The waiting room is packed. Some of the idle conversation is loud, some whispered. You can hear at least four different languages. The renal unit at St. Paul's Hospital sees hundreds of people a day. Close to half of them speak little or no English.

Most are elderly, here for dialysis or to monitor the effects of diabetes. Seing Seing sits low on her seat, holding her hands together on her lap. Her husband, San, is beside her. He has come to all Seing's appointments since moving to Vancouver from Burma seven years ago. San offers to answer questions about his wife's health. But the doctors and nurses talk to Seing directly through an interpreter. The couple's request for language assistance is posted in thick black marker on the clinic's large whiteboard””the daily inpatient list.

“Best as we can, we try not to use family members” as interpreters, says David Landsberg, director of the renal program. “Even if their English is perfect, just so I know it's not being filtered.” Landsberg says he feels more comfortable with a translator who's trained to be as neutral as possible. “If I'm talking about life expectancy, they may not want their son to know how bad things are. And it's really bad when the family member starts crying and they're the interpreter. That's happened quite often.”

Ten years ago it likely would have been a family member interpreting, or a neighbour, or a hospital volunteer. But policy has changed. The Provincial Language Service, a program of the Provincial Health Services Authority, now employs 250 interpreters. They're contracted to work in the city's hospitals, clinics, and nursing homes for $40 an hour. After hours, they're available by phone. And if a patient speaking a lesser-known language shows up, hospitals use a U.S.–based language line by phone for three dollars a minute.

With 20,000 requests in 60 languages last year, the costs add up. Interpreting services alone cost $1.4 million out of last year's Provincial Language Services' $2.1-million budget. But health officials say the consequences of ill communication would make patients that much sicker. And the price would be even higher with a misdiagnosis. They say patients come in sooner if an interpreter is available rather than waiting until their condition becomes a costly emergency.

And there are ethics to consider. Landsberg says he has had great difficulty when asking for consent from family members to be live kidney donors. “I've actually had situations where the information wasn't translated, because the donor worried about how it would affect them.”

Using professionals in place of family isn't supposed to shut out spouses, parents, or children. And if a patient wishes to refuse a procedure, the doctor hears about it either through an English-speaking family member or an interpreter. The current policy means that the North American model of patient-doctor confidentiality has a better chance of being maintained.

“You know, honestly, it's [interpretation is] as important as using my stethoscope,” Landsberg says.

Curious to know more about translation in hospitals? CBC reporter Theresa Lalonde presents more voices during The Early Edition on CBC Radio One this Wednesday (October 18) from 5:30 a.m. to 8:30 a.m.