By Lisa M. Lines, PhD, MPH
According to the American Community Survey, over 25 million residents of the United States - more than 1 in 12 - spoke English “less than very well" during 2008-2012 (US Census). The number of people with limited English proficiency is expected to grow substantially over the next decade. People whose first language is not English confront many barriers to accessing medical care – in addition to the difficulties with understanding English, the US health care system is especially complex and hard to navigate for immigrants. The use of professional interpreters is associated with improved communication (fewer errors and better comprehension), lower problematic health services utilization, better clinical outcomes, and greater satisfaction with care (Karliner 2006).
The National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS standards) require that health care organizations provide language services to patients with limited English proficiency. However, many hospitals are not compliant with these regulations (Diamond 2010).
In the following interview, we talked with Monica Rief, a professional interpreter who works with patients whose first language is Spanish or Portuguese in North Carolina.
Dr. Lines: What are the benefits of working with a professional interpreter?
Ms. Rief: Bridging the communication gap is of course the obvious first. Beyond that, the professional interpreter has received training on terminology specific to the field (for example medical or legal) as well as the privacy policies mandatory in both situations. Not only do we interpret, but we also act as an advocate for the patient. Effective communication extends beyond mere language; it also takes cultural beliefs and practices into account so both parties can understand each other.
Clinicians receive similar benefits as that of the patient. They are able to communicate with confidence, knowing their message is being properly conveyed to the patient, and vice versa. When a family member interprets for the patient, it is uncertain whether the message was delivered and received properly. This may lead to critical errors in the care that the patient receives, possibly the difference between life and death.
Professional interpreters have also received training on how to deal with blood spills, the machinery in hospital rooms, where to stand so that we are out of the provider's way, as well as where to stand in order to be of better service to the patient. We understand the questions asked. For example, today a patient told me privately that she reacts badly to anesthesia. When the anesthesiologist asked her, she said she did fine. I interpreted exactly what she said, but added what she told me in private. He said, oh, that's what I was asking.
Dr. Lines: What is the most important thing you think clinicians (physicians and nurses) should know/understand/keep in mind when working with a medical interpreter?
Ms. Rief: Speak directly to the patient. The interpreter acts as a voice for the provider and patient, speaking in the first person and conveying the message in its entirety. If the patient is upset, we interpret in the same manner. So it's not just words, it's actions and feelings that we convey, as well.
Dr. Lines: What is the most important thing you think clinicians should understand when caring for patients with limited English proficiency?
Ms. Rief: Always ask the patient whether they require an interpreter to be assigned to them during their visit. At times the patient does not realize that this service is available to them, free of charge. It is their legal right.
Another thing that came to mind is that the interpreter knows that being an advocate includes being respectful towards the patient when they want to speak English. Advocating their right to speak, so to speak. Not treating them like second-class citizens. I believe oftentimes there is discrimination evident in how they treat their patients. Having an interpreter around helps with that as well, as again and advocate for them to receive the same level of respect and care as someone who speaks their language.
Dr. Lines: How can clinicians contribute to a successful working relationship with a medical interpreter?
Ms. Rief: Understand that we are a voice to both parties. We are there to do a job, the same as they are. Sometimes clinicians are not respectful of our time. If we are scheduled to be there for two hours, please don't ask us to wait beyond that time. This is how we make a living. We aren't there as volunteers, and our time is just as important as theirs.
Dr. Lines: What are some common mistakes you see clinicians making when working with medical interpreters and their clients?
Ms. Rief: Not speaking directly to the patient is a common "mistake". I place that in quotes because that may be something that the provider may not know to do at first. The interpreter usually relays this to the provider and the patient before both parties begin, so everyone is aware how to proceed. Sharing a signal beforehand of when a pause is necessary is also helpful. At times the interpreter needs clarification before continuing.
Dr. Lines: How can clinicians avoid misunderstandings and miscommunication when working with medical interpreters and their clients?
Ms. Rief: Convey the message clearly to the patient. Understand that the role of the interpreter is to be their voice. Whatever the provider says will be communicated to the patient.
If there is something that should not be shared with the patient, then don't say it. There have been times when the patient has said something and I relay the message to the provider, and they said, oh that didn't need to be shared. It can be embarrassing. Same goes for provider. Part of my job is to summarize what is being said so no one is left out. So if the patient is asking where I'm from etc, I say to the provider, she's asking me where I'm from. And vice versa. We are the only ones who understand everyone in some cases, so it becomes part of our role to make sure everyone understands. This helps with no misunderstandings, or bad feelings – we don’t want someone to think we are talking about them!