Working with Interpreters

Title VI of the Civil Rights Act of 1964 bans discrimination based on race, color, or nationality and requires interpreter services for all Limited English Proficiency (LEP) patients receiving federal assistance which includes Medicare and Medicaid.  Failure to provide these services is considered discriminatory and illegal and federal funds may be withheld if discrimination is found. This is however an unfunded mandate and most insurers do not pay for interpreter services.  Consequently, interpreter services are often underutilized despite the fact that we know that the use of qualified interpreters narrows and almost closes the gap between quality of care in English speaking patients and patients with LEP.

Who Can Serve as a Health Care Interpreter?

An interpreter is someone who translates the spoken word, while a translator interprets written words. Trained bilingual staff, on-staff interpreters, contract interpreters, telephone and video interpreters, and trained volunteers can serve as health care interpreters.  Although it is tempting to utilize other individuals as interpreters, the following people are not ideal health care interpreters: patients’ family and friends, children under 18 years old, other patients or visitors, and untrained volunteers.  Washington state law mandates that professional interpreters are tested and trained.

Working Effectively with an Interpreter

Please watch the following clip of an interpreted visit.  As you do, jot down some thoughts about what went well and things that could be improved – then read on for best practices.  The skills below are important to embrace when working with interpreters.

Prepare for the visit

• Introduce yourself to the interpreter request that the interpreter interpret everything into the first person.
• Discuss confidentiality of the encounter and the role of the interpreter.
• Acknowledge the interpreter as a professional in communication. Respect their role.
• Allow time for a pre-session with the interpreter if possible. When working with a professional face-to-face interpreter to facilitate communication with a limited English proficient (LEP) patient, a pre-session can be helpful to both the healthcare provider and the interpreter. The pre-session is an opportunity to be clear about the nature of the upcoming encounter and any particular concerns that the provider would like to address regarding the patient’s condition. This is especially important when addressing sensitive topics such as delivering serious news.  This provides the interpreter with the information necessary to make any adjustments in their interpreting.

Speak directly to the patient

• Position your chairs or the video monitor such that you are looking at the patient and not the interpreter. Consider placing the interpreter next to you or behind you so you are not tempted to shift your gaze away from the patient to the interpreter.
• During the medical interview, speak directly to the patient, not to the interpreter.
• When working with ASL (American Sign Language) interpreters, do not walk or stand between the patient and the interpreter when they are communicating.  You may need to ask the ASL interpreter to translate what will happen during the physical exam portion before conducting it if you need the interpreter to stand behind a curtain to maintain modesty during the exam.
• If clarification from interpreter is required, tell the patient before speaking directly to the interpreter.

Speak slowly and simply

• Speak more slowly rather than more loudly.
• Assume, and insist, that everything you say, everything the patient says, and everything that family members say is interpreted.
• Be patient. Providing care across a language barrier takes time. However, the time spent up front will be paid back by good rapport and clear communication that will avoid wasted time and dangerous misunderstandings.

Short phrases and pauses

• Speak at an even pace in relatively short segments.
• Pause so the interpreter can interpret.
• Give the interpreter time to restructure information in their mind and present it in a culturally and linguistically appropriate manner. Speaking English does not mean thinking in English.
• Do not hold the interpreter responsible for what the patient says or doesn’t say. The interpreter is the medium, not the source, of the message. If you feel that you are not getting the type of response you were expecting, restate the question or consult with the interpreter to better understand if there is a cultural barrier that is interfering with communication.
• Be aware that many concepts you express have no linguistic or conceptual equivalent in other languages. The interpreter may have to paint word pictures of many terms you use. This may take longer than your original speech.
• Ask the patient what they believe the problem is, what causes it, and how it would be treated in their country of origin.

“Teach back”

• Us this technique to assess the patient’s understanding of their medical illness and treatment plan.
• Ask the patient to repeat back important information that you want to make sure is understood.
  • “I want to make sure that I explained this well, can you let me know what we are doing with your antibiotics?” 

Things to avoid:

• Avoid using highly idiomatic speech, complicated sentence structure, sentence fragments, changing your idea in the middle of a sentence, and asking multiple questions at one time.
• Avoid making assumptions or generalizations about your patient or their experiences.  Common practices or beliefs in a community may not apply to everyone in that community.
• Avoid patronizing or infantilizing the patient. A lack of English language skills is not a reflection of low cognitive function or a lack of education.

