By Cindy McGlynn
Summer 2004, Vol 7 No 4
A young man enters the emergency room of a U.S. hospital. He’s South East Asian and doesn’t speak English. He has with him a bilingual friend who tells doctors the man is hearing loud noises. As the ER doctor prepares to send the client for a battery of audiology tests, a trained medical interpreter arrives. The interpreter is fluent in English and Cambodian, the client’s mother tongue. After she speaks with the client for a few minutes, it becomes clear that the loud noises are explosions. The man is having flashbacks to bombings in his village. The best audiology services on the planet won’t help him, since what he needs is mental health care.
This type of situation vividly illustrates the value of professional interpreters in health care settings. Statistics show that trained interpreters improve diagnosis, make for better prognosis and, ultimately, save health care dollars. With an increasingly multilingual population, advocates insist that the need for interpreters is not a special request, but a basic need. In fact, interpreter services are key to meeting a broader need — opening access to health care. Dr. Jose Silveira is director of Portuguese Mental Health and Addiction Services at Toronto Western Hospital. “As soon as language services are available, people come out of the woodwork,” he says. “Since our Portuguese unit got going five years ago, we have been overwhelmed. But where were these patients going before? Well, they weren’t going anywhere.” Beyond simple access, “good communication is key to good health care,” says Silveira. “For the patient, having interpreter services means an increased likelihood of symptom resolution and an increased quality of life. For the provider, it increases the accuracy of the diagnosis, uncovers subtleties that otherwise would not come out and increases the likelihood that clients will follow recommendations.”
In theory, governments agree. The U.S. Civil Rights Act of 1964 requires any institution receiving federal funding to serve individuals equally, regardless of country of origin. This means having interpreter services readily available. The law is less specific in Canada, although the Charter of Rights and Freedoms and human rights legislation provide a framework for language rights. But until very recently, many health care providers relied on family members or volunteers to interpret for clients. Some still do. With 18 per cent of Canadians and eight per cent of Americans speaking only languages other than English as their mother tongue (according to 2000 U.S. Census Bureau and 2001 Statistics Canada data), this ad hoc system rarely meets demand.
Dr. Eric Hardt, medical consultant to interpreter services and clinical director of geriatrics at the Boston Medical Center, has worked for decades to build an exemplary interpretation service at his hospital. With an annual budget of 2.2 million dollars, the service includes a team of 30 full-time interpreters, 25 per diem interpreters and other contracted staff, working in more than 50 languages. He explains the many reasons why volunteer interpreters are not considered best practice. “Many of these are great people, but that doesn’t necessarily mean they’re very good at functioning as an interpreter,” he says. “They have no training or supervision; they don’t understand the techniques; they have no understanding about roles and no sense of medical professionalism, like issues of confidentiality.”
In practice, the most basic role of the interpreter is to deliver, as faithfully as possible, messages transmitted between people who don’t share a common language. To practise in a health care setting, an interpreter needs extra training to understand terminology, diagnosis, roles and procedures for good communication to occur. Interpreters may also need to remind doctors of their role. This means ensuring doctors speak directly to the client, not the interpreter, who usually sits slightly behind the client. It means not stepping out of role to answer medical questions about the client.
“Doctors might ask interpreters to do things that are outside their scope of practice,” says Cynthia E. Roat, who developed Bridging the Gap, the most widely offered training for U.S. medical interpreters, and is co-chair of the U.S. National Council on Interpreting in Health Care. “For example, they may ask the interpreter what is wrong with a patient or if they think the patient is telling the truth. These are inappropriate questions. We’re not trained in medical interviewing or mental health interviewing. But a doctor could ask an interpreter if the speech is slurred. This is a very good question.”
Stella Rahman, co-ordinator of Cultural Interpretation Services at the Centre for Addiction and Mental Health (CAMH) in Toronto, has a freelance team of 92 trained interpreters working in 55 languages. She personally interviews each candidate and says the professional training interpreters need is rigorous. “I look for a proof of language competency test in English plus the language they are interpreting for,” she says. “I look to see if they have gone through interpreter training and whether that included a code of ethics that covers professional issues like accuracy and confidentiality.”
In Ontario, proof of language competency usually means having passed one of two standard language competency tests – the Cultural Interpreter Language and Interpreting Skills Assessment Test (CILISAT) or the Interpreter Language and Interpreting Skills Assessment Test (ILISAT). Interpreter training involves anywhere from 40 to 90 hours of education, covering areas like cultural sensitivity, codes of ethics and roles of interpreters (see sidebar). Medical interpretation is further specialized, although neither Canada nor the United States has a national accreditation body.
Interpreting for mental health settings is yet another subspecialty with a dearth of training services. Only a few Canadian organizations, like CAMH, offer their own mental health training to interpreters. And Roat says she’s only aware of three or four U.S. organizations that offer mental health training. Interpreters must also know when it is their role to go beyond basic interpreting. Cornelia Brown, executive director of the Multicultural Association of Medical Interpreters of Central New York (MAMI of CN.Y.) works with people who have experienced domestic or sexual violence. Her organization offers training based on the Bridging the Gap program and includes a discussion of advocacy issues. An example might be the appropriateness of helping beyond the interpreting session, perhaps by helping the client get a referral to a medical specialist. “One guideline is that the patient must want you to do advocacy, and the patient would have to have a serious health problem if the advocacy weren’t done,” says Brown.
The demand for qualified interpreters may be clear. But for now, the question of who will foot the bill for funding for both interpreter training and services is up in the air. Silveira says the issue is on the radar of the Ontario ministry of health and has been identified as a focus in the literature that will guide the next decade in health care service in the province. Roat says a fresh perspective is needed to resolve systemic issues. “Oncology developed because of a growing cancer rate among an aging population. Geriatrics developed as population got older. Now our populations are becoming much more heterogeneous linguistically. We need to change how health care is provided so interpreters become as much a part of the landscape as an X-ray machine, a pharmacy or an exam room. It’s that basic.”
“Statistics show that trained interpreters improve diagnosis, make for better prognosis and, ultimately, save health care dollars.”
“We need to change how health care is provided so interpreters become as much a part of the landscape as an X-ray machine, a pharmacy or an exam room. It’s that basic.”
Language proficiency – Interpreters should be fluent in both the language they are translating from and the one they are translating to. In Ontario, interpreters should have Cultural Interpreters Language and Interpreting Skills Assessment Test (CILISAT) or Interpreter Language and Interpreting Skills Assessment Test (ILISAT) credentials.
Specialized medical interpretation training – Interpreters should be trained in medical terminology and diagnosis and how to respond professionally to medical and ethical dilemmas.
Mental health training – Specialized training offers familiarity with terminology, ethics, diagnosis and specifics about the mental health system and specific interpreting situations and dilemmas that may arise.
Code of ethics – Interpreters should have a clear understanding of their role and the importance of confidentiality, respect, impartiality, accuracy and completeness of communicating the client’s message.
Cultural sensitivity – Interpreters must be culturally competent in all languages they interpret for.
Personal skills – Interpreters are organized, tactful, empathetic and assertive.