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Medical Ethics: Schwartz Center Rounds |
Departments of aMedical Oncology, bInterpreter Services, and cSocial Services, Massachusetts General Hospital, Boston Massachusetts, USA
Key Words. Language • Interpreters • Communication • Cancer
Correspondence: Lidia Schapira, M.D., Department of Medical Oncology, Massachusetts General Hospital Cancer Center, Gillette Center for Breast Cancer, 55 Fruit Street, YAW 9, Boston, Massachusetts 02114, USA. Telephone: 617-726-6500; Fax: 617-724-6898; e-mail: lschapira{at}partners.org
Received February 21, 2008; accepted for publication March 24, 2008.
Disclosure: T. L. has consulting relationships with AstraZeneca, Bristol-Myers Squibb, and Sanofi-Aventis; all are regarding drug development for lung cancer drugs. No potential conflicts of interest were reported by the authors, planners, reviewers, or staff managers of this article.
This article is available for continuing medical education credit at CME.TheOncologist.com
Learning Objectives
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Learning Objectives
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ABSTRACT |
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Professional medical interpreters play a crucial role in mediating language-discordant encounters between cancer patients and oncologists. Trained interpreters allow for timely information exchange that is both accurate and culturally sensitive. Rising numbers of immigrants will increase the demand for interpreters. Medical oncologists need to respond by establishing collaborative practices with interpreters or using remote interpretation services. The article provides specific recommendations for working with medical interpreters and reviews common areas of concern for patients and healthcare professionals facing language and cultural barriers.
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As it turns out, one of the house officers, who is Yemeni, accompanied me during this meeting. Now I did not know that he was Yemeni or that he was a fluent Arabic speaker. I described what we found on tests and thought the interpretation was going very well, because I would say two sentences and the interpreter would then appear to say two sentences. And yet when I looked for any emotional reactions on the part of the family, they seemed a bit more muted than I would expect for the nature of what I was telling them. They certainly showed concern, and we left the room after I offered to help arrange a transfer of care to a local oncologist. As soon as we left the room, the Yemeni resident turned to me and said: "Tom, I hope you understand that the interpreter did not tell them that he had cancer. Instead he told them he had an infection and that he was going to get antibiotics and everything was going to be fine back home." He then told me that, because the interpreter was of a lower social class than the patient, it was inconceivable for him to deliver the kind of news I had just discussed in the patient's room.
This anecdote helps set the stage for today's conversation on language and culture and the crucial role of staff interpreters as brokers of language and culture.
Staff Interpreter: I have been working as a Spanish medical interpreter for 2 years, and at this hospital for one and half years. It is not easy to interpret for a provider who gives bad or sad news to a patient and it is especially hard when we have known the patient for a period of time. Commonly, we meet patients when they go to the emergency room the first time and we have the opportunity to interpret for them through all the painful process of being diagnosed with a life-threatening condition. Generally, during an encounter, we have a couple of seconds to process all the information before it is transmitted to the patient and in our minds, during those seconds, we try to find the correct and accurate balance of words; but it is difficult because even though we are just going to interpret what the provider says, the patient is going to know about this through our voice. This is why it is very important for interpreters to have a brief interview with the clinician prior to meeting with the patient, in order to be ready for the information that is going to be transmitted.
Second Staff Interpreter: I have been here for 2 months and this period has been an emotional seesaw. At one point we may be giving good news such as discharging a mother who just had her first baby. The next request for an interpreter may be an hour later and it has us delivering bad news. It is very traumatic for us: sad and difficult. Many times we become attached to patients and all of a sudden we have to tell them that something is not going well. It is very difficult and it does affect us. We have to disappoint them and tell them, unfortunately, everything that the doctors have done has not worked out. We have a good support group and share our experiences. We do talk and this helps us deal and cope with all of this.
Senior Oncologist: I grew up in a multilingual household in South America where it was normal for someone to begin a sentence in one language and finish in another. As an adolescent, I had fantasies of being a simultaneous interpreter at the United Nations and through my tone and words I imagined having a dramatic influence on world affairs.
