Working Together for Patients with Limited Proficiency in English
September/October 2011
Medical Interpretation
Working Together for Patients with Limited Proficiency in English
Effective communication between the patient and the medical provider plays a vital role in the delivery of high-quality medical care. But what if that patient is a non-English speaker? Not only do healthcare facilities have a duty to provide language assistance services to limited-English proficient (LEP) patients to ensure quality medical care, but currently there are requirements for equal language access that recipients of federal funding must adhere to.
According to Title VI of the Civil Rights Act of 1964, “No person in the United States shall, on 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” (Health Consumer Alliance, 2004). Further, The Office of Minority Health’s National Standards on Culturally and Linguistically Appropriate Services (2007) mandate healthcare facilities receiving federal funding to comply with a set of four standards in regards to “language access services.” These four mandates are detailed below.
- Healthcare organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.
- Healthcare organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.
- Healthcare organizations must assure the competence of language assistance provided to limited-English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).
- Healthcare organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.
But having federal requirements in place to ensure LEP patients have access to language assistance services does not guarantee a successful language-mediated medical encounter. A number of factors contribute to a successful interpreted session in healthcare, such as the medical provider’s ability to understand and respect the interpreter’s roles as a conduit, clarifier, and cultural broker.
Ways to Identify If You Need an Interpreter
The first (and most important) step of a successful interpretation session in healthcare is identifying the need for an interpreter. In some cases, the need for an interpreter to facilitate communication will be obvious (i.e. the patient lacks the most basic English speaking skills). But that is not always the case. What if the patient’s comprehension of English is limited, meaning he or she understands certain words and phrases? What if the parents or guardians of a minor are in need of interpretation services but the patient is not? What if the patient is accompanied by an English-speaking relative who has volunteered to interpret? Under these circumstances, should the medical provider still seek the assistance of a qualified and professionally trained interpreter? Absolutely. And if the LEP patient refuses interpreter services, this must be documented and the patient must sign a waiver, ideally in his or her native language. Why is all of this necessary? Because of the dangerous and highly avoidable medical errors that may result from faulty communication between patient and provider.
Unfortunately, there are many healthcare institutions that still rely on bilingual personnel, and/or English-speaking relatives, to facilitate communication with LEP patients. Doing this may have ethical and practical ramifications, while also posing a greater liability for the institution. The inaccurate collection of even the most basic information by untrained or unqualified bilinguals can have devastating effects for all parties involved.
Before the Interpretation Session
Once the need for an interpreter has been identified, there are several steps the medical provider should follow in order to adequately prepare for the interpreted session. First, you should identify the language or dialect the patient is speaking. Many language service companies will provide healthcare facilities with various tools to assist in language identification, such as posters and desktop reference cards. If these tools are not currently available at your facility, you may also ask the patient to write down his or her language, dialect or place of origin.
Keep in mind, given our globalized world, that a tourist from the Netherlands may be a Sudanese refugee and, thus, may not be able to communicate clearly in Dutch, or that a “Russian” patient may be better served by an Armenian interpreter. You should also consider that a patient requesting an interpreter in “Chinese” could be referring to one of the following languages: Mandarin, Cantonese, Fuzhao, Hakka, Taiwanese, or others. Some providers of telephonic interpretation services have trained personnel to help you determine the best language match for your LEP patient. Once the ideal language has been identified, you should make a note on the patient’s file for future reference.
Next, if you have a gender-sensitive topic (i.e. an OB-GYN checkup or a urologist appointment), or a patient that, for cultural reasons, may prefer an interpreter of the same gender, please make your request accordingly and make a note of that request. For face-to-face medical encounters, an interpreter of the same gender is typically the way to go. Since telephonic interpreters are connected only by sound, a gender-specific request is a secondary consideration.
Finally, if you plan to refer to a questionnaire or form throughout the medical encounter, and you are using a telephonic interpreter, please email the appropriate documents to your language service provider (LSP) so that the interpreter has a copy. This will ensure the interpreter is fully prepared and equipped to deliver the best interpretation possible.
