Medical Interpreter Workforce - Current Needs

Transcription

1 Culture InSight New England s Medical Interpreter Workforce An Assessment of Training Needs Fall 2009

2 Table of Contents INTRODUCTION...3 A Word About Health Care Disparities...4 Language As A Barrier to Care...5 Organizing The Interpreter Community...6 Assessing the Need For Training...7 Survey Methodology...8 Organizations Involved...8 INTERPRETER TRAINING NEEDS ASSESSMENT SURVEY: Results & Analysis...10 A Note About The Data I. Languages Interpreted Most Often...10 II. Interpreter Training and Education...12 III. Interpreter Work Experience...13 VI. Preferences for Additional Training...16 Desired Additional Training in Medical Specialty Desired Additional Training In Behavioral Health Desired Additional Training in Disease Category Desired Additional Training in Interpreter Skill VII. Education...21 VIII. Interpreter Skills...22 IX. Demographics of the Interpreter Workforce...23 Conclusion...25 Recommendations...25 Works Cited Harvard Pilgrim Health Care Foundation Culture Insight

3 INTRODUCTION A Dramatic Story of Change Statistics can tell stories, and the story that is told by the demographic data of the Boston area during the past 50 years is dramatic. In 1960, more than 90% of the population of the City of Boston was white, according to the US Census. Blacks comprised just 9%; the number of people of Hispanic origin wasn t even measured. Forty years later, that picture had changed significantly. In 2000 the majority of Boston residents were non-white Asian, Black, Latino or of another race while the white population was just under 50%. Statewide, the trend is similar: In 1990, 11.2% of Massachusetts population was minority. By 2000 that number had risen to 17.3%. 1 As the minority population has increased, so too has the number of foreign-born residents. The 2000 Census data indicated that one in every four Boston residents was born outside the US. This trend is not unique to Boston, or even to Massachusetts. Immigration data and projections show a growing foreign-born population in Massachusetts, New Hampshire, and Maine: 2 New England s Medical Interpreter Workforce: An Assessment of Training Needs 3

4 This demographic trend has significant implications for health care professionals. With increasing frequency, doctors, nurses, and other health care professionals are seeing patients who do not speak English, or speak with limited proficiency. Some bring friends or family members along to appointments to serve as interpreters, a scenario fraught with potential problems ranging from miscommunication to compromised patient privacy. Professional medical interpreters are becoming increasingly important members of health care teams. This report takes a look at the current state of the medical interpreter community in New England, as part of an overall process of evaluating current and future needs. Data from a first-of-its-kind survey reveal the languages most often interpreted; the experience level, education and training backgrounds of interpreters; and the specific skills interpreters use as well as the areas in which they would like further training. Just as in all areas of health care, the medical interpreting profession must maximize the use of resources, people, and funds. The interpreter community must look for ways to provide convenient, high-quality, cost-effective training that enables new recruits to enter the field and career interpreters to continue to sharpen their skills and keep up with changing needs. The results of this survey, displayed in the next section and summarized at the end, will help local health care leaders analyze the needs of this important workforce as they work to ensure high-quality health care for all populations both today and tomorrow. A Word About Health Care Disparities Much has been written about health care disparities in the U.S. The fact is that throughout our nation, research shows that minorities receive lower quality health care, even when factors such as health insurance and socio-economic status are not in play. In its 2002 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, The Institute of Medicine (IOM) concluded that minority patients are less likely than whites to receive the same quality of health care, even when they have similar insurance coverage or the ability to pay for care. 4 Harvard Pilgrim Health Care Foundation Culture Insight

