The United States is a diverse country that includes

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1 Using a Medical Interpreter with Persons of Limited English Proficiency Kimberly Schoonover, MD Abstract Objective: To provide an overview of important aspects of interpreting for medical visits for persons with limited English proficiency (LEP). Methods: Literature review. Results: When working with persons of LEP, providing a professional medical interpreter will facilitate optimal communication. Interpreters may work in different roles including as a conduit, cultural broker, clarifier, and advocate. In-person and remote (videoconferencing or telephonic) interpreting are available and one may be preferred depending on the medical visit. Clinicians should recognize that patients may have a preference for the interpreter s gender and dialect and accommodations should be made if possible. Prior to the visit, the provider may want to clarify the goals of the medical encounter with the interpreter as some topics may be viewed differently in certain cultures. When using an interpreter, the provider should maintain eye contact with and direct speech to the patient rather than to the interpreter. The provider should speak clearly, avoid complex terminology, and pause appropriately to allow interpretation. Additionally, providers should assess patient understanding of what has been discussed. After the medical visit, providers should consider discussing with the interpreter any issues with communication or cultural factors noted to have affected the visit. Conclusion: Providers should utilize a professional medical interpreter for visits with persons with LEP. Appropriate communication techniques, including talking in first and second tenses and maintaining eye contact with the patient rather than the interpreter, are important for a successful visit. Realizing patients may have interpreter preferences is also important to facilitate patient-centered-care. Key words: language barriers; quality of care; physician-patient communication; interpreter services. The United States is a diverse country that includes many persons whose first language is not English. According to the U.S. Census Bureau, more than 63 million persons age 5 and above (about 51 million adults) reported speaking a language other than English at home. Also, about 25.7 million of the population age 5 and up (around 10.6 million adults) noted speaking English less than very well [1]. Protecting people from discrimination based on the language they speak is highlighted in Title VI of the Civil Rights Act of 1964 (which focuses on those receiving federal funding). President Clinton, furthermore, in 2000 signed Executive Order 13166, which encouraged federal agencies to provide appropriate access of their services to those with limited English proficiency (LEP) [2,3]. The benefits of using professional interpreters is welldocumented. In addition to increased satisfaction with communication when professional medical interpreters are used [4], they also make fewer clinically significant interpretation errors compared to ad hoc interpreters (ie, untrained individuals such as bilingual staff member, family member, or friend who are asked to interpret) [5 7]. LEP patients who do not have a professional interpreter have less understanding of their medical issues, have less satisfaction of their medical care, and may have more tests ordered and be hospitalized more often compared to those who do utilize professional medical interpreters [8]. In addition to improved satisfaction and understanding of medical diagnoses, hospitalized persons requiring interpreters who utilized a professional medical interpreter on admission and discharge were noted to have a shorter length of stay than persons who required an interpreter and did not receive one [9]. Despite the documented benefits of using professional interpreters, they are underutilized. Reasons include From the Department of Medicine, Mayo Clinic, Rochester, MN. Vol. 23, No. 12 December 2016 JCOM 567

2 using medical interpreters Table 1. Commonly Asked Questions about Working with Interpreters and Persons of Limited English Proficiency How do I know if a patient needs an interpreter if he or she did not request one and does not seem to understand what I am asking? Should I use a family member to interpret? When should I consider requesting an interpreter of the same gender as the patient? When should I discuss the goals of the medical visit with the interpreter prior to meeting with the patient? How do I communicate effectively with a patient while using an interpreter? What do I do if the patient is facing the interpreter rather than me? What do I do if the patient and interpreter are speaking back and forth without an adequate interpretation of what is being said? Ask open-ended questions that require more than a yes/no answer or ask the patient to tell you what he or she understands from what has been discussed. A professional medical interpreter is preferred, but the patient has the right to decide. If the patient requests this. If you are working with certain cultures where discussing gender specific concerns with the opposite gender is considered inappropriate. When medical visits involve difficult conversations, such as a patient learning that he or she has a serious medical condition. Speak to and face the patient, use straightforward word choice, allow for interpretation after 1-2 sentences and after every question. Assess where the interpreter is seated. Have the interpreter sit next to the patient (and consider slightly behind) to focus the conversation between you and the patient. Ask the interpreter for sentence-by-sentence interpretation. Explain that all statements should be interpreted so that all persons are able to understand what is being spoken. underfunded medical interpreting services [10,11], lack of awareness of the risks involved with using an ad hoc interpreter [2,12], providers using their own or another worker s limited second language skills to communicate rather than using a professional medical interpreter [13,14], perceived delay in obtaining a professional medical interpreter, and judging a medical situation as minor rather than complex [13]. In this article, the roles, importance, and considerations of using a professional medical interpreter are explored. CASE STUDY Initial Presentation A 23-year-old married Somali-speaking female who moved to the United States recently called a local primary care provider s office to schedule an appointment. When asked the reason for the visit, she said the reason was private. The clinical assistant scheduled her with the next available provider. When the patient arrived for her clinic appointment, a clinical assistant roomed her and her mother and asked the patient the reason for the visit. The patient remained quiet and her mother replied that she needed to speak with the doctor. When the female medical provider entered, she observed that the patient appeared anxious. When the doctor initiated conversation with the patient, she noted that her English was limited. Her mother tried to explain the reason for the visit saying her daughter was having severe pain. She then pointed towards her daughter s lower abdomen. The clinician noted the limited English abilities of the patient and mother and used the interpreter line to request a Somali interpreter and placed the first available interpreter available on speaker. How can patients who need an interpreter be identified? If a person does not speak any English, then an interpreter is necessary; however, sometimes whether a person from a non-english speaking background would benefit from an interpreter is unclear. If a patient is answering only in nods or yes/no responses or answering questions inconsistently, further evaluation should be done. Asking open-ended questions and/or having the patient repeat what is his or her understanding of the conversation will help determine if the person may benefit from an interpreter [12] (Table 1). Health care systems can facilitate identifying patients in need of an interpreter by routinely collecting information on LEP status. The patient should be asked during registration if her or she speaks English and has a preferred language, and the answers should be recorded in the medical record [3]. If an interpreter is used during the hospital stay, it should be recorded to alert future providers to the need of an interpreter [15]. Patients 568 JCOM December 2016 Vol. 23, No. 12

