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Commentaries

Medical Interpreters: Improvements to Address Access, Equity, and Quality of Care for Limited-English-Proficient Patients

VanderWielen, Lynn M. PhD, MPH; Enurah, Alexander S. MD; Rho, Helen Y. MD, PhD; Nagarkatti-Gude, David R. MD, PhD; Michelsen-King, Patricia MA; Crossman, Steven H. MD; Vanderbilt, Allison A. EdD

Author Information
doi: 10.1097/ACM.0000000000000296

Abstract

In the United States, limited-English-proficient (LEP) patients experience health care disparities, including reduced likelihood of physician and mental health provider visits, lower incidence of mammograms and influenza vaccinations, and increased risk of patient safety events.1,2 Patients who face language barriers are less likely to have a usual source of health care, demonstrate an increased risk of medication nonadherence, and receive preventive services at reduced rates.3,4 To address health disparities and patient safety among LEP patients, many health care organizations apply a multidimensional strategy to improve provider competency through training modules such as TeamSTEPPS5 while simultaneously addressing language barriers directly through language interpreting services. Despite documented risks of poor interpreting services, the U.S. health care system does not have a required standardized certification for medical interpreters.

Medical Interpretation Services in the United States

In most current U.S. health care settings, interpretation services are provided by personnel ranging from employed professional interpreters to untrained, ad hoc interpreters including bilingual medical staff or bilingual family and friends.4 Interpretation requires an absolute command of two languages, in-depth knowledge of cultural context, and the ability to manipulate registers ranging from formal to casual, including slang.6 Studies have demonstrated that family members and bilingual clinical staff commit many interpretation errors, including omissions, embellishments, false fluency, use of false cognates, paraphrasing, and giving opinions.4,7 Ad hoc interpreters are significantly more likely to commit an interpretation error of clinical consequence,8 yet employed hospital interpreters have also been found to commit errors of clinical significance.4,7 In fact, interpretation errors have been responsible for catastrophic mistakes, including preventable quadriplegia.4,9 Additionally, ad hoc interpreters are unlikely to be properly trained in medical terminology and patient confidentiality, and their involvement can hinder the provider–patient encounter by inhibiting discussion of sensitive subjects such as intimate partner violence and sexual activity.3,9

Although telephonic and video conference interpretation are also largely available to health care providers, physicians and interpreters demonstrate a preference for in-person interpretation.10,11 Standardization of medical interpreter training and certification may substantially reduce the barriers to equitable care experienced by LEP patients in the health care system, and recent efforts of the U.S. courts system provide a successful and realistic example of how these goals may be achieved.

Certification for Federal Court Interpretation Services in the United States

In 1978, the U.S. Congress recognized the need for appointed interpreters and passed the Federal Court Interpreters Act, mandating that the U.S. courts institute a system of certified or otherwise qualified interpreters for judicial proceedings.12 As the role of court interpreters became more formalized, researchers began to investigate how the actions of this additional party could—albeit unintentionally—shape the outcome of court proceedings. Initial studies revealed, for example, that interpreter politeness could affect juror perception of witness testimony,13 and individuals had been found wrongfully convicted on the basis of inaccurate interpretation.14 Recognition of these issues contributed to the standardization of interpreter qualifications, including the federal court system’s certification process to provide qualified interpreters. Today, three categories of interpreters exist for the U.S. federal court system: certified interpreters, professionally qualified interpreters, and language-skilled/ad hoc interpreters.15

Certified interpreters must pass a written and an oral examination, which aim to simulate real court proceedings. These exams evaluate the interpreter’s simultaneous and consecutive interpretation and sight translation skills. Exams are written and scored by linguistic experts who have passed the federal exam and have extensive field and test construction experience. This testing system has been independently evaluated by psychometricians and is demonstrated to be valid and reliable.16 The federal certification process is currently only available for Spanish interpreters, but it has previously included Navajo and Haitian Creole.

In the federal court system, professionally qualified interpreters have earned credentials that demonstrate their interpreting abilities.15 This may include, but is not limited to, the United Nations interpreter test or the U.S. Department of State conference or seminar interpreter test.15

Finally, language-skilled/ad hoc interpreters do not qualify as professionally qualified interpreters but demonstrate satisfactory abilities to interpret in the court setting. This vague categorization is currently the only national requirement for medical interpreters. The health care industry needs to turn to the federal court system’s interpreting classifications and certifications to address health care disparities and improve access, equity, and quality of care among all LEP patients.

