More than 31 million foreign-born people live in the United States.1 Eighteen percent report speaking a language other than English at home, and almost half say they speak English “less than very well.” Under Title VI of the Civil Rights Act of 1964 and Executive Order 13166, patients with limited English proficiency (LEP) have the right to a trained interpreter. Any practice receiving federal funding aside from Medicare part B must comply. Failure to use interpreters for LEP patients has led to higher hospital admission rates, increased use of testing, poorer patient comprehension of diagnosis and treatment, and misdiagnosis and improper treatment.2–4 This article provides some general guidelines to help maximize communication with LEP patients when using interpreters of all skill levels.
What is a “trained language interpreter”?
Trained language interpreters have formal education in interpreting and abide by a professional code of ethics that includes confidentiality, impartiality, accuracy and completeness. Good medical interpreters are not only fluent; they are also familiar with medical terminology and have experience in health care. Although there are several accredited training programs for medical interpreters, there is no national certification. In fact, only Washington offers state testing and certification. Fortunately, most companies that offer interpretation services have developed procedures to “qualify” their interpreters and can provide verification of their training and certification.
Well-trained interpreters convert the meaning of all messages from one language to another without unnecessary additions, deletions or changes in meaning and without injecting their own opinions. They act as message clarifiers when there is a possible misunderstanding and are always careful to ensure that neither party is left out of the discussion. Interpreters can also act as cultural clarifiers when traditional health beliefs or practices lack equivalent terms. Well-trained interpreters will communicate both verbally and nonverbally, in such a way that their presence is barely noticed by either party. Trained interpreters are costly but can save time and resources in the long run by decreasing the number of callbacks, misdiagnoses and unnecessary tests, and increasing patient comprehension, compliance and satisfaction.
Although the success of an encounter with an LEP patient is strongly dependent on an interpreter’s training, family physicians can do several important things to facilitate the process. For example, if you have a choice or feel that a patient would prefer it, ask for an interpreter of the same gender as the patient. Some patients feel more comfortable having someone of the same sex interpret for them, particularly when discussing personal issues.
According to the Civil Rights Act of 1964 and Executive Order 13166, patients with limited English proficiency have the right to a trained interpreter.
Well-trained interpreters abide by a code of ethics and interpret without unnecessary additions, deletions or changes in meaning, and without injecting their own opinions.
Friends or family members may unconsciously screen what they hear and provide only a summarized interpretation to the other party.
Guidelines for using trained on-site interpreters
Other points to keep in mind when working with an on-site interpreter include the following:
Confidentiality. Prior to the office visit, give any necessary background information to the interpreter. Remind the interpreter that everything you and the patient say needs to be interpreted and that all information must be kept confidential. When you enter the exam room, introduce yourself and the interpreter to the patient. Have the interpreter explain to the patient that all information will be kept confidential.
Addressing the patient. If you can, position the interpreter so that he or she is sitting beside the patient, facing you. Maintain eye contact with the patient (if culturally appropriate) and be careful to address the patient, not the interpreter. For example, look at the patient and ask, “Have you had any fever?” instead of asking the interpreter, “Has she had any fever?” Before entering the exam room, ask the interpreter to speak in first person when speaking for either you or your patient (e.g.,“I think you have an ear infection”). Statements in the third person (i.e., “The doctor thinks you have an ear infection.”) can create a barrier between you and your patient. When both sides talk directly to each other, the interpreter has the opportunity to melt into the background and unobtrusively become the voice of each party.
Time constraints. Because English is relatively direct compared with other languages, interpretation might take longer than you expect. Consequently, you should allow for extra time. When interacting with LEP patients, keep your sentences brief and pause often to allow time for interpreting. Avoid highly technical medical jargon and idiomatic expressions that may be difficult for the interpreter to convey and the patient to comprehend. Use diagrams and pictures to facilitate comprehension. Listen without interrupting and make it a point to confirm that the patient understands by asking him or her to repeat important instructions back to you. Pause at several points during the conversation to ask whether the patient has any questions. Many cultures see questioning physicians as a sign of disrespect and may be hesitant to respond initially. Finally, if you have any concerns or questions about the interpretation, don’t hesitate to ask the interpreter.
Guidelines for using trained phone interpreters
If you don’t have an on-site interpreter available, using a phone interpreter service is another option. (For a partial list of companies that provide these services, see the resources box). Costs for phone interpretation services vary between $2 and $3 per minute, but you may be able to negotiate a lower price based on volume. Setting up an account with a service is the most cost-effective method for frequent users. If you rarely need interpreter services, some companies will allow you to access their services without an account, but will generally charge more per minute and add on a service fee of several dollars for each call.
A distinct advantage of phone interpretation is that companies generally offer a wide variety of languages from which to choose. The main disadvantage to phone interpretation is that the interpreter does not have the ability to read the nonverbal clues accompanying the interactions. Though the same general principles for using on-site interpreters apply, the following points are unique to working with phone interpreters:
Confidentiality. Interviews using phone interpreters should be conducted in a private room with a speakerphone. For three-way conversations, consider investing in splitters and extra handsets. These are relatively inexpensive and help to maintain privacy. Begin every phone interview by reminding the patient and the interpreter that all information must be kept confidential.
