Language Interpretation and Health Care

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?

7 Comments

  1. Another infrastructure issue is cost. I was recently involved in trying to research ASL interpreter options for a patient in a private medical setting. The patient’s insurance didn’t cover interpreters. The cost of the interpreter to the medical facility was going to be double what the facility would be paid by the patient’s insurance for the patient’s visit. It’s ridiculous for either patients or physicians to eat the cost of interpreters, who should be considered a necessary medical expense, in my opinion.

    Language-proficient healthcare professionals are wonderful; in that medical setting mentioned, the physician is fluent in Spanish and the PA in Tagalog, which covers a lot of the patients’ needs. But the staff is small enough that they simply can’t cover everything; I really think insurance (and/or state or federal governments) should be mandated to cover outside interpreting.

  2. My background comes from medical school iin a diverse setting with many patients with limited English proficiency, where some sort of interpreting was needed at least once a week, and a residency in a less diverse setting where the need for interpreters was less frequent, perhaps once or twice a month. I’ve used a combination of live professional interpreters, the telephone interpreting service and my own non-fluent skills in French and ASL. I’ve also seen a few encouters when bilingual HCPs were available, and I’ve seen professional and family members used to interpret in various settings.

    I have had nothing but positive experiences with both live interpreters and the telephone system. I don’t know for sure my patients’ perceptions, but I do know that I always ask at each encounter if all their questions have been answered and have generally found this to be the case. In these settings live interpreters or bilingual providers were not available. I have seen the telephone system used to find a interpreter for an emergency patient at 3AM who only spoke Ukranian, a language that was very uncommon in that US city. And I have seen the telephone system used to carry out a lengthy and complex interdisciplinary family meeting in a rehab setting. I have had positive experiences with HCPs who are fluent in the patient’s language as well, but found that these occurances generally happened by chance rather than design. We had no way of knowing that the only intern fluent in Spanish would be on call the night that the patient whose family only spoke Spanish would be admitted, or that the Deaf teen would come to the ER the day we had an ASL-fluent provider.

    I have also seen the telephone system removed by nursing from a patient room after the delivery of the baby (because the new mother had no further need for communication?) and encountered providers that did not know our hospital subscribed to the interpreting service or how to access a live or telephone interpreter. Further, most health care providers are not educated about how to conduct a patient encounter with an interpreter present, and many cut short their usual question set because of the increased time needed for interpretation. I have seen providers insist that the live Vietnamese interpreter would work for a patient who spoke language Cambodian, because most patients who speak Cambodian also speak Vietnamese, even though the patient in question did not. I have seen HCPs use an English-fluent family member as a surrogate to obtain patient consent without even attempting to have the information communicated to the patient. And I have encountered physicians who refused a request for an ASL interpreter because they felt that communication was adequate even though the patient and family did not.

    The common elements of these experiences are that the success or frustration level generally depends on the HCP knowledge of available services and the willingness to use these services. The quality of interpreters via these several hospital systems and the telephone system have been excellent, but an excellent interpreter is useless if the doctors, nurses or other professionals don’t know how to use the system or are unwilling or unable to spend the extra time needed to communicate effectively through a live or telephone interpreter. I think that training in the available services and in the best way to use them should be manditory for health care students in all fields. It is not reasonable to expect that a provider fluent in Cantonese will be available in the ER at 11PM on a given Sunday, but it is reasonable to expect that every HCP in that ER knows how to obtain an interpreter in a timely fashion and to effectively work with live, telephoned and video relay interpreting services.

  3. We used http://www.languageline.co.uk/ in our healthcare setting for ESL callers, and had dedicated relay and Texbox/teletype interfaces. It was a blessing to get a Xhosa interpretee for a POW refugee with injuries, or a someone to help a new mother who forgot her English due to stress and could only talk in Quebecois. As it’s the UK we had several French nurses who could have gone to bat in an emergency, but the fact that we could get a ‘terp with the caller’s background in 4 minutes was a relief to everyone.

    I love Language Line.

  4. Two words Universal Language. Semi-serious, I get that it would be pretty impractical to implement and wouldn’t necessarily help for sign users, but it solve the problem for most people.

  5. Thanks for a great starting point to this discussion, Abby Jean. I worked as an ASL interpreter in many outpatient clinics settings (I was available days!) in the late 80s, so I’ve observed some of the positive changes with relief. When I had my hands in the field, we were still encountering strong resistance from medical practitioners due to rank privilege. I ranted about that in this 2009 post.

    One issue which surprised me, and can be helpful as we advocate for better access, is that cost is not the issue. An informative article in the J of General Internal Medicine, V24, No2, 256-262 called
    Getting By: Underuse of Interpreters by Resident Physicians
    , by Diamond, Schenker, Curry, Bradley and Fernandez concludes:

    begin quote  Four recurrent themes emerged: 1) Resident physicians recognized that they underused professional interpreters, and described this phenomenon as “getting by;” 2) Resident physicians made decisions about interpreter use by weighing the perceived value of communication in clinical decision making against their own time constraints; 3) The decision to call an interpreter could be preempted by the convenience of using family members or the resident physician’s use of his/her own second language skills; 4) Resident physicians normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care.
    Conclusions
    Although previous research has identified time constraints and lack of availability of interpreters as reasons for their underuse, our data suggest that the reasons are far more complex. Residents at the study institutions with interpreters readily available found it easier to “get by” without an interpreter, despite misgivings about negative implications for quality of care. Findings suggest that increasing interpreter use will require interventions targeted at both individual physicians and the practice environment.
     quote ends

    My recipe for better health care involves a fundamental change: a knowledgeable staff member not present throughout the visit would ask the patient to summarize what they learned and what if any meds, activities, or other follow-ups they were planning. Finally, they’d schedule a return visit as needed. In the infuriating case where an interpreter was needed but not used, the gap would be clearly illuminated in the post-visit summary. This approach would force health care practitioners to acknowledge when they are communicating adequately with their patients, regardless of linguistic, racial or class barriers, cognitive or memory impairments, or someone being held against their will.

