Using a Medical Interpreter with Persons of Limited English Proficiency

• What professional interpreting services are available to the clinician?

For the most part, access to interpreters via a telephone service is widely available [10]. The cost of providing interpreters in-person and/or remotely varies depending on the health care site [29–31] In general, considerations of using professional medical interpreters, whether remotely or in-person, involves accessibility and cost. There are certain sites that have explored having a shared network of interpreters available via the telephone and videoconference to reduce the cost of providing interpreters for individual hospitals [32]. While the costs of providing a person with LEP with interpretation varies depending on the health care site, the costs of not providing a professional medical interpreter should be considered as well, which include greater malpractice risk and potential medical errors [32]. In addition, the use of employees as interpreters takes time away from their respective jobs, which results in staff time lost [31].

In-person interpreting may be preferred for certain medical visits, as an in-person interpreter can interpret both verbal and nonverbal communication [16]. When emotional support is anticipated, in-person interpreting is usually preferred by providers [24]. There may be improved cultural competence when using an in-person interpreter, which may be important for certain visits such as those involving end-of life care discussions [4]. One concern may involve the comfort level of the patient if he or she personally knows the interpreter; this can occur in smaller ethnic communities [12]. Telephonic interpreting may be preferred in certain medical situations where confidentiality is desired [16].

For providers working with persons who are deaf, options for interpreting include in-person sign language interpreters as well as remote videoconference interpretation [10].

• Are in-person interpreting and remote interpreting comparable?

In general, using in-person or remote interpreters does not significantly change patient satisfaction. In a study involving Spanish-speaking patients in a clinic setting, persons requiring an interpreter rated satisfaction of interpreting between in-person, videoconferencing, and telephonic methods highly with no significant differences. Of note, though, medical providers and interpreters preferred in-person rather than the 2 remote interpreting options [33]. In a different study involving Spanish, Chinese, Russian, or Vietnamese interpreters, satisfaction of information exchange was considered equal among the 3 interpreting modalities, although in-person interpreting was felt to establish rapport between clinician and patient with LEP better than telephonic and videoconferencing interpreting [35]. Additionally, in a study of providers in a clinic setting who worked with persons with LEP, no significant differences were noted in provider satisfaction of the medical visit, or in the quality of interpretation or communication, when using in-person versus remote videoconferencing interpretation. Providers, though, noted improved knowledge of the patient’s cultural beliefs when using in-person interpreting [4].

Regarding the question of a difference in understanding when using in-person versus remote interpreters, a study was done in a pediatric emergency department (ED) that compared in-person and telephonic interpretation. Family understanding of the discharge diagnosis was high (about 95%) regardless of whether an in-person or telephonic interpreter was utilized [36]. In a different study comparing telephone and video interpretation in a pediatric ED, while quality of communication and interpretation were rated similarly, the parents who used video interpretation were more likely to name their child’s diagnosis correctly [29].

Case Continued

The physician proceeded with introductions and explained that all conversations would be interpreted. She further stated that if there were any questions, the patient and mother should feel free to ask them. Via the interpreter, who was male, the provider began by asking about the nature of the abdominal pain. The patient looked to her mother and then down without answering. The mother nodded, but did not say more. The provider wondered if their reticence might be due to discomfort with discussing the issue through a male interpreter. The physician asked the patient if she would prefer a female interpreter and, once that was confirmed, she asked if she wanted an in-person or telephonic interpreter. The mother requested a female in-person interpreter.

• How might gender-specific issues impact working with an interpreter?

As gender concordance of patient and physician [37] at times is desired, gender concordance of patient and interpreter [16,18] may also be important to optimize communication of gender-specific issues [16,18,37]. For example, an Arabic-speaking man from the Middle East may prefer to discuss sexuality-related concerns in the presence of a male rather than female interpreter [16]. An Arabic-speaking female who has a preference for female providers may prefer a female interpreter when discussing sexuality and undergoing a physical examination [19]. In one study, the majority of Somali females preferred female interpreters as well as female providers for breast, pelvic, and abdominal examinations [38]. If a same-gender interpreter cannot be present, an option is to have the interpreter either leave the room or step behind a curtain or turn away from the patient during a sensitive part of the physical examination [39].

• What are recommended strategies for using a medical interpreter?

It is often helpful to have a brief discussion with the interpreter prior to the medical visit with the patient to speak about the general topics that will be discussed (especially if the topics involve sensitive issues or news that could be upsetting to the patient) and the goal of the visit [2, 11]. Certain topics may be viewed dissimilarly in different cultures, thus approaching the interpreter from the view point of cultural broker or liaison [10] may bring to light cultural factors that may influence the medical visit [40,41]. the name of the interpreter should be noted for documentation purposes [10].

To start the visit, introductions of everyone involved should take place with a brief disclosure about the role of the interpreter and assurance of confidentiality on the part of the interpreter [2,11]. Also, the provider should set the expectation that all statements said in the room will be interpreted so that all persons can understand what it being spoken [10].

There are several options for where each person should be positioned. In some medical visits, a triangle is pursued where the interpreter sits lateral to the provider, but this may lead to challenges in maintaining eye contact between the patient and provider. Another option is have the interpreter sit next to [10] and slightly behind the patient to improve eye contact between provider-patient and to maintain the patient-provider relationship [2,41]. When seated, the medical provider should try to sit at the same level as the patient [16]. Seating is different with persons requiring the use of sign language interpreters as the interpreter needs to be visible to the patient for communications purposes. One possibility is having the interpreter sit beside and slightly behind the provider; this positioning allows the patient to understand what is being communicated and also allows the patient to understand what is being communicated and allows him or her to see the provider during the conversation [40].

There are 2 main communication styles used by interpreters: consecutive interpreting, where the interpreter exchanges what has been said by the clinician or patient after each one has finished speaking, and simultaneous interpreting, where the interpreter translates as the person is speaking. Interpreters and medical providers may have a preference and it is important to clarify, if needed, which method is preferred [21].

The provider should face the patient and direct conversation to him or her rather than to the interpreter. Third-person statements should not be used, such as “tell her,” as this directs the conversation to the interpreter rather than to the patient [10]. By using the first and second person (when addressing the patient) and making eye contact, the relationship between the provider and patient is emphasized [14,40].