I left my country of origin when I was in University and finished my medical studies in the U.S. As a senior medical student in 1981, I interviewed at this hospital for a residency position. A respected and well-known physician conducted the interview and immediately asked why I spoke so many languages. When I replied with excitement that it allowed me to communicate directly, without intermediaries, and to experience the richness of diverse cultures, he responded abruptly and coldly that scientific medicine had little to do with communication. I trained at another prestigious hospital in this city.
Many years later, I found a venue for integrating my interest in language and culture with the study of medicine in collaboration with a medical anthropologist. I am relieved and encouraged to find the biomedical culture has evolved over the past 25 years, both here and across the country, and is now much more open to acknowledging the importance of sensitive communication and more respectful of personal and cultural diversity.
Physician Moderator: One question I have relates to the contribution of culture and language: which is more important in real-time conversations? As I think about that experience I had with my patient, I think culture was probably a greater factor in establishing good communication.
Interpreter: Culture and language go hand in hand. If the clinician has good communication skills, the professional interpreters just need to abide by the standards of professional practice.
Physician Moderator: Can you give us some insight into how individual communication styles and practices impact on your job as interpreters?
Interpreter: We need to interpret exactly what the clinician says and yet we know that sometimes it can be understood in a different way. There are even different dialects within a language and so things could have different meanings. We have to clarify in order to get the message across.
Clinical Social Worker: I am a clinical social worker in the Francis H. Burr Proton Therapy Center and the Claire and John Bertucci Center for Genitourinary Cancers. Patients come from all over the world to get treated in the proton center. I recently worked with a Spanish-speaking patient who, when I asked, was interested in participating in the weekly drop-in prostate cancer support group for men treated with proton beam radiation. I informed the patient I would need to prepare the group and explain that there would be a Spanish-speaking participant with an interpreter. Members of the group were very receptive and my experience has been that the men are open to new members and welcome them. The men really want to help make it easier, share their knowledge and their experience. I called the interpreters' office to make the necessary arrangements and explained that I would prefer a male interpreter and that the same interpreter be able to attend each meeting. I found they were very responsive to my request and arranged to have the same interpreter every week. Thanks to him, this gentleman was able to participate in the group and he really enjoyed the experience. It was also a learning experience for the group members.
Cancer Center Director: I am very proud of the interpreters we have here. At the Massachusetts General Hospital, we recognized the need for interpreters to have specific training in order to assist cancer patients seeking treatment and information. We also noticed there were special challenges associated with interpreting for cancer patients. Some of the more difficult topics include discussing side effects from treatments and clinical trials. We developed a series of workshops designed specifically for interpreters covering basic principles of cancer treatment and clinical research. Our goal was to enhance the effectiveness of interpreters in the clinical setting by providing disease-specific knowledge and a general overview of the vocabulary used in conversations between oncologists and their patients.
Senior Interpreter: We believe in the value of establishing a partnership between the clinician, the interpreter, and the patient. As Dr. Chabner points out, in order to prepare the staff interpreters for their work in the Cancer Center, we developed a curriculum that provides more in-depth information about cancer types and available treatments as well as the terminology commonly employed in clinical research. We focused mainly on expressions frequently used in obtaining consent for treatment and terms that are quite specific to the work of oncologists. We invited interpreters from hospitals in Boston and then hosted a national meeting, which was very well received.
Senior Oncologist: Medical schools now include courses in cross-cultural communication as well as training in proper use of medical interpreters. I am hopeful that we are moving away from cultural insensitivity and stereotyping, as we begin to understand how these attitudes adversely impact clinical practice.
