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Interpreters in Health Care: A Concise Review for Clinicians
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INTERPRETERS IN HEALTHCARE: A CONCISE REVIEW for Clinicians Mary J. Kasten M.D. , Anthony C. Berman Ed.D. , Amanda B. Ebright M.D. , Jay D. Mitchell M.D. , Onelis Quirindongo-Cedeno M.D. PII: DOI: Reference:
S0002-9343(20)30012-7 https://doi.org/10.1016/j.amjmed.2019.12.008 AJM 15527
To appear in:
The American Journal of Medicine
Please cite this article as: Mary J. Kasten M.D. , Anthony C. Berman Ed.D. , Amanda B. Ebright M.D. , Jay D. Mitchell M.D. , Onelis Quirindongo-Cedeno M.D. , INTERPRETERS IN HEALTHCARE: A CONCISE REVIEW for Clinicians, The American Journal of Medicine (2020), doi: https://doi.org/10.1016/j.amjmed.2019.12.008
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
Highlights
Use of trained medical interpreters has been shown to increase quality of care and lower healthcare disparities Speak slowly, simply and in short sentences when working with medical interpreters Look and speak to your patient not to the interpreter Avoid using untrained individuals including family members to interpret and never use a minor for medical interpretation
INTERPRETERS IN HEALTHCARE: A CONCISE REVIEW for Clinicians Mary J. Kasten, M.D. Divisions of Infectious Diseases and General Internal Medicine Associate Professor of Medicine, Mayo Clinic Alix School of Medicine Rochester, Minnesota Anthony C. Berman, Ed.D. Contracted Educator, Mayo Clinic Alix School of of Medicine, Mayo Clinic Rochester, Minnesota
Amanda B. Ebright, M.D. Division of Hospital Internal Medicine Assistant Professor of Medicine, Mayo Clinic Alix School of Medicine Rochester, Minnesota
Jay D. Mitchell, M.D. Department of Family Medicine Assistant Professor of Medicine, Mayo clinic Alix School of Medicine Onelis Quirindongo-Cedeno, M.D. Division of Community Internal Medicine Assistant Professor of Medicine, Mayo clinic Alix School of Medicine Rochester, Minnesota
None of the authors declare a conflict of interest for this manuscript. Funding Source: None All authors had a role in researching and writing this manuscript. Running head: Interpreters in Health Care Key words: Interpreters, Culture, Healthcare, Language, Healthcare disparities Correspondence to: Dr. Mary J. Kasten, M.D.Mayo Clinic 200 First Street SW Rochester, Minnesota E-mail:[email protected]
Abstract: INTERPRETERS IN HEALTHCARE: A Concise Review for Clinicians
Health care providers are frequently faced with the challenge of caring for patients who have limited English proficiency. These patients experience challenges accessing healthcare and are at higher risk of receiving suboptimal healthcare than native English speakers. Healthcare interpreters are crucial partners to help break down communication barriers and prevent these patients from facing health care disparities. Many providers lack the skill-set and knowledge that are vital to successful collaboration with an interpreter. The objective of this article is to address a number of questions surrounding the use of healthcare interpreters and to provide concrete suggestions which will enable providers to best serve their patients.
Key words Medical Interpreter Health Literacy Communication Cultural Broker Health disparities
INTERPRETERS IN HEALTHCARE: A Concise Review for Clinicians Healthcare interpretation is much more complex than simply having an individual who is bilingual available to translate for the patient and the provider. According to the U.S. Census Bureau (1), more than 60 million Americans speak a language other than English at home, and more than 25 million Americans speak English “less than very well”. Patients with limited English proficiency experience challenges accessing healthcare and are at higher risk of receiving suboptimal healthcare than native English speakers. Over 100 languages other than English are commonly spoken in the United States (2). Healthcare disparities faced by this diverse patient population with limited English proficiency, include an increased risk of drug complications, poor understanding of their illnesses, or misdiagnosis due to being misunderstood by their physicians (3, 4). Consequently, healthcare interpreters are now frequently joining the care team for our diverse patient populations. However, many providers lack the skill-set and knowledge that are vital to successful collaboration with an interpreter. In this article we address a number of questions surrounding the use of healthcare interpreters with the aim of breaking down communication barriers and providing concrete suggestions which will enable medical providers to best serve their patients during these encounters.
What are the benefits of using healthcare interpreters? An interpreter is a person who renders a message from one language into a second language (5). According to the National Council on Interpreting in Healthcare, a professional medical interpreter is any individual paid and provided by the hospital or health system to interpret (6). Studies have reported the positive benefits of trained interpreters on communication: better comprehension of health issues, better compliance with medical recommendations, improved patient satisfaction, and improved clinical outcomes for patients with limited English proficiency (1, 4, 7, 8). The use of professional medical interpreters can raise the quality of clinical care for patients with limited English proficiency to approach or equal that for patients without language barriers (4). Without access to professional interpreters, the large and growing limited English proficiency population will continue to suffer differentials in health and healthcare (4). What does the law say about providing healthcare interpretation services? Title VI of the 1964 Civil Rights Act established the core legal basis for equal treatment from federal agencies for those with limited English proficiency (9). As a federal agency, the Department of Health and Human Services (DHHS) and its Office for Civil Rights have the responsibility for establishing requirements and enforcing regulations related to provision of language and communication services in healthcare settings. These regulations apply to any entities that accept funding from the government (e.g. Medicaid , Medicare payments) (9). Section 1557 of the Affordable Care Act of 2010 likewise establishes protections for individuals with limited English proficiency and applies to programs which receive any federal funding or participate in the Healthcare Marketplace (10). Importantly, individual states may also have in place additional legal mandates or procedures (9). In addition to these federal and state legal mandates, accreditation (Joint Commission on Accreditation of Healthcare Organizations) (11), professional (International Medical Interpreters Association) (12), and advocacy (National Council on Interpreting in Healthcare) (13) organizations have additional requirements, guidelines, and best practices. Guidance for providers/institutions to understand their general responsibilities is perhaps most clearly outlined in the National Standards for Culturally and Linguistically Appropriate Services in Health and Healthcare (The National CLAS Standards) (14). Issued in 2013 by the Office of Minority Health within the DHHS, the National CLAS Standards provide a “blueprint” for healthcare entities to improve and advance care to diverse communities. This document establishes 15 standards of which four are devoted to Communication and Language Assistance: 1. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all healthcare and services. 2. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 3. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 4. Provide easy-to-understand print and multimedia materials and signage in the language commonly used by the population in the service area.
