As promised, here is a post and a place to discuss policies and procedures about language interpreting in a health care context. Unfortunately, it is going to be a slap dash post as I’m knee deep in a number of things, both professional and personal, including preparing to clean ALL THE THINGS and cook a great number of the things for the upcoming U.S. Thanksgiving.
So. Here are some assorted thoughts and resources on interpretation policy!
My first and most prominent thought is the absolute importance of having interpretation done well. It is essential that the health care provider be able to understand the patient’s reported symptoms and experiences and sensations, their medical history, their concerns, and their desires and goals for the medical treatment or care. It is also essential that the patient be able to understand the instructions and questions of the provider and discuss any potential treatment options, including tests, medications, and therapies. Without accurate and competent translation, the provider cannot understand what is wrong and the patient cannot understand how it will be addressed. While there are times that medical treatment takes place without communication – primarily emergency situations when the patient is unconscious – that is definitely the exception rather than the rule and is not a good model for non-emergency care or even most emergency care. Communication is crucial and should be important to all individuals involved in health care transactions. In other words, bad communication could kill people. So, this is an enormously important issue, both to people who do not speak English (or whatever the predominant language is where they are) and to people with hearing impairments and d/Deaf people.
Problems with interpretation:
In my experience, there is usually a vast gulf between interpretation policies as written and as implemented in practice. Even when a policy requires use of a trained and certified interpreter during all interactions, with clear instructions on when and how to obtain an interpreter, there will be interactions where no interpreter is present. (See, for example, this recent audit of interpreter use by New York City police finding that officers routinely failed to comply with the existing interpretation policy.) This is in large part because of logistical difficulties with interpreter use that I’ll discuss below and seems to be a feature of nearly every interpreter policy. This kind of built in failure rate makes me inherently nervous about relying on interpreters.
Interpreter policies are logistical nightmares, in large part due to the difficulty of matching language competence to language need that we discussed last week. This is especially true in areas with significant language variation – the court where I worked had several Spanish interpreters and an Armenian, Russian, Farsi, Cantonese, and Tagalog interpreter on call all the time, and still had incidents when a litigant needed interpretation in a language that wasn’t available. This is even more difficult in an emergency room situation, when it is impossible to anticipate when a need will arise and there is no way to just have everyone wait for a bit until an interpreter gets there. This leads to using interpreter phones – where the provider and patient use a handset to speak to an off-site interpreter, which are both expensive and clunky. Even if an interpreter is on staff, finding them in the building, pulling them out of a meeting or their break, and getting them to the desired location to provide interpretation is often a hassle.
There also needs to be an entire infrastructure around training interpreters and measuring and certifying their competence. Language knowledge is not enough for competent interpretation, interpreters must also be trained in interpretation skills and professional standards. There is a lot to well-done interpretation – positioning yourself so the provider and patient can maintain eye contact, knowing when and how to ask clarifying questions, providing concurrent interpretation without interrupting the flow of the conversation. This training and certification requires time and money.
The limited-English-proficient patient has very limited ability to address problems in interpretation policy. To address the failure to provide an interpreter at all, they can provide their own, usually by bringing a friend or family member to do the interpretation. This is a big problem for a number of reasons. First, there’s no way to know the competency of the friend or family member in interpreting, especially with specialized medical vocabulary and concepts. When the doctor tells me that the leg pain I am experiencing could be a rupture of my plantaris tendon, plantar fascitis, or tendonapathy, is there any probability that my sister will be able to interpret that accurately? (Personally, I’d have trouble identifying even what portion of the leg was being discussed if I didn’t have Medline open to get those terms in the first place.) Second, this is a major confidentiality issue. If I am going to the doctor to discuss genital warts, I am unlikely to be as frank or forthcoming if my brother is my interpreter. This is especially true for medical issues around sexuality, pregnancy, mental health, and injuries from domestic violence, when discussing symptoms and experiences can open the patient to strong stigma effects. This is even more problematic if a child is serving as an interpreter and being expected to interpret discussion about conflicts between his parents or his mother’s suicidal thoughts, which could be dangerous or traumatic for the child.
Overall, I am most concerned about the inherent non-compliance caused by the logistical hassle and the patient’s agency being limited to bringing a friend or family member to interpret, and it is these issues that make me prefer language proficient medical professionals rather than reliance on interpreters. I also think that language proficiency for providers would help with cultural competence issues, but that’s more a side effect.
So – have at it! Interpretation? Language proficient providers? What makes sense? What do we want?