Monroe, Alicia D. MD; Shirazian, Taraneh MD
A mother is preparing dinner for her two young sons, ages seven and two. The eldest runs frantically into the room holding the two-year-old, who is slumped over and has a blue tinge to his skin. Between sobs, the eldest explains that the baby has swallowed detergent. Immediately alarmed, the mother tries in vain to rouse the child and finally decides to take both children to the emergency room a few blocks away. By the time she reaches the triage window the baby is completely limp. The mother is desperate and screaming when the nurse approaches. There is just one problem: the mother can't understand the nurse's questions and the nurse doesn't understand the mother's language.
Similar scenarios are played out in health care every day. Although Title VI of the Civil Rights Act1 requires that language services be available to persons with limited English proficiency to ensure meaningful access to health services, many health care institutions are struggling to reach full compliance. Strategies employed to manage linguistic barriers may still include using the elder son to interpret for the mother and nurse, medical providers trying to “get by” with limited language proficiency and hand signs, or treating the baby initially with little to no case history. These methods of interpretation are all potentially dangerous and surprisingly widespread. Communication through untrained interpreters is more likely to include mistranslations or omissions of physicians’ questions, truncated or slanted patient responses, interpretive errors, and inadequate information about diagnosis or treatment.2–5 Using such alternatives can result in grave consequences for the patient, including misdiagnosis and even death. Trained bilingual (staff, contract, or volunteer) interpreters have been identified as the preferred interpretive solution.6 In this article, we review the development and implementation of a program to expand interpretation services through a service-learning partnership between academic institutions and health care organizations. Bilingual undergraduate and medical students become trained medical interpreters and render community service while developing cultural skills.
Prioritizing Language and Culture in the Clinical Setting
Language provides the framework through which the cultural world view is constructed,7 and serves as the vehicle for sharing the substance of health problems and concerns. Definitions of what constitutes health and illness differ among cultural groups, social classes, families, and individuals. The meaning given to the illness experience, the “language of distress” persons use to communicate their suffering to others, and when and from whom treatment is sought are influenced by cultural, social, religious factors.8 Providers must determine the patient's preferred language, assess personal proficiency in the patient's language, and access the need for interpretation services prior to exploring patients’ concerns. Whether physicians communicate directly with patients or with the assistance of a medical interpreter, physicians should strive to create an environment that facilitates both trust and candid disclosure of personal information.
To understand the patient's perspective, physicians need to gather specific information about the patient's explanatory model of illness, the patient's fears, concerns, and expectations for treatment.9 Unresolved linguistic and cultural barriers can contribute to misunderstandings about diagnosis, treatment, and self-care options. Expanding medical interpretation resources, and teaching physicians the skills and attitudes needed to provide culturally responsive health care, are challenges facing medical educators and health care institutions.
Service-learning programs10 encourage student involvement in the community, and promote students’ self-reflection on identity issues and their role in health care delivery.11 Although existing programs promote cross-cultural education and understanding,12 few provide students the opportunity to be an integral players in the health care system. Service-learning opportunities that enable students to provide meaningful service while participating in health care can support the development of insights and attitudes needed to provide culturally appropriate health care.
The Interpreter's Aide Program
The Interpreter's Aide Program (IAP) is a service-learning program that was implemented at Brown Medical School in 1997. The IAP is a collaborative effort among Brown students, the Rhode Island Hospital (RIH) Department of Social Work, and Brown Medical School. This three-way partnership strengthens the IAP and expands interpretation services to Spanish- and Portuguese-speaking patients at RIH. The IAP allows both medical and undergraduate students the unique opportunity of becoming trained interpreters in the hospital setting. The IAP was originally proposed in response to the large need for interpretation services that existed in the RIH emergency department, and was subsequently expanded to provide student interpretation services to many hospital departments. As medical interpreters, students bridge communication gaps between patients and health care providers and facilitate patients’ access to health services. Premedical and medical students learn first-hand about the complex interplay of language and culture in the medical setting. The goals of the IAP include fostering students’ understanding about the intricacy of physician–patient communication, as well as allowing students to become more aware of their own personal attitudes and biases.