The bottom line is that healthcare providers are obligated, both legally and in terms of best practice, to provide services designed to meet the communication needs of their patients; not providing these services when necessary is considered to be discriminatory and/or illegal (1). What training and certification is available for professional interpreters? Most Certified Medical Interpreters have passed both a written and an oral exam, however this process is not available for all languages. National certification for interpreters is provided by the Certification Commission for Healthcare Interpreters (CCHI) (15), the National Board of Certification for Medical Interpreters (NBCMI) (16), or the National Association for the Deaf (NAD) (17). The CCHI provides two types of certification for healthcare interpreters. Interpreters can claim to be a Core Certification Healthcare Interpreter if they pass the CCHI electronic exam, have received at least 40 hours of training in healthcare interpretation, and report proficiency both in English and the language they are seeking to interpret. The CCHI has an oral/performance exam for Spanish, Arabic, and Mandarin, and the NBCMI also has an oral exam for Russian, Cantonese, and Korean, and by passing one of these oral exams, an interpreter can become a Certified Medical Interpreter. The National Association for the Deaf has an interpreter assessment and certification program in conjunction with the Registry of Interpreters for the Deaf, which involves a written exam, interview, and performance exam. Trained professional interpreters have received formal education in interpreting, have developed a basic understanding of medical terminology and diseases, and know the responsibilities of their positions (5), however training is still evolving, and can vary widely (6). Once certification has been attained, professional sign and spoken language interpreters maintain their credentials though clinical education units, seminars, and classes. What can you expect from a professional medical interpreter? Professional medical interpreters are trained to translate spoken word and to use the exact words spoken by the healthcare provider. The provider needs to remember that medical jargon will be interpreted as medical jargon, and high level vocabulary will be interpreted with high level words. The interpreter should not be expected to change wording to make it more understandable for the patient. Professional interpreters may inform the provider of the potential for communication errors; this, however, should not be an absolute expectation. Ideally the interpreter will speak the same dialect as the patient and be familiar with the patient’s culture. U.S. medical interpreters are expected to be fluent in English and the language they interpret. Studies have shown that using a professionally trained medical interpreter results in fewer communication errors than using an ad hoc interpreter (an untrained person called upon to interpret) (4, 18). Professional medical interpreters have had training in confidentiality and are expected to keep all information about the patient confidential, similar to any other healthcare provider. Untrained interpreters are more likely to violate confidentiality, make translation errors, and increase the risk of poor outcomes (1). How can a healthcare interpreter serve as a cultural liaison? The medical interpreter is often also able to act as a cultural liaison (i.e. one who can identify for the provider cultural or social factors which might impact the encounter). A brief pre-visit meeting with interpreters asking for their input into the background of the patient and for tips with regard to cultural expectations is often helpful (19). An example is that the interpreter could inform a provider that for
religious reasons a patient may avoid handshaking with members of the opposite sex. A brief meeting following the visit between the provider and interpreter can be helpful in clarifying issues that the provider may not have understood due to cultural beliefs or practices. What are some techniques a provider can use to most effectively work with a healthcare interpreter? There are a number of things that the provider should consider in order to make the most effective use of an interpreter: Previsit
Meet with the interpreter before the interview for introductions and to establish shared ground rules/behavior. Ask the interpreter questions such as, “Have you worked with this patient before? Is there anything that would be helpful for me/you to know before going in?” Allow extra time for the interview. Set-up/Environment Identify all persons in the room and who, if anyone, has some English proficiency. In an office setting: Position the interpreter next to or slightly behind the provider. In a hospital room or emergency room setting: Interpreter and provider should stand on the same side of the bed to avoid the patient having to swing head back and forth between interpreter and provider. Be sure the patient can see your face. Be sure you can see the face of the patient. Be sure any light source is on your face and not behind your head. This is especially important when interacting with a deaf or hearing impaired patient. Speaking Techniques Look at and speak directly to the patient in the first person, as if the interpreter was not present. Speak clearly at a normal pace in a normal volume. A common error is to speak too loudly. Speak in short sentences or short thought groups. Ideally speak only one or two sentences at a time before allowing the interpreter to translate. Ask one question at a time, avoiding the “stacking” of questions (“Do you have any chest pain, shortness of breath, or palpitations?”). Use simple, common, everyday words. Avoid complex medical terms and acronyms (PE, COPD, ICU). When such terms must be used, be sure there is adequate definition/patient education. Avoid slang (“Bug Juice” for antibiotics). Avoid idioms (“Fit as a fiddle”, “Alive and kicking”, “Fall ill”, “Draw blood”). Consider adopting the patient’s terminology for a symptom/issue, after clarifying to be sure you have a shared understanding (“So you use the ‘purple’ inhaler that we call ‘Albuterol’ ?”). Avoid humor, as it can fail to translate. Do not allow the interpreter to answer for the patient. Keep control of the conversation by interrupting if necessary. If a lot of conversation occurs between interpreter and patient, ask the interpreter to explain. Check for Understanding
Use visual aids (diagrams, models, and models) as much as possible to enhance communication. Provide frequent “wait time”, as pausing can be helpful for both the patient and the interpreter. Check often for understanding by asking questions. Be careful with explanatory analogies to be certain they are relevant and not idiomatic. Use “Tell me what I said” or “Show me what I said” or “How will you explain this to your family?” to check for understanding. Re-state what the patient has said in order to reinforce understanding. Ask for feedback from the interpreter before bringing closure to the interview. Summarize the conversation at the end, providing closure to the interview. Provide a written outline of your take home points so they can be reviewed later.
