Even people who speak English fluently often find that conversations with healthcare professionals sound like Greek to them. So imagine if you speak only Greek or Spanish or Farsi and want to have, say, an in-depth conversation with an oncologist about the risks and benefits of an aggressive form of chemotherapy.
Until recently, the most likely interpreter in such an encounter would be a family member, often a poor choice because he or she might be reluctant to share bad news or be unfamiliar with medical terminology. But new developments are helping patients with limited English communicate better with their healthcare providers — including a 2-year-old California law that requires health insurers to provide interpreting (oral) and translating (written) services to patients with limited English proficiency, draft standards on how medical interpreting should be conducted in hospitals, two new certification bodies for medical interpreters and the rapidly increasing use of remote interpretation service by phone or video conference.
"Getting competent interpreting services to everyone who needs them is not all the way there, but we've come a long way," says Mara Youdelman, managing attorney of the Washington, D.C. office of the National Health Law Program, an advocacy group for the underserved that has studied the need and effect of medical interpretation services.
The need is certainly there. According to the federal Department of Health & Human Services' Office of Minority Health, at least 25 million Americans speak English less than "very well." Census data show that at least 40% of California residents speak a language other than English at home. (In Los Angeles, that number rises to more than 50%.)
And a 2002 report from the Institute of Medicine on health disparities found that language barriers between patients and the professionals who care for them can result in poor, shortened or wrong communication, poor decision-making and below-optimal outcomes for members of minorities.
Kathy English, now the director of healthcare marketing solutions for Internet networking firm Cisco Systems, which develops technology for remote video medical interpretation, says she got a firsthand lesson a few years back on the need for medical interpreting. She worked as a hospital floor nurse and was caring for a patient just out of surgery who spoke only Spanish. Soon after the operation, the patient began moaning in pain and pointing to his stomach. Unable to speak Spanish, English says she couldn't ask about the source of the pain, so she gave an approved dose of pain relief drugs but didn't call the doctor.
When, an hour later, the patient was still moaning and clearly in excruciating pain, English says she did call the doctor, who, on arrival, took the patient back to surgery. "If I had been able to understand the precise pain location, I would have called the doctor sooner, and speeded up his second surgery, pain relief and recovery," English says.
The right to medical interpreting falls under the Civil Rights Act of 1964. That right was further emphasized by a 2000 presidential executive order stating that healthcare organizations receiving federal funds must make medical interpretation available to patients with limited English proficiency.
According to a 2009 report by the federal Agency for Healthcare Research and Quality, California has the most comprehensive medical interpretation laws of any state. Two years ago, a law took effect in the state requiring commercial health plans to provide medical interpretation to plan members during doctor and hospital visits. The provisions also included translation of key documents, such as a plan's explanation of benefits, into very commonly used languages. And new efforts at improving the quality of medical interpretation across the country should refine the services patients can expect.
One of these changes is voluntary certification for interpreters. To be certified, interpreters must show competency in the language they will be interpreting, including medical terminology, as well as an understanding of ethics issues such as maintaining a patient's privacy. That level of competency has been long awaited. A 2002 study funded by the Commonwealth Fund found, on average, 31 mistakes in each encounter of medical interpreting in 13 sessions reviewed. Mistakes were most likely to occur when an ad hoc interpreter was used, such as a family member or hospital employee with limited medical background.
For now, healthcare organizations vary in how they test the competency of their interpreters; some groups have even developed their own courses and exams. Competency tests will be even more important next year when new national standards kick in. The standards include putting patients' language of choice into their medical records and determining that interpreters are doing a competent job. In 2012, the standards become one of the factors in a hospital's accreditation evaluation.
The two certifying organizations call for interpreters to be recertified every four or five years. This is crucial, says Hala Fam, head of the interpreter program at Ronald Reagan UCLA Medical Center. Fam, who started her career as a hospital interpreter speaking Farsi, says keeping up with drug names, new technology and changing terminology is challenging — but it's a skill she expects of the interpreters she works with.
Next month, Fam will add quite a few interpreters to her five-person team when UCLA joins the Health Care Interpreter Network, a cooperative of at least 17 California hospitals that share trained healthcare interpreters though a video/voice call center. The network requires its interpreters to take a 40-hour course and pass a competency test. When a patient requests an interpreter, hospital staff can access the network if no hospital-based interpreter is available via video- or telephone-conferencing. "Even a hospital which has a dozen full-time interpreters could often find it impossible to be available for every patient who needs interpreting," says Frank Puglisi, the network's executive director.
The network also includes clinics and health plans that serve Medi-Cal patients, and languages include Spanish, Cantonese, Mandarin, Thai, Russian, Farsi, Tongan and Hindi as well as American Sign Language.
Puglisi says many patients prefer the phone or video conferencing system to an in-person interpreter because they feel it affords them greater privacy — though respecting the patient's privacy and modesty is part of the training all interpreters seeking certification are taught. (Hospitals in the network include Harbor-UCLA Medical Center, Rancho Los Amigos National Rehabilitation Center and Riverside County Regional Medical Center.)
Numbers show the service is needed. Melinda Paras, of Paras and Associates in Emeryville, which manages the video network, estimates that Los Angeles County USC Healthcare Network, which became part of the network three years ago, now averages 30 to 50 calls/video conferences each day.
Youdelman of the National Health Law Program says patients should not hesitate to ask for translation services out of cost concerns. "Hospitals are not allowed to charge patients for the service," she says.