In the German health care sector, the ability to speak German is a precondition to receive immediate and appropriate medical support. Language barriers between patients and medical staff can not only have fatal outcomes but also contribute to the formation of prejudices amongst medical staff towards non- German speakers. Lisanne Knop is improving healthcare access for migrant populations and is fostering a more inclusive healthcare system through Triaphon, a low threshold language support system for hospitals that leverages the multilingualism of Germany’s migrant population.
Die neue Idee
Increasing rates of migration to Germany have surfaced prejudices and created challenges for systems ill-equipped for the inclusion of non-German speaking people. Being able to clearly articulate your medical needs can be decisive over life and death. A medical doctor by training, Lisanne Knop experienced the consequences that misunderstandings from language barriers can have on patients’ lives. She developed Triaphon together with her medical colleague Korbinian Fischer.
Triaphon is a low-threshold, on-demand translation service that improves healthcare access for non-German speakers and reduces prejudices in the healthcare system. Through a multilingual volunteer community, Lisanne supports hospitals 24/7 with translation services - currently in 7 languages - with doctors needing to call only one phone number. Triaphon is built on smart processes in recruiting, training and operations, thus reducing practical and psychological barriers for its implementation and being a tool to overcome cultural reservations standing in the way of an inclusive health care system.
Triaphon does not aim to replace professional translation services which are necessary in longer, more technical conversations, but is closing a gap in situations where time is of the essence (e.g. emergency rooms) or professional services are too costly to be authorized (e.g. for basic examinations and purely informational conversations), whilst at the same time highlighting the need to make the overall German health care sector more accessible for non-German speakers.
While Triaphon is supporting doctors and patients to improve access to the right treatments, the interaction between patients, doctors, and translators also reduces prejudices and frustrations experienced due to obstacles in communication. Patients gain a voice in the treatment process as they can request more information about the medical procedures, communicate about their problems faster and easier, and can hold doctors accountable for their actions.
The existence of Triaphon also reduces the initial hesitations of non-German speakers to seek help in hospitals in the first place. For doctors, language barriers are significantly reduced through Triaphon, as they don’t pose an additional burden in their stressful schedule. Doctors can instantly reach out for support, thereby reducing structural resentment toward non-German speaking people. As the volunteers connect patients and medical staff through their interpretation services, they are positioned as important assets, helping the medical system see value in immigrant communities and embrace diversity rather than fear it. This contributes to a shift in the mindset of medical staff and administration, who see the value of language diversity and better understand the impediments that non-German speakers experience when entering the German health care system.
Since its inception in 2017, Triaphon has already contributed to better treatments for over 7000 patients across Germany and Austria. As it makes use of already existing technical equipment, such as hospital phones, it can be easily introduced into new environments and technically implemented. Beyond expanding to new sectors such as midwives and public health NGOs, Lisanne and Korbinian are lobbying on a policy level with public insurance companies and federal ministries to highlight the shortcomings of the German health care sector in terms of language support and push for a law change to make it easier for patients to access language support.
According to a study by Lindholm et al. (2012) , language barriers have a negative influence on the quality of medical treatment. With a peak of 745,000 refugees in 2016 and 550,000 more thereafter, the number of non-German speakers needing medical support has seen a significant increase recently.
With limited time dedicated to each patient in hospitals, doctors perceive non-German speaking patients as a burden. In an environment, where communication is key to understand the reasons for someone coming to the hospital, language barriers bring about terrible results. Non-German speaking patients can be labelled as “language barrier” and sent to the next doctor instead of describing the observation of symptoms. Patients who do not understand the information given by their doctor have a higher risk of hospitalization. They are less likely to comply with treatment, are more likely to make errors with medication or might be inhibited to go to the hospital in the first place.
Not only is the quality of medical treatment affected by miscommunication, it can lead to prejudice or even structural racism based on missing language skills. Medical staff associate patients with language barriers with frustrating, negative experiences, therefore reinforcing stereotypes and resentments towards them. According to the University of Fulda, language barriers in health care institutions have empirically proven to lead to xenophobia and aggression - 37 percent of all aggressive behavior towards doctors is due to language barriers and an alienation of patients and doctors.
Besides the pressure that occurs due to heavy schedules, a non-existing failure management affects non-German speaking patients disproportionately, where mistakes by medical staff are not communicated transparently. Non-German speaking patients who often don’t know the German health care system are consequently less likely to write complains or sue hospitals. This increases their vulnerability and marginalization in the public health sphere.
