Clinical Case

Your next patient is a Spanish-speaking 24-year-old female who begins by telling you that she is embarazada. Despite her bashfulness, you debate whether or not to call in the interpreter, since the waiting room is overflowing and between her broken English and your high-school Spanish you think you can get by without formal interpretation.

Medical Interpreting

According to the U.S. Census Bureau, 60.6 million Americans (approximately 20.8 percent) do not speak English as a primary language, and 25 million of those speak English less than well (known as “limited English proficiency” or LEP); many indicators show this number will only continue to grow. This demographic is higher risk of adverse events during hospital encounters, often due to communication issues, leading to tragic outcomes and malpractice suits including cases of missed intracerebral hemorrhages, unnecessary or incorrect surgeries, misused medical devices, and fatal medication dosing.^1,2 Medical interpreters (as opposed to translators who work with the written word), are essential to bridging the language gap.

Regulations

Section 1557 of the Affordable Care Act focuses on services available to limited-English-proficiency patients and builds on anti-discriminatory precedents set by Title VI of the Civil Rights Act. Current rules mandate that covered entities must communicate availability of interpreter services and are, “obligated to take reasonable steps to ensure access to services.” It also limits the use of ad hoc (or nonqualified) interpreters such as family, friends, or untrained staff to certain situations (e.g., emergencies, patient’s request).³ A new 2022 proposed change to Section 1557 hopes to expand its scope to other HHS activities (including Medicare Part B) and telehealth services, require staff training on availability of services, and further define the roles of qualified versus nonqualified interpreters.⁴ The Joint Commission’s standards follow similar requirements. However, actual increases in available services in emergency departments based on prior state-level requirements have been mixed.⁵

Many medical interpreters are certified by organizations such as the National Board of Certification for Medical Interpreters, or the Certification Commission for Healthcare Interpreters, which require both written and oral testing and documented experience, as well as additional training in medical ethics, terminology, and patient privacy regulations. These include ASL interpreters. However, it has not been feasible to develop and validate certifications for all of the over 350 different languages spoken in the U.S., let alone find qualified interpreters for each language. Some certifying bodies may provide provisional interpreters in cases where they cannot certify an interpreter for a certain language or dialect. In other cases, medical staff may have to rely on ad hoc interpreters.

Tips for Working with Medical Interpreters

Prepare ahead before entering the patient’s room. Have an initial plan for the conversation including what information you want to convey and specific questions you want to ask. If possible, discuss these ahead with the interpreter. Being patient, using clear language, and a respectful tone will go a long way to establishing trust with the patient and their families. Beware of possible prejudices and assuming cultural values of the patient and others who speak that language. Physicians should document the interpreter’s name and identification number if available in the patient’s chart.

Telephone-Based Services

Remote tele-interpreter services have certainly improved access to certified and qualified interpreters with extended availability and a wide range of spoken languages. Users must ensure a reliable connection speed and good audiovisual capabilities (especially for the elderly and hearing- or sight-impaired), and consider the of lack visual cues such as body language and facial expressions that can be a source of misunderstandings when compared to in-person services.⁶

Using Ad Hoc Interpreters

In emergency cases, ad hoc interpreters (friends, family, community members, or untrained staff) will need to be used because of extenuating circumstances. Ideally, medical staff should attempt some vetting of the ad hoc interpreters and confirm the patient agrees with using this person to interpret.⁷ Unfortunately, non-adult children are often used as ad hoc interpreters, which can be fraught with issues. Ad hoc interpreters have a higher rate of potentially consequential errors compared to professional interpreters (22 percent versus 12 percent) and outcomes significantly are improved for individuals with over 100 hours of training (2 percent).⁸

Although there are no current standards forbidding it, multilingual physicians may be tempted to use their own language backgrounds to forgo an interpreter.⁹ Being bilingual is often not enough to be a medical interpreter, which requires precision, experience, and knowledge of medical jargon, as well as culturally specific idioms and phrases. For example, the French-Canadian patient who claims to have chair blesseé has a flesh wound and not a holy seat and the Spanish-speaking patient who is constipado may just need a nasal decongestant and not a stool softener. A physician once attemtpted to use his limited Diné, which is notably hard to pronounce, to ask a Navajo patient for their ch’ah (stool sample) and just ended up getting a chuckle and her chąąʼ (hat) instead.

Documentation

Providing patient-facing documentation such as procedural consent forms, discharge instructions, and medication prescriptions in the appropriate language can provide a distinct challenge. Some electronic-health-record packages provide discharge instructions for common diagnoses in common languages; however, these are certainly not extensive and can lack individualized information. Although tempting to use, current online language translation programs can be inconsistent, worse than human translators, and possibly even lead to dangerous mistranslations.^10-11

Clinical Case Resolution

You decide to call in the interpreter and find out the patient was actually telling you that she was pregnant (and not embarrassed) and had heavy first-trimester bleeding. After the appropriate work-up, you are glad to have had the medical interpreter present to appropriately communicate the nuances of a threatened abortion and address your patient’s concerns in her primary language.

Dr. Cassone is an attending physician based in northern New York and has worked in several multicultural contexts, including Native American reservations and with Médecins Sans Frontières.

References

1. Divi C, Koss R, Schmaltz S, Loeb J. Int J Qual Health Care. 2007;19(2):60-7.
2. Surinder S. Medical translation gone wrong: 7 devastating medical translation errors. K-International/TheLanguage Blog website. Published Feb 8, 2018. Accessed August 11, 2023.
3. Office of Civil Rights. U.S. Department of Health and Human Services website. Last reviewed February 3, 2023.
4. Centers for Medicare and Medicaid Services, et al. Nondiscrimination in health programs and activities: a proposed rule by the centers for medicare & medicaid services on 08/04/2022. Federal Register website. Published August 4, 2022. Accessed August 11, 2023.
5. Ginde A, Sullivan A, Corel B, at al. Reevaluation of the effect of mandatory interpreter legislation on use of professional interpreters for ED patients with language barriers. Patient Educ Couns. 2010;1(2):204-6.
6. Benda NC, Bisantz AM, Butler R, et al. The active role of interpreters in medical discourse – An observational study in emergency medicine. Patient Education and Counseling. 2022;105(1):62-73.
7. Balch, B. The United States needs more Spanish-speaking physicians. American Association of Medical Colleges website. Published July 18, 2023. Accessed July 18, 2023.
8. Flores G, Abreu M, Barrone CP, et al. Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters. Annals of EM. 2012; 60(5): 545-553.
9. Regenstein M, Anders E, Wynia MK. Promoting appropriate use of physicians’ non-English language skills in clinical care: A white paper of the Commission to End Health Care Disparities with recommendations for policymakers, organizations and clinicians. American Medical Association, Chicago IL 2013.
10. Kreger V, Aintablian H, Diamond L, et al. Google translate as a tool for emergency department discharge instructions? Not so fast! Annals of EM. 2019;74(4):S5-6.
11. Taira RB, Kreger V, Orue A, Diamond L. A pragmatic assessment of Google Translate for emergency department instructions. J Gen Intern Med. 2021;36:3361-3365.