Consider this case example of an encounter between a provider, patient and interpreter:

Transcription

1 Working with Interpreters Consider this case example of an encounter between a provider, patient and interpreter: An older female Bhutanese refugee goes to the doctor to begin treatment planning for her diabetes and high blood pressure. She speaks Nepali, but more specifically, a Nepali dialect that is common to her particular refugee population. The clinic hired a Nepali interpreter who spoke a different dialect. During the appointment the doctor used the phrase, use it or lose it, regarding her lack of physical exercise. In interpretation, the message was changed to, your arms and legs will be removed if you don t use them. Quite distraught, the woman left the appointment confused at her diagnosis, angry with the interpreter and suspicious of the doctor. How did you react after reading this example? What was the role of the doctor, interpreter and patient in the encounter? What could have been done differently in order for the patient to have a better experience? This module examines the topic of interpreter use in health care services to improve communication between patient and provider. For health care providers to ensure quality and culturally competent service, they must accommodate the needs of patients with limited English proficiency (LEP). This module addresses various aspects of working with interpreters to improve patient-provider communication and health service delivery. Introduction: The United States is growing more diverse every year. Current estimates put the number of Americans with a first language other than English at around 46 million (Schapira et al., 2008). Members of diverse populations who seek medical care often encounter barriers to good service due to communication problems with health care staff. This is especially true for the 19 million Americans who have limited English proficiency (LEP). Language barriers in the health care industry can lead to misdiagnosis, deferment of care, avoidance of needed services and inconsistency in visits (Flores et al., 2003). Not only do problems exist for health care recipients, they also exist for providers and organizations. The cost of care increases for facilities that try to accommodate LEP patients without the proper staff or services. Also, with the risk of errors in health services increasing, there is a greater risk of liability for organizations (Flores et al., 2003). For these reasons, the medical profession and civil rights advocates have stressed the need for professional medical interpreters in health care settings in which patients have limited English skills.

2 Interpreters in the medical profession assist in the communication between the patient and provider. Their roles and responsibilities require them to act as a language and cultural broker in real-time conversation between patient and provider (Schapira et al., 2008). They contribute to the goal of improving the overall healthcare experience for LEP patients. Additionally, and perhaps more importantly, the presence of an interpreter in the medical visit can help decrease the disparity in quality of care and health care access for patients with LEP (Karliner, Perez- Stable & Gildengorin, 2004). Why is there a need for medical interpreters? Good patient-provider communication is vitally important to ensure quality care and service to all who have health care needs. When there are barriers to the communication process between providers and patients, the breakdown can be detrimental to the quality of care, resulting in negative consequences. For doctors serving patients of diverse backgrounds it is essential that they attempt to communicate with sensitivity to cultural and linguistic differences in order to provide the best care possible. Medical interpreters assist in bridging the gap in patient-provider communication. The communication problems that exist between patients and providers do not only involve the exchange of words. Cross-cultural variations contribute to communication and perception differences that greatly impact the patient-provider relationship. There are three main areas where patients and providers are likely to differ (Hudelson, 2004). These include cultural beliefs regarding the expectations of roles, communication styles, perceptions about health and ideas about medicine. Understanding these differences can help providers be proactive about medical visits. Differences in perceptions of the patient s health problem Patients may have a different belief about where their illness comes from than that of the provider. Often patients are diagnosed in their home countries and cultures in systems that vary greatly from the Western medical model. Traditional healers and spiritually-related treatment methods are often used and approach health and healing very differently than a Western model. Problems between patients and providers often arise due to these differing opinions. Interpreters can serve as cultural liaisons and can help explain the differences in perception to the provider and patient. This is especially helpful in situations where certain diagnoses, such as tuberculosis or psychological problems, are highly stigmatized (Hudelson, 2004). Interpreters work as a cultural broker is extremely valuable in the treatment planning stage of the medical encounter as they can provide much needed understanding about illness and medications. Different expectations of the clinical visit Depending on where they are from, patients may have different expectations of the medical experience. Some patients may approach Western medicine with caution and cynicism, believing that the doctor may not be trustworthy. Others may believe that every visit should be absolutely comprehensive, including all lab work, and that the doctor should be in an authoritative role. When faced with a visit that isn t this way patients may believe they are not getting quality

