Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Dr. Irène Mathieu, and I’m a general pediatrician and Assistant Professor of Pediatrics at the University of Virginia. I’m also a health equity researcher and a bilingual primary care doctor who cares for patients in both English and Spanish.
Today we will be reviewing what you need to know before your first patient encounter using an interpreter. Let’s start with a few definitions. I often hear people use the words “interpreter” and “translator” interchangeably. However it’s important to remember that “interpretation” refers to spoken language and “translation” refers to written language. For example, an interpreter translates from one language to another out loud, while a translator might translate a written document from one language to another. You will probably need both interpretation and translation services at different times during your clerkship and your career in medicine. There are many ways to obtain interpreter services. The gold standard is to have a person trained and certified as a medical interpreter who can physically be in the room during the patient encounter. But that’s not always possible. The next best option is to have an interpreter on a video-chatting interface, which many clinics and hospitals have for team members to use. This way, an interpreter can dial in remotely and attend the patient encounter virtually. If a video interface isn’t available, you can also access an interpreter on the phone. Usually you would turn on speakerphone so that both you and the patient can hear the interpreter simultaneously.
Ask your resident and attending how you should best access language services.
When faced with a patient who speaks a language you don’t, the first question is to determine whether or not an interpreter is needed. Before you start the encounter, do a review of the patient’s chart. You may be able to see from previous encounters whether an interpreter was used, and if so, for what language. If the patient is hospitalized, you can also get this information from talking with the team who has been caring for the patient. If the language is a less common one, pre-arrangements for an in-person or virtual interpreter to be available at the time of the visit may need to be made. Check with the staff to find out how to get this arranged. This might take a little time, so if possible, make sure you give yourself at least a day or two to find an interpreter for a less commonly spoken language.
In some cases, you may speak the same language as the patient, but not be certified to provide medical information in that language, even if it’s your first language. If you aren’t certified as a bilingual provider, then you should use an interpreter. For information on getting certified as a bilingual provider, contact the interpreter or language services office at your institution. For instance, I was able to get certified as a bilingual provider in Spanish and English as a medical student by taking a written and oral test provided by a testing company through my medical school’s language services office. By getting this certification, you can feel confident about your skills providing medical care in a non-English language, and others on your team will know you are able to communicate with patients in a different language. But don’t forget that it’s important to constantly improve your skills and, like other aspects of medicine, that you are studying and learning how to expand your communication abilities in your non-English language or languages.
In other cases, the patient may speak some English and you are unsure about whether or not they really need an interpreter. In a case like this, I recommend having an interpreter available in case you or the patient runs into difficulty communicating. It is much easier to have an interpreter on standby than to have to stop and find one in the middle of an important conversation.
What if a member of the medical team speaks the patient’s language? Unless they are certified as a bilingual provider in that language, they should not serve as interpreter. This is because medical interpretation is a specific skill set that involves knowledge of particular vocabulary as well as interpreter etiquette. Just because a team member is, for instance, a nurse who speaks French, does not mean that they know, and can accurately interpret medical French.
Sometimes patients bring friends, community members, or family members to serve as interpreters during the visit. We do not recommend utilizing such folks as interpreters for a couple of reasons. Again, friends or community members, while well intentioned, may not actually have the skills needed to provide medical interpretation. It can also get socially tricky if you need to discuss something with the patient that they may not want a friend or community member to know about. For example, imagine you need to ask a patient about their sexual history and the person they have brought to interpret is a religious leader in their community, or their teenaged child. This could result in a very uncomfortable situation, and the patient may not be willing to be completely open and honest.
In pediatrics, an important concept to know about is adultification. This is when kids are put in situations of inappropriate power or responsibility, such as serving as an interpreter for their adult family members. Adultification can be psychologically and emotionally detrimental, and it disproportionately affects children of color and children of immigrant parents.
Before you get started, it’s important that you verify the patient’s preferred language. This may sound obvious, but unless you ask, you may not know which language is actually most comfortable for the patient! For example, you might assume that a patient who comes from Guatemala would prefer Spanish. However, in Guatemala there are many languages that are spoken, including Garífuna and over 20 distinct Mayan languages. These languages are unrelated to Spanish and to one another. While it may be more difficult to locate an interpreter who speaks Kaqchikel (which is one of the Mayan languages), the extra time you take to attempt to do so may make a huge difference in your ability to communicate with the patient. Furthermore, languages come with their own histories and cultural implications. For example, an indigenous person from Guatemala who has experienced anti-Mayan discrimination may have negative associations with the Spanish language, and feel less comfortable speaking it even if able to do so, than speaking their own first language. If an interpreter who speaks the patient’s preferred language is not available, ask them if there are any other languages they would feel comfortable using for the visit.
It’s very important to consider the physical positioning of everyone in the room during any patient encounter, but especially when you are working with an interpreter. If you have an in-person interpreter, you, the patient, and the interpreter should be seated roughly in the formation of a triangle. It’s important that you and the patient face each other in order to facilitate speaking directly to one another rather than to the interpreter. This positioning works if you are using video interpretation services as well. The interpreter’s role is to facilitate your conversation, not to take part in it. If your interpreter is on the phone, the most helpful position is usually to place the phone equidistant between you and the patient, so that you can both hear and be heard by the interpreter.