It is also important to be aware throughout the interview of non-verbal signs suggesting the patient is having difficulty understanding. Non-verbal communication includes eye contact, inattention, gestures, posture, body movements, and facial expressions. Attention to these non-verbal clues can be critical to determining the patient is struggling to understand the provider’s message (20). What should a provider do when a patient declines a professional interpreter? Sometimes patients decline the offer to use healthcare interpreters. Reasons for refusal of an interpreter could include the discussion of a sensitive topic, that the patient may know the interpreter in the community setting, or that the interpreter does not speak the same dialect. The provider can choose a more anonymous method of interpretation such as a telephone interpreter, thereby providing adequate and anonymous interpretation. Patients may insist that a family member or friend with adequate English proficiency act as their interpreter. This is highly discouraged, and children should not be used as interpreters except in emergency situations where there is no access to any other method of interpretation. Providers who allow a family member to interpret are highly encouraged to have a trained healthcare interpreter stay for the interview. The trained interpreter can support the provider in case clarification is needed and can assure accuracy. The pitfalls of using family members or friends as medical interpreters are numerous, as family or friends may have their own agenda, they may be uncomfortable being honest in relaying bad news, and patients may be uncomfortable being honest regarding sensitive issues. Side conversations unrelated to the healthcare visit can make the visit less efficient. Most importantly, there is no guarantee that the information interpreted will be accurate or will remain confidential. The use or refusal of a medical interpreter should always be clearly documented in the medical record. This documentation should also include who conducted and who interpreted the interview. What are the alternatives to an “in-person” interpreter? Phone medical interpreters are commonly used when an in-person interpreter is not available. Institutions can subscribe to a service or pay by the minute for phone interpretation. Many smaller clinics and hospitals with limited need for interpretation or without the resources for in-person interpretation can rely on large telephone interpreting services which hire certified interpreters across a spectrum of languages. Large institutions may also have occasions when an in-person interpreter is not
available for a particular language and a phone interpreter is necessary. In addition, as previously indicated, some patients may be more comfortable sharing information with their provider through a phone interpreter rather than with an in-person medical interpreter. Phone interpreters can provide excellent interpretation. However it is often more challenging for the phone interpreter to act as a cultural liaison compared to an in-person interpreter. Providers need to introduce the phone interpreter to all present and their relationship to the patient. The importance of transparency is especially important when working with a phone interpreter. An example is to state, “I am going type some information about our discussion into your chart”. The provider must make an extra effort to check in with the patient, and if the patient or provider does not feel the interpretation is going well a new phone interpreter should be requested. (21) Video Remote Interpreting via tablet, smart phone, or computer-based applications providing a link to professional interpretation services is becoming increasingly popular. When used, the device should be positioned so the interpreter can see the patient. A pre-visit between the medical interpreter and the provider prior to the provider entering the room can allow the remote medical interpreter to act as a cultural liaison like in a face-to-face visit. This technology can also be used for medical interpretation for the deaf, versus closed captioning (spoken word appearing on a screen), texting, writing, or typing when in-person sign language interpreters are not available. What are some additional resources for a provider who is working with an interpreter? Nationally and internationally, there are many organizations dedicated to medical or healthcare interpretation. These are rich with information and resources, including information on certification requirements, training, conferences, active research, and related issues of importance, including diversity, healthcare disparities, health literacy, and others. For a provider desiring additional resources regarding working with interpreters, the following websites are offered (1):
Agency for Healthcare Research and Quality – Overview of Medical Interpreter Standards of Practice http://www.ahrq.gov/professionals/systems/hospital/lepguide/lepguidefig5.html Improving patient safety for patients with Limited English Proficiency
Cross Cultural Healthcare Program http://www.xculture.org A bridge between communities and healthcare institutions
DiversityRx http://www.diversityrx.org Improving healthcare for a diverse world
National Board of Certification for Medical Interpreters http://www.certifiedmedicalinterpreters.org
Fosters improved healthcare outcomes, patient safety, and patient/provider communication
National Standards for Culturally and Linguistically Appropriate Services in Healthcare http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53 Dedicated to improving the health of racial and ethnic minorities
Registry of Interpreters for the Deaf http://www.rid.org Advocates for best practices in interpreting for users of languages that are signed
CONCLUSION It is our duty, both ethically and legally, to provide an environment where our patients can feel comfortable knowing they will be listened to and offered information in a language they can understand. The use of a well-trained healthcare interpreter is often the most important step in fulfilling this duty. While more time, thought, and preparation are involved in preparing for a successful patient encounter utilizing a healthcare interpreter, there are a number of specific behaviors that can serve to benefit both the patient and the provider in these interactions. REFERENCES 1. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician 2014; 90(7): 476480. 2. Shin HB, Bruno R. Language use and speaking ability: 2000. United States Census Bureau Available at: https://www2.census.gov/library/publications/decennial/2000/briefs/c2kbr-29.pdf Accessed March 27, 2018. 3. Gandhi TK, Burstin EF, Cook EF, Puopolo AL, Haas JS, Brennan TA, Bates DW. Drug complications in outpatients. J Gen Intern Med 2000; 15: 149-154. 4. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007; 42(2): 727-754. 5. National Council on Interpreting in Health Care. The terminology of health care in interpreting: A glossary of terms. The National Council on Interpreting in Health Care (NCIHC) 2008; 1-10. 6. National Council on Interpreting in Health Care. The terminology of health care in interpreting: A glossary of terms. Working Paper Series: The National Council on Interpreting in Health Care (NCIHC) 2001; 1-10. 7. Bagchi AD, Dale S, Verbitsky-Savitz N, Andrecheck S, Zavotsky K, Eisenstein R. Examining effectiveness of medical interpreters in emergency departments for Spanish-speaking patients with limited English proficiency: Results of a randomized controlled trial. Ann Emerg Med 2011; 57(3): 248-256. 8. Flores G. The impact of medical interpreter services on the quality of health care: A systematic review. Med Care Res Rev 2005; 62(3): 255-299. 9. Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med 2007; 22 (Suppl 2): 362-367.
10. Patient Protection and Affordable Care Act – Section 1557. Available at: https://www.hhs.gov/civil-rights/for-individuals/section-15578. Accessed May 22, 2017. 11. Joint Commission on Accreditation of Healthcare Organizations. Crosswalk of joint commission ambulatory program and the national CLAS standards. Available at: https://www.jointcommission.org/topics/health_equity.aspx. Accessed May 22, 2017. 12. International Medical Interpreters Association. Translation resources. Available at: http://www.imiaweb.org/resources/translations.asp. Accessed May 22, 2017. 13. National Council on Interpreting in Healthcare. Available at: http://www.ncihc.org/ethics-andstandards-of-practice. Accessed May 22,2017. 14. Office of Minority Health. National standards for culturally and linguistically appropriate services (CLAS) in health and health care: A blueprint for advancing and sustaining CLAS policy and practice. Office of Minority Health (OMH), U.S. Department of Health and Human Services. 2013; Available at: https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf. Accessed May 22, 2017. 15. Certification Commission for Healthcare Interpreters. Available at: http://www.cchicertification.org. Accessed March 28, 2018. 16. National Board of Certification for Medical Interpreters. Available at: http://www.certifiedmedicalinterpreters.org. Accessed March 28,2018. 17. National Association for the Deaf. Available at: http://www.nad.org/?s=certification+of+interpreters. Accessed March 28, 2018. 18. Flores G, Abreu M, Barone CP, Bachur R, Lin H. Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med 2012; 60(5): 545-553. 19. Dysart-Gale D. Clinicians and medical interpreters: Negotiating culturally appropriate care for patients with limited English ability. Fam Community Health 2007; 30(3): 237-246. 20. Berman AC, Chutka DS. Assessing effective physician-patient communication skills: “Are you listening to me, doc?” Korean J Med Educ 2016; 28(2): 243-249. 21. Ratanawongsa N, Cardenas A, Occeña B, Critchfield J, Mercer M, Myers K. Certified Medical Interpreters’ Perspectives on Relationship-Centered Communication in Safety-Net Care. August 2018. https://doi.org/10.15694/mep.2018.0000169.1 Acessed 4/24/19.
