Mid-career training for medical interpreters

“She tells me where it hurts, and then we go to the doctor together. But I don’t really know what a uterus is.” This is what a twelve-year-old Laotian boy told the Associated Press when he and his mother made headlines in California recently. He misinterpreted the dosage of medication her emergency-room doctor recommended, and she was back in the hospital within days, suffering from acute dizziness and unable to get out of bed. No one faulted the boy for doing his best with a sixth-grade vocabulary, but California lawmakers want to make sure relatives and loved ones aren’t forced into such ad hoc roles.

These are interesting times for the profession of medical interpreting. Scrutiny from media and government is rising, and the medical community has a renewed interest in providing consistent, high-quality language services. The California example does not involve professional interpreters, but it demonstrates clearly the current state of language services for limited-English-proficiency (LEP) patients and the wave of inquiry that is already happening and is sure to swell. With the spotlight so focused, health-care providers are eager to fulfill the need for those patients who have been underserved in the past. However, quality is always a concern.

Language services providers (LSPs) deal with these massive questions every day. Clients turn to us for high-quality interpreters, and we want to offer affordable solutions without compromising excellence. It is important to invest in technologies such as remote simultaneous interpretation, over-the-phone interpretation and video conferencing. Every LSP knows, however, that we first have to invest in quality. Even the most high-tech gadget can’t guarantee that the words being spoken by a doctor or a nurse are being conveyed correctly. And in the absence of national certification for medical interpreters, it falls on LSPs to assure the standards of quality.

While we expect that our interpreters are well versed in the code of ethics and standards of practice and that they keep up with the latest terminology, we are also accountable for the quality of the interpreting that is provided. Every LSP grapples with how to ensure that the level of interpreting that comes out of its offices is consistently high.

“Things were acceptable before, not now. There are liability issues and so much more awareness. I will not lower the standards,” says Karin Ruschke, cochair of the National Council on Interpretation in Health Care’s (NCIHC) Standards, Training and Certification Committee and president of Chicago’s International Language Services.

Standard interpreting procedures
In late 2005, the National Council on Interpreting in Health Care (NCIHC) released its National Standards of Practice — 32 guidelines for interpreters on best practices. The standards address the vital issues of accuracy, confidentiality, impartiality, respect, cultural awareness, role boundaries, professionalism, professional development and advocacy that all interpreters confront regularly. Some key examples include:

  • The interpreter advises parties that everything said will be interpreted. For example, an interpreter may explain the interpreting process to a provider by saying “everything you say will be repeated to the patient.”
  • The interpreter maintains transparency. For example, when asking for clarification, an interpreter says to all parties, “I, the interpreter, did not understand, so I am going to ask for an explanation.”
  • The interpreter promotes direct communication among all parties in the encounter. For example, an interpreter may tell the patient and provider to address each other, rather than the interpreter.
  • The interpreter continues to develop language and cultural knowledge and interpreting skills. For example, an interpreter stays up to date on changes in medical terminology or regional slang.

For the complete standards of practice, see www.ncihc.org

In an effort to control quality, a company can screen and monitor its interpreters, and it can encourage them to pursue continuing education. As a company that has primarily made its name in translation and is now enhancing the scope of its interpreting services, Eriksen Translations is keenly aware of the need for quality assurance (QA). A system is in place that is highly personalized and offers guidance to interpreters, but the company recognizes the need to formalize its methods. Particularly given the fresh observance of language access laws, more clients will require documentation that proves an interpreter’s level of competence.

Several types of training are available for beginning interpreters. Interpreters who are already established would benefit most from refresher courses that review standards and inform them about the latest trends in medical interpreting, such as legal policy, cultural awareness issues and any client-specific concerns. Other than conference workshops and a small selection of companies that provide continuing education, there is a distinct lack of opportunities. If continuing education is considered costly and is often difficult to access, how can LSPs expect new recruits or even the most experienced linguists to remain on the cutting edge?