The lack of empathy for language barriers as well as the responsibility vacuum can be traced back to two major structural issues. Firstly, the Code of German Social Law V states that medically insured patients are neither entitled to the coverage of interpretation costs in case they don’t speak German nor is it part of the medical treatment of doctors to provide an interpreter. Whilst the law puts the responsibility on patients to provide for their own translation services, they can hardly ever foresee when a medical emergency occurs in their lives, making it impossible to plan for a translator. Secondly, hospitals are increasingly driven by economic logic, turning the doctor-patient interaction into a vendor-customer relationship.
The support of professional on-site translators, therefore, often needs to be approved by the hospital's management, who have only limited insights into the day-to-day reality in the hospital environment. The need for approval limits the doctor's capacities to consult translators in urgent situations, whilst at the same time translations for basic treatments are hardly ever approved as the funding would be taken out of the hospital’s budget.
Even if provided, more complicated technological solutions like video translation offered by private companies have too high a logistical barrier to be consulted in urgent cases. Due to the urgent need of translation, it has become custom for medical staff with respective language skills to be asked to interrupt their work and commute, making treatments inefficient and adding to their already overburdened schedule. Even though the increasing capacities of AI technology and tech solutions for translation offer a certain level of means to communicate, these often prove as too weak to translate cultural sensitivities, slang and, according to doctors, are unreliable in urgent medical situations.
These barriers have created informal structures to grow within hospitals where alleged volunteers are waiting in hospitals to offer their services only to ask for money after they had helped patients to translate. Inadequate interpreter services can have serious consequences for patients as misinformation can lead to death, in the worst-case scenario.
To improve access to the healthcare system for non-German speaking patients, Lisanne is systemically reducing the issue of “language barriers” by creating easy access to translation services as well as integrating its usage in the routines of medical staff, shifting their mindsets away from seeing language diversity as a problem to provide medical care.
To reach out to a Triaphon interpreter, who is available 24/7, one only needs to dial a number for the language that one needs. All interpreters are being called at the same time, with the first one to answer the call being the one to translate. The translator then interprets the conversation between the doctor and the patient as long as needed and can, if necessary, forward to another translator, if he/she does not feel comfortable in that situation.
Being aware of the time sensitive hospital environment, Lisanne is putting a lot of effort in reducing any friction points that would complicate the use of Triaphon. Triaphon is offered at a low monthly rate and does not charge per call, which incentivises medical staff to call as often as possible, moving away from cost-efficient decision making towards a health oriented one, where the patient becomes the center of attention again. Doctors only need a phone and the number of Triaphon.
To establish the use of Triaphon in the daily hospital routines, every clinic implementing Triaphon receives a training for all doctors and nurses. During these trainings, Lisanne and her team do calls with translators to simulate emergency situations and get acquainted with the different steps of using Triaphon, reducing any reservations towards using it. One part of the training is to create an overall awareness of the problem that Triaphon is working on. Through role plays staff are encouraged to change perspectives and understand how communication barriers are experienced by patients when they see the doctor. This fosters empathy towards non-German speaking patients and reduces prejudices towards them.
Lisanne has developed different materials, from stickers with the hotline’s number to brochures that can be distributed across all central hospital meeting points and digitally via the intranet to remind medical staff about the problem background and nudge them to use the solution. Additionally, Lisanne and Korbinian are collaborating with universities to include the impact of language barriers on people’s health and her solution in the classrooms, to raise awareness as early as possible. Furthermore, they have started a pilot to include Triaphon into the practical training sessions that students must undergo during their training to make the use of ad-hoc translation services a routine as early as possible.
On the other side of the hotline, Lisanne has successfully fostered a powerful community of translators who currently provide language support in 7 languages and are available 24/7. Lisanne has created an effective way of recruiting volunteers. Initially she started with recruiting relatives of non-German speaking patients accompanying the latter to the hospital to help translate. Lisanne found that they were very eager to share some hours of their time to support others struggling with language barriers who could not rely on family support. Her volunteer community consists of three different subgroups. The smallest group are professional translators who have found Triaphons training curriculum quite valuable for enhancing their skills. The second group participate with the intention of earning a small revenue (volunteers are paid a small stipend for taking over shifts regularly).
