04/22/2009
By Mathew Call
Medical Interpreting & Cultural Services
University of California Davis Health System
Why Medical Interpreters are Healthcare Professionals
Medical or healthcare interpreting is a recently organized profession which
explains the confusion as to what category of profession as well as what the
healthcare interpreter's role is. Medical interpreting is a specialty field
within the larger profession of interpreting and translating. It is less a
body of work within the health services industry. Interpreters deal with
spoken or signed languages, translators deal with written texts.
Interpreting and translating spans the entire gamut of international
relations as well as every kind of interaction between immigrant and
deaf/hard of hearing populations and the services to which they have a right
here in the United States of America. Interpreters work in hospitals,
clinics, courts, conferences, schools, government offices, etc. Even though
each venue's protocol differs, all interpreters and translators belong to
the same industry. According to the United States Department of Labor,
Bureau of Labor Statistics:
Interpreters and translators enable the cross-cultural communication
necessary in today’s society by converting one language into another.
However, these language specialists do more than simply translate words—they
relay concepts and ideas between languages. They must thoroughly understand
the subject matter in which they work in order to accurately convert
information from one language, known as the source language, into another,
the target language. Strong research and analytical skills, mental
dexterity, and an exceptional memory also are important. In addition, they
must be sensitive to the cultures associated with their languages of
expertise…Medical interpreters [in particular] need a strong grasp of
medical and colloquial terminology in both languages, along with cultural
sensitivity regarding how the patient receives the information. They must
remain detached but aware of the patient’s feelings and pain. (http://www.bls.gov/oco/ocos175.htm)
The ASTM Standard Guide for Language Interpretation Services (Standards
F2089-01), released in 2001, identifies the components of quality language
interpretation services and establishes criteria for each component. These
criteria define the minimum standard of quality services in the language
interpretation industry with reference to distinctive characteristics of
specific settings. It evaluates the interpreting industry as a whole, with
the understanding that there is one industry and one interpreting profession
operating in varied settings (including healthcare). (http://www.astm.org/Standards/F2089.htm)
Clifford D. Stromberg, attorney and renowned ethicist states in his Key
Issues in Professional Ethics (Reflections on Ethics, ASHA 1990) that a
practice profession (as opposed to a technical profession) is distinguished
by three essential characteristics:
1) A profession has a defined or limited scope of practice and a related
body of knowledge.
2) Professionals adhere to a clearly articulated set of values or code of
ethics.
3) A profession has a special monopoly over the right to provide a
particular service through licensure or certification.
By examining these three characteristics: the scope of practice (and the
education/training necessary to practice), the set of values (i.e. standards
of practice), as well as the topic of certification/licensure, healthcare
interpreting emerges very clearly as a healthcare practice profession
closely resembling other practice professions.
Scope of Practice
The ASTM Standard Guide mentioned above asserts that, in addition to
knowledge of the subject matter and corresponding terminology, the
interpreter should have a “broad general education,” which may include the
following:
• Post-secondary education or its equivalent
• The ability to familiarize him/herself with new fields rapidly and
thoroughly, and
• In-depth knowledge of one or more fields of specialization, which may
include certification through testing in certain fields (for example, in
legal and medical)
Regarding the educational background for interpreters, the U.S. Department
of Labor states:
Interpreters and translators must be fluent in at least two languages. Their
educational backgrounds may vary widely, but most have a bachelor’s degree.
Many also complete job-specific training programs. Although a bachelor’s
degree is often required, interpreters and translators note that it is
acceptable to major in something other than a language. An educational
background in a particular field of study provides a natural area of subject
matter expertise. However, specialized training in how to do the work is
generally required. Formal programs in interpreting and translation are
available at colleges nationwide and through nonuniversity training
programs, conferences, and courses. Many people who work as conference
interpreters or in more technical areas—such as localization, engineering,
or finance—have master’s degrees, while those working in the community as
court or medical interpreters or translators are more likely to complete
job-specific training programs. Experience is an essential part of a
successful career in either interpreting or translation. In fact, many
agencies or companies use only the services of people who have worked in the
field for 3 to 5 years or who have a degree in translation studies or both.
(http://www.bls.gov/oco/ocos175.htm)
As the federal government makes clear, most interpreters have a bachelor's
degree. Only after obtaining a degree, job-specific training may sometimes
occur. Because medical interpreting in particular carries with it such heavy
liability, it is even more likely to be required of healthcare interpreters.