5 There are many factors at work here. The IOM report focuses on three potential sources of disparities: 1. The way healthcare systems are organized and operate can contribute to differences. Here the IOM cites factors such as pressure to limit spending, which might disproportionally affect patients who are least educated or likely to push their doctor for more services. Additionally, says the IOM, many health plans do not offer professional interpretation or translation services to patients that don t speak English. Professional interpretation and translation services are important to help non-english speaking patients fully participate in treatment decisions and discuss concerns with their doctor privately. 2. Patients attitudes and behaviors can contribute to disparities. Some minority patients may put off health care visits because they don t trust health care professionals. Others reject their doctor s recommendation, or don t follow their doctor s instructions exactly. In some cases this may be the result of inadequate communication. 3. Health care providers biases, prejudices, and uncertainty when treating minorities can contribute to health care disparities. Doctors attitudes and beliefs sometimes subconscious may influence the quality of care they provide minority patients. The IOM makes a number of recommendations to reduce disparities, including this: More minority health care providers are needed, especially since they are more likely to serve in minority and medically underserved communities. In addition, more interpreters should be available in clinics and hospitals to overcome language barriers that may affect the quality of care. 3 Language As A Barrier to Care Language barriers can have a negative impact on the quality of care minorities receive, or even on the amount of care. A 2006 article in the New England Journal of Medicine titled Language Barriers to Health Care in the United States says this: Patients who face such barriers are less likely than others to have a usual source of medical care; they receive preventive services at reduced rates; and they have an increased risk of non-adherence to medication. Among patients with psychiatric conditions, those who encounter language barriers are more likely than others to receive a diagnosis of severe psychopathology but are also more likely to leave the hospital against medical advice. Among children with asthma, those who confront language barriers have an increased risk of intubation. Such patients are less likely than others to return for follow-up appointments after visits to the emergency room, and they have higher rates of hospitalization and drug complications. Greater resources are used in their care, but they have lower levels of patient satisfaction. 4 New England s Medical Interpreter Workforce: An Assessment of Training Needs 5

6 Indeed, ineffective communication can lead to tragic results. In a July, 2009 interview on National Public Radio, patient advocate Mara Youdelman of the National Health Law Program told this story, from among the many that she keeps on file: "There's one case that came out of Florida where an 18-year-old young man collapsed into a coma, and unfortunately paramedics and personnel in the emergency department never got an interpreter to speak with the man's girlfriend or mother," she says. They had told medical workers the man had been "intoxicado" Spanish for nauseated. But emergency room staff took the word to mean "high on drugs." For 36 hours they treated him for suspected overdose. "And it was only after the 36 hours when there was no recovery that they started to do a neurological examination," she says. "In the meantime the young man suffered a severe subdural hematoma and was left quadriplegic." 5 Ad hoc interpreters family members, friends, untrained support staff are often a poor substitute for a trained professional medical interpreter. Usually unfamiliar with medical terminology and with confidentiality requirements, their presence may also inhibit the patient s willingness to share information about sensitive topics such as substance abuse, domestic violence, or mental health concerns. Particularly troubling is the use of children as medical interpreters: not only are they less likely to be proficient enough in both languages to facilitate effective communication, but they may also be upset or even traumatized by what they learn or perceive during medical appointments with a parent, grandparent, or older relative. Organizing The Interpreter Community In the Boston area, the need for skilled, reliable medical interpreters became clear in the 1980s. So in 1986, representatives from Beth Israel Hospital, Brigham and Women s Hospital, Cambridge City Hospital, New England Medical Center, Massachusetts General Hospital and Somerville Hospital came together to form the Massachusetts Medical Interpreters Association, the first organized group of its kind in the US, dedicated to defining educational requirements, setting standards and advancing the professionalism of this important discipline. The organization is now known as the International Medical Interpreters Association (IMIA). Today it is widely recognized that qualified medical interpreters contribute to better health outcomes, enhanced communication between provider and Limited-English Proficient (LEP) patients, increased clinician and patient satisfaction, and reduced legal risks. It is also recognized that in order to meet the growing need for professional medical interpreter services, current interpreters may require additional training, and new interpreters must be recruited. 6 Harvard Pilgrim Health Care Foundation Culture Insight

