Trained interpreters: a necessary expense

Title VI of the 1964 Civil Rights Act, which prohibits discrimination on the basis of ethnicity by any entity receiving federal funds, directs that physicians who receive Medicare and Medicaid funds must arrange interpretation for patients with little or no proficiency in English. How far must I go in implementing this unfunded mandate?

Response

If you've ever been ill while vacationing in a land whose language you did not speak, you probably don't need to be convinced of the compassion and fundamental humanity of having foreign language interpreters for medical encounters. In the U.S., having interpretation available has been federally mandated since 2000 for anyone who receives Medicare or Medicaid funds for patient care.

The dictates of our professional ethics long preceded the law in emphasizing that physicians must provide care with compassion and respect for human dignity; must, while caring for a patient, regard responsibility to that patient as paramount; and, more recently, must participate in efforts to reduce medical error.

It doesn't take any stretching of the imagination or even any deep thinking to realize that errors are more likely to occur when patients and physicians don't understand each other than when they do. The documented reduction in adverse drug events and improvements in patient safety in hospitals where computerized physician order entry replaced handwritten orders demonstrates that misunderstanding of the written word contributes to medical error. How much more likely, then, that misunderstanding of the spoken word would do so. The lion's share of the medical encounter is conducted in oral speech.

Messages that encourage interpreter services emphasize being certain that patients understand you -- your explanation of their diagnosis and treatment plan, your instructions on how and when to take their medications. Little mention is made of your understanding them -- as though the physical exam and diagnostic testing speak for themselves.

Imagine the reduction in time, frustration and even unnecessary testing that could be achieved if you understood properly the history of your patient's current complaint, and the tests and results that he or she already had received for these signs and symptoms. Imagine the enhanced patient-physician communication and trust. On this level, proper communication with patients who have limited proficiency in English, and with those who have limited health literacy, is a matter of personal and professional pride and self-interest -- not a matter of obeying the law.

Once you are convinced of the need for language access services in your practice and have gathered some facts on the number of languages spoken by your patients and the average frequency with which you see each limited English proficiency population annually, you are in a position to determine the optimal type(s) of services for your practice. Options include: trained bilingual physicians and/or support staff, trained telephonic interpreters, and trained on-site interpreters.

The option you choose depends on the geographic location of your practice as well as your need for language access services. Professional or trained on-site interpreters often are not available in rural locations, which leaves little choice other than remote telephonic interpretation.

What do we mean by "trained" interpreters?

Competency in medical interpretation requires more than fluency in a language or even knowledge of medical terms in a language. Trained medical interpreters have received professional instruction in medical concepts and terminology, interpretation skills and process, communication skills, ethics, confidentiality and cultural issues. There is a national code of ethical and agreed-upon standards for practice in interpretation, but standards for training are only in the development stage.

This places physicians in a somewhat awkward situation; you may be able to gain a sense of the quality of the program by reviewing the curriculum utilized in the training of your interpreter. It is hoped that consensus will be achieved for training standards within the next few years.

Why is it so important to use trained interpreters rather than family or friends, or bilingual staff who have not received any formal training in interpretation?

The justification for using trained interpreters in all but "low risk" clinical situations -- patient scheduling, annual vaccinations or a wound recheck -- comes from evidence that the use of family and friends or "ad hoc" interpreters has been associated with medical errors. On the other hand, research has shown that use of professional interpreters improves quality of care and contributes to both continuity of care and greater patient satisfaction.

Physicians are therefore faced with the importance of using trained interpreters without a mechanism for financing them. Fortunately, there are some strategies you can implement to minimize your financial outlay.

If there are large numbers of patients with limited English proficiency who speak one language, the optimal choice is to use trained bilingual staff.

Medicaid or State Children's Health Insurance Programs provide reimbursement for interpreter services in 10 states currently; it is worth checking to see whether your state is one of them.

You may be able to negotiate discounted rates with local hospitals that provide interpreter services.

Try to develop collaborative contracts for use of remote, telephonic services with other local and regional physician practices, such as through an independent practice association or network.

Some bilingual students who are in health professions have volunteered to serve as medical interpreters. These students should be provided with training in medical interpretation before their service in this capacity. This option may be more realistic in an urban area with a large number of health professions schools, but, with the increasing numbers of Hispanics in rural areas, it is also possible that you can recruit students from local community colleges and provide them with a small stipend to serve as interpreters if you pay for their training.

Finally, if you do need to use an on-site interpreter, it may be more cost effective to schedule patients with limited English proficiency on a specific day for nonemergent appointments.

Margaret Gadon, MD, MPH, director of the Health Disparities Program, American Medical Association, Chicago