3 service (Hudelson, 2004). In these encounters interpreters can explain the role of the doctor, the goals for the visit and help patients to understand the culture of Western medicine. This helps both the provider and patient in improving the quality and effectiveness of the visit. Differing communication styles Cross-cultural communication may be one of the biggest barriers to quality health service. Nonverbal communication, such as gestures and eye contact, can often be interpreted differently between cultures, causing confusion in the visit. Interpreters can help the provider to understand what may or may not be offensive to certain patients. Another challenge to communication is differences in styles. Medical terminology often doesn t exist in other languages the way it does in English (Hudelson, 2004). Finding ways to express and understand these differences often creates challenges in the medical encounter. Interpreters can bridge these differences by presenting information to each party in a way that is culturally appropriate yet meets the medical standards presented by the provider. It is clear that the cross-cultural differences faced by many providers working with LEP patients can lead to communication problems. Medical interpreters serve as a very important cultural adviser in the medical encounter and can greatly improve the quality of health care for patients with limited English proficiency. Interpretation Standards As the U.S. has become increasingly more diverse it has become clear that patients with limited English proficiency should be guaranteed certain rights to ensure that they receive quality health care. Title VI of the Civil Rights Act of 1964 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 (Section 601 of the Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d). National origin is seen as including LEP; therefore any health care facility in the U.S. that receives federal funding must provide services that will help all people use their services. This means that health care organizations must meet the needs of LEP patients by providing interpreters free of charge. If the patient prefers, they can choose to have a family or friend interpret for them, waiving the benefit of a professional interpreter (Schapira et al., 2008). As a guide for health care organizations the U.S. Department of Health and Human Services and the Office of Minority Health created the National Standards on Culturally and Linguistically Appropriate Services (CLAS). These 14 standards were created to assist health care providers become more culturally and linguistically accessible by requiring services that will ensure better access to health care for LEP patients (Office of Health and Human Services, 2007). CLAS Standards require that health care organizations must: Offer and provide language services, such as having trained bilingual staff and interpreters available to patients in need at no cost Provide written notices and other signage as well as informing patients of their rights to language services in the preferred language

4 Assure competence of interpreters and bilingual staff through training and certification programs Have patient-related materials available and post signage in the languages of commonlyencountered groups (recommendation is 5% of the general population) in the service area. (Stanford Geriatric Education Center, 2008) Individual states also create language interpretation standards in order to be in compliance with federal law and ensure quality health care for their diverse patients. An example of language interpretation standards created in Minnesota are the Hennepin Ethical Standards, which provide a set of standards for interpreting in the delivery of Hennepin County service. These standards are focused on the roles and responsibilities of the professional interpreter in the service setting. The Hennepin Ethical Standards are: Confidentiality: All information, divulged by anyone in any interpreted exchange, is strictly confidential. The person doing the interpreting may reveal information only if required to by current law or rule. Accuracy: Any person doing interpreting is expected to transmit the content and spirit of the original language into the other language without omitting, modifying, condensing or adding. If there are problems or misunderstandings with interpreting any information, the person interpreting must advise everyone involved. Impartiality: Any person doing interpreting refrains from interjecting personal opinions or biases into the exchange. S/he will withdraw from assignments or situations where personal opinions or biases may affect impartiality. Conflict of Interest: Any person doing interpreting shall inform all parties if s/he has a real or perceived conflict of interest and s/he shall remove her/him self from the interpreting situation. S/he does not need to disclose the nature of the conflict of interest. Maintains Professional Distance: Any person doing the interpreting understands the boundaries of his/her role and refrains from becoming personally involved in the situation. Knows Own Limit: Any person doing interpreting declines to interpret beyond his/her training, level of experience and skills. (Hennepin County, n.d.) Hennepin County has also created a set of interpreting competency standards to ensure that interpreters in Hennepin County are competent and well-trained.