This is why this type of mid-career training would be desirable for freelancers. As Holly Mikkelson, author of The Interpreter’s Rx and an associate professor at the Monterey Institute of International Studies, confirms, “By providing continuing education for interpreter and translator contractors, companies can control the content of the training that is presented and make sure it meets their needs. It is a win-win situation for companies and contractors alike.”

In developing a training program, four main components are considered: terminology, standards and ethics, stories from the trenches and role play.


For interpreters, keeping up with doctors and studying the latest news in the medical arena are essential. While it is vital to convey subtleties of daily language, medical terminology is also a must. At the Cochlear Implant Center at New York University’s (NYU) Medical Center’s Department of Otolaryngology, interpreters can be required to explain highly technical concepts to parents of pediatric implant patients. The knowledge of terminology related to the subject matter should be a given; qualified interpreters should easily be able to tackle statements such as “In a normal hearing ear, the hair cells within the cochlea act as transducers of mechanical and hydraulic vibration of the tympanic membrane, ossicles of the middle ear and perilymph and endolymph of the inner ear to chemo-electric energy capable of stimulating the eighth nerve.” In addition, for an interpreter to successfully interpret in this setting and be helpful in the process of mapping a patient’s hearing, he or she should be aware of what the procedure entails. While that level of study is part of an interpreter’s own development, offering updated research resources and techniques will be part of the curriculum.

Standards and ethics

More significant will be the direction offered regarding ethical and practical guidelines, both those of the industry and those of individual hospital or medical settings. There has been longstanding federal legislation affecting the conduct of medical interpreters, but constant review of laws such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) is important. HIPAA was enacted in 2003 and as a safeguard for patient privacy should be regularly discussed. The overriding policy that is receiving renewed attention is Title VI of the US Civil Rights Act of 1964: “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, or be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” This is a basic policy in the world of interpreting as it drives any federally-funded program to seek out language services, whether on a volunteer basis or through professionals.

Additionally, there are industry-specific organizations that are just as important to interpreters. Recently, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which plays a significant role in the implementation of Title VI, has established a new standard effective January 2006 requiring “patient/client/resident’s language and communication needs” be noted in records.

“Joint Commission standards have long required hospitals to respect patients’ language and cultural differences,” explains Paul Schyve, M.D., senior vice president of JCAHO. “Providing culturally and linguistically appropriate services goes beyond patients’ rights. In fact, these issues are critical in the delivery of safe, quality patient care.”

Other associations are also establishing guidelines to help standardize practices from within the field. In late 2005, the NCIHC released a new set of standards that will have major repercussions for interpreters and health-care providers alike. As Shiva Bidar-Sielaff, cochair of the NCIHC Standards, Training and Certification Committee and manager of Interpreter Services at the University of Wisconsin Hospital & Clinics, says, “On a daily basis, health-care interpreters seek guidance on what constitutes good practice. The National Standards of Practice for Interpreters in Health Care define the acceptable ways by which health care interpreters can ensure a successful interaction between providers and LEP patients. These standards are a major step forward towards consistency in interpreter practice, laying the groundwork for meaningful training programs and the possibility of medical interpreter certification on a national level.”

These recently released 32 standards of practice define acceptable ways by which interpreters can abide by the code of ethics, which lays out the principles of behavior in medical settings. They offer guidance to interpreters to make sound decisions when confronted with challenging situations. An interpreter may, for example, witness a health-care provider who is rude to a patient. The code of ethics states that “the interpreter strives to render the message accurately, conveying the content and spirit of the original message, taking into consideration the cultural context.” The first standard of practice then indicates that “the interpreter renders all messages accurately and completely, without adding, omitting, or substituting.” With these guidelines in hand, a professional interpreter would not doubt that he or she is required to say everything the provider says, even if it seems rude.

