of a shift of what's coming in the door.

Sam Frenkel (01:50) It has been very interesting living in this place. San Diego, I certainly thought was more diverse. DC is certainly exceptionally diverse in plenty of ways, but walking around this city, you see everyone from everywhere. And obviously if people are walking around, they are finding their way into emergency departments. from language to culture to ethnicity to race to... Everyone is coming into the emergency departments around here. It is wonderful. And I think part of what we'll talk about is all the struggles and difficulties of trying to see people who have different expectations or different prior experiences than you do and how to manage that in a way that you can still provide good care for them. It is something that isn't a major focus of any part of training and something that a lot of us slowly piece together over careers.

Eyal Heldenberg (02:54) Yeah, yeah, like it's kind of a dynamic learning throughout the time. And you're right, we talk to many providers and it seems like, you know, if you treat a patient, you know, from your culture, from your language, healthcare is, you know, it's hard enough, but when you try to, you know, integrate more of a, cultural nuances and of course language barriers, it kind of becomes even more difficult. the get-go. I wonder if you could share your, what's the current workflow? Like how institutions, for example, in your institution, what is the workflow to handle those cultural and language barriers when they come?

Sam Frenkel (03:32) cultural barriers, there is no official workflow. I think there isn't a lot of understanding or training. I don't want to say support, there isn't a lot of, "we understand that people of many different cultures come in and let's make sure that you have a good understanding of these cultures and how they view medicine, they view doctors, how they view just people of authority in situations." So it is up to each of us to try and figure out how to make our way through these experiences. And all of us have plenty of stories of making huge mistakes and hopefully the patients don't suffer from that. But if someone has an expectation they come in with due to language, culture, heritage, whatever it may be, and you don't find the right way to acknowledge that and work with it, they may not accept your care. They may not do what you ask them to do to stay healthy. There are a lot of ways where it has huge impacts and part of why I'm excited to have this conversation is so we can dive into a lot of that.

Eyal Heldenberg (04:46) we talked with many providers on the importance of medical interpretation. you need to make sure as a provider, according to the law, but also as kind of as a practical manner to make sure you have someone certified or qualified to do this. you know, to do this communication. So I wonder if this is kind of your daily practice. How do you view the specific workflow?

Sam Frenkel (05:17) With translation, Translation has been different at every hospital I've worked at. And that was true through multiple hospitals, just while I was in residency, through each hospital as an attending. I was very fortunate to have in-person Spanish interpreters at my prior job, but if you weren't speaking Spanish, then it went back to, most places have these iPads.

Eyal Heldenberg (05:18) Yep.

Sam Frenkel (05:43) and every provider in healthcare hates them for the most part. I mean, they do the job and we don't have a better way to do it, so we all use it. But, I mean, the patient shows up in the emergency department and the nurse in triage has an iPad, they pull up the language, it takes a few minutes, they talk to this person and get a very brief story, as much as they can. You know, the line's out the door, the emergency department is full, they cannot get a great story There just isn't time for them. Someone three people back may be dying from a heart attack or a stroke. You have to just get through people and you get to ask three questions. Where does it hurt? How long does it hurt? Yeah, don't know if you had surgery, whatever the third question is, and then you have to move that patient forward. write a quick blur, or they write that quick blur, and the translator's turned off. That patient then waits. They get put into either another room to see someone for a little bit longer, or they get pulled back into the main emergency department, where generally the nurse that's there will pull up the translator, and hopefully you're not in another room and can get in there and do it at the same time. But plenty of times, if you are in room two and that person's really sick and new person gets pulled into room one the nurse will go in there speak to them or a slightly longer period with the translator but you then have to pull this iPad back in restart this whole process this adds on time every time the software no barrier has been wonderful about cutting down on that time in-person interpreters or Wonderful for that since they also have some of the, and potentially have some of the cultural intuition, though that also can become an issue if they are male and this is a female patient talking about something they feel is, needs to be protected, or they feel uncomfortable talking about in front of men. There are plenty of times where they are not perfect, but in person is wonderful in a lot of ways. AI has been a nice bridge between the two to get us fast access. That's really our flow. And then you go back into the room and whenever you need more information to explain things or give them discharge instructions, you pull that translator up again and that's how the flow in the emergency department has worked.