The third group are those who want to volunteer for free (making up the biggest part of the community). Volunteers gain self-confidence as they can support doctors in important decision-making processes and be respected for their expertise in foreign languages. Through Triaphon, their language skills are of immense value to the medical sector, which sometimes is the first time that their language skills are perceived as something of added value in Germany. Lisanne and her team organize decentralized events for their diverse group of translators to meet physically and co-create solutions that the volunteer community sees are needed at Triaphon.
As Triaphon is growing, some volunteers have become full time team members working in engaging the community as translators, if needed. Since 2017, Lisanne has recruited a community of 150 volunteers. Around each language a core group of volunteers exist with others more loosely participating. It is guaranteed that, for now, at least 2 people are on duty with 2 others on stand-by in each language. To ensure a high quality of translation services, Triaphon has implemented several quality checks in their process. Lisanne can also monitor how helpful the translation services were through evaluations that are provided by the doctors and the patients at the end of the call. If negative feedback occurs, she reaches out to the translator and inquires. Additionally, she has put a program in place where through training calls her staff members are reaching out to all volunteers to check their quality and provide extra trainings if needed.
As of January 2020, Triaphon is used in 16 hospitals across Germany as well as by five NGOs in Germany and Austria that support non-German speakers in health-related issues. To spread her model, she is increasing her public relations efforts, particularly in the medical media. In the long run, she is aiming for the coverage of the overall medical health care system beyond hospitals. Therefore, Lisanne has started collaborating with midwives who often have non-German speaking patients.
Within 2 years a total of about 5,000 calls have been made via Triaphon, each of them standing for an eye-level medical treatment. With an average rating of 4.8/5, Triaphon shows highest satisfaction rates amongst users. Nearly all users have said that it offers values to medical staff as well as patients and that they would recommend it to other hospitals. Additionally, this has created a better understanding of the importance of language amongst doctors and nurses. Moreover, it creates empathy for people who don’t speak German. The regular use of Triaphon in hospitals has lifted the language barrier prejudices that nurses and doctors had; instead of seeing a non-German speaker as a language barrier patient, they see them as “Triaphon patients”.
Having already proven in one hospital, that using Triaphon can save money as it reduces unnecessary treatments caused by language barriers and limits the more expensive usage of professional translators, Lisanne is now working intensively on convincing the public insurance companies. The companies cover millions of patients in Germany to back her solution and include Triaphon into their payment schemes for hospitals.
As insurances decide which services they accept to pay for their clients, this could lift the cost for hospitals and make Triaphon a federal solution that saves money to the overall health care system whilst at the same time improving access for non-German speaking people. Besides this, she is working with the German Ministry of Health on research to further demonstrate the economic value of Triaphon to also change the law which for now leaves patients responsible to pay for a professional translator.
Lisanne was raised with the mindset of needing to give back to society when one is privileged. This was in part due to both of her parents being professional academics who took social engagement very seriously. In her direct surrounding she experienced how people falling from the norm are discriminated and how much of a difference inclusive measures can make if they strengthen self-efficacy.
Lisanne had always been very active socially. Always on the lookout for the most effective leverage to have social impact, she felt that as a practicing doctor she would be able to give back to society. During her first practical experiences at German hospitals Lisanne became more and more frustrated with the way the medical health care system worked. The treatment of patients felt like assembly-line work, the patient was usually not the center of attention, and as a doctor, one could not help a patient the way one wanted to due to time-restrictions and regulations. Together with fellow medical students, they founded a group of dedicated students in Hamburg, Germany, to discuss and act on alternative ways to go about medicine.
Whilst working as an intern at a Berlin hospital, strong language barriers and concomitant miscommunication got more and more of her attention. One day, Lisanne witnessed the tragedy of a three-year-old Vietnamese boy dying due to the lack of crucial information in the emergency room as the boy’s mother did not speak a word of German. If his mother could have communicated that her son was vomiting not only once, but for months, the doctors would have thought of a brain tumor immediately and could probably have saved him. Instead they thought of a stomach flu and gave him the wrong treatment.
This was when Lisanne got the idea of Triaphon and the moment when she could not go back to “just” practicing as a doctor. Lisanne is driven by the vision to create a fully inclusive heath care system that works less on power and responsibility division, but more on societal involvement, creating empowering support systems and building societal resilience.