The IAP has largely been an outgrowth of students’ vision and passion, supported by RIH and medical school administrators. During the planning phase of the IAP, data were gathered that showed the need for interpreter services at RIH and the availability of resources needed to train the students. For example, in 1996, requests for interpreter services at RIH by language was 73% for Spanish, 7.5% for Russian, 7% for Portuguese, 4.4% for Cambodian, 3.6% for Armenian, and 4.5% for all other languages. Currently, RIH employs professional interpreters to provide interpretation in Spanish, Portuguese, Cambodian, Laotian, Cape Verdean Creole, Russian, and Armenian; however, the need for services exceeds the capacity provided by the staff interpreters, and this was true in 1996 as well. Spanish and Portuguese were selected as the primary languages for the IAP based on patient need, the availability of professional interpreter's at RIH to train and evaluate the students in these languages, and the large number of Brown students who have fluency in Spanish and Portuguese. Students are recruited to the program based on their interest in serving as trained interpreters and on their language skills. At this time there is one student in the program that speaks Thai, and there is interest in recruiting students who are fluent in Russian or Cambodian (Khmer) languages. When a patient needs an interpreter for a language that is not covered by the IAP or the professional staff, a medical interpretation consulting service or the AT&T language line is used.
Primarily student-organized and directed, the program requires dedicated student leaders and volunteers to provide its services. Annual recruiting and retention of Brown University students who are fluent in Spanish, Portuguese, or other priority languages is an essential component of the program. Students interested in the IAP attend a formal orientation to become acquainted with the responsibilities and challenges they will face as medical interpreters. Students electing to volunteer sign a contract that outlines their roles and responsibilities. Students schedule IAP training to avoid conflicts with their academic schedules and begin their training under the supervision of professional staff interpreters. For some students this may be their first exposure to the pressured hospital environment, and having a professional interpreter with them allows them to ease into a demanding setting. Students initially “shadow” professional interpreters to gain experience with the interpretation process. Subsequently, through active participation in medical interpretation, students’ language and interpersonal skills are observed and assessed by the professional interpreters. Students demonstrating proficiency in language and communication skills have their language skills further evaluated with an oral and a written examination. After shadowing trained interpreters for four to six four-hour sessions (depending on the student's skills), and successfully completing the language examination, the students become interpreter's aides (IAs). IAs commit to serving as medical interpreters for a minimum of four hours per week.
In 1997–98, eight students completed the training and served as IAs. Over the next few years student participation continued to increase to current levels of thirty-four to thirty-six students per year. In 2000–01, twenty-eight new students were trained as IAs, and eight returning IAs continued their service to the program. In 2001–02, twenty-four new students completed IA training, and ten previously trained IAs continued with the program. Students successfully completing the training spend from one to four years in the program, with the average time spent in the program being one year. The most common reasons students give for leaving the program include study abroad, competing academic demands, and graduation. A cadre of students trained as undergraduates continue to serve in the program during the preclinical years medical school. Third- and fourth-year clinical rotations prohibit students from fulfilling the required four-hour-per-week commitment to the program.
IAs provide interpretation services primarily in the adult emergency department, the pediatric emergency department, subspecialty clinics, internal medicine clinic, and radiology. Students receive instruction in obtaining informed consent and in the requirements of the Health Insurance Portability and Accountability Act of 1996. Student interpreters are not sent to inpatient medical or surgical units, psychiatry, or urology clinic. Obstetrical care is not provided at RIH. Although a conscious decision was made not to have students interpret in areas of the hospital that are likely to require personally sensitive discussions about mental health or sexual issues, these issues can emerge from time to time in the emergency department. Students are taught to maintain a professional demeanor at all times, and they have been instructed to contact one of the professional interpreters whenever they feel unsafe or when medical, family, social, cultural, or communication issues emerge that are affecting the complete and accurate exchange of information between physician and patient
Beginning with the shadowing process, students learn the importance of cultural sensitivity when working with patients and physicians. Students observe how the professional interpreters serve as language interpreters and cultural brokers to facilitate communication, understanding, and trust between providers and patients. As a component of the medical interpreter training, students are asked to tell about their family and cultural background, when their family came to the United States, and if they have lived in a community where a language other than English was used as a medium of communication on a regular basis. This component allows students to demonstrate their language skills and fosters self-awareness. Students are also asked about the dangers of using inappropriate or untrained interpreters such as family members, children, or neighbors in the medical setting.