  6. One issue which surprised me, and can be helpful as we advocate for better access, is that cost is not the issue.

    I suspect there may be differences between hospitals, especially teaching hospitals, and private medical practices (e.g., one’s primary care physician) on that issue. Residents would not be paying for the interpreter out of their own pocket; physicians in private practice would.

  7. Oh lordy, let me try to be concise and not rant….

    For the better part of three years (and on rare occasions, still), I’ve had vocal cord apraxia, which prevents me from voicing. I already knew ASL when I lost speech, and I also had a lot of pain and mobility issues that made handwriting or typing slow, painful, or impossible, so I used ASL terps in medical settings.

    By law, all healthcare providers are supposed to provide a terp for anyone who needs one, and in my state there is an on-call service for medical emergencies, as well. Here’s a sampling of some of what I experienced. (And just think — I could understand what was being said to/about me, unlike most in these situations.)

    – Providers spoke about, not to, me. (“Does she…?”) This happened among every sort of provider (MDs, nurses, therapists, clerks, etc.) even when they knew I was hearing, including providers (my PCP!) who knew me before I lost my voice. Suddenly, they were rude and dismissive, eager to get me out of their office. Sometimes a terp wouldn’t be allowed into an area (e.g., MRI), and then I would suffer terrible pain or scary situations in transferring, because the nurses or techs didn’t understand me. I began to get very assertive about demanding terps go with me *everywhere.*
    – A doctor who’d been my PCP years before, whom I’d left in part because he refused access to me with my service dog, never pays for interpreters (which is against the law, but he acts like he’s above it). He was the only Lyme specialist in my region, so I went to him, and a friend who was a professional terp went with me, for free. He’s very arrogant, and I’m not surprised by that study that found money not to be the issue, because, in general, the practitioners who cared and listened before were most willing to work with a terp, and those with G-d complexes were not.
    – The state agency coordinating interpreters had no familiarity with MCS and sometimes ignored my “preferred terp list” so that, if I didn’t check and do lots of advocacy, I’d end up with someone fragranced and/or someone who was unprepared for my unique situation/language needs.
    – Some healthcare settings had staff terps. The first time this happened, and I requested my preferred terps thru the state system, they assured me theirs would be fine, and I didn’t feel like I could argue. Their terp corrected my sign/was patronizing and often interpreted incorrectly. (e.g., I told the provider I had “chronic fatigue syndrome” and the terp voiced, “fibromyalgia.”) I felt terrible, and blamed the bad communication on myself and my signing skills. The person who took me to the appointment is Deaf and knew the terp. He asked me how I liked her, and when I told him, he said he felt the same and refused to work with her. After that, I demanded appropriate terps.
    – Twice, I had an outpatient surgical procedure. The first time, the hospital had a lot of lead time and provided a terp. The second time, it was last minute (but not an emergency, at night, so I didn’t qualify for the emergency terp service), and they couldn’t find anyone. The first time, despite very difficult circumstances (my dominant arm was undergoing the procedure, and almost all of my face was covered), the terp was very skilled, and I was able to communicate with the doctor and nurses. The second time, my partner came to interpret. It ended up being 2.5 hours long, instead of under an hour (like the first time) because of a problem. She told me later how upsetting and gross it was for her to witness, which is a big problem with having family interpret — they do not have the professional distance necessary. It was traumatic for her. Secondly, she usually relies a lot on lip reading and facial expression, as she’s nowhere near fluent in ASL, so she rarely understood me, and guessed a lot. If I hadn’t already gone through the procedure before, it would have been frightening to be unable to see anyone and not able to speak to them or ask questions. The nurses kept telling her what a great job she was doing. They had no idea how much we were floundering, how little of my meaning was coming across. I didn’t want to correct their misperception and make my partner feel worse than she already did.

    The worst situation, and the one that would most be helped by the kind of “exit interview” proposed above, was what happened with my psychotherapist. I couldn’t leave bed except for critical healthcare, so we met by phone. When I lost my voice, we used TTY (teletype)/hearing carry over (HCO) relay, which was slow and often had technical problems. I started paying for ASL terps to come to my home, but trying to express my innermost feelings without total language fluency was also problematic. And, of course, an interpreted or relayed conversation takes about twice as long, but I don’t think she realized that.

    I kept begging my therapist to get a TTY, telling her about how she could get a used one cheap online. She kept refusing. I became so frustrated with our bad communication that I gave up and stopped seeing her.

    Eventually, a friend intervened and told her she was required by law to accommodate my disability. My therapist borrowed one from an ILC for two sessions to tell me she was terminating with me. In those conversations, when we were finally communicating, I learned that she didn’t realize we hadn’t been communicating before. Which explains why she kept saying what a wonderful service the relay was for us. She didn’t realize how often the relay operator misread what I said or left out chunks that had been garbled. But she terminated with me anyway.

    A relay operator isn’t an interpreter, but some of the same issues arise. I wish there had been an impartial third party to check with both of us about what we thought was taking place.

    I’ve never heard of the interpreting phone lines described above except for VRS (video relay service), which is an ASL terp service in the US. (I didn’t have the technology for that.) It would be great if hospitals and other healthcare settings had videophones for when no terp can get there in time, although since ASL is such a context-based language, VRS is notoriously spotty.

    I’m sorry this was so long. It’s a very tender subject for me.