The Echo in the Room

Interpreting as a Profession

The National Council of Interpreting in Health Care (NCIHC) developed nine principles and 32 standards of practice central to medical interpreting that have been adopted for interpreters in all health and human service fields. The nine principles are: accuracy, confidentiality, impartiality, respect, cultural awareness, role boundaries, professionalism, professional development, and advocacy [6]. These interpreter ethics aim to increase interpreting quality, reduce language barriers, increase access to health care, and improve patient-physician communication [6, 7].

Not only is it important that professional interpreters understand the ethics of the profession, they must also demonstrate proficiency in both English and the LEP's native language, as well as have enough cultural knowledge to serve as a cultural broker [8]. Because many insurance providers do not cover interpreter services, many providers continue to rely on ad hoc interpreters for language services, resulting in reduced access to regular care, adverse medication effects, inability to understand diagnoses, increased patient dissatisfaction, increased medical errors, additional diagnostic testing, lower health literacy, and decreased patient adherence to medical treatment [9].

Ad Hoc Interpreters

The term ad hoc interpreters is used to describe individuals who are not trained or working as professional interpreters. This can include patients' family members (including children), friends, and bilingual staff. Ad hoc interpreters are more likely than trained interpreters to commit errors and negatively impact the LEP patient's quality of care. Untrained interpreters may have inadequate knowledge of both languages and limited knowledge of medical terminology, be unfamiliar with confidentiality rules, and commit errors that create a risk to patient safety [2, 5]. Although national certification for professional interpreters exists, certification is not a federal standard. While some states are moving toward certification [2] North Carolina is not among them.

Professionally Trained Interpreters

Being bilingual is not enough to be called a professional interpreter. Professional interpreters typically attend training in interpreter ethics, communication, cultural competency, and the roles of an interpreter. Professional interpreters are expected to adhere to the NCIHC principles and standards of interpreting in all encounters. The use of professionally trained interpreters can increase patient satisfaction, result in more adherence to provider instructions such as filling prescriptions, allow patients to ask more questions and have a better understanding and recall of the information they receive from their provider, and increase trust between the patient and provider [5].

Professionally trained interpreters are taught to be the echo in the room. They are the voice of the patient and the provider so that the two can interact as if a language barrier did not exist. Professional interpreters need to refrain from changing the message in any way, ensuring the accuracy of the interaction. They should refrain from interjecting their own opinions and remain impartial. They need to assure the patient that their information will remain confidential, helping to build trust between the patient and their provider.

Professional interpreters should encourage patient autonomy and respect, avoiding the use of third-person statements and encouraging direct communication between the patient and provider [6]. As part of their professionalism and professional development, interpreters should be familiar with a patient's language, culture, beliefs, and practices and be prepared to serve as cultural brokers when necessary to eliminate any misunderstanding [6].

Modes of Interpreting

Professional interpreters are available in various forms to provide language services for LEP patients, including in-person, telephonic, and video remote interpreting. In-person interpretation is considered the preferred interpretation mode, as it allows interpreters to account for verbal and non-verbal communication, manage the flow of communication, and mitigate possible cultural misunderstanding [4, 10]. Both LEP patients and providers prefer in-person interpreters [4]; however, when in-person interpreting is not readily available, remote methods are very useful in providing language access, especially for languages of limited diffusion.

Video remote interpreting allows for visual communication, whereas telephonic interpretation does not, making it a secondary choice for most providers. Reliance on video and telephonic interpretation has increased with some providers, though use of this technology is limited due to hardware and connectivity issues that can arise with broadband internet connection and microphone and speaker quality [7]. Professional interpreters report that telephonic interpretation works well for administrative, supplemental, or follow-up medical care appointments. For more complex scenarios, telephonic interpretation falls short. In lieu of in-person interpreting, video remote interpreting offers better interpreting quality over telephonic interpreting [4].

Common Barriers

The University of North Carolina at Greensboro Center for New North Carolinians operates a fee-based interpreter bank providing professionally trained interpreters to local area providers as well as the Interpreter Health ACCESS Project, a program to provide free assistance to individuals in the community who are uninsured and are having trouble navigating the health care system and accessing care. Interpreters working for both programs have reported common barriers experienced by LEP clients in accessing health care.

Even before getting in the door, simply calling to make an appointment can be a challenge if the provider does not have a way for an LEP patient to access language services. Difficulty making or receiving calls or voicemails from a provider can also create gaps in communication. As most insurance does not reimburse for language services, and North Carolina does not reimburse for interpreting and translation services for Medicaid, some LEP patients find that they cannot access interpreters at some providers, including some dental clinics and specialty physicians. Those without insurance may also experience difficulty accessing language services.

Another barrier to quality health care is a lack of providers that are trained in how to work with interpreters. All staff at a provider's office or clinic, including front desk staff, should know how to work with LEP patients in a way that is linguistically and culturally appropriate, and a major part of this is knowing how to properly work with interpreters. During reception and check-in, staff should make eye contact and clearly communicate with patients, including allowing enough time for the encounter to be interpreted. Training bilingual staff, whose main role is not interpreting, to adhere to interpreter ethics and respect role boundaries within the interpreting encounter is essential for providing quality interpreting services.

Some interpreters have identified some of their most common challenges with providers as: having providers not address patients directly, difficulty with proper positioning in the room, side conversations in the room, and having multiple providers in one visit for a single patient. Aftercare instructions are not always detailed, and providers leave interpreters to sight-translate (verbally render a written message) without affording patients the benefit of being able to ask questions or get clarification. Video remote interpreting and telephonic interpreting also present their own unique challenges, including bad connections, having multiple interpreters for longer appointments, being unable to sight-translate documents, and having difficulty explaining forms.

Other Things to Consider

Access to health care is not a simple issue to address. It intersects with many other challenges to create a multi-dimensional problem that does not stop at language barriers and a lack of professionally trained interpreters. Poverty, food insecurity, and economic woes are experienced by many immigrants and refugees [1]. In addition, lack of affordable child care, substandard housing, lack of transportation, inaccessibility of grocery stores, unemployment or underemployment, and lack of access to social services and community support all factor into health outcomes for immigrants and refugees [1]. Having professionally trained, culturally responsive interpreters in various languages and dialects can help, but it is not the only factor that needs to be addressed.

Best Practices for Providing Quality Language Access

In order to provide high-quality, culturally and linguistically appropriate language services, providers should be trained in how to work with an interpreter. This means that providers need to allow for extra time to meet with patients, speak to patients directly, and speak in short sentences to allow the interpreter to provide the most accurate interpretation possible. Providers should limit their use of idioms and technical jargon and understand that professional interpreters are required to interpret everything that is said in an interpreting encounter. Providers should limit their use of ad hoc interpreters and refrain from using children to interpret for their parents [9].