All interpreters must be trained in the skills specific to interpreting but
as stated above, it is not always necessary to have a degree in
interpretation or translation. Sign language interpreters, for example, are
required to have a degree in order to obtain national certification but not
necessarily a degree in interpreting. Because medical interpreting is a
newly organized profession, those who've been in the field the longest may
not have the required bachelor's degree. The profession is proceeding with
caution regarding this issue. As with every new practice profession, care
must be taken so as not to create a shortage of practitioners as the
transition to higher standards occurs. This is the phase we are temporarily
in and solely for this reason may experience and formal testing sometimes
substitute for a degree.
According to Izabel Arocha, M.Ed, president of the International Medical
Interpreters Association, the interpreter must have the appropriate
educational background and cultural knowledge to be able to match all
language registers and cultural nuances. Additionally interpersonal and
public speaking skills must be developed after which, no matter the
languages, consecutive, simultaneous, and sight translation skills must then
be developed. Only after all these foundation competences are present can an
interpreter specialize into a field such as medical/healthcare interpreting.
As with any healthcare profession, “The first part of an interpreter’s work
begins before arriving at the jobsite. The interpreter must become familiar
with the subject matter that the speakers will discuss, a task that may
involve research…” (U.S. Dept. of Labor). This is one of the reasons why
interpreters need broad post-secondary education. Interpreters must try and
predict what type of demands they may have to deal with. Medical
interpreters are vital members of the healthcare team working with other
healthcare professionals such as physicians, nurses, therapists, social
workers, etc.
Interpreters must work very independently without direct supervision.
Throughout the workday and within the framework of their designated
standards of practice, all the aforementioned healthcare professionals
regularly make ethical judgments and decisions depending on the current
interaction. Interpreting is no different. All information learned is
confidential (within certain confines). They must be aware of any potential
conflict of interest, as well as personal judgments, values, beliefs or
opinions that may lead to preferential behavior or bias affecting the
quality and accuracy of the service provided. They must strive to support
mutually respectful relationships between all the parties in the
interaction. Different professionals will make different decisions based on
their past experience, training, and most of all the interaction at hand,
all of which may be perfectly acceptable. No two professionals would do
exactly the same thing in every situation like technicians would. Often this
expertise is not learned in school, yet is professional in nature, and could
not be construed as technical.
Ethical dilemmas arise without failure in every single interpreted
assignment. Ethical decision-making is a central part of what any practice
professional including interpreters must learn to grapple with. What if a
patient tells the interpreter something but requests s/he not inform the
doctor? What if the doctors are conferencing in front of the patient and
request the interpreter remain silent? What if the patient responds s/he has
never taken drugs but the interpreter happens to know this is not true? The
list is endless. In ethics, there is never one simple correct answer and
several options may be acceptable while several will surely result in
disaster. This is a major distinction of practice professions as opposed to
technical jobs. Two renowned scholars in the field of interpreting, Robert
Q. Pollard, Ph.D., Professor of Psychiatry at the University of Rochester
School of Medicine and Robyn K. Dean, M.A. C.I./C.T. have stated:
We view interpreting as a practice profession, like medicine, law, teaching,
counseling, or law enforcement, where careful consideration and judgment
regarding situational and human interaction factors are central to doing
effective work. We contrast the practice professions with the technical
professions, such as engineering and accounting, where knowledge and skills
pertaining to the technical elements of a job are largely sufficient to
allow the professional to produce a competent work product. Interpreters
function more like practice professionals than technicians due to the
significance of situational and human interaction factors on their ultimate
work product; that is, factors beyond the technical elements of the source
and target language…Interpreters cannot deliver effective professional
service armed only with their technical knowledge of source and target
languages…Like all practice professionals, they must supplement their
technical knowledge and skills with input, exchange, and judgment regarding
the consumers they are serving in a specific environment and in a specific
communicative situation” (in Consumers and Service Effectiveness in
Interpreting Work: A Practice Profession Perspective).
