For U.S. immigrants with limited English proficiency, the language barrier can be particularly challenging at the doctor’s office. These patients sometimes struggle to describe how they are experiencing their symptoms.
A new paper from researchers at the University of California, Riverside and Pitzer College asserts that older immigrants are especially likely to describe pain, anxiety, depression, and distress using culturally embedded metaphors and idioms that are easily lost in translation. If practitioners are unable to understand such expressions, they risk undermining diagnoses, treatments, and overall trust in the medical system, the researchers say.
“Language is not merely a tool for communication; it is the medium through which people make sense of their suffering,” the researchers write in the perspective article, which was published online today in The Gerontologist.
Rachel Wu, the article’s senior author, is an associate professor of psychology at UCR. The lead author, Senyao Yu, recently earned a bachelor’s degree at Pitzer College and will begin graduate studies at the University of Chicago in the fall. The other co-author, Tania Rodriguez, a former graduate student in Wu’s lab, earned her doctorate from UCR in June.
Yu came up with the idea for the paper while working in Wu’s lab on the use of tablet computers for English-language coaching among older adults in low-income, senior-living communities. The tablet software had a translation feature.
“It worked well for most things, but there were phrases that simply couldn’t be translated — and in a medical setting, that has real consequences,” Wu said. “Participants were telling Nica [Yu] and our other research assistants about it during the interview portions of the study.”
‘Idioms of distress’
The paper focuses on native Mandarin and Spanish speakers, who make up a substantial portion of the aging immigrant population nationwide. The growth of this population, the authors note, will lead to an increase in reliance on healthcare services in the coming years.
The researchers investigate “idioms of distress,” culturally specific ways of expressing mental or physical suffering that often rely on metaphors, bodily sensations, or concepts with no exact equivalent in English. They’re not simply colorful turns of phrase, the researchers say. Rather, they reflect deep cultural understandings of what illness is, how emotions are experienced, and how suffering should be communicated.
“We focused on expressions that are culturally specific — for example, things that a Chinese patient might say to describe fatigue or discomfort that are rooted in traditional ways of thinking about the body, particularly around the heart and concepts of internal energy,” Yu said. “The word ‘xīn,’ for instance, means ‘heart’ in Mandarin — and a lot of language about symptoms is built around it.”
A person might describe emotional exhaustion as “xīnlèi,” or a “tired heart,” Yu said. Another phrase, “qì dǔ,” is often translated as “blocked air” and can convey emotional stagnation, grief, or psychological distress.
In Spanish, terms such as “agüitado” can describe being in a low mood, and “apagado” can convey emotional numbness or hopelessness, the researchers say.
Western medicine often distinguishes between mental and physical health, the authors note. But culturally rooted expressions may blur those boundaries.
“In Chinese medicine, health is thought of holistically — hot and cold, internal energy, the body as an integrated system,” Wu said. “Mental health, for instance, isn’t really acknowledged as a separate category from physical health the way it is in Western medicine. So, what a Western doctor might diagnose as depression, Chinese patients might describe as ‘heart fatigue’ — and not in a metaphorical sense, either; that’s genuinely how they understand what’s happening in their body.”
She continued, “But if a patient believes the source of their problem is their heart, in the Chinese medical sense, doctors may request a cardiology referral in an American medical clinic, when what’s actually going on is something else entirely. The attribution shapes everything downstream.”
A Mandarin-speaking patient who says she feels “qì dǔ” may be describing grief or emotional stagnation, but the literal translation, “blocked air,” could prompt concerns about asthma or gastrointestinal problems, the researchers say.
Likewise, a Spanish-speaking patient who reports feeling “apagado,” or “feeling dimmed,” may be experiencing hopelessness or emotional numbness, but the phrase might be interpreted as simple fatigue.
Role of medical interpreters
Such misunderstandings, researchers say, can influence how clinicians assess symptoms and determine treatment. Even with medical interpreters present, the meaning of culturally specific words and phrases can be flattened, distorted, or lost entirely — with real consequences for a patient’s well-being, the researchers say.
Professional interpreters play a crucial role in healthcare, but the paper emphasizes how difficult their task can be. They must balance literal accuracy with emotional nuance and cultural context. Sometimes, they engage in what researchers call “cultural editing” — simplifying or adjusting a patient’s words to make them understandable to clinicians.
An interpreter might replace a culturally rich expression with a more familiar English phrase or word, such as “sad,” “anxious” or “stressed.” The translation may be accurate enough to enable the doctor’s conversation with the patient to continue, but it can also erase the cultural assumptions and emotional complexity embedded in the original language.
Who serves as the interpreter also can matter.
Many older immigrants rely on relatives, friends, or bilingual staff members rather than professionally trained medical interpreters, the authors say. Family members may provide valuable cultural context and emotional support, but they may also omit sensitive information, simplify explanations, or filter out distressing details.
In many cases, the burden of interpretation falls on adult children, who must navigate complex medical discussions while also managing family relationships and emotional concerns. The result, according to the authors, is that some patients’ most significant descriptions of suffering can become invisible within clinical conversations.
The article doesn’t suggest that doctors are uncaring or that interpreters are ineffective, and it doesn’t provide evidence of specific mistranslations causing poor outcomes. Instead, it reviews the existing literature, arguing that even as American medicine has become more accommodating to non-English-speaking patients, it may still underestimate how differently patients can think about and describe illness itself.
The issue extends beyond individual visits to the doctor.
Previous research has shown that language barriers are associated with lower patient satisfaction, reduced understanding of treatment recommendations, lower use of preventive health services, and decreased access to mental health care, the authors note.
Yet despite the growing awareness of language barriers in medicine, the authors say surprisingly little research has directly examined the role of culturally embedded, difficult-to-translate concepts in shaping health outcomes.
Most existing studies focus broadly on language discordance between patients and providers. Fewer investigate how specific cultural metaphors and idioms influence diagnosis, treatment decisions, or patient experiences.
Further investigation needed
The authors call for further research on how culturally specific expressions influence diagnosis, treatment decisions, and patient trust. They propose experiments in which clinicians receive either literal translations or culturally contextualized explanations of patients’ symptoms to see whether their diagnoses change.
They also suggest practical interventions, including:
1. Training clinicians to recognize common idioms of distress in various languages.
2. Developing quick-reference guides for frequently encountered phrases in different languages.
3. Involving community members and interpreters in designing communication tools.
4. Encouraging clinicians to ask follow-up questions rather than relying on literal translations alone.
For example, instead of assuming that “tired heart” means fatigue, a doctor might ask: “Can you tell me more about what that feeling is like for you?”
As America’s population becomes increasingly diverse, the researchers say, healthcare systems may need to become more attentive not only to the languages patients speak but also to the cultural worlds those languages represent.
The phrase “tired heart” may never be included in a diagnostic manual. But understanding what it means to the person saying it could be an important step toward more accurate — and more humane — care, the researchers say.