3 may speak a dialect of a common language and this also should be noted, as an interpreter with a similar dialect to the patient should ideally be requested when necessary [16]. Furthermore, health care systems can measure rate of screening for language need at registration and rate of interpreter use during hospital stay to assess language need and adequacy of provision of interpreters to LEP patients [15]. It should be noted that patients may be wary about the presence of an interpreter. In one study involving pediatric oncologists and Spanish-speaking parents, the former reported concern regarding the accuracy of interpretation and the latter were concerned about missing out on important information even with the use of professional medical interpreters [17]. The concern for accuracy of interpreting was shared in a study by Chinese and Vietnamese Americans with LEP [18] as well as in a Swedish study involving Arabic-speaking persons. In the latter study, Arabic-speaking patients also felt uncomfortable speaking about bodily issues in the presence of interpreters [19]. In a study of Latina patients, there were concerns about confidentiality with interpreters [20]. What is the role of the interpreter? Should they offer emotional support to the patient? Interpreter-as-conduit reflects a neutral, more literal information exchange and is preferred by certain medical providers who prioritize a more exact interpretation of the medical conversation. In this role, the interpreter assumes a more passive role and the emphasis is on the interpreter s linguistic ability [21]. Providers need to be aware that word-for-word interpretation may not align with what is regarded as culturally sensitive care such as when the term cancer is to be used. Also, word-forword interpretation does not necessarily mean the patient will understand what is being interpreted if the terminology does not reflect the literacy level or dialect of the person with LEP [22]. Interpreters may also assume an active role, sometimes referred to as clarifier and cultural broker. Clarifying may be utilized, for example, when a medical provider is discussing complicated treatment options. This requires an interpreter to step out of a conduit role (if that is the preferred role) and confirm or clarify information to ensure accurate information exchange [21,23]. As a cultural broker, communication between provider and patient is exchanged in a manner that reflects consideration of the patient s cultural background. Interpreters may explain, to the provider, the cultural reason for the patient s perspective of what is causing or contributing to the illness. Cultural brokering may as well include communicating the medical terminology and disease explanation, given by the medical provider, in a way that the patient would understand. This role, additionally, can involve educating the provider about aspects of the culture that may influence the patient s communication with him or her [22]. Furthermore, interpreters may fulfill an advocate role for patients by helping them understand the health care system and increasing patient empowerment by seeking information and services that the patient may not know to ask about [23]. The interpreter may offer emotional support during a medical visit, for example, where the diagnosis of cancer is conveyed. In such a case, an interpreter s emotional support may be considered by providers to be appropriate. In contrast, with visits related to mental health evaluations, having the interpreter remain neutral, rather than being a more active participant by offering emotional support, may be preferred [24]. In addition to interpreters remaining more neutral during mental health visits, providers may prefer that interpreters not speak with the patient prior to the visit, depending on the mental health condition, as negative therapeutic consequences may occur [21]. Trust is an important element of the providerpatient relationship and, as such, there is concern on the part of some providers that if the trust of patients falls to the interpreter rather than to the provider, then therapeutic progress may be compromised [24]. In general, clarifying with interpreters the goals of the visit and expectations regarding speaking to the patient outside of the visit may ensure the provider-patient relationship is not diminished [21]. What are the disadvantages and caveats of using family members or bilingual staff as interpreters? Although family members and other ad hoc interpreters may be present and willing to interpret, the risk of miscommunication is greater than with professional Vol. 23, No. 12 December 2016 JCOM 569