Eyal Heldenberg (08:16) every touch point you need to wait for another agent, for another interpreter, It's not like the same one goes with the patient.

Sam Frenkel (08:27) No. So you pull up this roller with an iPad and you hit the button and put in the code and then you find the language and then however long it takes to find someone, they don't necessarily have someone available all the time and you may want somebody for a video so you can say, Hey, can you ask about here" but only audio is available. But every time you go in, you have to go through the same process of finding the language, finding

Eyal Heldenberg (08:47) Hmm.

Sam Frenkel (08:54) calls and it finds whatever person. Usually it's not the same person. And then they go through the same, give me your name, the hospital, okay, can I talk to the patient? They explain what they're doing to the patient and then you can proceed.

Eyal Heldenberg (09:10) Got you, and all in all it takes a couple of minutes basically, every time.

Sam Frenkel (09:15) So Spanish on the iPads tends to be faster. There are a few languages that are faster. The more rare the language, the longer it takes, which obviously is fair. There are just fewer people who are able to speak both languages proficiently enough to translate, and those people have to be willing to give up their time to just be available for translation.

Eyal Heldenberg (09:18) Mm-hmm. Yeah, yeah. So I think maybe, you know, this is a kind of a, there is a clear cut between kind of a relaxed outpatient clinic when there is, you have those 15 minutes or 20, whatever. And the ER that just don't have time, cut, cut, cut. Like you need to go to, so I think in your case, in the ER case, it's the access to care, the time is kind of on the seconds, not on the minutes. Like you need you need to be super efficient. which leads me to the next question. You've seen this workflow. I wonder if you have any initial thoughts on how can emergency departments better design this specific workflow with the interpreting services.

Sam Frenkel (10:07) Absolutely. one of the hospitals that I worked at did, it wasn't for this purpose, but I think what they designed actually would work well for this. you're always trying to minimize the amount of wasted time in the emergency department, the amount of time you're sitting there waiting. The ideal flow in the emergency department is you show up, you're immediately seen by everyone, all of your tests get done in parallel, and then you get dispositioned as quickly as possible. If that happened every time, people's wait times would be 30 minutes or an hour, not many. I think that a way that this hospital did that with English speaking patients who could be essentially turned over quickly is there was a doctor, a nurse, and a tech who ran this small zone and the patient would be brought in and all of us would go into the room at the same time. we would all have one conversation and then that person would go back to the waiting room, you'd bring in the next person. And we essentially just, we had a few rooms we did this with and there was a person who would just take people in and out and then put new ones in. So we, as a team just went in and while I was talking to the patient, the nurse was doing their charting and putting in the vital signs, the tech was drawing blood and doing the EKG. And so all of this happened in this tiny period of time, for most emergency department visits. You show up, you see the triage nurse, then you see the nurse in the main ER, then you see the doctor, then the tech comes in to draw the blood. Each thing happens in series instead of in parallel. So if you could take, especially in translation, if you pull everyone into the triage room and say, hey, we have a patient who speaks Tagalog and we need a translator, I've pulled up the translator, pulled the doctor and the tech and we're all gonna do this at the same time, cutting down on that three to five minutes of waiting for the translator and giving them the information they need to get started and them explaining their job, that's 15 minutes of that person's day. And you do that however many times a day, that's a lot of time.

Eyal Heldenberg (12:30) Yeah, it adds up. I think one of one other, I don't know to call it trick or it's kind of a budget thing is just getting more iPads, more devices because sometimes this lack of resources, right? Because there is another usage and now you need it, right? I don't know if you encountered that.

Sam Frenkel (12:50) All the time. so there's, my department has, I'm sure I'm misquoting them, but I think that we only have two of these iPad translators, and one almost always sits out front where it belongs. You need someone, the person in triage, to be able to say, what language do you speak? If you're having an emergency emergency, you're having stroke-like symptoms, this is a massive heart attack, and you can't explain that you have chest pain or that your arm doesn't move. So one has to sit out there, which means that there's really one floating around. And if it's in room 20 and you need it in room four, you're waiting until they're done. And then even afterwards, you may not know where it is. So we're constantly paging overhead saying, hey, does anybody have the translator? Can you bring it to room four as soon as it's available? And in meantime, that person just sits there and you can try and if you're lucky enough to have another way to translate with that person, then great.