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Current estimates indicate that there are 6,900 languages in the world today [1]. The U.S. Census Bureau estimates that for >46 million Americans, English is not their first language, and at least 21 million of those speak English poorly or not at all [2]. This language divide makes their interaction with the medical establishment more challenging and often interferes with access to quality services [3]. Recognizing the importance of clear communication in health care, federal law, under title VI, requires all health care organizations receiving federal funds to provide appropriate interpretation services by bilingual staff or professional interpreters free of charge for patients with limited English proficiency [4]. However, the Office of Civil Rights allows patients the option of using family or friends in lieu of a professional [5]. In these situations, it is recommended that a waiver of interpreter be signed by the patient to ensure informed consent, because most patients do not understand the dangers of miscommunication resulting from faulty interpretation. Choosing an untrained interpreter may have important consequences on the final outcome. Studies have clearly documented that, in medical settings, untrained interpreters—such as relatives, friends, secretaries, and janitors who have bilingual skills and happen to be available—are unreliable and may contribute to errors and miscommunication [6, 7]. The contribution of language barriers to the higher cancer mortality rates among underserved and minority populations is unknown at this time, but deserves to be noted as one of the barriers to access to quality cancer care.
Medical interpreting refers to the process of facilitating real-time communication, while medical translation deals with the written word and allows for reflection and revision in the preparation of texts. Several interpreting methods are available, which vary in cost, availability, and possibly in accuracy. Simultaneous interpreting is a near verbatim running rendition performed within milliseconds of the original speech, similar to a voiceover. This can be accomplished with or without the interpreter in the room; the latter is known as remote simultaneous interpretation and is often employed at the United Nations and at major international conferences [8]. This type of service requires the use of a headset for each party and a mechanism that allows each party to hear only the language he or she understands. In consecutive interpreting, the interpreter listens as the speaker speaks and then interprets once the speaker indicates she or he has paused or finished. Here too, the interpreter can be located in the same room or may be available via phone service. Finally, ad hoc interpretation refers to the use of untrained interpreters. One study compared these methods and found that remote simultaneous medical interpreting was both quicker and more accurate [8].
There are wide gaps in the availability of interpreter services, in part because of the lack of uniformity regarding government requirements and public and private reimbursement strategies and policies. Under Medicaid and the State Children's Health Insurance Plan (SCHIP), states may pay for interpretation services and state expenditures are eligible for federal matching payments of 50% or more [9]. It is estimated that 10 states pay for interpreter services under Medicaid and SCHIP. Some states authorize reimbursement for interpreter services, while others contract with specific organizations to provide such interpretation. In some areas, hospitals may include interpretation costs as allowable costs used to establish overall payment rates. Medicare does not pay for interpretation, although it is estimated that over two million seniors have limited English proficiency [9]. This important omission is worth noting because Medicare policies influence coverage by private insurance companies. Although data are scarce, private insurers for the most part do not cover interpreting costs. Some managed care companies actually demand the provision of interpreters without providing any funds for these services! The American Medical Association and others have raised concerns about physicians having to bear the costs of interpretation [10, 11]. A thoughtful analysis of possible payment models published by Ku and Flores [9] reviews four different options that include insurance payment directly to interpreters, insurance contracting with telephone interpretation firms, funding community organizations to form language banks that recruit and train interpreters and serve as preferred contractors for insurers, and finally a modification of existing reimbursement schemas for physicians such that an additional payment is required for every encounter codified as involving a patient with limited English proficiency. The extra dollars could be used either to hire bilingual clinicians or to pay for interpreters, at the discretion of each practice or hospital [10, 11].
There are currently no national standards for the training and licensure of medical interpreters, with the consequence being that hiring practices vary considerably, and there are no data on the quality of services rendered. There are, however, standards of practice, which are not enforced in all hospitals. In the past two decades, in response to the growing demand for interpreters, more individuals have been hired without clearly delineated training requirements, expectations, job descriptions, or ethical mandates. Some have only a few hours of "training." Several advocacy and professional groups, such as the International Medical Interpreter Association and the California Health Interpreters Association, have published standards of practice that delineate competencies [12]. The National Council on Interpreting in Healthcare has published a code that outlines appropriate behavior in nine areas of practice [13]. These are: confidentiality, accuracy, completeness, impartiality, professional boundaries, professional development, cultural competence, respect for all parties, and professional integrity. Ethical practice dictates that the interpreter cannot give advice and must respect the physician's message without additions, omissions, or distortions. The emphasis on impartiality may, in certain emotional or controversial situations, place the interpreter in an ethically difficult position. Some have argued that real neutrality is a myth [14], although it remains the "standard" model championed by interpreter societies and the medical profession. In fact, this debate led to an expansion of the role of the medical interpreter to include that of a clarifier, culture broker, and patient advocate. The problem remains that there is no standard training for these new roles and there are no measurable parameters to assess performance [15]. However, at least two professional societies in the U.S. (the American Translators Association [16] and the Registry of Interpreters for the Deaf [17]) have successfully developed certification procedures.
