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Featured Article from The ATA Chronicle (January 2010)

 

Post Traumatic Stress Mess Or How I Learned to Stop Worrying and Love Medical Interpreters
By Michael King

The tricky thing about drawing a line in the sand is knowing how to respond when people start to test it. At least, this has been my experience recently when dealing with the complex issue of medical interpreters.
About a year ago, I was hired to manage the behavioral health department of a system of clinics. Many of our patients speak Spanish, and until I arrived, the modus operandi had been for staff to ask family members or friends to accompany patients to interpret. If no such resource was available, the providers would request that a bilingual staff member facilitate communication. This was one of the first clinic practices I set out to change, but I never expected that the effort would take so long or that a final resolution of the issue would prove so challenging.

Client Education Starts at Home
What I quickly realized as I began my work was that our clinic was far from the only one in our organization that approached medical interpreting in a less-than-ideal fashion. All clinics either used family members or, more often, enlisted the aide of a bilingual staff member, usually a medical assistant or nurse. Unfortunately, our behavioral health department had no medical assistants or nurses. Left with only front desk staff, those asked to interpret were persons who had no training in professional interpreting and no background in medical concepts or terminology.

Coupled with the task of finding another source of medical interpreting was my obsessive desire to train staff to understand the difference between translation and interpreting. This is not as easy as you might think, and the resistance I encountered as I gently corrected people was nothing if not comical. Some psychiatrists resisted the distinction out of hand, not stopping to think that if a layperson confused him or her with a psychologist, we could all rest assured that the offending party would receive a prompt and thorough reeducation.
I persisted in my pedantic ways and achieved mitigated success. For example, my supervisor at the time, who was bilingual, gave an interview last winter to the local affiliate of the Spanish television network Univision about the services we provide. The issue of interpreting came up briefly and she fumbled on the word, later telling me that this was the only time in the interview that her delivery was not pitch perfect. I smiled broadly. That’s one battle won, I thought to myself.

Quality Versus Economics
In short shrift, I forbade front desk staff from interpreting and hired a local professional interpreter for all patients requiring language services in Spanish. The interpreter was extraordinarily gifted and maintained a mode of professionalism I admired. From my organization’s perspective, she was also quite expensive, charging a two-hour minimum that stood even if patients did not show for their appointments. I understood that this was justifiable—interpreters are paid for their time and our clinic is located some 20 miles from a large city center. I defended my decision by explaining this reality and pointing out that the needs of a behavioral health clinic are different from those of medical clinics. Given that our appointments last anywhere from 30 to 90 minutes, we could not reasonably pull support staff from their other duties and still manage workflow. I was allowed to continue hiring the interpreter, with the mutual understanding that this was a temporary measure and that we would work toward finding a more financially viable long-term solution.

In the ensuing months, there were a few occasions I was called to interpret. Clinic staff would unwittingly schedule two patients who required interpreting services at the same time but with different providers, or they would forget to contact the interpreter. We had no contract for telephone interpreting and some of our providers were booked out as far as a month. Rather than tell patients who arrived for their appointments as expected and on time that they would have to reschedule, I offered my services with the disclaimer that I was not the interpreter we normally use, but would help facilitate communication.

In the back of my head, I heard the voice of the famous doctor of the original Star Trek series: I’m a translator, damn it, not an interpreter!

All in all, I performed much better than expected given my lack of formal training. But my brief interludes as an interpreter were not without incident. One day, the topic of post traumatic stress disorder arose. I interpreted the expression as desorden de estrés postraumático. Curious as to whether I had gotten it right, I consulted my Spanish dictionary when I returned to my office. Not bad, except that in Spanish trastorno is the word usually used for disorders of a medical nature, while desorden is more often used to connote the disorder as a mess or disarray. Post Traumatic Stress Mess…great! I shuddered internally, but consoled myself with the perspective that the error did not obscure the meaning of the communication. My foible, I told myself, was akin to the extraneous indefinite article that John F. Kennedy notoriously added to his 1963 Ich bin ein Berliner speech in West Berlin. Nonetheless, after this I doubled my efforts to ensure that the professional interpreter was always scheduled properly.

One Small Step
As time passed, the pressure to find less costly methods of procuring interpreting services grew. I identified a local nonprofit organization that would train our bilingual staff to serve dual roles and would give them a base level of knowledge in interpreting methods, ethics, and legal issues. Although from an experiential standpoint this was not preferable to a professional interpreter, at least I could get the staff some measure of training. Alas, I was told that the course would be too expensive, especially in light of employee turnover and the certain need to train new staff continually.

I consulted the organization that provides the instruction and was told that they could also provide staff members—presumably the more stable, long-term ones—with the training they would need to teach future interpreting classes internally. In response, I learned that dual-role interpreters, even untrained ones, presented a workflow challenge for my company. It appeared that our other service lines, which had continued to use their bilingual medical assistants and nurses, had been experiencing severe challenges in their ability to see patients promptly. Every time a medical assistant or nurse had to interpret for a doctor, that was one less member of the support staff available to take vitals or perform other essential duties. Every time a front desk staff member was pulled, one less person was available to check patients in or out or answer phone calls. The resources of the clinics were particularly strained when three or four patients required interpreting services at the same time. Something, I was told, had to give.

Many good minds contributed their ideas on the issue and attempted to find a solution that was both appropriate for the standard of care and sustainable from a business perspective. That a solution was not readily apparent only underscored the enormous logistical challenge the issue presented.
After performing a number of interpreting appointment time studies and pro forma financial analyses, clinic administrators focused on telephone interpreting as a potential answer. Several concerns with this approach were raised and answered, and our company resolved to conduct a pilot project in a small sample of clinics. I requested that behavioral health be included in this initial phase.

Not long afterward, in a meeting with our behavioral health administrator and medical director, I was told that some of the physicians in other clinics were expressing resistance to the idea of using telephones to contact interpreters. Apparently, they were more than content to continue using their medical assistants and nurses. At word of this, the medical director chimed in. “Well, I’ve been practicing psychiatry for 20 years,” he declared, “and I’ve never had a problem with asking front desk staff to translate.” He paused, glanced in my direction, and amended, “…interpret.” Well, I thought, at least that’s progress.

 

Tips on Advocating for Medical Interpreting
Are you unsure of how to approach your employer about the need for professional interpreting services where you work? Perhaps the following tips can help:

Be persistent yet patient. Efforts to change institutional practices are long-term endeavors. Aim to educate first, and then work on practical solutions.

Focus on practicality. In order to advocate successfully for a change in business practices, you have to demonstrate how your approach makes sense from the perspective of your organization’s business model. Provide clear and convincing evidence that the status quo is unacceptable.

Understand the relationship between quality and cost. Or, as economists might say—there is no such thing as a free lunch. You can argue that all interpreters should be contracted from an organization that is ISO certified, but given the cost for this level of quality, what is the likelihood that your appeal will be taken seriously?

Be willing to compromise and offer options. The quickest way to shut down a discussion is to insist that there is only one right way to resolve a challenge. Come to the table with options.

Accept small victories. All progress is meaningful. If your organization began by asking the family members of patients to interpret and subsequently agreed to use only bilingual staff—even if untrained—treat this as a success.

Maintain open dialogue. It is not always a bad sign if your organization does not act immediately on your suggestions. The most important goal is to keep avenues of communication open.

Remember that both you and your organization want the same thing. In the final analysis, both you and your company want to provide high-quality care to patients. If your company disagrees with your proposed solutions to the issue of medical interpreting, investigate its concerns and work to resolve them.

Michael King translates from Spanish and Italian into English, specializing in the fields of business and law. He has worked in education, health care, and state government.