At the Start of the Session
Once the interpreter is on the line (telephonic interpreting), on site (face-to-face interpreting) or available remotely (video remote interpreting), you should introduce yourself and explain the situation and the set-up (i.e. I am the RN, and the LEP patient is complaining of stomach pains. We will be communicating by using a dual handset telephone). You should then let the interpreter know of your desired objectives. Finally, be sure to make special requests (the patient is hard of hearing or slightly sedated) or instructions (the parents of the patient, who is a minor child, are the ones needing interpretation) known. The more information you provide the interpreter, the better equipped he or she will be to deliver a successful interpretation
The interpreter will likely start by conducting “the pre-session,” which is an introduction to explain to the patient and the provider how to best communicate through the interpreter. Even if you have heard the pre-session before, the patient may not have. The pre-session reminds participants that all that is said will be interpreted, all will remain confidential and that both parties should address each other directly, in the first person, as if the interpreter were not present.
How to Manage the Session
Below are some tips to help you manage the interpretation session in the most effective way possible, ensuring quality medical care is never compromised for the LEP patient.
- Look at and speak directly to the patient, not the interpreter.
- Speak at an even pace and pause after short segments so that the interpreter may render the interpretation.
- Be aware that some concepts have no exact linguistic equivalent and the interpreter may have to describe them in greater detail. Because of this, the interpretation may take longer than your original statement.
- Avoid using metaphors, idioms, complicated sentence structures, sentence fragments, changing ideas in the middle of a sentence, interrupting the interpreter before the interpretation has been rendered, and asking a question while another is being answered
- Try to avoid using high-level medical terminology or medical acronyms. If you must use them, be prepared to explain to the interpreter what they mean and what they involve.
Try to remember that the interpreter is only the conduit of the message. He or she is not responsible for what your patient says, or does not say, or whether the answers are vague or too detailed. It is also important to remember that all parties, including the interpreter and you, the medical provider, may ask for repetition, clarification, or explanation at any time during the encounter. Interpreters are trained to interpret everything that they hear. If you wish to avoid having your comments to colleagues interpreted for the patient, make sure they are made out of earshot of the interpreter. Finally, remember that your interpreter is also a cultural broker. Encourage the interpreter to inquire, explain, and alert you of culturally sensitive areas. You should respect their knowledge of cultural matters and consider their suggestions for more appropriate alternatives.
Ending the Interpretation Session
To ensure the patient clearly understands the treatment recommendations that have been provided, the interpreter should ask the LEP patient to repeat this information in his or her own words. As the healthcare provider, it is important to make sure the interpreter does not miss this crucial step in the medical interpretation process. If there is confusion on the patient’s end, the healthcare provider must clarify the message, through the interpreter, until it is understood. At this stage of the interpretation, you should also ask the patient if he or she has any further questions or needs any additional clarification.
About Interpreting
Remember that your interpreter is a highly trained professional and is deserving of the utmost respect. Please keep in mind that it is impossible for interpreters to memorize every word and they should be allowed to consult their dictionaries and glossaries, as needed. If the LEP patient or interpreter is having trouble understanding a specific term or concept, try to explain it using examples. Be sure to allow the interpreter to instruct the patient about the need to pause, speak up, repeat, explain, or clarify. Interpreters are trained to convey in English everything that is said in the foreign language. If necessary, remind the interpreter of this fact. Finally, remember that patience is necessary in order to effectively communicate across language and cultural barriers. The well-being of your LEP patients is worth it.
Armando Ezquerra Hasbun is the director of programs for Language Services Associates, Inc. (LSA), one of the world’s leading providers of translation, localization and interpreting service. He is also a federally-certified court interpreter, a certified trainer for the nationally recognized “Bridging the Gap” medical interpreter training program, and an adjunct professor of interpretation at La Salle University. Hasbun may be contacted via e-mail at ahasbun@lsaweb.com.
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