In preparation for the 2018 Interpreter Services’ Conference celebrating the 20th anniversary of providing language services at Michigan Medicine, several members of the conference organizing committee attended the 2017 IMIA Conference, in Houston, Texas. The conference, held at the beautiful Royal Sonesta Galleria Hotel, consisted of a plenary session followed by two panel discussions and several simultaneous presentations or workshops. The conference included presentations touching every aspect of interpretation in health care settings ranging from the need to update the medical interpreter’s code of ethics to interpretation in religious ceremonies, and the suggestion of new techniques for use during interpretation to help manage encounters. We took notes about what we would like, and would not like, to see at our conference next year in Ann Arbor.
In general, I found the panels much more enthralling than presentations because attendees were provided with different visions on a given subject of interest and their intrinsic capacity to generate discussion. I especially enjoyed the Saturday morning panel, which was devoted to patient safety. This was so because patient safety involves the lot of us: the medical team and patients and family alike, although somebody may argue: What about Interpreters? Are we not part of the scene too, when it comes to limited English proficient (LEP) patients? Sure, we are. But in what capacity? This is something that we have to answer ourselves as nobody is going to do it for us. Where do we, Interpreters, really want to stand?
The panel “The Triadic encounter: LEP-patient safety first”, moderated by Mohamad Anwar (President-Elect, Minnesota Chapter Vice Chair IMIA), included Dr. Sheldon Riklon (Marshallese Physician; Associate Professor, University of Arkansas for Medical Sciences), Cyndy Dunlap (DNP, RN, NEA-BC, FACHE Vice President, Clinical Initiatives and Quality, Texas Hospital Association Foundation), and Eric Candle (President ECdata, Inc.; U.S. Coordinator IMIA) as panelists.
From the start, it became clear that communication, in every circumstance, is the key to patient safety; even though there are still some pointy corners that we, as interested professionals, need help to polish to help in this endeavor.
Medical Interpreters assist hospitals with LEP patients. However, did we ever stop to think what do we understand about LEP patients? How do we define the LEP patient? Sure, we all know that LEP patients are people with a limited or less-than-proficient knowledge of the English language. But still, how do we define “limited”? How do we define “proficient”? What does it entail for somebody to be considered language limited or language proficient? Is it a self-categorization? Is there any clear cut line that a patient has to cross to fall within one category or another? What are the grey areas in between “limited” and “proficient”? Are the defining lines fixed or mobile? And if they are mobile, what makes them mobile?
Those are questions that in general remain ill answered within the global healthcare community. And they should promptly be addressed to help us define the Medical Interpreters’ position within the entangled mesh of healthcare providers.
The main challenges are, of course, communication and, tightly associated, access to medical care. We need to be sure that patients know what is going on with their healthcare in terms they understand. The most important issue we are facing here is COMMUNICATION, as poor communication perpetrates different levels of access to health care and, thus, entails discrimination. And we should stress NOT TO COUNT on bilingual medical staff. (Although, if not properly explained, this position might contribute to greater misunderstandings among colleagues.) And what if the LEP patient (or culture, language) is not represented by hospital personnel?
Albeit sometimes too often overlooked, Medical Interpreters have important roles in cross-cultural communication and in cross-institutional communication. To that end, in the hospital setting, Medical Interpreters should be able to:
- Participate in the institution: help in planning discharge and education materials. (Consolidate effort, separate qualifications.)
- Have discharge papers be provided in the language of the LEP patient. (Because different systems – cultures – imply different ways of understanding. As already described by Whorf (1941): (…) the forms of a person’s thoughts are controlled by inexorable laws of pattern of which he is unconscious. These patterns are the unperceived intricate systematizations of his own language. (…) His thinking itself is in a language. (…) And every language is a vast pattern-system, different from others, in which are culturally ordained the forms and categories by which the personality not only communicates, but also analyzes nature, notices or neglects types of relationship and phenomena, channels his reasoning, and builds the house of his consciousness. Moreover, (…) the linguistic order embraces all symbolism, all symbolic processes, all processes of reference and of logic.)
- Help in building business skills. The Medical Interpreter is highly valuable to the institution in reducing miscommunications that have costly outcomes.
- Medical Interpreters educate care providers about certain things that are, or are not, appropriate in the patients’ culture.
- Medical Interpreters help prevent any misreading.
- Help in recruitment/diversity staff. (Institutions need to reflect the communities served.)
Hence, to eliminate disparities among patients it is required to EDUCATE PROVIDERS on how to WORK WITH Medical Interpreters, NOT on how TO USE Medical Interpreters.
It goes without saying that with LEP patients, communication between patient and provider is possible thanks to Medical Interpreters; without the Interpreter, something is missing. If any type of connection is even possible, most likely end in misunderstanding. The Medical Interpreter facilitates communication and therefore, increases understanding, which in turn decreases hospital readmissions, reduces cancellations for both procedures and clinical appointments; and also reduces the total number of visits to the Emergency Department by decreasing its overuse for minor/simple repeated issues. There is also a strong need to involve patients and families in preparing for and following instructions prior to procedures. All in all, the presence of a Medical Interpreter during an encounter among provider and LEP patient will, in the long run, increase the cost-effectiveness of the original clinical visit. Again, communication is the key to achieve meaningful access to health care.
With his/her knowledge of the LEP patient culture and way of understanding, the Medical Interpreter can change the approach of a community to health care; he will provide a change of mindset, which will help improve cultural understanding. But for all of that, the Medical Interpreter MUST BE fully recognized as part of the medical team. Something that will come only by enforcing education and educating providers. However, as I already discussed elsewhere (Porta, 2014), there is, and always has been, among Medical Interpreters, a tension struggle about professional recognition and patient trust. Medical Interpreters need to be a much a part of the medical team as anybody else caring for and/or treating a patient. This struggle arises from the need for professional recognition. This much needed professional recognition places Medical Interpreters at a greater distance from the patient who might not recognize them anymore as members of their community and, therefore, prompting a real risk for the loss of trust that can greatly undermine communication, and with it, the achievement of our ultimate goal, patient safety. If the Medical Interpreter teams with the LEP patient to gain as much trust as possible, this may place the Medical Interpreter in a vulnerable position among medical staff who might then find it hard to consider the Medical Interpreter as an integral member of the patient care team.
That is the theory, but in which position do we, Medical Interpreters, feel more at ease? In which position do we feel we may be able to provide our best service to LEP patients and their families?
- 2007. Medical Interpreting Standards of Practice. International Medical Interpreters Association, Boston; 49 pp.
- 2005. National Standards of Practice for Interpreters in Health Care. National Council for Interpreters in Health Care, Washington, D.C.; 20 pp.
- Porta, David. 2014. Some thoughts prompted by Atul Gawande’s ‘Complications’. UMHS Interpreter Services Blog.
- Whorf, B L. 1941. Language, Mind, and Reality. In: Carroll, John B. (Ed.) 1956. Language Thought and Reality: Selected Writings of Benjamin Lee Whorf. The MIT Press. Cambridge, Massachusetts.