Setting the stage. The phone interpreter does not have the advantage of seeing you or your patient face-to-face. After introducing yourself, give a brief statement summarizing the clinical situation (e.g., “This is a doctor’s office and I’m with a patient who is six months pregnant”).
Time constraints. Because of the cost of using a phone interpreter, it is important to use your time wisely. Before calling, prepare yourself by compiling a list of questions you want to ask and the information you need conveyed. Often, two separate phone calls will be necessary during the patient visit: one to take the patient’s pertinent history and another on completion of the physical exam to discuss findings, diagnosis and treatment. Always leave time at the end of the phone call for questions or to have the patient repeat important instructions back to you.
There are many resources available to help you better understand the cultural backgrounds of the patients in your community. Two good Web-based resources include DiversityRx (http://www.diversityrx.org) and the Cross Cultural Health Care Program (http://www.xculture.org). Further information about caring for patients with limited English proficiency is available at http://www.lep.gov. For help locating an interpreter association near you, contact the National Council on Interpreting in Healthcare at http://www.ncihc.org. Companies that provide trained telephone language interpreters for health care workers include Language Line (http://www.languageline.com), CyraCom International (www.cyracom.net), Telelanguage (http://www.telelanguage.com) and MultiLingual Solutions (http://www.mlsolutions.com).
Using untrained interpreters
It is not uncommon for LEP patients to have family members or friends interpret for them. Although the guidelines state that LEP patients can select an interpreter of their choice, using friends and family members has its limitations. For example, most untrained interpreters don’t have enough medical knowledge to be able to understand or explain medical terminology. Patient confidentiality may also be an issue. With friends or family members in the room, patients may be unwilling to volunteer sensitive information. It may also be difficult for friends or family members to interpret what is being said. Often, they will unconsciously screen what they hear and give a summarized interpretation to the other party. This decreases the accuracy of the interpretation and may also serve to weaken the doctor-patient relationship. If you don’t have access to an interpreter, it may be best to use a bilingual staff member rather than a patient’s friend or family member. However, some states have laws about who can perform medical interpretation. Before you ask a bilingual staff member for help, check with your state health officials.
Most patients are willing to use a nonfamily member as an interpreter once they are assured that patient confidentiality will be maintained. However, if a patient insists on a family member and you feel communication isn’t accurate or adequate, you have the right to call in your own interpreter as well. When using someone other than a trained interpreter, have the person doing the interpreting review the guidelines for on-site interpreters above.
A few words about documentation and billing
When documenting an encounter with an LEP patient, it is important to include the language spoken and the interpreter’s name (for on-site services) or the company used (for telephone services). If a patient insists on using a family member or friend, document that this was by choice (i.e., “per patient request”). Although you cannot bill a patient for the actual service provided by the interpreter, you may be able to bill a prolonged service code (99354-99357) in addition to the appropriate E/M code. (For more coding information, see “Time Is of the Essence: Coding on the Basis of Time for Physician Services,” FPM, June 2003, page 27.)
When you speak the language
You may decide you have enough proficiency in a foreign language that an interpreter isn’t necessary. Unless you are fluent in the language, it is a good idea to use an interpreter (especially following the exam) to ensure and document patient understanding. To do so, simply call a phone language service or ask an on-site interpreter to join you in the exam room at the end of the patient visit. Ask the interpreter to ask the patient if he or she has any additional questions. Also ask that the patient repeat back to you any instructions you may have given. You may be surprised to discover that you and the patient were not communicating as well as you thought!
Phone interpretation services generally offer a wide variety of languages from which to choose. Costs vary from between $2 and $3 per minute.
Using a phone interpreter for a patient visit usually requires two separate phone calls: one to take the patient’s history and another following the physical exam to discuss findings, diagnosis and treatment.
It is not uncommon for LEP patients to have friends or family members interpret for them. Using untrained interpreters, especially children, has limitations.
Untrained interpreters may not understand what is being said or they may filter what they hear and give only a summarized interpretation to the patient.
Depending on state law, it may be preferable to use a bilingual staff member rather than a patient’s friend or family member if a trained interpreter isn’t available.
Unless you are fluent in the language, it’s always a good idea to use an interpreter to ensure and document patient understanding.
Failure to use interpreters for patients with limited English proficiency (LEP) has led to higher hospitalization rates, increased testing, misdiagnosis and poorer patient comprehension.
While the success of an encounter with an LEP patient strongly depends on an interpreter’s training, family physicians can do several things to improve the interaction.
Physicians should avoid medical jargon and idiomatic expressions, use pictures to facilitate comprehension and ask the interpreter to speak in the first person.
Physicians who don’t have access to an on-site interpreter or have very few LEP patients in their practices may find a phone interpreter service to be more convenient and cost-effective.