7 Assessing the Need For Training Culture InSight (CIS) is a branch of the Harvard Pilgrim Foundation that is committed to improving the quality of health care for people of various ethnic and linguistic backgrounds. Since 1994, CIS has trained more than 1,000 medical interpreters in multiple languages. Currently CIS offers a 48-hour Foundations in Medical Interpreting program as well as regular half-day Enhanced Medical Interpreter workshops in mental health, oral health, asthma and diabetes. Program evaluations routinely show that participants in these training programs are interested in receiving additional training in specific medical conditions, medical specialties, as well as in specific interpreter skills. Like all professionals, interpreters need continuing education to develop and maintain the professional skills required to ensure effective communication between providers and patients, and to prevent adverse effects that can result from inadequate communication. In order to better assess the educational and training needs of New England s interpreters, and to stimulate more conversation and greater cooperation among the area s training organizations, Culture InSight staff initiated the Interpreter Training Needs Assessment Survey, the first on-line survey of its kind. The survey was designed to help leaders in the region understand what is needed to help interpreters meet the anticipated requirements of the National Interpreter Certification, as well as ongoing needs for continuing education. The survey was conducted in partnership with IMIA; Language Access for New Americans (LANA) at United Way of Greater Portland, ME; Maine Office of Multicultural Affairs; and South New Hampshire Area Health Education Center. In preparation for this assessment, CIS staff interviewed leaders of organizations, including interpreter coordinators and trainers, and engaged them in the development and piloting of the survey tool. T.A. Wilson & Associates, a management consulting and organizational development firm with experience in survey administration, was engaged to tabulate and analyze results. The partners listed above assisted in developing survey questions and provided valuable feedback that expanded choices of categories of diagnoses, conditions, behavioral topics and interpreter skills for the survey. These partnering organizations also helped conduct a pilot survey that insured the relevance of the questions and categories. The survey was disseminated to 1,050 interpreters in six New England states; 254 completed responses (193 online and 61 on paper) were received. Only completed surveys were included in the final analysis. While we recognize that this survey is limited in scope, we do feel that the results provide valuable data that can and should guide decisions about training opportunities and priorities in the New England region. New England s Medical Interpreter Workforce: An Assessment of Training Needs 7

8 Survey Methodology The online survey was administered from October 14, 2008 to December 2, 2008, a 50- day-period during which CIS, IMIA, and other organizational partners each sent two or three blasts to their members directing participants to the online survey hosted by T.A. Wilson and Associates. The sample pool for the online version of the survey consisted of: 610 IMIA members (self-identified interpreters from MA, ME and NH) 156 staff and former students of Culture InSight 92 interpreters from Language Access for New Americans (LANA) at United Way of Greater Portland, ME 200 interpreters from the South New Hampshire Area Health Education Center Of the approximately1,050 people who received the survey online, 193 responded, an 18% response rate that well exceeded the typical response rate of 10% for IMIA online surveys. The paper format survey was distributed at the 2008 IMIA Conference in Boston in October, Sixty-one people completed and turned in a paper survey. In addition to collecting robust demographic data, the survey asked participants to select topics of interest for future training in several categories. Organizations Involved Partners and administrators of the survey included: Culture InSight is a branch of the Harvard Pilgrim Foundation that is committed to improving the quality of health care for people of various ethnic and linguistic backgrounds. Through training programs for medical/social service providers and consulting for health care organizations, CIS promotes cultural competency and medical equality. International Medical Interpreters Association (IMIA) is the largest and oldest medical interpreter association in the country. With over 1500 members and 70+ languages represented, the IMIA is committed to the advancement of professional medical interpreters in order to ensure equal access for linguistically diverse patients. Language Access for New Americans (LANA) is a Maine-based organization that aims to improve access to services for refugees and immigrants with limited English skills by improving the quality and increasing the number of interpreting and translating services in their state. The Maine Office of Multicultural Affairs is a branch of the Maine Department of Health and Human Services. Their primary role is to function as a resource to all state agencies 8 Harvard Pilgrim Health Care Foundation Culture Insight