Eyal Heldenberg (13:32) Wow.

Sam Frenkel (13:47) But otherwise, they're waiting and you're wasting your and their time.

Eyal Heldenberg (13:55) this is something that could easily be, you know, with the right budget, it's not like amazingly high, but with the right budget, those kind of small, you know, problems in workflow could be easily, solved.

Sam Frenkel (14:10) I'll vote for you for president if you want. You just gotta...

Eyal Heldenberg (14:12) haha Yeah, we should do it. Perfect. you know, before this episode, we discussed a couple of things and I want you to take us to these cultural competency elements. What do you think should be included in medicine training programs for those specific properties?

Sam Frenkel (14:39) So that's a really... think there are a bunch of different parts that are worth putting in to training. It's hard to narrow this down to one thing. I think the main point I would want to get out there is that it is really easy to assume that someone understands what you're saying to them. It is really easy when you're and this is resident, you feel so rushed and plenty of times you, this is the first time you're seeing something early on. you someone nods their head and go, okay, I think they understood what I'm saying. And you run out of the room and go tell your attending like, okay, we're good. We can go do the procedure or they said they don't want to stay. I don't know why. taking that extra 30 seconds or a minute to make sure that someone can repeat back to you. Here's what you said to me. Here's what I'm taking away from it. And the outcome is going to be X. If I am telling you that I want to leave, I understand that there are real consequences to that or you're saying you want to put a needle into my knee. I'm telling you my knee hurts, you told me to put a needle in there. There are plenty of people who just say, the doctor must know. And yeah, we're never trying to hurt anyone or make the wrong decision, but we are not perfect. having that joint decision-making , you know, there are risks to this and every procedure. They're a risk to most benign antibiotic. Yeah, we are just, it is so important to have that conversation because you are gonna feel better at the end of that interaction, not just the like, I don't know what happened, but I guess they're not my problem anymore. You get to say, I discussed this with this person, we made this decision together. They understand what's going on and now we get to move forward and you go home feeling better, they go home feeling better. I think making sure that you take the time to make sure they can repeat back to you what was said and why it's important would be a wonderful thing for residents to take away.

Eyal Heldenberg (16:53) Yeah, you're right, because this is something that could become a habit for a provider in those situations, right? Just keep patient autonomy, right? You are feeling more comfortable that, yeah, he understood, he repeats, he knows what's going on. So it makes you kind of feel more, assured that you can proceed. You know, before the episode we talked about, I'm now exploring this whole workflow of consent forms, consent forms in languages, in languages aspects. I wonder if you could take us to this from your experience, like what is the right workflow or maybe the wrong workflow, but in practice that, you know, that usually as part of, you know, this limited English proficiency patients that they need to sign or they need to understand something, you need to do this procedure, this surgery

Sam Frenkel (17:46) Yeah, I mean it's really tied to what we just talked about. it's really easy for me to go to the hospital I work at now has a very wealthy, a portion of its population is very wealthy. They all speak English very well. They are very well read and versed. They've all done their more research sometimes than I would like them to before coming in. Sometimes that's a different issue. And for those people you say, yeah, this is really easy. You need X procedure done. Here are the pros, here are the cons. I have a piece of paper for you to sign. I wrote down the pros and cons on it, or it's already pre-filled out, or whatever the procedure is. If you get it, sign at the bottom. And they go, have two questions. Here they are. You answer them, and they sign at the bottom. Great. But as soon as you start questioning whether this person speaks English well enough or doesn't speak English at all. Most hospitals that I've worked at have forms in Spanish, but my Spanish is not good enough to have this conversation in a way that's fair to patients. And some of them, I haven't asked the patient before this point, "Can you read well enough to understand this form?" So am I just throwing a form in front of them, having them say, "Okay, this is the doctor, the doctor thinks this is a good idea, I'm gonna sign whatever they tell me to because that's ethnically, culturally what we do with doctors in my culture." That's. That's not what any of us want. I don't want to be making decisions for these people when they have the ability. So being able to not just have the right written consent, being able to put in there, okay, here's what's going on. Here it is written. Here it is verbally. We're gonna go through this translator and make sure that you, again, can repeat back to me. Here is the risks. Here are the benefits. I'm getting this procedure because of X. And because we discussed the risks and benefits and the benefits to me outweigh the risks, let's proceed. Now I'll sign at the bottom of this form and everyone can go into this. I don't have to worry. I'm halfway into trying to put a central line can be like a big needle up here into the neck and have them turn around and like, what are you doing? I don't want someone moving. I want them to really understand.