Optional Questions: You are seeing Aku Ogal a 23 year old woman from Somalia with limited English proficiency. You are working with a trained medical interpreter. Which of the following should you avoid during your visit with this patient? a. Use of humor b. Simple explanations c. Looking directly at the patient d. Adopting the patient’s terminology for her condition e. Use of Visual Aids The correct answer is A Although humor can help build rapport when clinicians and patients share the same language and background it can be misunderstood and often is challenging to appropriately translate. Simple explanations are important to aid in understanding for all patients, but especially important when using an interpeter. Most patients will feel more engaged when they are spoken to directly, even though they do not understand the language. There are some cultures where patients may out of respect not make eye contact with a provider, however in most situations looking and speaking directly to the patient is helpful. Adopting a patient’s terminology is a helpful aid to understanding when working with patients with limited English proficiency. Visual aids can also be helpful not only for patients with limited English proficiency but for all who are visual learners. Reference: Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician 2014; 90(7): 476-480.
You are seeing Maria Diaz a 54 year old Spanish speaking refugee from El Salvador with the help of a trained healthcare phone interpreter. You can expect that the interpreter a. b. c. d. e.
Will inform you if the patient seems confused or upset Has proficiency in both Spanish and English Will simplify your language to improve the patient’s understanding Will be familiar with the customs of most patients from El Salvador All of the above
The correct answer is B Ideally the interpreter will inform you if your patient seems confused, and may ask you to simplify your language or clarify jargon but this should not be an expectation. All medical interpreters must at a bare minimum be proficient in both the patient’s and the health care provider’s languages. Trained interpreters may be familiar with the traditions of the patient, but may be completely ignorant of the local customs despite sharing a common language.
Reference: Medical Interpreting Standards of Practice. Developed by International Medical Interpreters Association and Education development center Inc. Available at https://www.imiaweb.org/uploads/pages/102.pdf. Accessed May 7 2019.
Jose Gonzalez is a 45 year old man admitted to the hospital with pneumonia. He is a new patient to your facility. When you meet him on rounds, two family members are present: his teenage son and wife. Also present is a nursing assistant who is speaking to the family in Spanish. You introduce yourself and notice Mr. Gonzalez responds appropriately in English and then turns to speak to his family in Spanish. His son then greets you in English and explains that his father understands and speaks some English but that he (the son) is bilingual and can translate. An in-person trained interpreter is not available. You should A) B) C) D) E)
Accept the offer of the teenage son to provide medical interpretation Ask the patient if he prefers to have his son interpret Ask the son if the patient’s wife speaks English and can interpret Ask the nursing assistant to provide medical interpretation Utilize your hospital’s “language line” medical interpretation service for professional medical interpretation via speaker phone.
The correct answer is E While patient preferences are important and should be heard, medical interpretation performed by a trained interpreter is not only best practice, but is our legal responsibility to provide. Minors should not be asked to provide medical interpretation. For a variety of reasons (such as conflict of interest, lack of familiarity with medical terminology, confidentiality) family members and friends should also not be asked to provide interpretation. While the bilingual nursing assistant might seem to be a reasonable alternative, unless she has been trained, her competence as an interpreter is uncertain. Untrained individuals should not be used as medical interpreters. In cases where patients decline a professional interpreter, this should be carefully documented in the medical record. A helpful strategy to circumvent this problem is for the provider to request a trained interpreter be present while friends/family provide the translation. This allows the trained interpreter to advise on the accuracy of communication and the potential to intervene/correct if necessary. Reference: Office of Minority Health. National standards for culturally and linguistically appropriate services (CLAS) in health and health care: A blueprint for advancing and sustaining CLAS policy and practice. Office of Minority Health (OMH), U.S. Department of Health and Human Services. 2013; Available at: https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf. Accessed May 22, 2017. Priya Patel is a 62 year old woman from India who is being seen for new edema. She is visiting her daughter who is in a chemistry PhD program in the US. She speaks a small amount of English and is seen with her daughter in the clinic who speaks excellent English. A Punjabi interpreter is available and introduced to the patient and her daughter. The patient seems nervous and is insistent that her daughter interpret. Which would be the best next step?
A. Ask the patient and daughter if the interpreter can stay to help if needed. B. Dismiss the interpreter and document in the record that the patient refused a trained medical interpreter and that daughter interpreted C. Ask the interpreter to briefly step out and then inquire with patient and daughter if there is a problem with this specific interpreter D. Inform the patient and daughter that your practice is to always use a trained medical interpreter when you do not speak the patient’s native language E. Ask the interpreter for input regarding the situation The correct answer is C The health care provider has recognized that the patient seems nervous and rapport may be damaged if the provider continues to insist that this interpreter is used. Ideally a trained interpreter should be used, and it is therefore appropriate to inquire into the concerns the patient has prior to documenting that the patient refused an interpreter. Many communities of immigrants in the US are small and patients and interpreters may know each other socially. Patients may be concerned about confidentiality. The best next step would be to inquire if there is an issue with this interpreter and if the patient might be more comfortable with a phone interpreter. This would be best done with the interpreter out of the room. If the patient denies issues with this interpreter, and does not want to use a phone interpreter it would be reasonable to inform the patient that for your own comfort you always have a trained medical interpreter available. Asking the interpreter for input when the patient is not present may be helpful, but would not be the next best step. Reference: Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician 2014; 90(7): 476-480. Which of the following is not a legal requirement for US health care providers and institutions? A. Offer free language assistance to individuals who have limited or no English proficiency B. Offer free sign language interpretation to a deaf individual C. Inform all individuals of the availability of language assistance services clearly and in their preferred language. D. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals should be avoided. E. Provide easy-to-understand written materials and signage for persons of all languages seen at that institution The correct answer is E All of the above are legal requirements for US health care providers and institutions except for providing easy-to-understand written materials and signage for of all languages seen. Ideally health care providers and institutions should have easy to understand written materials in the common primary languages of their patients. A requirement that they have materials for all patients see could be an impossible burden for providers and institutions when over 100 languages are commonly seen in the US. Reference: Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med 2007; 22 (Suppl 2): 362-367.