The IAs’ cross-cultural education is supplemented and reinforced through each interpretation experience, independent reflection, and by participation in IAP seminars. The IA seminar series has two components: the technical seminars and the cross-cultural seminars. The technical seminars are designed to enhance students’ skills in accurate and effective medical interpretation. These seminars highlight frequently encountered medical terminology, concept-for-concept translation, health literacy issues, and patient and physician nonverbal communication in the interview process. Technical seminars utilize the expertise of RIH staff interpreters to allow the students to ask questions and pose scenarios to those with the greatest expertise in interpretation.
The cross-cultural seminars promote student self-awareness through independent and group reflection. Seminars are designed to allow the students time and space to process what they have seen and heard in their interview encounters. The hospital is a difficult environment where the physicians and patients do not always see eye to eye, and where IAs may feel caught in the vulnerable “middle” position. Students need to feel empowered as interpreters to maintain appropriate boundaries, and to recognize their strengths and limitations. Seminar discussions are focused on helping students to come to terms with personal strengths and biases and to understand how their cultural, racial, and ethnic background affects the way that they interact with patients and providers. Continued reflection is supported as students are encouraged to share personal experiences, their health beliefs, and their biases, and to examine how these could affect their work as interpreters. The different backgrounds and interests of the students enrich these discussions. IAs are recruited from both the medical school and the undergraduate campus. Some students are premed while others are studying history, Portuguese, or Hispanic studies. The sharing of diverse perspectives and experiences allows students to better understand themselves, fellow interpreters, patients, and health care providers. The IAP's medical school advisor provides support and mentoring for the IAP volunteers and leaders, participates in the orientation and seminar program, and serves as a continuity liaison between the hospital sponsor and the students.
The cross-cultural seminars incorporate the greater Rhode Island community by inviting community agency representatives and practitioners to ensure that the topics are not discussed in a vacuum. In the seminars, students learn about the culture of medicine as well as information about health beliefs and practices that have been observed among patients in the community. Cross-cultural seminar topics included “I Know Why I'm Sick: Cultural Beliefs Surrounding Health and Illness,” “End of Life Decision Making,” “Prevention: Do I Really Need To Be Tested?,” and “The Culture of American Medicine.” The seminars incorporate standardized patient cases and role-plays to assist students in enhancing their interpretation skills for working with challenging clinical and cultural issues.
During seminar discussions over the past five years, students have shared many reflections and insights gained through the IAP. For instance, the IAs observed that the volume of information conveyed to patients in a concept-for-concept interpretation did not consistently facilitate patient understanding of the medical issues. Thus, some IAs followed up the detailed concept-for-concept interpretation by asking the physician to summarize the information provided, and then the IAs would interpret the summary for the patient. In theory, the position of the interpreter is one of neutral filter between patient and physician; however, the student interpreters often find themselves in the role of advocate. As advocates they seek clarification from physicians when patients don't understand treatment instructions and management plans. However, the power differential limits IAs’ ability to give physicians feedback about rude or dismissive behavior toward patients.
Another type of feedback, qualitative program evaluation data, has been gathered in ongoing meetings with RIH staff and with student interpreters. Since 1998, the IA coordinators and the faculty advisor have met regularly (one to three times per semester) with members of the Social Work Department and the professional staff interpreters to receive feedback on the IAP and to troubleshoot any logistical problems. The Social Work Department staff and the professional interpreters have consistently reported that the program is an asset to the hospital and the community. When describing the program, the professional interpreters consistently make comments such as “The program is wonderful”; “Students do an excellent job interpreting for the patients”; “Students are very conscientious—they won't fake it, if they need help they ask, they use good judgment.”
The director of hospital interpreter services is very enthusiastic about the program:
The resources the hospital spends to support the IAP's student coordinators, orientation programs, seminars, student training, and supplies are a wise investment. ... The program supports interpreter services at the hospital, reduces the stress on the staff by expanding the pool of interpreters, offers an alternative to the AT&T line, and helps the hospital meet its quality standard of limiting the time patients must wait after an interpreter is requested.
In 1999, the hospital conducted a limited survey of 15 hospital staff regarding their experiences in working with interpreters (staff, student, contract, AT&T). The staff reported that they used staff interpreters most commonly, but those who had an opportunity to work with an IA reported that the students met their interpretation needs. IAs report that they are treated with respect and gratitude by the physicians. Patients frequently express appreciation and gratitude to the IAs for their involvement in their care.
