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Back to Table of Contents | April 2010

Clinical and Health Affairs

Using Medical Interpreters

By Dionne Hart, M.D., Juan Bowen, M.D., Ramona DeJesus, M.D., Alejandro Maldonado, and Fatima Jiwa, M.D.

Abstract
Research has demonstrated that appropriate use of interpreters in clinical encounters improves outcomes and decreases adverse events. This article reviews both the medical reasons for working with trained medical interpreters and the related laws, and offers practical tips for working effectively with interpreters.


Twenty patients are waiting in a busy emergency room in a Twin Cities hospital. At least two do not speak English but are accompanied by family members who do. Staff members in the ER are tempted to ask these family members to interpret, as they believe it would save everyone time. But should they? Is it ever advisable, ethical, or even good medicine to communicate through a family member rather than a trained medical interpreter?

Such dilemmas are becoming increasingly common in Minnesota, as every year our state grows more diverse. Roughly 8.5% of our population, or about 420,000 individuals, speak a language other than English at home.1 Almost 7% of Minnesota public school students (57,665) have limited English proficiency.2 More than 124 languages are currently spoken in the state. The seven major ones are English, Spanish, Hmong, Somali, Russian, Vietnamese, and Arabic. Minnesota also has the highest percentage of Cushite, Finnish, Miao/Hmong, Ojibwa, Swedish, and Tibetan speakers in the United States. Although many non-English speakers live in urban communities (more than 90 languages are spoken in Hennepin County), in the past decade rural counties throughout the state have seen an influx of newcomers who speak little, if any, English.3,4 

Because so many Minnesota residents now speak a first language other than English, it has become increasingly common for physicians to see patients with limited English proficiency. Many providers wonder if using a patient’s family members or friends to interpret is appropriate. The short answer is no. Family and friends should not be used to provide interpretation services (unless requested by the patient). Instead, they should use bilingual staff members, trained medical interpreters, or interpreter services.

Working with medical interpreters can be intimidating to physicians and other clinicians who are new to the experience. Fortunately, with training and practice, any provider can improve his or her ability to effectively communicate with the aid of an interpreter.

This article reviews both the legal and medical reasons for working with medical interpreters and offers practical tips for doing so effectively.

Reasons for Using Professional Interpreters

Health care organizations and providers who receive federal funding are mandated by federal law (the Civil Rights Act of 1964) to provide access to interpreter services or they risk a discrimination claim.5 The law is clarified in the U.S. Department of Health and Human Services’ Office of Minority Health’s National Standards on Culturally and Linguistically Appropriate Services (CLAS).5 Four of the 14 standards (4 through 7) address the legal requirements for health care organizations regarding language services. The following is a summary of those standards:

  • Interpreter services must be offered and provided to all patients with limited English proficiency during normal hours of operation in a timely manner and at no cost to them.
  • The availability of language services must be explained to patients in their preferred language.
  • Professional interpreters and bilingual staff must be used to assure competence. Family and friends should only provide interpretation services at the request of the patient.
  • Health care organizations must provide access to easily understood patient materials including applications, consent forms, and medical or treatment instructions in the languages most commonly encountered. They must also post signage in those languages in service areas.6

The CLAS standards call for use of “competent” medical interpreters, either in person or through a telephonic service. Competent interpreters are objective parties who take into account cultural terms, concepts, and expressions in order to convey information accurately to both the patient and the provider. These interpreters usually have completed training that covers interpretation skills and techniques, the ethics of interpreting during health care encounters, key medical terminology, basic clinical concepts, the workings of the U.S. medical system, the role of culture and how to manage cultural issues, and professional interpretation issues.7

Although both the United States and Minnesota have certification requirements for American Sign Language and English interpreters in schools, there is no certification process for medical interpreters. There is, however, a growing trend toward creating one, with the Certification Commission for Healthcare Interpreters leading the effort. In addition to the legal reasons for using trained medical interpreters, use of professional interpreters decreases the chance of communication problems that could lead to diagnostic and medication errors.7 This ultimately saves

Skills Training for Physicians

The Minnesota Medical Association’s Minority and Cultural Affairs Committee has begun offering an educational program designed to teach physicians in Minnesota about the appropriate use of trained medical interpreters in clinical encounters. In conjunction with Linking Services, the committee is conducting skills training sessions for residents and physicians. The hour-long sessions can be held in any clinic. To learn more about upcoming sessions or to schedule one at your clinic, contact Dennis Gerhardstein at dgerhardstein@mnmed.org or 612/362-3745 or Mandy Rubenstein at mrubenstein@mnmed.org or 612/362-3740.

health care dollars by decreasing the likelihood of negative outcomes, reducing the number of inpatient days and interventions, and increasing the rate of treatment compliance. Evidence shows that patients with limited English proficiency who do not receive appropriate language services are at greater risk for unnecessary hospital admissions and medical errors, are less likely to receive primary care and adequate follow up, and are more likely to undergo excessive testing. In addition, using trained interpreters has been associated with a better understanding of informed consent, treatment plans, and follow-up instructions.8 Family members and friends should not be used because patients may be less than forthcoming in their presence and the information they convey may be inaccurate, and there’s a greater chance of breaching patient confidentiality.

Working with Interpreters

Access to trained medical interpreters remains a problem. Twenty-four-hour onsite interpreter services may be available in large medical centers, large group practices, and academic medical centers; but these services are too expensive for smaller clinics or individual practices. Because it can be difficult to find competent interpreters in less-diverse communities, using trained bilingual staff members, contract interpreter services, and language lines are good options. A list of interpreter services available in Minnesota can be found at: http://articles.directorym.com/Interpreting_Services_Minnesota-r855379-Minnesota.html#855379-Minnesota.

