Claudia Mort, MD Candidate Class of 2023, University of Cincinnati College of Medicine
Claudia Mort is a third-year medical student at the University of Cincinnati pursuing Anesthesiology. Before medical school, she completed formal medical interpreter training and served as a Spanish-English medical interpreter in various community clinics and non-profits.
This work is not medical advice. Please consult your own sources.
- Importance of using medical interpreters
- Roles and limitations of medical interpreters
- Expectations when using medical interpreters
- Outcomes in anesthesiology
According to the United States Census Bureau, 21.6% of people over age 5 speak a language other than English at home, and 40% of these individuals qualify as being “LEP” or Limited English proficient. Spanish is the most spoken language in homes that are not primarily English speaking, at about 60%. This population is vulnerable to health disparities and adverse events secondary to communication problems.
Under Section 1557 of the Patient Protection and Affordable Care Act (42 USC 18116), healthcare institutions and providers receiving federal financial assistance from the U.S. Department of Health and Human Services must provide LEP patients a qualified interpreter and routine documents in their language free of charge in a timely manner. Similarly, the patient should not be excluded from access to care or discriminated against based on race, color, national origin, sex, gender, sexual orientation, and religion under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d. If patients are not offered reasonable and adequate language services, they are entitled to file a civil rights complaint to the Office for Civil Rights (OCR). If an entity or physician does not rectify practices, the OCR may seek further actions to suspend or terminate federal financial assistance from the United States Department of Health and Human Services.
Roles and Limitations of Medical Interpreters
The role of medical interpreters is to facilitate the exchange of communication between a patient and a provider as verbatim as possible in consideration of cultural practices, context, slang, and linguistic variation. Because their role is to convey information, interpreters should not be expected to be knowledgeable about medicine, pharmacology, or medical procedures beyond basics. Interpreters may also inform the physician when a patient does not appear to demonstrate comprehension.
Limitations of interpreters are just to spoken language within the assigned appointment time. Therefore, they are not required or expected to share information in writing, communicate with patients outside of the appointment, advise personally, provide transportation, or assist with physical exams or room set-up. It is important to note that while sight interpreting – reading a document in English and vocally expressing it in the desired language – may be performed, it is not suitable for certain documents such as bill of patient rights and HIPAA. It may be helpful to think of an interpreter as a fly on the wall that speaks.
To become a medical interpreter, one must demonstrate fluency in at least two languages and must complete formal classroom training and examinations that include medical terminology, healthcare systems, sensitivity, roles/limitations, colloquialisms, and the course of medical visits in diverse settings. All medical interpreters follow the code of professional standards and ethics that highlight accuracy, HIPAA, cultural awareness, impartiality, and advocacy. To maintain impartiality and limit bias, interpreters limit interactions outside of the appointment time.
Interpreters may be “trained” or “certified.” Trained medical interpreters participate in a formal education program and pass a written test to earn a certificate. They are able to work in most healthcare settings. Certified interpreters go one step further and take an additional written and oral examination by the National Board of Certified Medical Interpreters (NBCMI) or the Certification Commission for Healthcare Interpreters (CCHI). Certifications from both entities are limited to languages in reasonable demand.
It is crucial to ensure interpretation is conducted by a properly trained individual. Under Section 1557, Google, family members, friends, and office staff are not adequate or equivalent to a qualified interpreter despite fluency or previous experience. A bilingual staff member may exclusively serve if they have formal training in interpreting. Using family and friends could be traumatic and often results in inaccurate, selective, and biased information that may be unintentionally coercive or problematic from a HIPAA perspective. The only exceptions are:
- In an emergency with imminent threat to the safety or welfare of an individual or the public.
- If an LEP patient denies language services in full understanding that a qualified interpreter is available free of cost. Family member/friend must agree and may not be a minor.
- If the provider only benefits from funding through Medicare Part B
Use of Medical Interpreters: Expectations
Language services are available in person, via phone and video. Interpreters will speak in first person. For example, “my belly hurts,” not “her belly hurts.” The interpreter will stand to one side and slightly behind the patient to ease eye contact between the patient and provider and may remind both parties to speak to each other directly, not towards the interpreter. In consecutive interpretation, providers may be asked to speak in short sentences and include a pause. In simultaneous interpretation, the interpreter works at the same time as the provider is speaking. In healthcare, consecutive interpretation is most common. If the physician steps out of the room, the interpreter will wait in the hall or a common area. Arrangements for consistent matching of interpreter to patient in future appointments are not necessary since the goal is for the patient to build rapport and trust with the physician.
The Joint Commission has cited communication barriers and misunderstandings as one of the most frequent contributors to errors and lapses in patient safety. Accordingly, LEP patients are especially vulnerable to serious medical errors that may compromise quality of care and even contribute to morbidity and mortality.
Using language services in anesthesiology ensures that patients are educated on their pre-operative instructions and preparation, magnitude of their condition and needs, schedule expectations, and future steps for adequate follow up. This is especially valuable for referrals, medication reconciliation, pharmacy, and patient identification of warning signs for possible complications. With access to a deeper level of communication that would otherwise not be possible with LEP patients, the anesthesiology team is able to collect a complete medical history, identify minimizing report of pain, use of alternative medicine that may impact physiology, and relevant cultural beliefs. On the other hand, this offers patients the opportunity to build trust in the team, adequately provide informed consent, and address barriers to perioperative compliance.
In conclusion, collaboration with medical interpreters increases patient healthcare literacy, perioperative safety, and optimizes post-operative comfort and recovery. Therefore, increased awareness of medical interpreters and diminishing language barriers by anesthesiology teams have the potential to greatly reduce perioperative complications and costs associated with surgical delays and readmission. Exceptional patient safety standards and quality of care in anesthesiology requires a critical emphasis on language and communication.
Bansal VK. Anesthesiology and the non-English-speaking patient. Anesthesiology. 2017;127(4):716-717. doi:10.1097/aln.0000000000001733
Improving patient safety systems for patients with limited English proficiency. Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf. Reviewed September 2020.
Section 1557 of the Patient Protection and Affordable Care Act. Office for Civil Rights (OCR). https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html. Reviewed October 27, 2021.
Shapeton A, O'Donoghue M, VaderWielen B, Barnett SR. Anesthesia lost in translation: perspective and comprehension. Journal of Education in Perioperative Medicine. 2017;19(1). doi:10.46374/volxix-issue1-shapeton
Detailed languages spoken at home and ability to speak English for the population 5 years and over: 2009-2013. U. S. Census Bureau. https://www.census.gov/data/tables/2013/demo/2009-2013-lang-tables.html. Reviewed November 30, 2021.
U.S. Census Bureau QuickFacts: United States. U. S. Census Bureau. https://www.census.gov/quickfacts/geo/chart/US/POP815219
Posted January 2022