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Featured Article from The ATA Chronicle (June 2007)


Telephone Interpreting in Health Care Settings:
Some Commonly Asked Questions
By Nataly Kelly

The following frequently asked questions regarding telephone interpreting in health care settings may be helpful for interpreters, language service companies, and health care providers who wish to learn more about telephone interpreting, as well as its potential benefits and limitations in health care scenarios. Electronic copies of this guide for educational purposes may be downloaded at no charge from www.atanet.org/chronicle/feature_articles_monthly_archive.php, or by e-mailing the author at natalyekelly@yahoo.com.

What is telephone interpreting?
Telephone interpreting is provided when an interpreter, who is usually based in a remote location, provides interpretation via telephone for two individuals who do not speak the same language. Most often, telephone interpreting is performed in the consecutive mode. This means that the interpreter listens to each utterance first and then proceeds to render it into the other language, as opposed to speaking and listening simultaneously.

Who performs telephone interpreting in health care settings?
In the U.S., the majority of telephone interpreting is performed by for-profit companies that are external to health care organizations. However, many large health care providers have interpreting services departments with staff interpreters who also perform telephone interpreting. In some countries, telephone interpreting is provided as a free service by the government.

Is telephone interpreting a replacement for face-to-face interpreting in health care?
No. Telephone interpreting and face-to-face interpreting both have important roles in health care settings, but the two types of interpreting do not replace each other.

When is face-to-face interpreting preferable to telephone interpreting?
Telephone interpreting should be avoided, if possible, in preference to face-to-face interpreting, in the following health care situations:

1. When mental health services are being provided: Telephone interpreting should not be used in most mental health settings. The presence of telephone equipment could itself present a hazard, since it could be used as a weapon. In addition, with certain mental health conditions, telephone interpreting might confuse the patient.

2. When serving patients who are hard of hearing: Some patients who are hard of hearing and/or elderly may rely more on lip reading than they realize. In these instances, it is preferable to have a face-to-face interpreter.

3. When communicating with children: Children often have difficulties communicating over the telephone. Therefore, when a provider is communicating directly with a child, it is usually preferable to have a face-to-face interpreter. If the provider is communicating with an adult about the child, however, telephone interpreting can normally be used.

4. When providing patient education with visual components: Often, for sessions in which the provider is giving instructions to the patient (e.g., wound care, blood sugar testing), teaching aids or equipment is used. When this occurs, it is usually preferable to have a face-to-face interpreter, since an over-the-telephone interpreter will not be able to see what is being demonstrated. However, if all of the patient’s instructions will be provided verbally, with no equipment demonstrations or visual aids, telephone interpreting may be an acceptable alternative.

5. When there are multiple individuals present with limited English proficiency: Telephone interpreting is best suited to conversations between a provider and one patient only. Telephone interpreting is not ideal when the provider is speaking to multiple patients at the same time (e.g., health education classes) or when multiple individuals are present (e.g., the patient and several family members).

When is telephone interpreting preferable to face-to-face interpreting?
Telephone interpreting is preferable to face-to-face interpreting in the following health care situations:

1. When both parties (patient and provider) are already communicating via telephone. Face-to-face interpreting is not a practical option when the primary interaction is taking place via telephone, so telephone interpreting is advisable in these cases. With the rise of telemedicine and a variety of services being provided over the telephone, these situations are increasingly common. For example, when patients call appointment lines, triage lines, nurse advice lines, and other numbers for service over the telephone, telephone interpreting is the best option.

2. When trained interpreters are not available in person. When it comes to choosing among the patient’s family member, friend, an untrained bilingual staff member, or a telephone interpreting service, it is usually preferable to choose the interpreting service. This assumes, of course, that the telephone interpreting service being used has professional, trained interpreters. Most health care organizations ensure this through the process of procuring a service provider. You also may ask the individual telephone interpreter what kind of training he or she has received, and what professional standards of practice he or she observes.

3. When it is preferable not to have another party in the room. Depending on cultural, religious, and individual preferences, some patients may prefer not to have another person physically present in the room, especially when discussing sexual health issues. Some patients may fear judgment from another member of their culture, a member of the opposite gender, or speaker of their language. Conversely, however, some patients may have a greater sense of trust when an interpreter is present in person. Patient preferences may vary even among groups of speakers of the same language. Each circumstance is different, but it is worth considering that the anonymity of a telephone interpreter can be an advantage at times, especially where modesty might be a consideration.

What type of equipment should be used for telephone interpreting?
A speakerphone is often less than ideal, as it can reduce audibility for all parties and pick up unwanted background noise that can interfere with the interpreter’s ability to hear both speakers properly. Telephones with two receivers, commonly known as “dual receiver telephones” or “dual handset telephones,” can be rented or purchased from providers. These devices can enhance audibility and improve the quality of the communication. Another option, if allowed by the facility, is to use cordless telephones with two handsets. Most handsets have the option to connect a headset, allowing both the patient and the provider to move around freely without being restricted by telephone cords. It is important to sterilize the equipment before and/or after each use. Disposable mouthpiece and earpiece covers may also be advisable.

Is it true that telephone interpreters cannot perceive any nonverbal cues?
No. A large amount of nonverbal information can be perceived through tone of voice, inflection, breathing patterns, hesitations, and other auditory input. Interpreters who work via telephone should be trained specifically in listening skills that enable them to perceive and process this type of nonverbal information better. Interpreters working via telephone cannot perceive information that is transmitted visually, such as gestures and facial expressions.

How necessary is the visual aspect of interpreting?
It depends greatly on the context and the circumstance. For some settings, such as one where patient education is being provided, an interpreter might benefit from seeing the process that is being described in order to interpret accurately. Also, if an interpreter has not been trained in telephone interpreting and is accustomed to interpreting in face-to-face settings, he or she may feel at a disadvantage when visual elements are removed. To ensure quality, what matters most is that the interpreter is competent in the type of interpreting being performed, be it face-to-face or telephonic, and that he or she follows professional standards of practice.