9 and to all communities served to improve services to minority and multicultural populations in the state of Maine. South New Hampshire Area Health Education Center is a community-based organization that provides education for health students and professions, focusing on addressing the issues of underserved communities in South New Hampshire. T.A. Wilson & Associates is a management consulting and organizational development firm. With more than 20 years of experience dealing with these issues firsthand, principal and founder Timothy A. Wilson worked with Culture InSight staff to provide services such as needs assessments and diversity organizational assessments. New England s Medical Interpreter Workforce: An Assessment of Training Needs 9

10 INTERPRETER TRAINING NEEDS ASSESSMENT SURVEY: Results & Analysis A Note About The Data The data in the following charts and graphs are taken from the 254 surveys completed by interpreters from Massachusetts (205 respondents), New Hampshire (21), Maine (5), Rhode Island (5), Vermont (2), and Connecticut (16). With approximately 80% of the responses coming from Massachusetts workers, the data are not wholly representative of the other states. Culture Insight is particularly interested in the three states it primarily serves Massachusetts, New Hampshire, and Maine and so occasionally this report will display data for these three states only. New Hampshire and Maine have only recently begun to train and professionalize interpreters due to increasing immigrant populations, and their samples are relatively small, particularly for Maine, with just 5 respondents. However, our partner organizations represent the biggest organized bodies of interpreters in NH and ME, and we believe that our sample is likely representative of the majority of interpreters in those states. As the interpreter workforce develops more fully in these states, further studies may be warranted. I. Languages Interpreted Most Often Mirroring a rise in Spanish-speaking populations throughout the US, as well as Boston s significant Hispanic population (14%), Spanish is the language most frequently translated by interpreters in the New England area, with Portuguese second. The third highest category is other (see details in the chart on the following page), which presents interesting challenges and opportunities for training organizations, and suggests that further exploration of these languages of lesser diffusion ranging from Polish to Korean might be useful, to see how well current training resources are aligned with immigration trends. 10 Harvard Pilgrim Health Care Foundation Culture Insight

11 Here is how this information breaks down by state for Massachusetts, Maine, and New Hampshire: Other is a category worth learning more about, particularly in Maine. The chart below provides a little more detail about this category, showing a range of languages among the three states. Interestingly, these data indicate that American Sign Language is one of the most common among these languages of lesser diffusion. Language MA ME NH Total American Sign Language Italian Polish Armenian French Hebrew Somali Romanian Korean Total New England s Medical Interpreter Workforce: An Assessment of Training Needs 11

12 II. Interpreter Training and Education The vast majority of interpreters have had some type of formal training, suggesting that New England has a group of well-educated and trained interpreters. The majority of respondents more than 67% have completed the Interpreter Certificate Program of 40 hours or more (CP-40). Nine respondents from MA stated they have a Bachelor s degree in interpreting or translation, and two (one from MA, and one from ME) stated they have a Master s degree in interpreting. The training community may want to consider tapping interpreters with this level of education as mentors to others who could benefit from their expertise. 12 Harvard Pilgrim Health Care Foundation Culture Insight

13 Here is how the training data breaks down by state: III. Interpreter Work Experience New England s interpreter workforce is an experienced group. The vast majority of interpreters (79%) have had more than three years of experience in the field, with 26.1% having had more than 11 years in the field. The graph below shows the years of experience of survey respondents forms a bell curve, with 6 to 10 years as the norm. New England s Medical Interpreter Workforce: An Assessment of Training Needs 13

14 IV. Field of Work as Interpreter The results of this question should not, of course, be surprising, since the survey participants were reached through the International Medical Interpreters Association. Still, it is interesting to note that some of the respondents work in other settings. Future research with a broader constituency might be warranted to determine the extent to which professional interpreters working in other fields, such as legal or educational, encounter medical terminology or issues in their work, and what their training needs might be. 14 Harvard Pilgrim Health Care Foundation Culture Insight