Whether working with an interpreter in person or by phone, all physicians should be aware of things they can do to make the experience better. The following pointers from the American Medical Association’s guide for working with patients with limited English proficiency can help physicians more effectively utilize medical interpreters working in the clinic or over the phone.9

 In the Clinic
Allow enough time for the session. Working with an interpreter may increase the amount of time you’ll spend with a patient. Allow time for a brief discussion with the interpreter before and after the office visit.

Have a brief meeting with the interpreter outside the room before meeting with the patient. Depending on the type of medical consultation, you may review basic information about the patient and the reason for the visit, go over documents that will be used during the visit, discuss the goals of the visit, and review seating and other details that can help facilitate the session. View the interpreter as a culture broker who can provide valuable information about appropriate social skills and such things as herbal or home remedies the patient may be using.

Use an appropriate seating arrangement. Sometimes it is best to place the interpreter to the side of or slightly behind the patient so that you maintain eye contact with the patient and so that the interpreter can listen to the interaction, observe body language and mannerisms, and view documentation.

Speak to the patient, not to the interpreter. Look at the patient so he or she is aware that you are directing the encounter. This limits the opportunity for side conversations between the patient and the interpreter as well.

Use short sentences, with appropriate pauses to allow for interpretation. Speak slowly and clearly. Lengthy sentences can be distracting and increase the chance of valuable information being lost. The following are good examples of simple sentences and questions that can elicit important information:

  • Please tell me the reason for your visit.
  • Please describe the nature of your concern.
  • What treatments have you tried?
  • What treatments have been helpful?

Avoid jargon and technical terms. Instead of telling a patient you will order an fMRI to identify probable causes of TBI, tell the patient you will order a special imaging test that will help you identify the possible causes of his or her brain problem.

Concentrate on the patient’s nonverbal behavior. Nonverbal cues such as posture, gestures, and facial expression can provide valuable clinical information.

Expect the interpreter to interpret everything said. Periodically, interpreters may attempt to summarize what you or the patient has said in an effort to be helpful or efficient. But this increases the chance that valuable information will be lost.

Confirm understanding by asking the patient to repeat key information back to you. The technique of reading back information is an opportunity to find evidence of misinterpretation or misunderstanding.

After the patient visit, debrief with the interpreter. Take a few minutes to obtain feedback from the interpreter about his or her impression of the patient’s effort to communicate his or her thoughts, use of language, and ability to provide clear, rational responses.

 Over the Telephone
Many of the above recommendations apply when using a telephone interpreter service. In addition, consider doing the following:

Conduct the interview in a private room with a speakerphone or a second handset to help maintain confidentiality. Dial the language line number in the presence of the patient. Once the interpreter is on the line, review the basics of the encounter, including the clinical situation and other information that would facilitate communication during the session.

Be aware of time. Most telephone services charge by the minute. Setting up an account with a phone interpreter service may be cost-effective for frequent users.

Conclusion

Minnesota’s population grows more diverse each year, increasing the likelihood that health care providers will interact with patients whose first language may not be English. Research shows that use of competent medical interpreters or trained bilingual staff can improve communication between physicians and patients, increase compliance with treatment and recommendations for follow up, and prevent misunderstandings that can result in a wrong diagnosis or medication error. For those reasons, physicians need to learn how to work effectively with trained medical interpreters. MM

Dionne Hart is a psychiatrist and chair of the MMA Minority and Cultural Affairs Committee. Juan Bowen is an assistant professor of internal medicine and Ramona DeJesus is an assistant professor of primary care and internal medicine at Mayo Clinic. Alejandro Maldonado is a professional medical interpreter, commissioner for the Certification Commission for Healthcare Interpreters, and the limited English proficiency coordinator for the Minnesota Department of Human Services. Fatima Jiwa is a pediatrician in St. Paul and a past chair of the MMA Minority and Cultural Affairs Committee.
 
References
1. U.S. Census Bureau. State and County QuickFacts; 2000. Available at: http://quickfacts.census.gov/qfd/states/27000.html. Accessed March 10, 2010.
2. Minnesota Department of Education. Minnesota Education Statistics, 2004-2005. Available at: http://education.state.mn.us/mdeprod/groups/InformationTech/documents/Report/010371.pdf. Accessed March 12, 2010.
3. U.S. English Foundation Research; 2010. Available at: www.usefoundation.org/userdata/file/Research/Regions/minnesota.pdf. Accessed March 12, 2010.
4. Minneapolis Foundation. Immigration in Minnesota: Discovering Common Ground. Available at: www.minneapolisfoundation.org/uploads/CuteEditor/Publications/Community/ImmigrationBrochure.pdf. Accessed March 12, 2010.
5. Title VI of the Civil Rights Act of 1964. Available at: www.justice.gov/crt/cor/coord/titlevi.php. Accessed March 12, 2010.
6. U. S. Department of Health and Human Services, The Office of Minority Health. National Standards on Culturally and Linguistically Appropriate Services. Available at: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15. Accessed March 10, 2010.
7. Exchange: Better Communications Means Better Health. Available at: www.health-exchange.net. Accessed March 10, 2010.
8. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with LEP? A systematic review of the literature Authors. Health Serv Res. 2007;42(2):727–54.
9. American Medical Association. Office Guide for Working with Limited English Proficient Patients, 2nd edition. Available at: www.ama-assn.org/ama1/pub/upload/mm/433/lep_booklet.pdf. Accessed March 10, 2010.

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