Rising numbers of immigrants will only increase the demand for interpreters. The unfunded mandate to provide such services will need to be addressed at state and federal levels and will likely result in more uniform and possibly stricter criteria for accreditation of hospital-based interpreters. Current training programs range from several hours to comprehensive curricula on language proficiency, interpreting skills, medical terminology, and ethical conduct. Biomedical research regarding the use and effectiveness of interpreters has focused mostly on the medical errors associated with language-discordant encounters and interpretation practices. Errors made by untrained bilingual staff or family serving as interpreters can have serious consequences and have been broken down into five major types: errors of omission, false fluency, substitution, editorialization, or addition [18]. This research has disclosed that, even with intensive training and professional expertise, interpreting accuracy drops off in situations where clinicians use long sentences, medical jargon, or terms that are unfamiliar to the interpreter. One particular setting in which interpretation errors have been documented is in conversations regarding consent for treatment in a clinical trial. A study by Simon and colleagues identified frequent and consistent errors during these discussions that reflect knowledge gaps on the part of the interpreters [19]. Explanations of randomization were typically poorly phrased and misinterpreted. In general, this is not an easy concept to explain or understand by the public at large and therefore a likely "trap" for interpreters who lack specialized training in the terminology commonly employed in clinical research. It is worth emphasizing that interpreters typically perform best when the source message is short, simple, and clear and when proper introductions are made at the onset of the interview that set up a collaborative relationship among the clinician, the patient and family, and the interpreter.
Interventions directed at improving communication by training physicians to work with interpreters have been reported in the U.S. as well as in other countries with large numbers of immigrants. Bischoff and colleagues described a series of interactive workshops for physicians working in Geneva, Switzerland, designed specifically to train physicians in working with interpreters [20]. Training resulted in greater ease in working in partnership with interpreters, in the handling of the three-way relationship, and in patient centeredness. Interestingly, this approach also led to increased cultural awareness and sensitivity among physicians. This successful example of training leading to practice change is in sharp contrast with more disturbing results in the U.S. A study published in the Journal of the American Medical Association reported on a national survey of resident physicians in 2004 that evaluated their education and practices related to the use of interpreters [21, 22]. The residents were asked if they received any type of instruction in hospital policies and procedures related to the use of interpreters. About one third reported receiving no instruction in working with interpreters. When facing language barriers, 77% of residents said they sometimes or often used professional interpreters, 84% used ad hoc interpreters, 77% used hospital employees, and 22% used children. More than half said they faced moderate or major problems in delivering cross-cultural care because of a lack of access to interpreters, lack of time, and lack of access to written materials in other languages. The authors concluded that residents need further training in patients' legal rights and in procedures and techniques to work with interpreters and reduce misinterpretation and errors. More importantly, physicians in training need role models and reminders by seasoned clinicians. Many excellent teaching cases on the wards of our hospitals could provide teaching opportunities for a faculty prepared to devote the time needed to address these important aspects of humane care.
Simple recommendations for working effectively with interpreters include the need to warn the interpreter prior to the meeting if sensitive information will be discussed and a proper introduction of the interpreter to the patient that promotes collegiality and delineates roles and expectations. All parties should be positioned so that the clinician and patient can maintain proper eye contact throughout the interview, and, finally, both the physician and interpreter should use short phrases devoid of jargon. Asking the patient to repeat what he or she has understood, and having the interpreter "back translate" the content, provides an additional tool to check the accuracy of translation as well as the patient's understanding (B. Lubrano, R. Brown, C. Bylund et al., personal communication).