Eyal Heldenberg (20:14) Wow.

Sam Frenkel (20:17) You need to turn your head away and keep turned away. I know that there's a sterile cover. I know that the sterile cover can be uncomfortable. You are still getting air. We've propped it up on the side to make sure that you are. If you're uncomfortable, please say something, don't turn. If I don't have a way to communicate with you... there's no guarantees that that won't happen and it's a bad outcome. And I don't want that. Obviously the patient doesn't want that. So getting consents in multiple languages, the written form is wonderful. And I think being able to do that written and verbal is the right way to make sure that we are appropriately consenting patients.

Eyal Heldenberg (21:00) Yeah, I think it's getting made to patient autonomy where you're making sure that they're fully aware to everything. maybe it's a use case. The consent form is there for a reason, right? It's not just a regular, "Here's your appeal to take" or something. The system thinks that this is something you need to stop, right? There is a step here to stop, to validate, right?

Sam Frenkel (21:25) Absolutely.

Eyal Heldenberg (21:26) And maybe in those cases, it's even more important to have a medical translator either on site, phone, video, whatever, because if the system wants you to stop as a provider, get all the right resources to keep this consent form in practice, right? I totally get your perspective on the importance of that. Maybe just a word on, you know, there are some, maybe we started with that. There are some cultural misunderstandings that could be, could be because, you know, you don't know the culture. You don't know exactly what to do there. I wonder if you have like a story or something like that you encountered with patients that, you know, if you would understand that you would probably do something else or

Sam Frenkel (22:17) Yeah, I mean I think one that I'll start out with a general and then I'll go to a specific example. Something that I think is always going to be funny to at least ER doctors is a lot of us, chief complaint of dizziness is this myriad of the unknown. If you come in for chest pain, I know generally you mean here. We're not talking about your head, we're not talking about your knee, like the pain is here. And there's still a differential. In English, the word dizzy can mean lightheaded. It can mean the room is spinning. can mean those are probably the two main ones. In Spanish, the word dizzy translates roughly to mariada. And my ex-girlfriend at the time, who was from Spain, told me, it just means you feel unwell. So it could mean so many things. and trying to clarify that word. If you, I was very lucky, it was early on in residency when she told me this, so I tried to be really clear with patients. Okay, you said that, this is the word I said. This is, think, what you're hearing, and I wanna make sure I'm understanding the actual feeling and not just your, not just this word, and just jumping to conclusions. A more specific example, I did have a patient, a pediatric patient, A few months ago now, kind of tail end of winter viral season. Seven or eight year old boy, otherwise pretty healthy, had his vaccines. He's coming in with kind of cough, congestion, sore throat, something we've seen a thousand times. We all deal with this all day. We have a pretty routine process as long as your exam is okay, the history is okay. And so I'm trying to explain this to mom who is on the bed and dad who is sitting next to the bed. And I wasn't paying too much attention to the grandmother who was behind mom. So I'm asking these questions and they continue to seem confused. I'm doing this with a translator. This is in Spanish. I'm doing this with a translator and me and the translator are both struggling a little bit with why there's these delays. can tell the translator also looks a little bit confused. And as I'm getting further and further into this, I'm realizing that in this family, the grandmother is the matriarch. She is the one who makes these decisions. She's the one who is the final decision maker. So the person I needed to be talking to was her. needed to, I missed the cultural cue here that she was the one to say, we're getting the care that we need. It's okay that we do this and not do that. She was pushing for antibiotics and she had just been whispering in her daughter's ear and the translator wasn't translating that part because it wasn't directed to me. And I missed it. It absolutely made this interaction longer and more uncomfortable for everyone. and clearly they were also frustrated for a little while with me directing questions to them when they were not the ones who had questions. So once I figured this out, I started talking to the grandmother saying, hey, what were you looking for here? How can I address your concerns? And it turned out she wanted antibiotics. I was able to explain to her why that wasn't the right choice in the situation. She said, okay. And it would have taken five minutes instead of 15. But that's me missing that cultural signal delayed their ability go home.

