Every year across the country, patients go to their primary care doctor for their annual physical exam. From California to Maine, whether it be a private practice group, a community clinic, or a family practice clinic at a large public hospital, the appointment will be similar and the behaviors of the healthcare providers at that visit will look the same. Patients can expect that the clerk will sign them in and give paperwork. Then, the medical assistant or nurse will do vitals and take them back to the exam room. The doctor will come in next to perform a physical exam, which will include listening to the heart, lungs, checking the eyes and ears and other body systems. They will then discuss with the patient any health concerns or medication needs and possibly refer the patient for further testing or appointments that might be required. This is expected behavior of all clinic staff and primary care physicians in this type of encounter.
Imagine if the clerk took the patient back, took the vitals and proceeded to draw some blood or if the physician asked the patient to run up and down the halls 3 times to check their lung capacity and then went out to the lobby and scheduled the next appointment for the patient? This would be considered non-standard behavior for these healthcare professionals and would likely be surprising and unsettling for the patient involved. This raises the question for healthcare Interpreters: How does a Medical Interpreter in a healthcare setting behave?
At the core of expected professional behavior in the field of medical interpreting are the 4 roles of the Interpreter set forth initially by Cynthia E. Roat, MPH and then used as the foundation of the “Bridging the Gap” training model by the Cross Cultural Health Care Program. The roles are that of conduit, clarifier, cultural broker, and advocate. In this model, the role of Interpreter is flexible and follows the concept of incremental intervention with the role of conduit being least intrusive and the role of advocate being the most intrusive. Movement across these roles is determined by the demands of the encounter. The ultimate purpose of maintaining these roles is to support communication between patient and provider, leading to better health outcomes for the patient. Additionally, the National Council on Interpreting in Health Care Standards of Practice and Codes of Ethics provides a critical foundation of the performance requirements for healthcare Interpreters. All Interpreters, both sign and spoken language who work in the healthcare setting, should study and know these roles and standards and base their behaviors and professional decisions on the best practices laid out in these models.
Going back to our example of the annual physical exam, imagine what would happen if the Medical Interpreter in this encounter offered the patient the name of another doctor for a second opinion, ran to get the patient a glass of water, or took over the discussion with the doctor and questioned the treatment options “on behalf of the patient”. According to the National Council on Interpreting in Health Care Standards of Practice and Codes of Ethics, none of these mentioned behaviors are considered best practices for Medical Interpreters. By engaging in these non-standard behaviors, Interpreters set inconsistent expectations about the role of the healthcare Interpreter for the other members of the team, as well as for the patients and their families.
Professionals in the field of Medical Interpreting have worked hard to earn societal respect for the role of a professional Interpreter. However, behaviors such as speaking for the patient, advising the patient, or being overly familiar with the patient can reinforce the inaccurate notion that Medical Interpreters are nothing more than family members, advocates, or friends of the patient, instead of professional members of the healthcare team. For the patient or their family, blurring those boundaries sends the message that the Interpreter is there as an ally, which can lead to over-dependence on the Interpreter. Such over-dependence can greatly interfere with the establishment of a patient-provider relationship and lead to less patient autonomy, resulting in poorer health outcomes. Finally, when Medical Interpreters behave outside of established professional standards, the Interpreter that follows that non-standard Interpreter may have difficulty establishing appropriate boundaries. This can easily compromise the relationships with both patient and provider for that second Interpreter.
Returning again to our annual physical exam, when a patient walks into a clinic and meets the Medical Interpreter assigned to their appointment, the answer to the question posed earlier, “How does a Medical Interpreter in a healthcare setting behave?” should now be obvious. The patient can expect that the Interpreter will provide communication that will allow them to establish a relationship with their healthcare provider in order to attain better health outcomes. The provider will also see an Interpreter that is a professional and valued member of the medical team. The Interpreter, in this and in any encounter, must constantly strive to understand the importance of demonstrating consistent professional behaviors. They are not advising patients, getting cups of water, or challenging doctors. When Interpreters are mindful of both the 4 roles of the Interpreter and the NCIHC standards, then they are able to behave in a manner that is consistent with other professionals. Thus, patients and providers can have confidence that they are working with a professional who knows their role so that they can fulfill theirs as patient and provider. If the provider does choose to have the patient run up and down the hall, the Interpreter will be there as conduit, but he or she will leave his or her running shoes at home.