5 The Hennepin Interpreting Competency Standards are: Self Introduction: Any person doing interpreting will introduce him/her self to all parties involved and explain his/her role. Self Positioning: Any person doing interpreting will position him/her self to best facilitate communication amongst all parties, unless otherwise directed. Communicate All Parties Content and Feelings: Any person doing interpreting shall communicate all the words and emotions expressed by all parties. Speak in First Person: Any person doing interpreting shall speak in the first person when communicating for both parties. That is, use I in reference to the speaker rather than he/she said. Speak in Appropriate Mode: Any person doing interpreting shall use consecutive and/or simultaneous interpretation mode as appropriate to the situation. Understand Content: Any person doing interpreting will ensure that s/he understands the message to be transmitted by seeking clarification, as needed from either or all parties. Remains Neutral: Any person doing interpreting must remain neutral by reminding all parties of his/her ethical obligations to be impartial, accurate, maintain professional distance and avoid any conflict of interest. Self Monitoring and Correction: Any person doing interpreting checks the accuracy of his/her own interpretation. S/he identifies and corrects any misinterpretation for all parties. Manage the Flow of Communication: Any person doing interpreting will manage the flow/pace of communication to preserve the accuracy and completeness of all parties communications. Cultural Brokering: Any person doing interpreting shares relevant cultural information with all parties involved and assists all speakers in reaching a mutual understanding. Complete Appropriate Documentation: Any person doing interpreting will complete appropriate documentation as required. (Hennepin County, n.d.) Clearly, the language interpretation standards that exist intend to create a health care atmosphere in which patients with LEP have better access to quality service. These legal mandates hold health care organizations accountable for serving patients with as much equity as possible, seeking to decrease the disparities that exists in health care access for patients with LEP

6 Challenges of Interpretation Reflection After reading these standards, reflect on how they exist in your practice. - Is the staff in your organization well-trained and up-to-date on these standards? - Do you always provide language services when they are needed? - Are there culturally and linguistically appropriate materials available for patients with LEP? The presence and use of interpreters presents very unique challenges to providing good health care. Whether the interpreter is professionally trained or an ad hoc friend or family member, communication between patient and provider is significantly altered. Here is an example of an encounter between a physician, interpreter and patient in which various parts of the communication are challenged: Physician to patient: How has your mood been lately? Interpreter to patient: How are you feeling? Patient: I don t have pain and my leg feels better. I take all medication and my pains are gone. Interpreter to physician: He feels good, no problems anymore. Physician to patient: Are you sad about anything? Interpreter to patient: Do you feel bad about your life? Patient: It s hard, my children are very good and I love them much. I need to be well for them. Interpreter to physician: He is fine, he loves his children very much and that makes him happy. It is clear that the messages between physician and patient were not being relayed correctly. There are many challenges presented by the use of interpreters that inhibit the health communication process. Making errors in the content of a message is one of the most significant threats to the process. Content Errors When content errors are made in the interpreting process content is reduced, omitted or revised (Aranguri, Davidson & Ramirez, 2006). Unfortunately this can often lead to misdiagnosis and misguided treatment planning. Content errors can occur for many reasons. One reason is the interpreter s lack of understanding of the medical terminology and context of the visit. This is especially true when family and friends are used to interpret. The physician may use language that isn t recognizable to the interpreter, so they change the content to fit their understanding (Marcos, 1979). Another reason for making errors in the content of a message is the patient s discomfort with sharing sensitive information with an interpreter. This is especially true if a family member or friend acts as the interpreter. For many family members, speaking about

7 matters related to reproductive health or psychopathology can be uncomfortable and may be inappropriate. Lastly, one of the main reasons for content errors in the interpretation process is the tendency for interpreters to take the appointment into their own hands. Lay interpreters, especially, sometimes see it as their role to speak for the patient, including their own opinion in the conversation (Marcos, 1979). In the process they tend to speak without actually including the patient in the conversation, a very dangerous practice that can result in misdiagnosis. Changes in Interaction Many medical visits begin with the patient and provider making small talk and informal conversation, which allows the doctor to build rapport and trust with the patient. This relationship building is an essential part of the interaction because patients are more likely to share important information if they trust their doctor. For some populations, such as Latinos, this relationship building is necessary to aid patients in easing into otherwise uncomfortable medical appointments (Aranguri et al., 2006). When an interpreter is a part of the interaction the opportunity for small talk often doesn t exist anymore and the provider simply jumps into the medical content of the visit. This lack of social interaction between the patient and provider creates a schism that bars the medical visit from reaching its full potential. Another important aspect of building a social connection in the visit is the opportunity created for the provider to better identify psychosocial disorders. Assessing the patient s social functioning can sometimes help them to better identify other problems that aren t so obvious on the surface (Aranguri, et al., 2006). Clearly, there are many obstacles presented in the medical encounter when an interpreter is present. To understand how to best mitigate these challenges it is necessary to better understand the roles and responsibilities of each person in the encounter. Roles In the medical encounter each person has a specific set of roles and responsibilities. An accurate understanding of such roles is crucial for the success of the visit. Role of the Interpreter The principal role of the interpreter in the medical encounter is to support the relationship between patient and provider through interpreting important health information to each party, resulting in better health communication (Stanford Geriatric Education Center, 2008). Interpreters have unique knowledge and experiences in the cultures and languages of the patients for whom they are interpreting, allowing them to convey health information to both parties in a way that considers cultural traditions, belief systems, understandings of health and sensitivity to both Western and non-western views on medicine. Because of this specialized skill interpreters are able to fulfill a very important role in the medical visit. Most importantly the role of the interpreter in a medical setting is to be the message converter for both parties. In this role interpreters listen to the speakers, observe body language and convert the messages from one language into another (Stanford Geriatric Education Center, 2008). They do so in compliance with the laws and standards put into place by their particular organization and by federal guidelines. For example, it is vitally important that as the message converter, the