15 V. Medical Settings Where Interpreters Work In Massachusetts, the Emergency Room Interpreter Law requires all hospitals to provide interpreter services in Emergency Rooms for patients who need them, so it is not surprising that the majority of respondents (64%) said they do most of their interpreting in the hospital. Further research may help to clarify why health clinics and group practices are not using, attracting or retaining medical interpreters. For those who interpret in the hospital, it might also be valuable to learn more about where most of the interpreting is taking place (e.g., emergency room, ICU.) The 47 people who chose Other corresponds roughly with the 45 people in the previous graph who interpret outside of health care settings. In future surveys it would be useful to learn more about what these settings are. New England s Medical Interpreter Workforce: An Assessment of Training Needs 15

16 VI. Preferences for Additional Training Although the interpreter workforce in New England is predominately well trained, most interpreters in the survey indicate interest in continuing training opportunities. Because many professional interpreters maintain very busy schedules, our survey explored their interest in one-day training opportunities in four areas: 1. Medical Specialty 2. Behavioral Health 3. Disease/Condition 4. Interpreter Skills Specifically, we asked: If money is not an issue, what would be the three training topics you would be most interested in attending for a day? Desired Additional Training in Medical Specialty From a list of 11 medical fields, the top two categories that interpreters chose were Cardiology (22.5%) and Mental Health (18.4%). Gastroenterology, Intensive Care, OB/GYN, and Pediatrics were essentially tied for third, each receiving about 10%. 16 Harvard Pilgrim Health Care Foundation Culture Insight

17 Broken down to the state level, the data are mostly consistent over our three states of focus, with a slight divergence from the majority in both Maine and New Hampshire, as shown in the chart below. This may reflect local requirements. State Choice Number 1 Choice Number 2 Choice Number 3 MA Cardiology (274 votes) Mental Health (213) Ob/Gyn (130) NH Cardiology (31) Mental Health (27) Gastroenterology (16) ME Ob/Gyn (8) Mental Health (6) Gerontology (4) Desired Additional Training In Behavioral Health Behavioral health issues are often sensitive and sometimes difficult, and require careful handling by all health professionals. Accurate, appropriate and sensitive interpreter services are a crucial element of effective behavioral health care for patients with limited English proficiency. Survey respondents identified domestic violence, psychological testing, and mental health competency hearings as the top three areas of behavioral health in which they would like further training. New England s Medical Interpreter Workforce: An Assessment of Training Needs 17

18 Desired Additional Training in Disease Category Interpreters were also asked to identify the top three disease categories in which they would like further training, out of nine choices. The majority of the interpreters surveyed selected cancer, cardiovascular health, and diabetes. The prevalence of these diagnoses in the immigrant population and the continuing emergence of new treatments and culturally appropriate diets and exercise make effective interpreter services particularly important for patients with these conditions. 18 Harvard Pilgrim Health Care Foundation Culture Insight

19 Broken down by state, these three top disease categories remained essentially consistent, with the addition of asthma as a top choice in Maine. State Choice Number 1 Choice Number 2 Choice Number 3 MA Cancer Cardiovascular Health Diabetes ME Cancer Diabetes Asthma NH Cancer Cardiovascular Health Diabetes New England s Medical Interpreter Workforce: An Assessment of Training Needs 19

20 Desired Additional Training in Interpreter Skill Practicing interpreters must constantly update their knowledge to keep up with emerging technologies, procedures and treatments. Respondents also selected areas of professional skill in which they would like more training. The majority selected training in advanced medical terminology, followed by simultaneous interpreting in mental health, and about equal third choices of ethics, telephone interpreting, and video interpreting. 20 Harvard Pilgrim Health Care Foundation Culture Insight

21 VII. Education New England s interpreters are well educated. More than 60% have a bachelor s degree or higher. Among those who don t have a bachelor s degree, 84% have attended some college or a certificate program. These data suggest that many members of New England s interpreter community are potentially capable of helping others sharpen their skills. New England s Medical Interpreter Workforce: An Assessment of Training Needs 21

