More than 25 million Americans speak English “less than very well,” according to the U.S. Census Bureau, and more than 60 million speak a language other than English at home.¹ This population is the least likely to receive preventive care, have access to regular care, or be satisfied with their care.² Patients with limited English proficiency are much more likely to have adverse effects from drug complications, poor understanding of diagnoses, low health literacy, and a greater risk of being misunderstood by their physicians.^3,4

Title VI of the Civil Rights Act requires interpreter services for all patients with limited English proficiency who are receiving federal financial assistance, with the exception of Medicare Part B.⁵ Failure to provide these services when necessary is considered discriminatory and illegal. In most states, however, these services are an unfunded mandate because Medicaid, Medicare, and most private insurers do not pay for interpreter services,⁵ although a prolonged service fee may be appropriate because of the extra time required for office visits.⁶ The American Academy of Family Physicians supports legislation to improve health care access and provide funding for patients with limited English proficiency and those who are deaf,⁷ but because professional interpreter services are not reimbursable, many clinicians still rely on family, friends, or bilingual staff as ad hoc interpreters, which increases the risk of patient dissatisfaction, medical errors, unnecessary testing, poor adherence, and malpractice exposure.^5,8 In one example, office staff misinterpreted the word intoxicado as intoxicated instead of the intended meaning of inadvertent toxicity. A fruitless evaluation for drug abuse was conducted while an intracerebral hemorrhage was missed, resulting in a $71 million malpractice award.⁹

Professional medical interpreters are trained to interpret the spoken word, whereas translators work with written words. Although the two professions are often confused, they require different skill sets, with interpreters working in live situations.¹⁰ National certification for medical interpreters is still fairly new and is provided by the Certification Commission for Healthcare Interpreters (http://www.cchicertification.org) or the National Board of Certification for Medical Interpreters (http://www.certifiedmedicalinterpreters.org). The Registry of Interpreters for the Deaf provides certification for deaf interpretation (http://www.rid.org).

Choosing an Interpreter

Professional interpreters are often not available, although larger institutions and universities employ them or use employee or community language banks as needed. Therefore, multilingual staff members should be encouraged to receive additional training in interpretation technique; fluency alone does not make them effective interpreters. With more than 100 languages spoken in the United States,⁴ the most feasible option for most offices is usually a telephone service such as LanguageLine Solutions (http://languageline.com) or CyraCom Language Solutions (http://www.cyracom.com). Soon after a request, an on-call trained interpreter is connected by phone for the interview. Clinics can subscribe to the service or pay per call ($2 to $3 per minute without a contract). Use of telephone interpreters is not inferior to having a bilingual health care professional.¹¹ However, if a patient insists on having a family member as an interpreter, this should be recorded in the patient's chart.⁶

Interpreter services for patients who are deaf are usually provided through video remote interpreting, in which a two-way video link facilitates American sign language communication. Video relays (on-screen sign language interpreters), closed captioning (spoken words appearing on screen), telephone typewriters, lip reading, and simple texting or writing are alternative means of communication. It is not advisable to rely on computerized translation services in which typed phrases are automatically translated online or spoken with a prerecorded voice. These are often rough renderings that miss critical information, even when used for something as simple as prescription labels.¹² However, they may have a role in translating specific medical terms that are misunderstood by patients who are otherwise fluent in English.

Using an Interpreter

Table 1 lists tips for using medical interpreters. It is best to meet briefly with the interpreter before the patient encounter to make sure he or she is the appropriate choice, give some clinical background, build rapport, and set goals.¹³ This is especially important with untrained interpreters; coaching on technique can greatly facilitate the interview. The interviewer should speak in the first person (“I” statements), not the third person (e.g., “tell her,” “he said”), and speak directly to the patient, whereas the interpreter should function as an inconspicuous conduit for the conversation.¹⁰ This is facilitated by seating the interpreter next to or slightly behind the patient.^10,13 The clinician should speak in short sentences, then wait for the interpreter to convey them.⁶ Jargon, idioms, acronyms, and jokes should be avoided; attempts at humor are often lost in interpretation. Participants must aim for complete transparency, where everything said is interpreted for everyone present.¹⁴ Because most patients comprehend at least some English, it is advisable to refrain from making comments that the patient should not hear.¹⁰ Control of the interview is maintained by limiting tangential discussions.