The health care sector can greatly benefit from guidance resulting from the standardization of court interpreting in the federal system. During court interpreter certification workshops, students are instructed as follows:

Interpreters are obligated to apply their best skills and judgment to preserve faithfully the meaning of what is said in court, including the style or register of speech. Verbatim, “word for word,” or literal oral interpretations are not appropriate when they distort the meaning of the source language, but every spoken statement, even if it appears nonresponsive, obscene, rambling, or incoherent should be interpreted. This includes apparent misstatements.17

Certification Examinations

Federal exam passing rates range from 3.6% to 12.5%.18 Experts agree that these low rates are not the result of a flawed examination process but, rather, that very few bilingual individuals who consider themselves qualified are actually competent to interpret in the court setting,17 as interpretation itself is a distinct skill, separate from language understanding and fluency.18 Individuals in the medical setting should anticipate and expect a similar high failure rate of standardized examinations, to ensure that certified medical interpreters render appropriate interpretations, which is integral for high-quality, equitable care. The Federal Court Interpreter Certification Examination program, in partnership with the National Center for State Courts, maintains a list of federally certified court interpreters.19 In health care, two organizations have created certification processes for medical interpreters: the Certification Commission for Healthcare Interpreters (CCHI) and the International Medical Interpreters Association (IMIA). The IMIA Certified Medical Interpreter status is available for Spanish and nearly 30 other languages and requires successful completion of written and oral exams. Oral examinations assess linguistic proficiency across the languages, consecutive interpreting, sight translations, and knowledge of medical terminology in both languages, as well as cultural awareness.20 The CCHI exam assesses health care terminology, interactions with other health care professionals, interpreting encounters, and cultural responsiveness and includes consecutive and simultaneous interpretation in addition to sight translations.21

Medical Interpretation Services and Health Policy

Despite two national organizations offering certification processes for medical interpreters and various state certification programs, the United States is a patchwork of state legislation and individual organization policy aimed at medical interpreting.22 We urge national leaders to legislate policy intended to standardize requirements for health care interpreting to ensure equitable care. Such legislation would steer organizations to measurable means to comply with past policy, such as Title VI of the 1964 Civil Rights Act, which states:

No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.23

The Supreme Court considers discrimination based on language as equivalent to discrimination based on national origin; therefore, organizations receiving federal funds such as, but not limited to, the Centers for Medicare and Medicaid Services and the State Children’s Health Insurance Program, violate federal law when substandard care is provided to patients because of language barriers.22 To enforce Title VI, the Joint Commission now includes specific, patient-centered communication standards and elements of performance aimed to address unique patient needs,24 yet fails to consider medical interpreter certification standards.

The U.S. Department of Health and Human Services has set forth Culturally and Linguistically Appropriate Services standards25 and published the 2013 Language Access Plan (LAP) in accordance with Executive Order 1316626 to reduce health care disparities associated with LEP patients. Provisions include free language assistance to LEP individuals by competent interpreters25 and 10 core elements to meet LAP goals.26 However, these policy actions fail to define quantifiable criteria to standardize medical interpreter competency.

Researchers have attributed a similar lack of competency-based metrics to persistent health care disparities in California following legislation requiring private managed care plans and individual and group health insurers to provide beneficiaries appropriate access to translated materials and language assistance when seeking care.22,27,28 More recent potential legislation, California bill number AB 1263, directly confronts this oversight by requiring a centralized certification examination for medical interpreters and the provision of a subsequent registry of certified medical interpreters in California.29 Researchers and policy leaders should closely examine outcomes of this legislation if it is passed and should consider similar national policy enhanced by this insight. Such policy is desperately needed to direct organizations to use certified interpreters, thereby truly addressing language discrimination. National reimbursement policies for Medicare and other third-party payers, including certification requirements for reimbursed services, would likely foster change at the individual organization level.30 Additional considerations would be required under such policy, as research indicates that clinicians underuse available interpreting services31,32 and are undertrained in appropriate interpreter use regardless of interpreter competency.3

Standardization of interpreter training and certification is only one step toward improving the delivery of appropriate health care to LEP patients. Research has demonstrated that despite having access to an interpreter, physicians perceive a compromised quality for care delivered via interpreter.33 One of the next, or concomitant, steps should also be to improve health care provider training in the use of interpreters.

Conclusion

A variety of health care disparities, ranging from reduced satisfaction with patient–provider interactions to gross morbidities resulting from incorrect or insufficient medical treatments, are attributed to language barriers and are widely documented in the literature.1–4 Legally and ethically, LEP individuals who interface with the health care system should receive the most appropriate services and quality of care equal to that of their English-speaking counterparts. Additionally, medical interpretation services are thought to be long-term cost-effective,34,35 although experts continue to advocate for additional cost-effectiveness research.36

To maximize equity in the health care setting, we ask national leaders to turn their attention to the current nonstandardization of medical interpreting services and the mélange of state and organization policy. We urge lawmakers to enact legislation intended to standardize requirements for health care interpreters to reduce language-based discrimination and consequently support equitable health care. Concurrent focus on interpreter and health care provider training is required to improve examination passing rates and appropriate use of interpreters. As guided by the evolution of the federal court interpreting certification program, subsequent research will be required to demonstrate the improvements and challenges that result from national certification standards and policy. Research should examine cost-effectiveness and ensure that certified interpreting services are appropriately carried out by health care practitioners. Ongoing commitment is required from lawmakers, health care providers, and researchers to remove barriers to care and to demand that equity remain a consistent goal of our health care system.

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