8 Interpreter draws clear boundaries regarding the inclusion of their own opinions. To ensure ethical and accurate practice it is inappropriate for interpreters to include their own opinion or advice in the messaging (Schapira et al., 2008). Other such guidelines for accurate message conversion are: - Listen attentively in one language - Repeat the original message accurately and completely in another language without adding, omitting, or changing key information or intended meaning - Interpreter is ethically bound to repeat everything - Utilize note taking when appropriate - Recommend optimal positioning for each member of the visit - Ensure confidentiality of patients health information (Stanford Geriatric Education Center, 2008) As a message converter the interpreter in the medical setting should be familiar with the concepts and terminology of the medical situation in which they are working. In a study of interpreters working in a psychiatric setting, providers emphasized the point that in order to be a good interpreter, one must be familiar with the psychiatric setting (Marcos, 1979). This concept is true in most clinical settings. Accurately converting messages into both languages requires the interpreter to be comfortable and competent in both languages, the medical setting and be knowledgeable of the standards under which they are working. Another role of the interpreter in the health care setting is to be a message clarifier. As a clarifier interpreters watch for possible words, concepts or ambiguous messages that may lead to misunderstanding or confusion for any of the parties. They also should intervene in the process when they need an explanation or simplification of a word or concept, or to confirm understanding of the speaker s message (The California Endowment, 2007). One of the most important responsibilities of the interpreter is to act as cultural broker or clarifier. In this role interpreters watch for culturally-based differences in terms or concepts that may lead to misunderstanding by any of the parties. They also intervene to explore whether differences in cultural perspectives cause misunderstanding. In the case that they do, they ask speakers to provide their own experiences or directly explain cultural terms to the patient or provider. They may also suggest culturally appropriate approaches to presenting the topics and issues in discussion (The California Endowment, 2007). As one interpreter stated, Culture and language go hand in hand. If the clinician has good communication skills, the professional interpreters just need to abide by the standards of professional practice (Schapira et al., 2008). Clearly, bridging the gap between cultural differences and health care communication is an important role of the interpreter. Finally, interpreters may also act as patient advocates in certain situations. The role of patient advocate is an optional role that interpreters decide whether or not to take on. In such a role, interpreters actively support change in the interest of the patient s health and well-being at times when they see it necessary. This may include actions such as reminding the provider to schedule interpreting for the patient s next appointment, or intervening when discrimination or barriers to