Healthcare interpreters do not function strictly as invisible conduits. They
are to skillfully weave in and out of four distinct roles outlined in the
established standards of practice: message converter, message clarifier,
cultural mediator, and on rare occasions patient advocate (referred to as
the incremental intervention model; see attachment #5-California Standards
for Healthcare Interpreters). This model gives the trained interpreter
options of how to handle any situation including ways of handling the
inevitable unfamiliarity that occurs for either the patient, provider, or
interpreter him/herself. These roles were hotly debated for several years
before a consensus was reached and their applicability varies depending on
the languages being used. Their aim is to allow the interpreter to support
the patient-provider relationship while minimizing the negative yet
maximizing the positive aspects of having a third party involved in a
medical encounter. Even the most technical of the roles, message converter,
must remain subjective, for like the human brain, language with its tone,
inflections, underlying meanings, cultural nuances, and body language is so
incredibly complex that science has yet to successfully produce a machine
that can interpret in the way a human professional interpreter can.
Interpreters are constantly making value judgments as to which is the best
way to reproduce an utterance depending on the dynamics of the interaction
and the parties involved. The incremental intervention model is making an
impact in the legal interpreting realm as well (see attachment #1).
Vicarious trauma is a phenomenon common to many practice professions which
has led to several organized outlets for case conferencing. It is not so
common in technical professions. Vicarious trauma and case conferencing are
also common in the profession of interpreting, especially healthcare
interpreting. The needs assessment process of the ASTM Standard Guide
declares the importance of providing an appropriate and adequate working
environment with the view to facilitating the interpreter’s performance and
avoiding professional burnout.
According to the ASTM Guide, “Interpretation is a complex, demanding task
that requires an excellent command of languages, possession of skills and
abilities specific to interpretation, and knowledge of the subject matter
being interpreted.” Therefore, the standard acknowledges that the
interpreter may incur liability for a lack of accuracy in interpretation. By
definition, the public expects practice professionals to be reliable and
responsible. The interpreter has an enormous (often unwanted) amount of
power. S/he is the only one in the encounter who knows everything that is
said. What would happen if s/he broke ethics and intentionally or
unintentionally misinterpreted? Just like the Hippocratic Oath physicians
take when entering the practice of medicine, so do interpreters hold
beneficence as the overarching guiding principle of their practice. Staff
medical interpreters may be covered by their institution’s liability or
malpractice insurance and it is common for freelance interpreters to
maintain this type of insurance just like many healthcare professionals do.
Established Standards
All practice professions (and especially healthcare professions) rely on
established standards of practice, a code of ethics, and/or a code of
professional conduct. The public depends on them for ethical reliable
services. Healthcare interpreting is no different. International, national,
and California state standards have all been established. Each built on the
preceding documents and compliment as opposed to contradict each other. (See
attachments #2 and #3 for non-contradictory attestation.)
International Medical Interpreters Association (IMIA)
Code of Ethics established 1987, revised 2006
http://www.imiaweb.org/code/default.asp
Medical Interpreting Standards adopted October 1995; attachment #4
http://www.imiaweb.org/standards/standards.asp
California Healthcare Interpreting Association (CHIA)
California Standards for Healthcare Interpreters adopted September 2002;
attachment #5
http://chiaonline.org/content/view/42/100/
National Council on Interpreting in Health Care (NCIHC)
National Code of Ethics adopted July 2004; attachment #6
National Standards of Practice adopted September 2005; attachment #7
http://www.ncihc.org/mc/page.do?sitePageId=57768&orgId=ncihc
Sign language interpreters have an additional code of professional conduct
that applies to all interpreting involving adults whether in healthcare or
otherwise. This code predates the three above.
Registry of Interpreters for the Deaf/National Association of the Deaf:
National Code of Ethics first conceived 1964, most recent revision July
2005: Code of Professional Conduct; attachment #8
http://www.rid.org/ethics/code/index.cfm
As of 23 February 2007, California state law fully adopts both the National
and California Standards for Healthcare Interpreters. SB853 mandates all
HMOs under the Department of Managed Healthcare to finance and provide
language assistance: “The Department will accept plan standards for
interpreter ethics, conduct, and confidentiality that adopt and apply, in
full, the standards promulgated by the California Healthcare Interpreting
Association or the National Council on Interpreting in Healthcare” Section
1300.67.04(c)(2)(H)(iii) (See attachments #9, #10, and #11). SB853 also
states that if healthcare organizations already have language assistance
programs in place, they must raise them to level of SB853 or higher for Medi-Cal
AND HMO patients. A quick internet search will provide plenty of articles in
California's major newspapers that have been covering this story. The
standards of practice for healthcare interpreters are now widely accepted
(see http://www.ncihc.org/mc/page.do?sitePageId=67997).