4 using medical interpreters medical interpreters [5,6]. This risk of miscommunication extends to partially bilingual medical providers who do not utilize appropriate interpreter services [10,25]. Ad hoc interpreters may try to answer on behalf the patient [6,26] and may not have the appropriate medical terminology to correctly interpret what the provider is trying to communicate to the patient [6]. Professional medical interpreters are trained to facilitate communication of a spoken language in a medical setting [2,10]. Certification is offered by the National Board of Certification for Medical Interpreters and the Certification Commission for Healthcare Interpreters. In order to be certified certain requirements must be met which include a minimum of 40 hours of health care interpreter training (which includes medical terminology as well as roles and ethics involved in medical interpreting) as well as demonstrated oral proficiency in English as well as another chosen language (such as Spanish) [10]. In certain circumstances, patients may feel more comfortable disclosing personal details with a professional medical interpreter rather than in the presence of an ad hoc interpreter. For example, more details of traumatic events and psychological symptoms were spoken of in the presence of a professional, rather than an ad hoc, interpreter in medical interviews of asylum seekers requiring an interpreter in Switzerland. In the presence of ad hoc interpreters, more physical symptoms were disclosed rather than psychological [6]. Furthermore, in visits concerning sexuality or abuse issues, using family members as interpreters may violate privacy concerns of the patient [2,27]. Additionally, in certain cultures where respect for elders is very important, parents who use children as interpreters may feel that the structure of the family changes when he or she interprets on behalf of the parent [18]. Also, what children consider as embarrassing may not be interpreted to either the parent or to the care provider [8]. Furthermore, one should note there are ethical issues of using non-adult children as interpreters in situations involving confidentiality and privacy by doing so, there may be resulting harmful effects on non-adult children [27,28]. Patients may at times decline the use of a professional medical interpreter and prefer to have a family member interpret; this preference should be documented in the patient s medical chart [10]. Caution should be had using an ad hoc interpreter when obtaining informed consent [12]. 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]. Telephonic interpreting offers greater accessibility as it is not limited by time of the day or geographic location and less common language interpreters are availble. Disadvantages of telephonic interpretation include lack of ability to interpret body language and, at times, problems with communication related to background noise [27]. Also, some providers feel that rapport building is more difficult with telephonic interpreting [13]. Using a double-headset telephone or speaker phone (in a private setting preferably), instead of passing the telephone headset between provider and patient, is recommended to optimize provider-patient communication [2]. 570 JCOM December 2016 Vol. 23, No. 12

5 Table 2. Considerations for In-person and Remote Interpretation Methods In-person Can interpret both verbal and nonverbal communication Can provide emotional support for patient during difficult conversations Potential disadvantages include a delay in obtaining an interpreter and patient privacy if he or she knows the interpreter Telephonic Can interpret verbal communication Offers privacy for patients who may know in-person interpreters Accessible for persons of less common languages, during different times of the day or night, for persons in geographic areas where in-person interpreters are not available Videoconferencing Potential disadvantages include background noise as well as inability to interpret nonverbal communication Can interpret verbal and nonverbal communication Accessible for many different languages Useful for persons requiring sign language interpreters Potential disadvantage includes technical problems that are due to wireless networking issues Remote videoconference interpretation is also an option in many places. Videoconferencing offers the advantage of interpretation of nonverbal communication that would be absent in telephonic interpreting [33]. Also, accessibility to languages is improved, especially for languages not covered by in-person interpreters depending on the health care site [34]. Disadvantages of videoconferencing interpretation include technical problems due to wireless networking issues [33] (Table 2). 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 Vol. 23, No. 12 December 2016 JCOM 571

6 using medical interpreters 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 providerpatient 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]. Choosing the right word is important to have meaningful communication. Interpreters advise that providers should understand that medical concepts may be unfamiliar to patients with LEP. Providers should use simpler words rather than medical terminology to discuss medical issues [42]. In general, straightforward word choice is recommended [16]. Providers are advised to not use acronyms or idioms. It is important to note that humor may be difficult to convey as well [10]. 572 JCOM December 2016 Vol. 23, No. 12