9 care (such as access, financial status, immigration status, patient s limited knowledge of rights/services available to them) are in place. When interpreters assume this role they may not always support the patient-provider relationship. It also requires the interpreter to act when patient safety is at risk or in other scenarios such as the balance of ethics, impartiality, patient autonomy and options before choosing appropriate action (The California Endowment, 2007). It is important to note that it is never the interpreter s responsibility to give advice during the encounter. It is their responsibility to respect the doctor s message and repeat it as accurately as possible (Schapira et al., 2008). Role of Provider The health care provider s role in preparing for and during the interpreted encounter includes guiding the medical encounter as well as evaluating the quality of interpreting. In preparation for the appointment, if the health care provider is aware of the necessity for a trained medical interpreter, he or she should request an interpreter for the visit if the patient hasn t done so already (Stanford Geriatric Education Center, 2008). Prior to the appointment, the provider should make any necessary arrangements for working with a client with limited English proficiency. This could include having pictograms or translated materials ready for the visit. It also should include a discussion with the interpreter about the content of the visit before the patient arrives. During many encounters the interpreter is only given a few brief seconds to process the information from the doctor and then relay it to the patient. If this information is sensitive or includes diagnosis of a life-threatening illness, the more time the interpreter has to prepare for the visit, the better the communication process will be (Schapira et al., 2008). During the actual medical encounter, the provider should set the tone for the visit by first allowing for brief introductions by all parties. During these introductions roles and expectations are defined in order to set up a collaborative environment (Schapira et al., 2008). The provider may benefit from directly asking the interpreter to interpret all information accurately; this will also help set the tone for the visit. If there is time during the introductions it may be appropriate to facilitate small talk between the parties, especially if the interpreter and patient don t know each other. This will help build trust in the triangulated relationship and may facilitate better health communication during the visit. As the medical visit progresses the provider should be positioned in a space that is conducive to good communication; often this is in a triangle in which all parties can see and hear one another. As communication begins providers should speak to and look at the patient, not the interpreter. The patient should feel as though they are the focus of the dialogue, not just the creator of message. This will also help earn the respect of the patient. Another important responsibility of the provider in an encounter with an interpreter is to make sure that the messaging is clear and understandable. When working with an interpreter it is important for providers to slow down, pause often and allow for the interpreter to repeat messages whenever necessary. This will allow for the content of messages to be interpreted in greater detail. Often providers are in a hurry during visits, which causes fluctuations in tone and

10 pacing when speaking. It is helpful for providers to even their pace and tone in the interpretation process so that interpreters can accurately hear the message and content provided. When communicating, the simple things often have the greatest impact. Keeping a warm and calm tone of voice may help patients feel more comfortable in the visit, as does showing respect through body language and facial expressions (Stanford Geriatric Education Center, 2008). Although not as important as guiding the medical visit, it is also important for the provider to evaluate the interpreter whenever possible in order to assure that the patient and provider are hearing the correct content. Realistically, most providers will not have the tools to adequately detect whether the interpreter is transferring messages accurately, but they can do a few things to aid in the evaluation process. One simple technique involves asking the patient to repeat back what has been said. This can confirm with the doctor if the content is being interpreted correctly and allow adjustments to be made if necessary. Providers can also attempt to read the body language and facial expressions of patients and inquire as to what certain reactions mean. The provider s role in the interpreted encounter is to ensure that the patient s needs are met despite the communication differences. Guiding the encounter in a way that facilitates good communication and remaining attentive to the important medical details will help patients access good health care. Role of the patient The role of the patient in the medical visit is one for which few guidelines or standards exist. The undefined role of the patient brings light to the concept of patient self-determination in the medical encounter. Ultimately it is the patient s choice as to whether they use an interpreter in the medical visit (Ulrich, 1999). This being the case, it is the patient s role to acknowledge the need for an interpreter and request one when needed. For patients who have very little skill in the English language this is usually not a problem as they have a strong desire to get results from the encounter. This can become a complicated issue when a patient does have some knowledge in English and thinks of themselves as competent enough to have the visit without the interpreter. In situations such as this, the doctor may find that both parties are having trouble communicating with one another and that the use of an interpreter would be beneficial. In this case, it might be helpful for the provider to explain that the interpreter will help her do her job as a physician, so as to not bring shame to the patient. Another role of the patient in the medical encounter is to be participatory in his or her own health care. It is important for patients to take part in the interview and make their own medical decisions around treatment planning. This is especially important to consider in an interpreted visit. Some patients may defer to their interpreter, whether family, friend or professional, to make medical decisions for them. Physicians should do everything possible to empower their patient to be active in the visit (Stanford Geriatric Education Center, 2008).