Students identify many benefits from participation in the program, including the opportunity to use their language skills to meet a need in the community and provide a valuable service. IAs enjoy learning from patients about their lives, and learning about the interpersonal and technical dimensions of health care. IAs gain multiple insights into the ways in which verbal and nonverbal communication can influence health care. They observe that when it takes longer for physicians to gather information and to explain the diagnoses to patients, physicians frequently become impatient. When physicians become rushed or frustrated, patients sometimes interpret physician behavior as disrespect or disregard of them or their problems. In addition, physicians may have difficulty counseling patients when they don't understand the patient's dietary habits (e.g., a patient with diabetes who drinks mango juice or eats three plantains for lunch).
This program was born out of students’ recognition of a gap between the need and availability of trained medical interpreters, and the belief that bilingual undergraduate and medical students could be trained to meet that need. The students were able to envision a possibility of a new, student service-learning program, and sought support from hospital and medical school advisors. The advisors and administrators clearly understood the magnitude of the problem, but were less confident that there were sufficient student interest and institutional support to create and sustain such a program. The student leaders worked with the Department of Social Work at RIH to gather key data and build a “business case” for the cost-effectiveness of the hospital's supporting the IAP. A presentation was made to the RIH foundation, which agreed to share the dream and support the program. In the early months of the IAP, the administrative infrastructure for the program was developed to address training, student responsibilities, the student coordinators and other program costs. Effective strategies for marketing the program to students are continually refined using electronic, radio, cable television, presentation to language classes, and announcements in student spaces. However, word-of-mouth continues to be one of the most effective recruitment vehicles.
As the IAP enters its sixth year, two energetic student coordinators have recruited 12 new students to join the ten returning student interpreters. Maintaining the continuity of the program from year to year and cultivating new student leaders are ongoing challenges but perceived to be worth the effort by the stakeholders.
Value of the Program
It is clear that when physicians and patients can't understand each other, good health care is impossible. The Interpreter's Aide Program is one model for expanding interpretation services through partnerships between academic institutions and health care organizations. Bilingual students have the opportunity to become trained medical interpreters, to render community service and to develop cross-cultural skills. Based on feedback from the student participants, the social work staff, and the professional interpreters, the program is valuable to the hospital and will be continued.
Expressed interest in the program suggests that other health care institutions can benefit from developing similar partnerships with local colleges and universities to expand availability of trained student interpreters.
The IAP would not have been possible without the support of many dedicated people. The authors would like to thank Mrs. Eva Simmons and Mr. William Fitzpatrick from the Department of Social Work at Rhode Island Hospital for all their collaboration and support. Special appreciation is also due to the RIH interpreters who have dedicated much time to the training of the student volunteers. Last, the authors thank Beverly Johnson, who served as the student coordinator of the program during 2000–01 and 2001–02.
1.HHS Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons 〈www.hhs.gov/ocr/lep/revisedlep.htm
〉. Accessed 7 November 2003. FR Doc. 0320179; August 6, 2003.
2.Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency room. JAMA. 1996;275:783–8.
3.David RA, Rhee M. The impact of language as a barrier to effective health care in an underserved urban Hispanic community. Mt Sinai J Med. 1998;65:393–7.
4.Elderkin-Thompson V, Silver RC, Waitzkin H. When nurses double as interpreters: a study of Spanish-speaking patients in a U. S. primary care setting. Soc Sci Med. 2001;52:1343–58.
5.Woloshin S, Bickell NA, Schwartz LA, et al. Language barriers in medicine in the united states. JAMA. 1995;273:724–8.
6.Department of Health and Human Services, Office of Minority Health. National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care, Final Report. 〈http://www.omhrc.gov/clas/frclas2.htm
〉. Accessed 7 November 2003. Fed Regist. 2000;65(247).
7.Putsch RW. Cross cultural communication: the special case of interpreters in health care. JAMA. 1985;254:3344–8.
8.Helman CG. Culture, Health and Illness. 4th ed. London: Arnold, 2001:79-107.
9.Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross cultural research. Ann Intern Med. 1978;88:251–8.
10.Seifer SD. Service-learning: Community-campus partnerships for health professions Education. Acad Med. 1998;73:273–7.
11.Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861–71.
12.Nora LM, Daugherty SR, Mattis-Peterson A, Stevenson L, Goodman LJ. Improving cross cultural skills of medical students through medical school-community partnerships. West J Med. 1994;161:144–7.