22 VIII. Interpreter Skills Self-evaluation is neither objective nor scientifically robust, but it is one tool for understanding the training needs that interpreters perceive they have. This survey asked interpreters to rate their skills in the following areas: Active Listening Consecutive interpretation Note taking Sight translation Telephonic interpretation Chuchotage or whispered interpretation Non-verbal communication Public speaking Simultaneous interpretation Written communication 22 Harvard Pilgrim Health Care Foundation Culture Insight

23 The skills that respondents seem to feel most confident about are active listening (86% excellent and very good), consecutive interpretation (74% excellent and very good), and written communication (67% excellent and very good). Skills that scored lowest in their self-evaluations were public speaking (40% excellent and good), simultaneous interpretation (43% excellent and very good), and chuchotage (whispered interpretation 44% excellent and very good). Notably, simultaneous interpretation was among the top choices for additional training back in Question 10. It is also worth noting which skills interpreters seem to have the least experience with. The three skills that scored highest in no experience were telephonic interpretation (18%), chuchotage (17%), and non-verbal communication (16%). These may also suggest opportunities to strengthen training. IX. Demographics of the Interpreter Workforce Interpreting is a female dominated field. But like all medical professions, it is important to have a more balanced workforce, so consideration should be given to the recruitment of men as opportunities open up. New England s Medical Interpreter Workforce: An Assessment of Training Needs 23

24 The majority of the interpreter workforce is between ages 40 and 49; 66% are over 40. Of interest, and some concern, is the small percentage of interpreters in their 20s. These younger workers will take their elders places as they retire, and these data indicate a potentially shrinking workforce that will have trouble addressing the needs of a growing elderly population as well as those speaking languages of lesser diffusion. An organized effort to recruit more professional medical interpreters would benefit both the field, and the patients they serve. 24 Harvard Pilgrim Health Care Foundation Culture Insight

25 Conclusion The interpreter workforce represented by these survey results is well educated, well trained, experienced, and interested in continuing education in the field. On average these interpreters are middle-aged and predominately female. More than 60% have at least a bachelor s degree. Survey results reflect an interest in specialized programs for continuing education and training. As the professional interpreter community works at the national level toward a certification program, interpreters must prepare by obtaining the skills and knowledge necessary to become certified when this is necessary, and training programs must create capacity for this greater demand. Respondents indicated particular interest in further training in: cardiology cardiovascular health mental health domestic violence psychological testing cancer care gastroenterology advanced medical terminology simultaneous interpreting in mental health Medical interpreting plays an essential role in moving our nation toward the goal of equal access and quality of care for all. Training of new interpreters, along with ongoing training for those already in the field, is a necessary and important step to ensure that all patients receive the best care that can be provided. Recommendations This survey and report highlight not only the need to make additional training opportunities available to professional medical interpreters, but also the importance for leaders in the field to look ahead and plan for a future where the need for these professionals will be even greater. Next steps in this effort should include: 1. Create a regional task force to examine issues raised by the survey results, and set appropriate goals for the region to achieve by Continue to encourage and facilitate discussions about training opportunities among training institutions. 3. Design further studies to gather more in-depth data about need and resources in the region. 4. Create a group that will examine the use of technology (such as the Internet) to make training opportunities more accessible. New England s Medical Interpreter Workforce: An Assessment of Training Needs 25

26 Works Cited 1 U.S. Census Bureau. 2 Federation for American Immigration Reform. Washington, DC. 3 Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, Washington DC Flores, Glenn. Language Barriers to Health Care in the United States. New England Journal of Medicine, No 3, Vol. 355: July 20, Accessed online on September 2, Ludden, Jennifer. Patient Interpreters Save Money, But Who Pays? National Public Radio, July 27, Accessed online on September 2, 2009: 26 Harvard Pilgrim Health Care Foundation Culture Insight

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