11 Types of Interpreters The type of interpreter used in the medical visit can often determine the quality of care the patient receives. It is for this reason that it is very important for patients and providers in the encounter to acknowledge the advantages and disadvantages of the different types of interpreters. Untrained interpreters Real-Life Example: A patient s daughter spoke good English and was used to interpret for her mother during medical visits. For months all the doctors assumed she did an excellent job interpreting until one day when a physician, who understood some of the language, did a consult. At this physician s request an interpreter was called to assist. At this point it was determined that the daughter had not told the patient she had terminal liver cancer. When asked what the daughter thought about both the patient and oncologist not knowing all of the information, she stated, It has never been a problem, because when I interpreted, I only told my mother what I wanted her to know, and only told the doctor what I wanted him to know. Untrained interpreters, otherwise known as ad hoc interpreters, are often used in the medical setting to aid communication between the patient and provider. Untrained interpreters can include family or friends of the patient, as well as clinic or hospital staff who aren t necessarily connected to the patient but who do speak the same language. Untrained interpreters are used for various reasons. One of the reasons is because the patient prefers to have a family member or friend do the interpreting. Some patients feel most comfortable making medical decisions with friends or family in the room. Others feel uncomfortable having a professional interpreter with them when sensitive medical information is discussed (Kutty, V. personal communication, June 12, 2009). Another reason untrained interpreters are used is a lack of adequate resources. Many health care facilities don t have the resources to staff professional interpreters. In such a situation the facility may resort to using staff with second language abilities. It is also common that professional interpreters, especially in certain languages, are not available. When professional interpreters are not available in certain languages the clinic or hospital is forced to find ad hoc interpreters or members from the community who may or may not be familiar with the patient. Although it may seem convenient, inexpensive and adequate to use untrained interpreters in the medical visit, there are some very serious considerations that must be made before choosing to do so. Untrained interpreters often do not have the background in medical terminology or appropriate interpretation practices and therefore cannot adequately communicate questions, diagnosis, symptoms and health concepts between the patient and provider (Aranguri et al., 2006). Bilingual clinic staff are sometimes relied on for interpreter services. Although medical staff often have comprehension of health language, they don t necessarily have the skills to relay them to patients correctly and with the right level of sensitivity. They are not trained in the appropriate way to deliver messages to each party, which can pose a threat to the communication

12 process. Additionally, staff used as interpreters may have feelings of resentment and discomfort with being used in the interpreted medical visit. Being asked to discuss personal issues of health and finances can be uncomfortable for the interpreter and result in intentionally omitted content in the encounter (Marcos, 1979). Before asking available bilingual staff to interpreter in a visit, providers should consider the preceding points. Commonly, family or friends are used as interpreters in the medical visit due to comfort or convenience. The use of family or friends as interpreters can inhibit good health communication in a number of ways. First, some family members may believe their role in the encounter is not only interpreter, but also decision maker; they answer questions for the patient instead of relaying messages back and forth. This can lead to misdiagnosis and loss of patient selfdetermination. Also, when sensitive information is discussed friends and family are often put in an uncomfortable position. This is especially true when children are used to interpret for their parents. Issues of chronic illness and death are often much too sensitive for children and therefore health information gets altered or omitted in the interpretation process. Additionally, cultural norms regarding roles of family members can be altered if children or other family members are used in such a private and sensitive encounter. For example, when working with Hmong clients, age, gender and community roles all impact who can speak about what kinds of issues. The use of untrained family or friends as interpreters can complicate the health care visit and overall health outcome for the patient (Parker & Kiatoukaysy, 1999). Schapira, et al. (2008) explores the various ramifications of using untrained interpreters in the medical visit. They describe five areas in which errors can occur. These areas are: errors of omission, false fluency, substitution, editorialization and addition. Errors of omission are most common, and often result in such clinical consequences as misdiagnosis and furthering of patient problems. Misdiagnosis leads to treatment planning that often doesn t address what the patient is actually feeling, resulting in further visits and costs to the patient and provider. Examples of clinical consequences of errors made by untrained interpreters: - Omitting questions about drug allergies - Omitting questions and remarks about past medical history - Omitting instructions about antibiotic use - Adding instructions about treatment planning that physician didn t include - Omitting patient s description of symptoms - Editing physicians instructions to patient regarding follow-up visit - Answering questions for the patient without asking patient (Flores et al., 2003) Serious consequences for the patient are not the only result of such errors, as health care organizations can also face legal costs for erroneously diagnosing and treating. The possibility for malpractice related lawsuits increases when untrained interpreters make errors in the visit resulting in poor care (Aranguri et al., 2006). Considering the costs of such lawsuits, hospitals