How can I ensure that confidentiality and privacy of health information are maintained when using telephone interpreters?
Professional interpreters should always be guided by a code of ethics and standards of practice. Many providers of telephone interpreting endorse the National Code of Ethics and Standards of Practice issued by the National Council on Interpreting in Health Care. Confidentiality is an important aspect of both documents. In addition, many companies have internal guidelines and policies, as well as confidentiality agreements that are signed by all interpreters. When a health care organization contracts with a telephone interpreting provider, these issues are usually addressed contractually to ensure that privacy is maintained.

How should medical records be documented when telephone interpreters are used?
For most telephone interpreting companies, the single most important item to note when tracking a call is the time at which the call took place. Therefore, it can be useful for providers to note the start time of a call with an interpreter, as well as the end time of the call. In addition, the provider should note the identification number of the interpreter, if applicable, and the name of the interpreter. Some companies do not allow the interpreters to provide their last names. If this is the case, the first name and the identification number are sufficient to track the call if a need ever arises. Aside from noting when the call took place and the interpreter’s identifying information, if more than one telephone interpreting provider is used in your facility, it may be helpful to note the name of the company as well.

Can a telephone interpreter help me convey written information (patient education materials, consent forms, prescriptions, etc.)?
Telephone interpreters can provide limited “auditory translation” by listening to the health care provider read information aloud from a written source document, and then rendering it into another language. However, this is not advisable for a variety of reasons. Any legal document, such as a consent form, should be made available in a language the patient can understand, if possible, in writing, as should patient education materials. It is preferable to translate such materials in advance. Doing so will also provide significant cost savings to organizations in the long run, especially when compared to the cost of paying for telephone interpreters to produce this same information verbally, to multiple patients, over time. In some cases, it is not possible to translate information in advance. For example, when a provider writes a prescription, there may be no choice but to have the telephone interpreter explain to the provider how to write those words so that the patient will understand them.

What about video interpreting? Does it have the potential to replace telephone interpreting and on-site interpreting completely?
Video interpreting combines some benefits of both on-site and telephone interpreting. High-quality video interpreting equipment can be cost-prohibitive, but as the costs associated with the technological requirements decrease, video interpreting is becoming a viable option in some cases. Still, there are certain settings for which having an on-site interpreter is usually preferred. In some situations, such as when dealing with a person with a terminal illness or mental health issue, there is no replacement for having another human being present. Likewise, there will continue to be situations in which telephone or audio-only interpreting is preferable, especially in situations where modesty and/or anonymity are important. As technology becomes more accessible and economical, it is likely that there will simply be audio and video streams when calls are placed over the Internet. If a patient prefers not to be seen, or if only the audio portion is required, it would be easy to choose to have either or both options available using Internet telephony. Also, both providers and interpreters will require extra training in video interpretation techniques and equipment use in order to provide a high-quality service.

Where can I learn more about telephone interpreting in health care settings?
There are not many resources devoted specifically to telephone interpreting in health care settings. However, the resource list below can be helpful for those interested in obtaining additional information, guidance, and practice.

TRAINING
Online Training for Doctors on Working with Interpreters
This web-based program, developed by Cindy Roat and Dr. Elizabeth Jacobs, confers up to 2.5 continuing medical education credits through Rush Medical College. It uses video and case studies to train doctors on: how to work with professional interpreters; how to guide an untrained interpreter; how to work with a telephonic interpreter; how to work with interpreters in mental health settings; and how to start to develop a language access program internal to a hospital or clinic. For more information, contact Bob Amend at (520) 722-1970 or bamend@md-inc.com.

BOOKS
Kelly, Nataly. Telephone Interpreting: A Comprehensive Guide to the Profession
(U.K.: Multi-lingual Matters, 2007).  .multilingual-matters.com
This publication includes a “Client Considerations” section with detailed advice, as well as a mnemonic with 20 guidelines for working effectively with telephone interpreters. The publication also includes model standards of practice for telephone interpreting in health care, along with practice scenarios. A free electronic sample chapter may be requested at the above link.

WEB RESOURCES
The Art of Working with Interpreters: A Manual for Health Care Professionals.
www.acebo.com/papers/art intrp.htm
This article by Holly Mikkelson provides helpful information on working with health care interpreters in various settings. It is available for download at the above link.

Moreno, Aura, and Lilian Ramsey. “Telephonic Interpreting in Health Care:Answers to a Few Questions.” Interpreters Voice (Fall 2006)
www.ata-divisions.org/ID
This article from the newsletter of ATA’s Interpreters Division includes several questions about telephone interpreting that are answered by professional health care interpreters.

Getting the Most from Language Interpreters
www.aafp.org/fpm/20040600/37gett.html
This article by Emily Herndon and Linda Joyce from Family Practice Management includes a small section with guidelines for working with telephone interpreters. It is available for download at the above link.

OTHER RESOURCES
The majority of telephone interpreting providers offer free client training materials (in print and electronic formats), web tutorials, newsletters, training sessions, and/or multimedia presentations.

Nataly Kelly is an independent consultant based in New Hampshire. She is also a certified court interpreter (State of Missouri) for English and Spanish. A former Fulbright scholar in sociolinguistics, her research interests focus on interpreter certification, quality improvement programs, and telephone interpreting. She currently serves on the National Council on Interpreting in Health Care’s Outreach Committee. She is the author of Telephone Interpreting: A Comprehensive Guide to the Profession (Multilingual Matters, 2007). Contact: natalyekelly@yahoo.com.