Although interpreters function primarily as conduits for a discussion, they may secondarily serve as clarifiers, cultural liaisons, or patient advocates.¹⁵ Clarification occurs when the interpreter interjects a brief explanation, often prefaced by the words “the interpreter would like to state….” The interpreter can also function as a cultural liaison to help the clinician understand cultural beliefs about illness causation or care. The interpreter may even serve as a patient advocate by helping the physician understand barriers to dietary modifications, filling prescriptions, or proper follow-up.¹⁵

Common Pitfalls

The use of untrained interpreters is the proverbial “broad path of least resistance,” resulting in many pitfalls. Ad hoc interpreters—usually friends or family—have multiple limitations (Table 2).^{4,8,13,16–19} The clinician does not know how effectively his or her message is being interpreted, which makes it easy to lose control of the interview. Nonprofessional interpreters have not received training about the Health Insurance Portability and Accountability Act and may not be aware of the need for confidentiality. Other potential problems include unfamiliarity with medical terminology, embarrassment about intimate or sexual issues (about which the interpreter may substitute euphemisms), unsolicited advice, and mixed motives or personal agendas.¹⁷ The use of younger children as interpreters is especially problematic because of their limited understanding of adult issues,¹⁶ and this practice is forbidden in several states. The use of nonprofessional interpreters increases the risk of nonequivalent interpretations, leading to possible misunderstandings.¹⁹ Partially bilingual physicians face yet another pitfall: deciding to use their own limited language skills vs. hiring an interpreter. It is much easier to ask questions in another language than to understand the response. Overconfidence in one's language abilities can lead to serious errors and substandard care.²⁰

Even when using a professional interpreter, care must be taken to avoid common mistakes (Table 3). More than one-third of all Americans have limited health literacy, which leads to difficulties in navigating the complex U.S. health care system²¹; this is especially true for patients with limited English proficiency. Limiting the discussion to three major points may help avoid overwhelming the patient and interpreter.²² Patients often do not understand directions, even though they may nod or say they do. It is best to use the “teach back” or “show me” technique, in which the patient is asked to repeat the directions in his or her own words.²² If the patient is unable to do so, the directions should by explained again through the interpreter, and the patient should continue trying until he or she expresses full understanding.

Benefits and Requirements

The benefits of using professional interpreters are well documented (Table 4).^{4,5,8,15,17–19,23,24} In addition to clear interpretation with fewer errors, interviews with trained interpreters are associated with improved comprehension and significantly greater patient satisfaction,²³ better care and compliance, and lower risk of adverse events, thus mitigating malpractice risk.¹⁷ The use of professional interpreters also reduces hospital stays and readmission rates.¹⁸

The National Standards for Culturally and Linguistically Appropriate Services include four mandates: (1) language assistance for patients with limited English proficiency should be offered at no cost; (2) patients should be notified of the availability of language assistance services in their preferred language, both verbally and in writing; (3) the competence of interpreters should be ensured, and the use of untrained persons or minors as interpreters should be avoided; and (4) easily understood print materials and signage should be provided in the languages commonly used in the service area.²⁴ Additionally, the Joint Commission, which accredits and certifies health care organizations in the United States, requires that hospital staff effectively communicate with patients when providing care, treatment, and services, and recommends language interpreters as one of the best options.²⁰ Table 5 lists several online resources available to physicians.

Data Sources: We searched PubMed, Clinical Evidence, the Cochrane Database of Systematic Reviews, and Medline (Ovid) using the terms medical interpretation, interpretation for the deaf, interpretation techniques, ethics for interpreters, limited English proficiency, language barriers in medicine, telephone interpretation, certification of health care interpreters, health literacy, teach back, and National Standards for Culturally and Linguistically Appropriate Services (CLAS). Search dates: May 2013 to August 2014.