CLAS Standards: attachment #12;
After years of research and collaboration, in March 2001 the U.S. Federal
government released a landmark 132-page report entitled National Standards
for Culturally and Linguistically Appropriate Services in Health Care. It
was prepared by the Department of Health and Human Services, Office of
Minority Health and has come to be known as the CLAS Standards. A total of
14 Standards are covered in the document. The Preamble states that Standards
4-7 are mandates or current Federal requirements for all recipients of
Federal funds. The following excerpt is taken from page 10:
Standards 4, 5, 6, and 7 are based on Title VI of the Civil Rights Act of
1964 with respect to services for limited English proficient (LEP)
individuals. Title VI requires all entities receiving Federal financial
assistance, including health care organizations, take steps to ensure that
LEP persons have meaningful access to the health services that they provide.
The key to providing meaningful access for LEP persons is to ensure
effective communication between the entity and the LEP person. For complete
details on compliance with these requirements, consult the HHS guidance on
Title VI with respect to services for (LEP) individuals (65 Fed. Reg.
52762-52774, August 30, 2000) at [www.hhs.gov/ocr/lep].
Standard 6 addresses the competence of individuals who perform interpreting
services:
Health care organizations must assure the competence of language assistance
provided to limited English proficient patients/consumers by interpreters...
Family and friends should not be used to provide interpretation services
(except on request by the patient/consumer). Accurate and effective
communication between patients/consumers and clinicians is the most
essential component of the health care encounter. Patients/consumers cannot
fully utilize or negotiate other important services if they cannot
communicate with the nonclinical staff of health care organizations. When
language barriers exist, relying on staff who are not fully bilingual or
lack interpreter training frequently leads to misunderstanding,
dissatisfaction, omission of vital information, misdiagnoses, inappropriate
treatment, and lack of compliance. It is insufficient for health care
organizations to use any apparently bilingual person for delivering language
services—they must assess and ensure the training and competency of
individuals who deliver such services.
Bilingual clinicians and other staff who communicate directly with
patients/consumers in their preferred language must demonstrate a command of
both English and the target language that includes knowledge and facility
with the terms and concepts relevant to the type of encounter. Ideally, this
should be verified by formal testing. Research has shown that individuals
with exposure to a second language, even those raised in bilingual homes,
frequently overestimate their ability to communicate in that language, and
make errors that could affect complete and accurate communication and
comprehension.
Prospective and working interpreters must demonstrate a similar level of
bilingual proficiency. Health care organizations should verify the
completion of, or arrange for, formal training in the techniques, ethics,
and cross-cultural issues related to medical interpreting... Interpreters
must be assessed for their ability to convey information accurately in both
languages before they are allowed to interpret in a health care setting.
In order to ensure complete, accurate, impartial, and confidential
communication, family, friends or other individuals, should not be required,
suggested, or used as interpreters. A patient/consumer may choose to use a
family member or friend as an interpreter after being informed of the
availability of free interpreter services unless the effectiveness of
services is compromised or the LEP person’s confidentiality is violated. The
health care organization’s staff should suggest that a trained interpreter
be present during the encounter to ensure accurate interpretation and should
document the offer and declination in the LEP person’s file. Minor children
should never be used as interpreters, nor be allowed to interpret for their
parents when they are the patients/consumers.
• See attachments #13 and #14 for a list of additional legislation that
mandates equal access to limited English proficient individuals in the
United States.
• Attachment #15 is the American Medical Association published Guide to
Communicating with LEP Patients which states: “Research indicates that when
family members, friends, strangers or other untrained individuals serve as
interpreters (known collectively as ad hoc interpreters), significantly more
interpretation errors of clinical consequence occur. Studies also show that
the use of ad hoc interpreters is associated with a high risk of
interpretation errors, omissions, distortions and redundancy. Ad hoc
interpreters are unlikely to have adequate training in medical terminology
and confidentiality, and sometimes may have priorities that conflict with
patients and may inhibit or preclude essential discussions on sensitive
issues such as domestic violence, substance abuse, psychiatric illness and
sexually transmitted diseases.”
• Attachments #16, #17, #18, and #19 show all the lawsuits that have
occurred when these legislations have been violated and untrained
individuals have attempted to act as interpreters, including one that ended
in a patient becoming quadriplegic and rewarded $71 million in settlement.