INTERPRETERS IN HEALTHCARE: A CONCISE REVIEW for Clinicians Mary J. Kasten M.D. , Anthony C. Berman Ed.D. , Amanda B. Ebright M.D. , Jay D. Mitchell M.D. , Onelis Quirindongo-Cedeno M.D. PII: DOI: Reference:
S0002-9343(20)30012-7 https://doi.org/10.1016/j.amjmed.2019.12.008 AJM 15527
To appear in:
The American Journal of Medicine
Please cite this article as: Mary J. Kasten M.D. , Anthony C. Berman Ed.D. , Amanda B. Ebright M.D. , Jay D. Mitchell M.D. , Onelis Quirindongo-Cedeno M.D. , INTERPRETERS IN HEALTHCARE: A CONCISE REVIEW for Clinicians, The American Journal of Medicine (2020), doi: https://doi.org/10.1016/j.amjmed.2019.12.008
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
Highlights
Use of trained medical interpreters has been shown to increase quality of care and lower healthcare disparities Speak slowly, simply and in short sentences when working with medical interpreters Look and speak to your patient not to the interpreter Avoid using untrained individuals including family members to interpret and never use a minor for medical interpretation
INTERPRETERS IN HEALTHCARE: A CONCISE REVIEW for Clinicians Mary J. Kasten, M.D. Divisions of Infectious Diseases and General Internal Medicine Associate Professor of Medicine, Mayo Clinic Alix School of Medicine Rochester, Minnesota Anthony C. Berman, Ed.D. Contracted Educator, Mayo Clinic Alix School of of Medicine, Mayo Clinic Rochester, Minnesota
Amanda B. Ebright, M.D. Division of Hospital Internal Medicine Assistant Professor of Medicine, Mayo Clinic Alix School of Medicine Rochester, Minnesota
Jay D. Mitchell, M.D. Department of Family Medicine Assistant Professor of Medicine, Mayo clinic Alix School of Medicine Onelis Quirindongo-Cedeno, M.D. Division of Community Internal Medicine Assistant Professor of Medicine, Mayo clinic Alix School of Medicine Rochester, Minnesota
None of the authors declare a conflict of interest for this manuscript. Funding Source: None All authors had a role in researching and writing this manuscript. Running head: Interpreters in Health Care Key words: Interpreters, Culture, Healthcare, Language, Healthcare disparities Correspondence to: Dr. Mary J. Kasten, M.D.Mayo Clinic 200 First Street SW Rochester, Minnesota E-mail:[email protected]
Abstract: INTERPRETERS IN HEALTHCARE: A Concise Review for Clinicians
Health care providers are frequently faced with the challenge of caring for patients who have limited English proficiency. These patients experience challenges accessing healthcare and are at higher risk of receiving suboptimal healthcare than native English speakers. Healthcare interpreters are crucial partners to help break down communication barriers and prevent these patients from facing health care disparities. Many providers lack the skill-set and knowledge that are vital to successful collaboration with an interpreter. The objective of this article is to address a number of questions surrounding the use of healthcare interpreters and to provide concrete suggestions which will enable providers to best serve their patients.
Key words Medical Interpreter Health Literacy Communication Cultural Broker Health disparities
INTERPRETERS IN HEALTHCARE: A Concise Review for Clinicians Healthcare interpretation is much more complex than simply having an individual who is bilingual available to translate for the patient and the provider. According to the U.S. Census Bureau (1), more than 60 million Americans speak a language other than English at home, and more than 25 million Americans speak English “less than very well”. Patients with limited English proficiency experience challenges accessing healthcare and are at higher risk of receiving suboptimal healthcare than native English speakers. Over 100 languages other than English are commonly spoken in the United States (2). Healthcare disparities faced by this diverse patient population with limited English proficiency, include an increased risk of drug complications, poor understanding of their illnesses, or misdiagnosis due to being misunderstood by their physicians (3, 4). Consequently, healthcare interpreters are now frequently joining the care team for our diverse patient populations. However, many providers lack the skill-set and knowledge that are vital to successful collaboration with an interpreter. In this article we address a number of questions surrounding the use of healthcare interpreters with the aim of breaking down communication barriers and providing concrete suggestions which will enable medical providers to best serve their patients during these encounters.
What are the benefits of using healthcare interpreters? An interpreter is a person who renders a message from one language into a second language (5). According to the National Council on Interpreting in Healthcare, a professional medical interpreter is any individual paid and provided by the hospital or health system to interpret (6). Studies have reported the positive benefits of trained interpreters on communication: better comprehension of health issues, better compliance with medical recommendations, improved patient satisfaction, and improved clinical outcomes for patients with limited English proficiency (1, 4, 7, 8). The use of professional medical interpreters can raise the quality of clinical care for patients with limited English proficiency to approach or equal that for patients without language barriers (4). Without access to professional interpreters, the large and growing limited English proficiency population will continue to suffer differentials in health and healthcare (4). What does the law say about providing healthcare interpretation services? Title VI of the 1964 Civil Rights Act established the core legal basis for equal treatment from federal agencies for those with limited English proficiency (9). As a federal agency, the Department of Health and Human Services (DHHS) and its Office for Civil Rights have the responsibility for establishing requirements and enforcing regulations related to provision of language and communication services in healthcare settings. These regulations apply to any entities that accept funding from the government (e.g. Medicaid , Medicare payments) (9). Section 1557 of the Affordable Care Act of 2010 likewise establishes protections for individuals with limited English proficiency and applies to programs which receive any federal funding or participate in the Healthcare Marketplace (10). Importantly, individual states may also have in place additional legal mandates or procedures (9). In addition to these federal and state legal mandates, accreditation (Joint Commission on Accreditation of Healthcare Organizations) (11), professional (International Medical Interpreters Association) (12), and advocacy (National Council on Interpreting in Healthcare) (13) organizations have additional requirements, guidelines, and best practices. Guidance for providers/institutions to understand their general responsibilities is perhaps most clearly outlined in the National Standards for Culturally and Linguistically Appropriate Services in Health and Healthcare (The National CLAS Standards) (14). Issued in 2013 by the Office of Minority Health within the DHHS, the National CLAS Standards provide a “blueprint” for healthcare entities to improve and advance care to diverse communities. This document establishes 15 standards of which four are devoted to Communication and Language Assistance: 1. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all healthcare and services. 2. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 3. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 4. Provide easy-to-understand print and multimedia materials and signage in the language commonly used by the population in the service area.
