Lost in Translation: Interpreter Services Vital to Care

Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.

As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?

For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.

“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”

If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”

However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”

The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”

Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”

For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.

Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”

Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.

Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”

Hospitals and large health care systems often have an interpreter services department that offers coverage in the most commonly encountered languages. Massachusetts General Hospital, for example, has staff interpreters who speak Spanish, French, and Italian, as well as Arabic, Chinese (two dialects), French Creole, Khmer, Portuguese, Russian, and Vietnamese.

For smaller practices, it may not be practical to have staff interpreters. “To have in-house interpreters, you have to have a good number of patients who speak [a particular language] to warrant having someone on your payroll who needs to be busy all the time,” Fernandez says. “If you only have this issue once in a while, it’s probably worth it to contact a language service over the telephone or video.”

Arocha also touts the benefits of remote interpreting for situations when in-person services are not available. “Remote interpreting [provides] 24/7 access in over 150 languages,” she says, “something that no city, no hospital, is ever going to get, even if they’re in a metropolitan area. There will be a day and a time and a language for which they can’t provide face-to-face services.”

Fernandez cautions that remote interpreting services can be expensive. Arocha says the average rate is around $2 per minute. However, even if a 15-minute call adds up to a $30 bill, “you will take a lot longer not having a professional interpreter there to assist.” There could also be a cost to your patient’s health and well-being if you are unable to provide appropriate care.

Flores encourages clinicians to explore more creative mechanisms to improve language access when traditional interpreter services are unavailable or cost-prohibitive. One clinic in Ohio, for example, “had the creative strategy of training Romance-language majors from the local college as interpreters” and having them volunteer at the clinic. Another option would be to work with local community-based groups that may have bilingual members; these individuals could be trained to provide interpreter services.

Working Together
What you should avoid is falling back on the misconception that anyone who can speak the language is better than no interpreter at all. “There’s now good evidence that the so-called ad hoc interpreters—family, friends, children, people pulled from the waiting room, people actually pulled from the streets—that’s a suboptimal situation and probably endangers patients more,” Flores says. “We know, for example, that they’re more likely to make not only errors but errors of clinical consequence.”

In one of the many studies that Flores has published on this topic (Pediatrics. 2003;111[1]:6-14), a total of 396 interpreter errors were identified in 13 pediatric clinical encounters. Of these, 63% were determined to have clinical consequences, such as the omission of questions about drug allergies and the omission of key information from the medical history.

Ad hoc interpreters—particularly family members—are also prone to editorializing or interjecting their own opinions into the encounter. This is something a professional interpreter is trained not to do. Interpreters do more than translate words from one language to another; they must understand what they are interpreting and provide a context if the patient or provider is confused. But they do not take sides in an encounter.

So how can clinicians guarantee that they are working with a properly trained medical interpreter? Arocha says the bare minimum of training that medical interpreters should have is 40 hours. There is already a trend in the growth of one-year college-based programs across the United States, and since spoken-language interpreters have tended to follow the path of sign-language interpreters, she anticipates the eventual development of Associate’s-degree or even Bachelor’s-degree programs.

“It’s a really highly specialized field,” Arocha points out. “People don’t realize that a medical interpreter needs to have a pretty deep knowledge of medical terminology.” Interpreters who are placed in large medical centers or hospitals, for example, may have to interpret during a primary care session with a patient, then switch to a clinical trial, then move on to a specific department, such as oncology.

“Interpreters really have to be incredibly versatile to be able to accurately interpret,” Arocha says. “That’s important for patient safety.”

In October 2009, the field of medical interpretation got a boost from the launch of the first national certification examination, which will result in a “Certified Medical Interpreter” credential. The Spanish-language exam was the first available; additional languages will be added this year.

“It’s important for health care providers to know about that,” Arocha says. “If they’re ever going to hire an interpreter, they should ask if the person is a certified medical interpreter. If not, they should say, ‘Well, go get certified and come back.’”

When working with an interpreter, it can be helpful to briefly prepare him or her for the upcoming patient encounter—particularly if you will be delivering bad news or if the patient is notoriously difficult. Also, introduce the patient and interpreter, so everyone is clear on what each person’s role is. Train yourself to maintain eye contact with the patient, even when the interpreter is speaking, and use short sentences to allow the interpreter time to comprehend and translate what you say. Remember that while medical interpreters do not take the patient’s or the provider’s side, they are there to help both.

“If we’re going to have a team that makes sure a patient stays healthy,” Arocha says, “the medical interpreter has to be included in that team.”                            

Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.

As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?

For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.

“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”

If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”

However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”

The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”

Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”

For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.

Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”

Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.

Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”

Hospitals and large health care systems often have an interpreter services department that offers coverage in the most commonly encountered languages. Massachusetts General Hospital, for example, has staff interpreters who speak Spanish, French, and Italian, as well as Arabic, Chinese (two dialects), French Creole, Khmer, Portuguese, Russian, and Vietnamese.

For smaller practices, it may not be practical to have staff interpreters. “To have in-house interpreters, you have to have a good number of patients who speak [a particular language] to warrant having someone on your payroll who needs to be busy all the time,” Fernandez says. “If you only have this issue once in a while, it’s probably worth it to contact a language service over the telephone or video.”

Arocha also touts the benefits of remote interpreting for situations when in-person services are not available. “Remote interpreting [provides] 24/7 access in over 150 languages,” she says, “something that no city, no hospital, is ever going to get, even if they’re in a metropolitan area. There will be a day and a time and a language for which they can’t provide face-to-face services.”

Fernandez cautions that remote interpreting services can be expensive. Arocha says the average rate is around $2 per minute. However, even if a 15-minute call adds up to a $30 bill, “you will take a lot longer not having a professional interpreter there to assist.” There could also be a cost to your patient’s health and well-being if you are unable to provide appropriate care.

Flores encourages clinicians to explore more creative mechanisms to improve language access when traditional interpreter services are unavailable or cost-prohibitive. One clinic in Ohio, for example, “had the creative strategy of training Romance-language majors from the local college as interpreters” and having them volunteer at the clinic. Another option would be to work with local community-based groups that may have bilingual members; these individuals could be trained to provide interpreter services.

Working Together
What you should avoid is falling back on the misconception that anyone who can speak the language is better than no interpreter at all. “There’s now good evidence that the so-called ad hoc interpreters—family, friends, children, people pulled from the waiting room, people actually pulled from the streets—that’s a suboptimal situation and probably endangers patients more,” Flores says. “We know, for example, that they’re more likely to make not only errors but errors of clinical consequence.”

In one of the many studies that Flores has published on this topic (Pediatrics. 2003;111[1]:6-14), a total of 396 interpreter errors were identified in 13 pediatric clinical encounters. Of these, 63% were determined to have clinical consequences, such as the omission of questions about drug allergies and the omission of key information from the medical history.

Ad hoc interpreters—particularly family members—are also prone to editorializing or interjecting their own opinions into the encounter. This is something a professional interpreter is trained not to do. Interpreters do more than translate words from one language to another; they must understand what they are interpreting and provide a context if the patient or provider is confused. But they do not take sides in an encounter.

So how can clinicians guarantee that they are working with a properly trained medical interpreter? Arocha says the bare minimum of training that medical interpreters should have is 40 hours. There is already a trend in the growth of one-year college-based programs across the United States, and since spoken-language interpreters have tended to follow the path of sign-language interpreters, she anticipates the eventual development of Associate’s-degree or even Bachelor’s-degree programs.

“It’s a really highly specialized field,” Arocha points out. “People don’t realize that a medical interpreter needs to have a pretty deep knowledge of medical terminology.” Interpreters who are placed in large medical centers or hospitals, for example, may have to interpret during a primary care session with a patient, then switch to a clinical trial, then move on to a specific department, such as oncology.

“Interpreters really have to be incredibly versatile to be able to accurately interpret,” Arocha says. “That’s important for patient safety.”

In October 2009, the field of medical interpretation got a boost from the launch of the first national certification examination, which will result in a “Certified Medical Interpreter” credential. The Spanish-language exam was the first available; additional languages will be added this year.

“It’s important for health care providers to know about that,” Arocha says. “If they’re ever going to hire an interpreter, they should ask if the person is a certified medical interpreter. If not, they should say, ‘Well, go get certified and come back.’”

When working with an interpreter, it can be helpful to briefly prepare him or her for the upcoming patient encounter—particularly if you will be delivering bad news or if the patient is notoriously difficult. Also, introduce the patient and interpreter, so everyone is clear on what each person’s role is. Train yourself to maintain eye contact with the patient, even when the interpreter is speaking, and use short sentences to allow the interpreter time to comprehend and translate what you say. Remember that while medical interpreters do not take the patient’s or the provider’s side, they are there to help both.

“If we’re going to have a team that makes sure a patient stays healthy,” Arocha says, “the medical interpreter has to be included in that team.”                            

Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.

As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?

For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.

“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”

If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”

However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”

The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”

Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”

For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.

Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”

Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.

Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”

Hospitals and large health care systems often have an interpreter services department that offers coverage in the most commonly encountered languages. Massachusetts General Hospital, for example, has staff interpreters who speak Spanish, French, and Italian, as well as Arabic, Chinese (two dialects), French Creole, Khmer, Portuguese, Russian, and Vietnamese.

For smaller practices, it may not be practical to have staff interpreters. “To have in-house interpreters, you have to have a good number of patients who speak [a particular language] to warrant having someone on your payroll who needs to be busy all the time,” Fernandez says. “If you only have this issue once in a while, it’s probably worth it to contact a language service over the telephone or video.”

Arocha also touts the benefits of remote interpreting for situations when in-person services are not available. “Remote interpreting [provides] 24/7 access in over 150 languages,” she says, “something that no city, no hospital, is ever going to get, even if they’re in a metropolitan area. There will be a day and a time and a language for which they can’t provide face-to-face services.”

Fernandez cautions that remote interpreting services can be expensive. Arocha says the average rate is around $2 per minute. However, even if a 15-minute call adds up to a $30 bill, “you will take a lot longer not having a professional interpreter there to assist.” There could also be a cost to your patient’s health and well-being if you are unable to provide appropriate care.

Flores encourages clinicians to explore more creative mechanisms to improve language access when traditional interpreter services are unavailable or cost-prohibitive. One clinic in Ohio, for example, “had the creative strategy of training Romance-language majors from the local college as interpreters” and having them volunteer at the clinic. Another option would be to work with local community-based groups that may have bilingual members; these individuals could be trained to provide interpreter services.

Working Together
What you should avoid is falling back on the misconception that anyone who can speak the language is better than no interpreter at all. “There’s now good evidence that the so-called ad hoc interpreters—family, friends, children, people pulled from the waiting room, people actually pulled from the streets—that’s a suboptimal situation and probably endangers patients more,” Flores says. “We know, for example, that they’re more likely to make not only errors but errors of clinical consequence.”

In one of the many studies that Flores has published on this topic (Pediatrics. 2003;111[1]:6-14), a total of 396 interpreter errors were identified in 13 pediatric clinical encounters. Of these, 63% were determined to have clinical consequences, such as the omission of questions about drug allergies and the omission of key information from the medical history.

Ad hoc interpreters—particularly family members—are also prone to editorializing or interjecting their own opinions into the encounter. This is something a professional interpreter is trained not to do. Interpreters do more than translate words from one language to another; they must understand what they are interpreting and provide a context if the patient or provider is confused. But they do not take sides in an encounter.

So how can clinicians guarantee that they are working with a properly trained medical interpreter? Arocha says the bare minimum of training that medical interpreters should have is 40 hours. There is already a trend in the growth of one-year college-based programs across the United States, and since spoken-language interpreters have tended to follow the path of sign-language interpreters, she anticipates the eventual development of Associate’s-degree or even Bachelor’s-degree programs.

“It’s a really highly specialized field,” Arocha points out. “People don’t realize that a medical interpreter needs to have a pretty deep knowledge of medical terminology.” Interpreters who are placed in large medical centers or hospitals, for example, may have to interpret during a primary care session with a patient, then switch to a clinical trial, then move on to a specific department, such as oncology.

“Interpreters really have to be incredibly versatile to be able to accurately interpret,” Arocha says. “That’s important for patient safety.”

In October 2009, the field of medical interpretation got a boost from the launch of the first national certification examination, which will result in a “Certified Medical Interpreter” credential. The Spanish-language exam was the first available; additional languages will be added this year.

“It’s important for health care providers to know about that,” Arocha says. “If they’re ever going to hire an interpreter, they should ask if the person is a certified medical interpreter. If not, they should say, ‘Well, go get certified and come back.’”

When working with an interpreter, it can be helpful to briefly prepare him or her for the upcoming patient encounter—particularly if you will be delivering bad news or if the patient is notoriously difficult. Also, introduce the patient and interpreter, so everyone is clear on what each person’s role is. Train yourself to maintain eye contact with the patient, even when the interpreter is speaking, and use short sentences to allow the interpreter time to comprehend and translate what you say. Remember that while medical interpreters do not take the patient’s or the provider’s side, they are there to help both.

“If we’re going to have a team that makes sure a patient stays healthy,” Arocha says, “the medical interpreter has to be included in that team.”