It should no longer be disputed that lack of appropriate linguistic and
cultural services in healthcare equals disaster to patient safety. Also see
http://www.healthlaw.org/library/folder.56882-Language_Access_Resources
• Attachment #20 is an article written by Leland Y. Yee as assistant speaker
pro tem of the California State Assembly about proposed legislation to
outlaw the use of children as interpreters which appeared in the San
Francisco Chronicle.
• Attachment #21 is a recent study showing that family members who function
as interpreters view themselves outside the established roles of a
healthcare interpreter.
• Attachment #22 is a recent study empirically comparing the quality of
interpreting between ad hoc interpreters (bilingual healthcare providers and
other untrained individuals acting as interpreters) and professional
interpreters. Its principal findings state: “We found that use of
professional interpreters is associated with improved quality of health care
for patients with limited English proficiency, and that professional
interpreter use is likewise associated with a positive impact that is
greater than that of ad hoc interpreters. In all four areas examined, use of
professional interpreters is associated with improved clinical care more
than is use of ad hoc interpreters, and professional interpreters appear to
raise the quality of clinical care for LEP patients to approach or equal
that for patients without language barriers” (emphasis added).
• Attachment #23 is a study from Journal of General Internal Medicine
showing that professional interpreters can improve the delivery of
healthcare to LEP patients. Attachments #24 is an article from the New
England Journal of Medicine showing the same.
• One survey by Margarita Battle of Massachusetts General Hospital revealed
that untrained interpreters translated the word “seizures” one time as
“kidnapping,” once as “lose consciousness,” once as “cramps,” once as
“stitches,” and five times the word simply wasn’t translated. It found that
these individuals commonly do not understand the provider’s words and fail
to seek clarification, misinterpret due to lack of adequate vocabulary to
interpret culture-specific idioms, specialized terms, etc. and often commit
omissions or changes in meaning.
• See http://www.nad.org/lawandadvocacy for a list of lawsuits that have
occurred when the Americans with Disabilities Act has been violated.
All these same types of things can happen with any unqualified practice
professional.
Certification/Licensure
There is no question as to how critical it is to have a way of knowing an
interpreter is minimally qualified for their work. With a credible
certification process, individual organizations need not invest so many
resources in internal interpreter screening. Certification helps protect
from legal liability and would certainly boost the institution’s credibility
in the case of reviews from organizations such as JCAHO or the U.S.
Department of Health and Human Services Office for Civil Rights.
Additionally, the existence of a quality standard for interpretation, as
embodied in a certification process, might make legislators more willing to
dedicate public funds to the reimbursement of interpreter services. And,
most importantly, providers in the institutions would be able to count on
accurate and appropriate interpreting, leading to clearer communication with
all the health, legal and financial benefits associated with it.
Legal certification exists and is in full force for federal and state court
interpreters for many languages. As of 2006 eight states have developed, or
are developing state certification for healthcare interpreters (Washington,
Oklahoma, Oregon, Indiana, Iowa, Massachusetts, North Carolina and Texas). A
few require licensure of practicing medical interpreters. Attachment #25 is
Texas H.B. No. 1341. National certification currently exists for sign
language interpreters and is jointly administered through RID and NAD
(National Association of the Deaf). The NAD website provides a beautiful
Table of State Laws and Regulations on Requirements of Interpreters which
includes all 50 states (http://www.nad.org/site/pp.asp?c=foINKQMBF&b=180366).
Many require not only certification but also licensure of sign language
interpreters. National medical interpreter certification for other languages
is currently being established. The following four organizations are heading
the project: IMIA, NCIHC, CHIA, and ATA (American Translators Association).
Attachments #26, #27, and #28 show in chronological order the progress of
the National Coalition on Health Care Certification.
Cynthia Roat, M.P.H. (founding member of NCIHC) compiled a 95-page document
entitled Certification of Health Care Interpreters in the United States: A
Primer, A Status Report and Considerations for National Certification
(attachment #29) which was released in September 2006. She explains what is
required to create and maintain a validated national certification. She
outlines the certification processes that have already been developed in the
U.S. by state agencies, commercial language companies, foundations, and
academic institutions.
The last question to address is how a professional healthcare interpreter’s
pay should fare when compared to other healthcare practice professionals.
The only pay scale that is up to market standards within the UC system is
that of sign language interpreters covered by the UPTE contract at UCLA
which ranges from about $30-$60/hour, comparable to other healthcare
practice professionals such as social workers, pharmacists, physician’s
assistants, psychologists, etc.