The bottom line is that healthcare providers are obligated, both legally and in terms of best practice, to provide services designed to meet the communication needs of their patients; not providing these services when necessary is considered to be discriminatory and/or illegal (1). What training and certification is available for professional interpreters? Most Certified Medical Interpreters have passed both a written and an oral exam, however this process is not available for all languages. National certification for interpreters is provided by the Certification Commission for Healthcare Interpreters (CCHI) (15), the National Board of Certification for Medical Interpreters (NBCMI) (16), or the National Association for the Deaf (NAD) (17). The CCHI provides two types of certification for healthcare interpreters. Interpreters can claim to be a Core Certification Healthcare Interpreter if they pass the CCHI electronic exam, have received at least 40 hours of training in healthcare interpretation, and report proficiency both in English and the language they are seeking to interpret. The CCHI has an oral/performance exam for Spanish, Arabic, and Mandarin, and the NBCMI also has an oral exam for Russian, Cantonese, and Korean, and by passing one of these oral exams, an interpreter can become a Certified Medical Interpreter. The National Association for the Deaf has an interpreter assessment and certification program in conjunction with the Registry of Interpreters for the Deaf, which involves a written exam, interview, and performance exam. Trained professional interpreters have received formal education in interpreting, have developed a basic understanding of medical terminology and diseases, and know the responsibilities of their positions (5), however training is still evolving, and can vary widely (6). Once certification has been attained, professional sign and spoken language interpreters maintain their credentials though clinical education units, seminars, and classes. What can you expect from a professional medical interpreter? Professional medical interpreters are trained to translate spoken word and to use the exact words spoken by the healthcare provider. The provider needs to remember that medical jargon will be interpreted as medical jargon, and high level vocabulary will be interpreted with high level words. The interpreter should not be expected to change wording to make it more understandable for the patient. Professional interpreters may inform the provider of the potential for communication errors; this, however, should not be an absolute expectation. Ideally the interpreter will speak the same dialect as the patient and be familiar with the patient’s culture. U.S. medical interpreters are expected to be fluent in English and the language they interpret. Studies have shown that using a professionally trained medical interpreter results in fewer communication errors than using an ad hoc interpreter (an untrained person called upon to interpret) (4, 18). Professional medical interpreters have had training in confidentiality and are expected to keep all information about the patient confidential, similar to any other healthcare provider. Untrained interpreters are more likely to violate confidentiality, make translation errors, and increase the risk of poor outcomes (1). How can a healthcare interpreter serve as a cultural liaison? The medical interpreter is often also able to act as a cultural liaison (i.e. one who can identify for the provider cultural or social factors which might impact the encounter). A brief pre-visit meeting with interpreters asking for their input into the background of the patient and for tips with regard to cultural expectations is often helpful (19). An example is that the interpreter could inform a provider that for
religious reasons a patient may avoid handshaking with members of the opposite sex. A brief meeting following the visit between the provider and interpreter can be helpful in clarifying issues that the provider may not have understood due to cultural beliefs or practices. What are some techniques a provider can use to most effectively work with a healthcare interpreter? There are a number of things that the provider should consider in order to make the most effective use of an interpreter: Previsit
Meet with the interpreter before the interview for introductions and to establish shared ground rules/behavior. Ask the interpreter questions such as, “Have you worked with this patient before? Is there anything that would be helpful for me/you to know before going in?” Allow extra time for the interview. Set-up/Environment Identify all persons in the room and who, if anyone, has some English proficiency. In an office setting: Position the interpreter next to or slightly behind the provider. In a hospital room or emergency room setting: Interpreter and provider should stand on the same side of the bed to avoid the patient having to swing head back and forth between interpreter and provider. Be sure the patient can see your face. Be sure you can see the face of the patient. Be sure any light source is on your face and not behind your head. This is especially important when interacting with a deaf or hearing impaired patient. Speaking Techniques Look at and speak directly to the patient in the first person, as if the interpreter was not present. Speak clearly at a normal pace in a normal volume. A common error is to speak too loudly. Speak in short sentences or short thought groups. Ideally speak only one or two sentences at a time before allowing the interpreter to translate. Ask one question at a time, avoiding the “stacking” of questions (“Do you have any chest pain, shortness of breath, or palpitations?”). Use simple, common, everyday words. Avoid complex medical terms and acronyms (PE, COPD, ICU). When such terms must be used, be sure there is adequate definition/patient education. Avoid slang (“Bug Juice” for antibiotics). Avoid idioms (“Fit as a fiddle”, “Alive and kicking”, “Fall ill”, “Draw blood”). Consider adopting the patient’s terminology for a symptom/issue, after clarifying to be sure you have a shared understanding (“So you use the ‘purple’ inhaler that we call ‘Albuterol’ ?”). Avoid humor, as it can fail to translate. Do not allow the interpreter to answer for the patient. Keep control of the conversation by interrupting if necessary. If a lot of conversation occurs between interpreter and patient, ask the interpreter to explain. Check for Understanding
Use visual aids (diagrams, models, and models) as much as possible to enhance communication. Provide frequent “wait time”, as pausing can be helpful for both the patient and the interpreter. Check often for understanding by asking questions. Be careful with explanatory analogies to be certain they are relevant and not idiomatic. Use “Tell me what I said” or “Show me what I said” or “How will you explain this to your family?” to check for understanding. Re-state what the patient has said in order to reinforce understanding. Ask for feedback from the interpreter before bringing closure to the interview. Summarize the conversation at the end, providing closure to the interview. Provide a written outline of your take home points so they can be reviewed later.