Video and phone interpretation

When utilizing phone or video interpreters consider:

• Telephone or video interpreters may be preferred by some patients if they have concerns about confidentiality within their local community.
• A phone interpreter costs ~$0.80 per minute (discounted rate – usually closer to $2/minute!) – not prohibitive, but don’t keep them on the line if you are not actively using them.
• The ‘rules’ for video and phone interpretation are the same as for in-person: Introduce everyone, use short phrases and simple language, and speak to the patient in the first person.
• A phone interpreter has no ‘picture’ of the room or nonverbal cues to help them figure out what is going on. You need to describe what is happening and state clearly what you would like the patient to do.
• If you use a video interpreter, you may need move the video screen or pull the curtain to ensure patient modesty during the physical exam.
• Agenda setting has two sides. When communicating via interpreters in general, it may be even more difficult for the patient to get their own concerns on the table. This may be even harder with a phone or video interpreter.

Feel free to stop for clarification and speak directly to the interpreter.  Ex- (“Interpreter, I’m going to be doing the exam now.  I have you on speaker phone but the patient is further away from the phone on the exam table, and you’ll need to be very loud.”)

Errors in Interpreted encounters

Professional interpreters make half the errors that untrained or “ad-hoc” interpreters do, and their errors are less likely to be clinically significant.  Errors can include:

• Omission: The interpreter did not interpret a word/phrase uttered by the clinician or patient.
• Addition: The interpreter added a word/phrase to the interpretation that was not uttered by the clinician or patient.
• Substitution: The interpreter substituted a word/phrase for a different word/phrase uttered by the clinician or patient.
• Editorialization: The interpreter provided his or her own personal views as the interpretation of a word/phrase uttered by the clinician or patient.
• False Fluency: The interpreter used an incorrect word/phrase, or word/phrase that does not exist in that particular language.

The risk of these errors is higher with phone and video interpreted visits.  At Harborview, under optimal conditions (well-trained interpreters, established patients, and chronic conditions) 31% of the utterances had errors, but only 4% were clinically significant. Far and away, the main issues were omission. To lessen the risk of errors utilize the techniques outlined in this chapter along with the “teach back” method, which reveals errors and misunderstandings.  This method can also be used with English speakers, of course.

If you will not be working through the module then please watch another version of the same encounter. Jot down a few notes on what went well and times the physician used some key principles outlined in this chapter.

Health Disparities and Tips for Communicating with LEP (Limited English Proficiency) Patients:

Health disparities can also arise from cultural differences. Language interpreters must find equivalence (vocabulary, idiomatic, grammatical, conceptual, and experiential).  Cultural misunderstandings often arise from conceptual and experiential inequivalence in communication between patient and provider.  Dr. Randy Curtis, an ICU doctor at Harborview Medical Center in Seattle studied this in ICU family conferences. LEP families received less emotional support, asked fewer questions, received less factual statements, AND had shorter face time with clinicians including the interpreter time.

LEP patients receive less care and poorer quality care on multiple measures. Misunderstandings, concerns about stereotyping, failed communication, and worse outcomes are born of minority culture patients receiving poorer quality information and education. A study from UCSF entitled “GettingBY” showed that residents and physicians sometimes practice their less than fluent Spanish on sick patients and feel like it is expedient, but that they know they are really just getting by.

It is important to recognize that these disparities exist and work to rectify them.  In addition to improving our skills in working with interpreters please refer back to the chapter on identity, culture and patient relationship (cross cultural care) for communication tips on how to explore cultural aspects of care.

Additional tips for working with LEP patients

• Use pictures when explaining things, drawn or from computer.
• If you are asking the patient to buy something over the counter, give them a note to show at the store about what they are looking for, better yet (if possible) a picture printed off the internet
• If drawing labs or doing studies, ask how patients want to receive the results. Options are an early follow up appointment (1-2 weeks) to discuss in person with an interpreter, or to call with an interpreter (instructions vary by clinic).
• It will take you longer to have a standard encounter with LEP patients. You must either lengthen the time of the clinical encounter, or limit your expectations about what can be covered well in any one visit. You may need to see the patient more frequently in the outpatient setting or block a longer time out for rounding in the inpatient setting.
• In the outpatient setting, an interpreter will often already be scheduled by staff. Other option is to call for a video or phone interpreter on the fly when you are meeting with the patient.  Depending upon your clinical location it may only take a few minutes to get an interpreter on the line.
• On inpatient services, the medical student may be the person responsible for determining the best timing and communicating the need for interpreter services for daily rounds.

References 

The recommendations above were taken from http://refugeehealthta.org/access-to-care/language-access/best-practices-communicating-through-an-interpreter/  (contributed by  The National Council on Interpreting in Health Care (NCHIC)

Taira, BR  Improving Communication with Patients with Limited English Proficiency. JAMA Internal Medicine, May 2018 Volume 178, Number 5