To start the encounter, always begin with introductions. Not only should you introduce yourself to the patient, but you should also give your interpreter a chance to introduce themselves to you and the patient. Make sure to take note of the interpreter’s name and/or identification number so that you can document this in your note later. This is also helpful in case you lose your connection with the interpreter or need to follow up with them later.
When speaking to a patient via an interpreter, remember to speak in short sentences and to pause after every 2 to 3 sentences in order to allow adequate time for the interpreter to communicate what has been said. If the interpreter needs clarification either from you or the patient, they should say something like, “excuse me, interpreter needs clarification.” Then they will ask you or the patient to explain more so they can correctly interpret what’s being said. One way you can utilize the skills of the interpreter is for cultural clarification. While sharing a language with your patient does not necessarily mean the interpreter understands everything about that patient’s culture, sometimes they can provide helpful context about a turn of phrase or a belief the patient expresses. If you’re confused about something the patient has said, it’s ok to ask the interpreter for clarification, in case they’re able to shed some light.
When it’s time for the physical exam, remember to say everything you are doing and allow the interpreter time to communicate it to the patient before proceeding. For example, you would want to let the patient know you are going to press on their abdomen before doing it, so you’ll need to wait an extra moment to ensure this information has been interpreted and the patient understands before proceeding. When it’s time to make a plan for next steps with the patient, it’s particularly helpful to use the teach-back method. For instance, you might ask the patient to explain the plan, which will allow you to ensure you are on the same page despite the language barrier.
Working with interpreters is not always easy. Let’s talk about a few issues you might run into. In some cases, a patient might decline interpreter services, even when you think they need one. I’ve had this happen when patients are hoping to practice their English skills or feel confident speaking conversationally in English, but may not know all of the medical terms necessary to fully express themselves or comprehend what the provider is saying. In a case like this, I will suggest to the patient that we have an interpreter available in case they are needed, but speak to one another in English for as long as possible.
In some cases, you may have two parents of a child in the encounter, one of whom speaks English fluently, and the other of whom does not. In order to make sure both parents feel heard, I always suggest using an interpreter that can speak the language common to both parents. It can create a worrisome power dynamic when only one parent fully understands what is happening during the encounter. Furthermore, the parent who speaks English often ends up serving as an interpreter for the parent who does not, and then you run into the same issues we discussed earlier, when a family member not trained and certified as a medical interpreter acts as one.
Other issues you might run into include problems with the interpreter service itself. For example, you may suspect that the interpreter is misinterpreting what you or the patient is saying. If this is the case, you could pause and ask for clarification yourself in order to understand exactly what is going on. For instance, you may suspect an interpreter has added information that you have not said to the patient. When I have encountered such a situation, I paused the encounter and respectfully acknowledged the interpreter was trying to explain the plan of care but I preferred for the interpreter to interpret only what I was saying.
If the interpreter is on a phone or video call and you are worried about misinterpretation or simply have a bad connection due to technical difficulties, you can always end the encounter and try to reconnect with a different interpreter. Sometimes visits can be complicated by ambient noise, such as a child crying in the exam room. In such a case, if possible, it can be helpful to step into another room to speak to the caregiver with the interpreter. If the parent is the only adult with a young child, that may not be possible. If it’s not possible, using the teach-back method at the end of your conversation can help to identify any miscommunications that may have happened due to distractions.
At the end of the encounter, you’ll likely have written materials you wish to give the patient. Some electronic health records contain translated patient information that you can easily insert into your after-visit summary. If you’re not sure about this, ask a more senior member of your team who is familiar with the electronic health record. There are also many vetted sources of translated patient health information online. For example, healthychildren.org, a website maintained by the American Academy of Pediatrics, has Spanish translations of all its articles free and available for public use. If you need to write out specific instructions, it is preferable to have a certified translator complete or review translations of information before providing it to a patient or family. If you have an in-person interpreter, they may be certified as a translator and be able to help you with this as well.
A recent study by Taira et al in the Journal of General Internal Medicine found that Google translate provided insufficient accuracy for discharge instructions from the Emergency Room, and that the accuracy of its translations varied considerably among different languages. For instance, while Google Translate was 90% accurate in translating discharge instructions from English to Spanish, it was only 55% accurate in its translation of English to Armenian. It’s also important to remember that just because a patient speaks a particular language does not mean they are able to read that language well. And just like in English, people have a range of medical literacy. Consider the use of pictorial or visual aids in the information you provide to patients. For instance, it may be helpful not only to provide written instructions about using an inhaler and spacer to a family in their preferred language, but also to include a picture of a child correctly using her inhaler and spacer as a visual aid. If you can’t provide your patient with a reliable translation of your after-visit summary or discharge instructions, write out the instructions in English and have the interpreter go over them with the family.
At the conclusion of the encounter, the patient may need to make a follow-up visit, head to the lab for a blood draw or see another member of the care team. Make sure they understand the next steps, and if making a follow-up visit is necessary, see if your interpreter can accompany the patient during that stage of the encounter as well. After the visit is over, be sure to document your use of interpreter services, including the name and identification number of the interpreter. It is also helpful to verify the language spoken during the encounter, especially if the electronic health record does not accurately reflect a patient’s preferred language.
Now you’re ready for your first patient encounter using an interpreter! I hope these tips were helpful. If you want to learn more about this topic, many professional societies offer guidelines and additional tips on the use of medical interpreters. I’ve included a few of these in the resources section of the show notes.
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