7 Clinicians are advised to speak clearly and not quickly and to use shorter sentences with appropriate pauses to allow time for the interpreter to interpret (if consecutive rather than simultaneous interpreting style is being used) [2,41,43,44]. In addition to limiting speech to one to two sentences at a time, asking one question at a time is important for optimal communication [43]. To improve information gathering, patients may respond better to open-ended questions [42], which is an aspect of patientcentered communication, as directive questioning often leads to shorter answers [43]. Furthermore, the provider should be aware that persons with LEP may know some English, so statements that one would not say to an English-speaking patient should not be said in the room with a person with LEP [10]. Encouraging the interpreter to clarify certain concepts, if necessary, may provide for improved information exchange [21] as well as encouraging the patient to ask questions during the medical visit may help elucidate potential areas of confusion [22,40,44]. Summarizing important concepts [40] and limiting the number of concepts discussed may increase patient understanding [10]. Additionally, asking the patient to repeat what was discussed in his or her words [10], rather than directly asking if he or she understands, will allow for more meaningful assessment of patient understanding [43]. Finally, recognition that interpreters may experience distress after certain visits, such as an oncologic medical encounters, is important and debriefing may be desired by the interpreter [22,45]. Also, discussing any communication concerns may be helpful [40,42] in addition to discussing certain cultural beliefs that impacted the visit may be educational for the provider [45]. Case Continued After the female translator arrived, the physician asked the patient if she felt comfortable with her mother in the room for this medical visit. After the patient confirmed that she wanted her mother present, the physician tried to further clarify the reason for the medical visit. Her mother, appearing very concerned, began speaking quickly to the interpreter without stopping for interpretation. When the mother did stop speaking, the interpreter, rather than informing the provider what was spoken of by the mother, dialoged with the mother and the back and forth conversation continued. What are strategies to optimize the medical visit when the provider is not satisfied with the flow of conversation? If there are conversations occurring between the patient and interpreter with the exclusion of the provider, the provider should request sentence-by-sentence interpretation by the interpreter. If the interpreter is answering on behalf of the patient, providers should redirect communication to the patient [10]. At times, patients may speak for longer periods without stopping for the interpreter to provide accurate information exchange. The provider in this case may need to interrupt conversation to allow the interpreter time to convey what is being said [14]. If there are family members who know English, but the patient and/or others do not know English, there may be a risk of miscommunication if the exchange of medical information is done by a combination of family members and the interpreter, as the medical information may not accurately reflect what the clinician is trying to convey. The provider may need to redirect the conversation flow through the interpreter to make sure there is consistent information being communicated [22]. Case Continued Finally, the provider interrupted. She emphasized with the patient, mother, and the interpreter that all that was being said should be interpreted. She asked the interpreter to sit next to the patient and mother (rather than lateral to the physician) so that eye contact between the patient and mother and the provider could be maintained thus supporting the patientprovider relationship. She then asked one question at a time to the patient. She needed to interrupt the conversation again when the mother started to speak to the interpreter without waiting for interpretation. The doctor reemphasized the need to allow time for the interpreter to adequately convey the information. After this the medical visit progressed successfully. Soon the provider found out that the mother was concerned that something serious could be happening to her daughter, as her daughter previously had a miscarriage. After hearing the mother s concern, the provider was able to clarify with the daughter that the pain was suprapubic and she was having burning when she urinated. After further evaluation, the provider diagnosed a urinary tract infection. Vol. 23, No. 12 December 2016 JCOM 573

8 using medical interpreters She told the patient about the diagnosis and provided her with appropriate medication and instructions on how to take it and for how long. The provider then asked the patient to tell her what she understood about the diagnosis and how to take the medication. The doctor then asked if either had any further questions. After the medical visit, the provider made sure that the patient s chart reflected the need for a Somali interpreter with the notation that a female interpreter was preferred. Conclusion When working with persons with LEP, providing a professional medical interpreter will facilitate optimal communication. In-person and remote (videoconferencing or telephonic) interpreting are options. When using an interpreter, the provider should maintain eye contact with and direct speech to the patient not the interpreter. The provider should speak clearly, avoid complex terminology, and pause appropriately. Clinicians should remember that patients may have a preference in the gender and dialect of the interpreter and accommodations should be made if available. Finally, asking the patient to repeat back in his or her own words what has been discussed is important to make sure the patient understood what was communicated during the medical visit [10,16]. Corresponding author: Kimberly Schoonover, MD, 200 First Street SW, Rochester, MN 55905, Schoonover.Kimberly@ mayo.edu. Financial disclosures: None. References 1. U.S. Census Bureau. American community survey. Accessed 11 Jul 2016 at 2. Wiener ESR, Ivonne M. Bridging language barriers: how to work with an interpreter. Clin Pediatr Emerg Med 2004;5: Perez-Stable EJ, Karliner LS. What do we know about patientclinician interactions with interpreters? J Gen Intern Med 2013;28: Napoles AM, Santoyo-Olsson J, Karliner LS, et al. 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