It is also important to be aware throughout the interview of non-verbal signs suggesting the patient is having difficulty understanding. Non-verbal communication includes eye contact, inattention, gestures, posture, body movements, and facial expressions. Attention to these non-verbal clues can be critical to determining the patient is struggling to understand the provider’s message (20). What should a provider do when a patient declines a professional interpreter? Sometimes patients decline the offer to use healthcare interpreters. Reasons for refusal of an interpreter could include the discussion of a sensitive topic, that the patient may know the interpreter in the community setting, or that the interpreter does not speak the same dialect. The provider can choose a more anonymous method of interpretation such as a telephone interpreter, thereby providing adequate and anonymous interpretation. Patients may insist that a family member or friend with adequate English proficiency act as their interpreter. This is highly discouraged, and children should not be used as interpreters except in emergency situations where there is no access to any other method of interpretation. Providers who allow a family member to interpret are highly encouraged to have a trained healthcare interpreter stay for the interview. The trained interpreter can support the provider in case clarification is needed and can assure accuracy. The pitfalls of using family members or friends as medical interpreters are numerous, as family or friends may have their own agenda, they may be uncomfortable being honest in relaying bad news, and patients may be uncomfortable being honest regarding sensitive issues. Side conversations unrelated to the healthcare visit can make the visit less efficient. Most importantly, there is no guarantee that the information interpreted will be accurate or will remain confidential. The use or refusal of a medical interpreter should always be clearly documented in the medical record. This documentation should also include who conducted and who interpreted the interview. What are the alternatives to an “in-person” interpreter? Phone medical interpreters are commonly used when an in-person interpreter is not available. Institutions can subscribe to a service or pay by the minute for phone interpretation. Many smaller clinics and hospitals with limited need for interpretation or without the resources for in-person interpretation can rely on large telephone interpreting services which hire certified interpreters across a spectrum of languages. Large institutions may also have occasions when an in-person interpreter is not
available for a particular language and a phone interpreter is necessary. In addition, as previously indicated, some patients may be more comfortable sharing information with their provider through a phone interpreter rather than with an in-person medical interpreter. Phone interpreters can provide excellent interpretation. However it is often more challenging for the phone interpreter to act as a cultural liaison compared to an in-person interpreter. Providers need to introduce the phone interpreter to all present and their relationship to the patient. The importance of transparency is especially important when working with a phone interpreter. An example is to state, “I am going type some information about our discussion into your chart”. The provider must make an extra effort to check in with the patient, and if the patient or provider does not feel the interpretation is going well a new phone interpreter should be requested. (21) Video Remote Interpreting via tablet, smart phone, or computer-based applications providing a link to professional interpretation services is becoming increasingly popular. When used, the device should be positioned so the interpreter can see the patient. A pre-visit between the medical interpreter and the provider prior to the provider entering the room can allow the remote medical interpreter to act as a cultural liaison like in a face-to-face visit. This technology can also be used for medical interpretation for the deaf, versus closed captioning (spoken word appearing on a screen), texting, writing, or typing when in-person sign language interpreters are not available. What are some additional resources for a provider who is working with an interpreter? Nationally and internationally, there are many organizations dedicated to medical or healthcare interpretation. These are rich with information and resources, including information on certification requirements, training, conferences, active research, and related issues of importance, including diversity, healthcare disparities, health literacy, and others. For a provider desiring additional resources regarding working with interpreters, the following websites are offered (1):
Agency for Healthcare Research and Quality – Overview of Medical Interpreter Standards of Practice http://www.ahrq.gov/professionals/systems/hospital/lepguide/lepguidefig5.html Improving patient safety for patients with Limited English Proficiency
Cross Cultural Healthcare Program http://www.xculture.org A bridge between communities and healthcare institutions
DiversityRx http://www.diversityrx.org Improving healthcare for a diverse world
National Board of Certification for Medical Interpreters http://www.certifiedmedicalinterpreters.org
Fosters improved healthcare outcomes, patient safety, and patient/provider communication
National Standards for Culturally and Linguistically Appropriate Services in Healthcare http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53 Dedicated to improving the health of racial and ethnic minorities
Registry of Interpreters for the Deaf http://www.rid.org Advocates for best practices in interpreting for users of languages that are signed
CONCLUSION It is our duty, both ethically and legally, to provide an environment where our patients can feel comfortable knowing they will be listened to and offered information in a language they can understand. The use of a well-trained healthcare interpreter is often the most important step in fulfilling this duty. While more time, thought, and preparation are involved in preparing for a successful patient encounter utilizing a healthcare interpreter, there are a number of specific behaviors that can serve to benefit both the patient and the provider in these interactions. REFERENCES 1. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician 2014; 90(7): 476480. 2. Shin HB, Bruno R. Language use and speaking ability: 2000. United States Census Bureau Available at: https://www2.census.gov/library/publications/decennial/2000/briefs/c2kbr-29.pdf Accessed March 27, 2018. 3. Gandhi TK, Burstin EF, Cook EF, Puopolo AL, Haas JS, Brennan TA, Bates DW. Drug complications in outpatients. J Gen Intern Med 2000; 15: 149-154. 4. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007; 42(2): 727-754. 5. National Council on Interpreting in Health Care. The terminology of health care in interpreting: A glossary of terms. The National Council on Interpreting in Health Care (NCIHC) 2008; 1-10. 6. National Council on Interpreting in Health Care. The terminology of health care in interpreting: A glossary of terms. Working Paper Series: The National Council on Interpreting in Health Care (NCIHC) 2001; 1-10. 7. Bagchi AD, Dale S, Verbitsky-Savitz N, Andrecheck S, Zavotsky K, Eisenstein R. Examining effectiveness of medical interpreters in emergency departments for Spanish-speaking patients with limited English proficiency: Results of a randomized controlled trial. Ann Emerg Med 2011; 57(3): 248-256. 8. Flores G. The impact of medical interpreter services on the quality of health care: A systematic review. Med Care Res Rev 2005; 62(3): 255-299. 9. Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med 2007; 22 (Suppl 2): 362-367.
10. Patient Protection and Affordable Care Act – Section 1557. Available at: https://www.hhs.gov/civil-rights/for-individuals/section-15578. Accessed May 22, 2017. 11. Joint Commission on Accreditation of Healthcare Organizations. Crosswalk of joint commission ambulatory program and the national CLAS standards. Available at: https://www.jointcommission.org/topics/health_equity.aspx. Accessed May 22, 2017. 12. International Medical Interpreters Association. Translation resources. Available at: http://www.imiaweb.org/resources/translations.asp. Accessed May 22, 2017. 13. National Council on Interpreting in Healthcare. Available at: http://www.ncihc.org/ethics-andstandards-of-practice. Accessed May 22,2017. 14. Office of Minority Health. National standards for culturally and linguistically appropriate services (CLAS) in health and health care: A blueprint for advancing and sustaining CLAS policy and practice. Office of Minority Health (OMH), U.S. Department of Health and Human Services. 2013; Available at: https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf. Accessed May 22, 2017. 15. Certification Commission for Healthcare Interpreters. Available at: http://www.cchicertification.org. Accessed March 28, 2018. 16. National Board of Certification for Medical Interpreters. Available at: http://www.certifiedmedicalinterpreters.org. Accessed March 28,2018. 17. National Association for the Deaf. Available at: http://www.nad.org/?s=certification+of+interpreters. Accessed March 28, 2018. 18. Flores G, Abreu M, Barone CP, Bachur R, Lin H. Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med 2012; 60(5): 545-553. 19. Dysart-Gale D. Clinicians and medical interpreters: Negotiating culturally appropriate care for patients with limited English ability. Fam Community Health 2007; 30(3): 237-246. 20. Berman AC, Chutka DS. Assessing effective physician-patient communication skills: “Are you listening to me, doc?” Korean J Med Educ 2016; 28(2): 243-249. 21. Ratanawongsa N, Cardenas A, Occeña B, Critchfield J, Mercer M, Myers K. Certified Medical Interpreters’ Perspectives on Relationship-Centered Communication in Safety-Net Care. August 2018. https://doi.org/10.15694/mep.2018.0000169.1 Acessed 4/24/19.