Eyal Heldenberg (26:10) I think this is a great example, like a story that exemplified. I wonder if you feel on yourself in this time in San Francisco with these diverse communities coming. Do you think that you are kind of getting used to these nuances to look at the patient to feel. Do you think you kind of as part of the experience this comes along?

Sam Frenkel (26:36) I hope that that's true. I am humbled very regularly in this way. And people come in from, in San Francisco, people come in from all over the world. And it doesn't have to be that different of a place from the last patient to have different family dynamic, a different idea of who doctors are and what they're supposed to do for you much it's okay to question them. There are absolutely times I've been very lucky to have a nurse who saw something and said, hey, can you go back into the room one more time and just explain this? Maybe this is silly, but do you mind just taking a minute and just go back? And go back in the room and you can tell that they're right. And I find a new way to explain something and They needed to hear me say, doctors are fallible. They needed to hear me say, it's okay that you have questions. Or they needed someone to really just say, this is the right thing. We're on the right path. You are doing okay. Please take these medications. I understand that that makes you nervous. But getting called back into the room or taking, I hope I'm getting better at it, but I... I am definitely not done yet. Not by a long shot.

Eyal Heldenberg (28:03) Yeah, it's a journey, Hopefully every day we get better at what we do.

Sam Frenkel (28:13) Yeah, it's, I mean, I, right now I don't work at an academic center, but I hope in 10 or 15 years I can, I can start doing work with residents again and just tell them how all of these stories of times where I made mistakes, made cultural mistakes, I've made medical mistakes. have done all sorts of things that, I mean, I would love to be able to rewind and erase, but since I can't, they might as well learn from the ridiculous silly things that I've done so that they can then make their own mistakes and continue to pass that forward. But yeah, I am.

Eyal Heldenberg (28:51) Yeah, yeah, totally.

Sam Frenkel (28:55) I'm very lucky to have partners who I can bounce these ideas off of who have been around for a lot longer and seen a lot more and they really can give you little tips and poke ahead in the room like, this is how you kind of handle that thing. That's been a very nice part of working at my current hospital as well.

Eyal Heldenberg (29:18) Right, nice. So I think there were many kind of good stories and good tips. think maybe, you know, the greatest tip, I think, or at least one of the top is kind of making sure you ask the patient to repeat kind of the instructions or everything. I think this is kind of a small step that could kind of really make this workflow and the treatment and the care kind of an elevated step. I don't know if you had other tips on your foreclosure, but...

Sam Frenkel (29:56) I hope we get to have this conversation in five years and look back and be like, wow, I gave that advice. That was the third best thing I could have told you. Here's something even better. no, for this stage in my career, that has been probably the best thing that I've been doing to build trust in these relationships across language and culture race and ethnicity and everything is just continuing to ask questions until it really, they're able to tell me in their own words what they've heard and what they think is happening. Because otherwise, I mean, really these, it is so easy to just, I mean, we've all done this. You just say, yeah, absolutely, I get it. And you don't, you just like, I don't have another answer for you. You asked me, do I get it? And I just said, yeah. In medicine, that person goes home and they don't take their medications. They don't trust you. And that's sad. And it can't all be on the doctor, but I hope that this is a place I continue to get better at making sure that people really understand the care that they're getting.

Eyal Heldenberg (31:17) Amazing. This is a great closure. So Dr. Sam Frenkel, I want to thank you for being with us in Care Culture Talks.

Sam Frenkel (31:24) Yeah, this is my pleasure. This is awesome. I hope we get to talk a lot more.