The interpreters' perspective was explored in one study of nine professional interpreters in Switzerland. Interpreters were reluctant to provide specific advice or criticism and instead recommended more training for physicians to increase their patient centeredness, understanding of the difficulties involved in medical interpretation, and knowledge of the patient's country of origin and customs [23]. Another study conducted in Canada analyzed videotaped encounters using professional or family interpreters in order to gain a deeper understanding of the interpreter's experience and role [24]. The tasks identified by professional interpreters were the transmission of information, the creation of a safe environment for the patient, cultural mediation, and maintaining professional boundaries. The study commented on evidence of a lack of proper respect and recognition for interpreters' capacities and status as a member of the medical team, and the absence of a place to wait within the institution. In the latter regard, interpreters expressed disappointment that they were often relegated to a seat in the patient waiting room. Family interpreters acted mostly as participants, often speaking as themselves rather than providing accurate renditions of both the doctor's and patient's comments, and often felt more comfortable in proactive caregiving roles. A U.S. study recently explored the expanded role of professional medical interpreters working for two midwestern interpreting agencies [25]. A majority of the interpreters (17 of 26 recruited for this study) had participated in a 40-hour course viewed as industry-recognized training. Those who had not attended the course had participated in other training or were recognized as trainers of interpreters. Analysis of practices showed that the interpreters assumed some of the clinicians' communicative goals by initiating information-seeking behaviors, editorializing information for emphasis, and volunteering medical information to patients. These communicative strategies may also pose risks to patients' privacy, have unintended clinical consequences, and interfere with the clinician–patient relationship [23].
Insights shared by staff interpreters at this forum highlight the deeply personal and emotional nature of the work and the opportunity to improve care for patients with limited English proficiency by integrating interpreters into the multidisciplinary team. Specialized training in the concepts behind the medical terminology commonly employed in oncology and clinical research can raise the level of proficiency and competence. Providing a dedicated office and a reliable mechanism for booking appointments is essential in order to maintain a professional status within the institution. Opportunities for professional support and advancement are sorely needed to retain talented professionals and raise the standards or performance at local and regional levels. Senior interpreters could expand their role and participate in multidisciplinary team meetings in order to help coordinate care for patients with special language and cultural needs.
Good communication between a clinician and patient is challenging even if both share cultural heritage and common values, and speak the same language. A recent monograph from the Institute of Medicine released in 2007 identifies six core functions for patient-centered communication in cancer care: fostering healing relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient self-management [26]. Successfully performing these tasks requires much more than specific knowledge of disease and treatment, and, in the event of language barriers between the clinician and the patient, depends largely upon interpreters. Little is known about the experience of cancer patients unable to communicate directly with their treating physicians and clinical staff either because of deafness or language barriers. One U.S. study explored the perspectives of a sample of pediatric oncologists, interpreters, and Spanish-speaking parents of children with newly diagnosed leukemia and found that all parties expressed concern about the accuracy and completeness of the interpretation [27].
Language, culture, life experiences, and beliefs shape an individual's perspective and relationship with the world. Serious illness inevitably affects all aspects of personhood and threatens the integrity of relationships on many levels. Responding compassionately requires an acknowledgment of that individual's uniqueness and respect for his or her life. Without language, we lose our most effective tool for establishing a meaningful relationship with patients and the opportunity to address individual worries and fears. Ultimately, professional medical interpreters have the unique ability to assist clinicians in establishing the healing connections that form the foundation of ethical and culturally sensitive care.
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Collection/assembly of data: Lidia Schapira
Data analysis and interpretation: Lidia Schapira, Karin Hobrecker, Bruce Chabner
Manuscript writing: Lidia Schapira
Final approval of manuscript: Lidia Schapira, Erika Vargas, Renzo Hidalgo, Marilyn Brier, Lourdes Sanchez, Thomas Lynch
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