Optional Questions: You are seeing Aku Ogal a 23 year old woman from Somalia with limited English proficiency. You are working with a trained medical interpreter. Which of the following should you avoid during your visit with this patient? a. Use of humor b. Simple explanations c. Looking directly at the patient d. Adopting the patient’s terminology for her condition e. Use of Visual Aids The correct answer is A Although humor can help build rapport when clinicians and patients share the same language and background it can be misunderstood and often is challenging to appropriately translate. Simple explanations are important to aid in understanding for all patients, but especially important when using an interpeter. Most patients will feel more engaged when they are spoken to directly, even though they do not understand the language. There are some cultures where patients may out of respect not make eye contact with a provider, however in most situations looking and speaking directly to the patient is helpful. Adopting a patient’s terminology is a helpful aid to understanding when working with patients with limited English proficiency. Visual aids can also be helpful not only for patients with limited English proficiency but for all who are visual learners. Reference: Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician 2014; 90(7): 476-480.
You are seeing Maria Diaz a 54 year old Spanish speaking refugee from El Salvador with the help of a trained healthcare phone interpreter. You can expect that the interpreter a. b. c. d. e.
Will inform you if the patient seems confused or upset Has proficiency in both Spanish and English Will simplify your language to improve the patient’s understanding Will be familiar with the customs of most patients from El Salvador All of the above
The correct answer is B Ideally the interpreter will inform you if your patient seems confused, and may ask you to simplify your language or clarify jargon but this should not be an expectation. All medical interpreters must at a bare minimum be proficient in both the patient’s and the health care provider’s languages. Trained interpreters may be familiar with the traditions of the patient, but may be completely ignorant of the local customs despite sharing a common language.
Reference: Medical Interpreting Standards of Practice. Developed by International Medical Interpreters Association and Education development center Inc. Available at https://www.imiaweb.org/uploads/pages/102.pdf. Accessed May 7 2019.
Jose Gonzalez is a 45 year old man admitted to the hospital with pneumonia. He is a new patient to your facility. When you meet him on rounds, two family members are present: his teenage son and wife. Also present is a nursing assistant who is speaking to the family in Spanish. You introduce yourself and notice Mr. Gonzalez responds appropriately in English and then turns to speak to his family in Spanish. His son then greets you in English and explains that his father understands and speaks some English but that he (the son) is bilingual and can translate. An in-person trained interpreter is not available. You should A) B) C) D) E)
Accept the offer of the teenage son to provide medical interpretation Ask the patient if he prefers to have his son interpret Ask the son if the patient’s wife speaks English and can interpret Ask the nursing assistant to provide medical interpretation Utilize your hospital’s “language line” medical interpretation service for professional medical interpretation via speaker phone.
The correct answer is E While patient preferences are important and should be heard, medical interpretation performed by a trained interpreter is not only best practice, but is our legal responsibility to provide. Minors should not be asked to provide medical interpretation. For a variety of reasons (such as conflict of interest, lack of familiarity with medical terminology, confidentiality) family members and friends should also not be asked to provide interpretation. While the bilingual nursing assistant might seem to be a reasonable alternative, unless she has been trained, her competence as an interpreter is uncertain. Untrained individuals should not be used as medical interpreters. In cases where patients decline a professional interpreter, this should be carefully documented in the medical record. A helpful strategy to circumvent this problem is for the provider to request a trained interpreter be present while friends/family provide the translation. This allows the trained interpreter to advise on the accuracy of communication and the potential to intervene/correct if necessary. Reference: Office of Minority Health. National standards for culturally and linguistically appropriate services (CLAS) in health and health care: A blueprint for advancing and sustaining CLAS policy and practice. Office of Minority Health (OMH), U.S. Department of Health and Human Services. 2013; Available at: https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf. Accessed May 22, 2017. Priya Patel is a 62 year old woman from India who is being seen for new edema. She is visiting her daughter who is in a chemistry PhD program in the US. She speaks a small amount of English and is seen with her daughter in the clinic who speaks excellent English. A Punjabi interpreter is available and introduced to the patient and her daughter. The patient seems nervous and is insistent that her daughter interpret. Which would be the best next step?
A. Ask the patient and daughter if the interpreter can stay to help if needed. B. Dismiss the interpreter and document in the record that the patient refused a trained medical interpreter and that daughter interpreted C. Ask the interpreter to briefly step out and then inquire with patient and daughter if there is a problem with this specific interpreter D. Inform the patient and daughter that your practice is to always use a trained medical interpreter when you do not speak the patient’s native language E. Ask the interpreter for input regarding the situation The correct answer is C The health care provider has recognized that the patient seems nervous and rapport may be damaged if the provider continues to insist that this interpreter is used. Ideally a trained interpreter should be used, and it is therefore appropriate to inquire into the concerns the patient has prior to documenting that the patient refused an interpreter. Many communities of immigrants in the US are small and patients and interpreters may know each other socially. Patients may be concerned about confidentiality. The best next step would be to inquire if there is an issue with this interpreter and if the patient might be more comfortable with a phone interpreter. This would be best done with the interpreter out of the room. If the patient denies issues with this interpreter, and does not want to use a phone interpreter it would be reasonable to inform the patient that for your own comfort you always have a trained medical interpreter available. Asking the interpreter for input when the patient is not present may be helpful, but would not be the next best step. Reference: Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician 2014; 90(7): 476-480. Which of the following is not a legal requirement for US health care providers and institutions? A. Offer free language assistance to individuals who have limited or no English proficiency B. Offer free sign language interpretation to a deaf individual C. Inform all individuals of the availability of language assistance services clearly and in their preferred language. D. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals should be avoided. E. Provide easy-to-understand written materials and signage for persons of all languages seen at that institution The correct answer is E All of the above are legal requirements for US health care providers and institutions except for providing easy-to-understand written materials and signage for of all languages seen. Ideally health care providers and institutions should have easy to understand written materials in the common primary languages of their patients. A requirement that they have materials for all patients see could be an impossible burden for providers and institutions when over 100 languages are commonly seen in the US. Reference: Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med 2007; 22 (Suppl 2): 362-367.