13 and health care organizations benefit greatly from using interpreters who are professionally trained to work in the medical setting. Trained Medical Interpreters Trained medical interpreters go through extensive training in the subjects of ethical practice, medical terminology and health care vocabulary (Kutty, V. personal communication, June 12, 2009). They are trained to repeat all spoken words verbatim and in a way in which both provider and patient can understand. Medical interpreters are professionally trained per the rules and guidelines set by the particular state and facilities in which they work. In a recent study done to assess the use of trained and untrained interpreters in the health care setting, physicians reported that they had more confidence in the health care visit in which a trained medical interpreter was used (Karliner et al., 2004). This study documented the opinions of clinicians regarding quality of health care when working with interpreters and limited English proficiency (LEP) patients. Doctors reported they believe that they have a stronger ability to empower LEP patients when they use a trained professional interpreter. Professional interpreters are also trained on how to interpret sensitive medical information in a culturally responsive manner, taking into account how such information should best be delivered. They often have the knowledge of how the particular culture with which they are working understands health, medicine, and healing, so they can approach these issues with care and consideration (Stanford Geriatric Education Center, 2008). Some facilities also have access to telephone interpretation services. These interpreters, although not as high in quality as the on-site trained interpreters, have bio-medical training and can improve the health communication process between LEP patients and health care providers. Training for Medical Professionals Clearly, the practice of working with patients who have limited English proficiency is a significant challenge for the health care profession. Providers are pressed to use fewer resources in less time, impacting the quality of care for all patients. Working with patients who do not speak English creates more barriers and can place a large burden on the health care provider. Providers can improve the interpreted visit a number of ways, enhancing the effectiveness and efficiency of the visit. Medical professionals should undergo any training that provides guidelines for working with medical interpreters and LEP patients. Providers will benefit from localized trainings that cover communication and positioning techniques. These trainings also cover the roles, responsibilities and skills of medical interpreters. During an interview, a medical interpreter in Minneapolis stated that one of the largest barriers to providing good service is working with providers who don t understand or respect the role and skills of interpreters. He recommended that providers undergo trainings in which detail is given about the triangulated relationship between patient, provider and interpreter (Kutty, V. personal communication, June 12, 2009). It has also been shown that quality of care increases for patients who have providers with an in-depth

14 understanding of the interpretation process and how to communicate best within it (Karliner, 2004). Providers share the same opinion, stating that they feel more comfortable in the interpreted visit after having attended trainings about how to best work with skilled interpreters. As patient populations continue to diversify, such training will become more and more necessary as providers encounter increasing numbers of clients with limited English proficiency. Conclusion Working in the medical setting with patients who have limited English proficiency continues to bring challenges to health care providers in Minnesota and across the United States. Interpreters offer a bridge in the communication process by clarifying and converting medical messages between the patient and provider, increasing the quality of care for the LEP patient. Understanding the roles and rights of all participants in the interpreted visit is important in building a quality and satisfactory health experience for LEP patients. More importantly, working with professionally trained interpreters can also help eliminate the disparities in health care that many LEP patients face due to the barriers in language and cultural understanding. Providers can ensure better quality in service and empowerment for their clients by advocating for quality trained medical interpreters for their patients who don t speak English while also seeking training on how to best work with interpreters in a medical visit. The resulting care for LEP patients will be higher quality and will decrease the disparities in health care for Minnesota s diverse communities.

15 References Aranguri, C., Davidson, B., & Ramirez, R. (2006). Patterns of communication through interpreters: A detailed sociolinguistic analysis. JGIM, 21, Bereknyei, S., Hooper, K., & Braddock, C. (2008). I don t speak Russian! : Working effectively with interpreters and translators (PowerPoint slides). Stanford Geriatric Education Center Program in Health Literacy and Ethnogeriatrics. California Health and Safety Code Retrieved on May 3, 2009 from Flores, G. (2006). Language barriers to health care in the United States. New England Journal of Medicine, 355(3), Hennepin County. (n.d.).ethics and competency standards for interpretation. Training documents for interpreters. Hudelson, P. (2004). Improving patient-provider communication: insights from interpreters. Family Practice, 22(3), Karliner, L.S., Perez-Stable, E., & Gildingorin, G. (2004). The language divide: The importance of training in the use of interpreters for outpatient practice. JGIM, 19, Marcos, L.R. (1979). Effects of interpreters on the evaluation of psychopathology in non- English-speaking patients. American Journal of Psychiatry, 136(2), Parker, M., Kiatoukaysy, L.N., (1999). Culturally responsive health care: The example of the Hmong in American. Journal of the American Academy of Nurse Practitioners, 11(12), Schapira, L., Vargas, E., Hidalgo, R., Brier, M., Sanchez, L., Hobrecker, K.I., et al. (2008). Lost in translation: Integrating medical interpreters into the multidisciplinary team. The Oncologist, 13, Title VI of the Civil Rights Act of In. 42 U.S.C. 2000d ed; ( Ulrich, L.P., (1999). The patient self-determination act: meeting the challenges in patient care. Washington D.C., Georgetown University Press.