The thorough review of all ethical principles and the corresponding standards of practice also includes the profiles of specific clients. What are the policies and procedures at a given hospital? Guidelines on a per-client basis will be useful to interpreters when faced with procedural questions. This is where our vast store of experience and the unique relationships we have with our clients will be useful. Having worked in a variety of medical settings, we know what they need and tell our interpreters exactly what is expected of them. Situations can range from mundane to complex, but at every turn there is a code of conduct that an interpreter must follow in order to provide the best service. Sharing experiences and the guiding principles that prevailed in a given scenario is invaluable to an interpreter who is being introduced to a new setting.

For example, an interpreter’s compassion might get in the way if he or she is asked by a patient to get a sip of water. Through training, an interpreter will learn, first, that he or she should not be alone with a patient and, second, in the event that this happens, to relay the question to a health-care provider because the patient might be due for a procedure and not allowed to have any water. Another example from a physical therapy session as to the importance of guidance and communication is the possibility of an interpreter removing a chair from the patient’s path, not knowing that the physical therapist has accounted for that obstacle when deciding how to test the patient’s progress. Interpreters know how to be unobtrusive and not let their good intentions interfere, but reinforcement is always useful.

Just as important as knowing what not to do, a qualified interpreter must know when a provider’s request does not imply violating the code of ethics. There are many gray areas, and navigating them can be easier when interpreters learn from one another’s experiences and from the guidance of a good trainer. For instance, standing in a sound booth behind a special screen that covers the interpreter’s mouth and reading a list of terms out loud may not be considered interpretation and so in the strictest sense would be unethical; such tasks are, however, essential to the mapping process for implant recipients.

Restricting one’s behavior is a component of interpreting that is also important to consider. It is challenging for an interpreter to tell a patient that they — interpreter and patient — can’t sit together in a waiting room, even though they are waiting to go into the same appointment. This kind gesture could lead to difficult situations later on, as most patients open up to interpreters and disclose information they should be offering to their health-care professionals. Often a patient will forget details that he or she has told the interpreter once the patient is in with the doctor, and interpreters should not put themselves in the position of having information that the patient is not offering the doctor. However, trained interpreters know there are instances when they can step out of their role and clarify cultural situations, for example. An interpreter might clarify that the patient is fasting due to a religious holiday and alert the health-care professional that he or she is not able to take oral medication. Interpreters must remain professional at all times; the act of balancing compassion and professionalism takes training and practice.

Similarly a health-care professional may ask an interpreter to sight translate a consent form for a patient while the professional leaves the room. Again, an interpreter should make every effort not to be left alone with the patient. Consent forms are of a legal nature, and a health-care professional must be present while a patient reads the form so that he or she can answer questions the patient may have. In an ideal world, a consent form should be translated into the patient’s language so that the patient reads it and then asks questions through an interpreter. There are some health-care facilities that offer translated documents, but this is not the case for many.

Experienced interpreters know how to be flexible and switch from a traditional interpreting setting to a setting where they have a more involved role. Medical interpreters are expected to be ready for anything that might come their way. The same person could interpret at a surgery follow-up appointment, then go to the burn unit and interpret for a recently admitted patient, go to an MRI and finally have to run to the audiology department. This dynamic calls for a trained professional who will be able to cope with a wide array of settings and excel in each.

Developing the program

A long-standing cooperative arrangement with NYU hospitals has made it possible to approach them to devise an observership that will benefit both interpreters and the hospital itself. Less experienced interpreters will trail behind more seasoned ones as they work, in order to become familiar with real-life scenarios and how to best handle them. In exchange for providing this opportunity, NYU will be assured that the interpreters the company sends are trained to address the specific needs of its hospitals.

Training for medical interpretation
— what direction should it take?

As Eriksen Translations developed and prepared to implement its training program in spring 2006, several additional questions arose — questions worth considering on an industry-wide level. The benefit of this training to both clients and interpreters is apparent, but benefits must be solidified while also ensuring that the company’s investment is not debilitating to the business.

  • Should training be mandatory, even for the most educated interpreters?
  • Are highly skilled in-house experts the appropriate people to lead training sessions for interpreters whom they will later manage?
  • How will the results of the training be quantified?
  • Fundamentally, the training will act as a QA measure for clients. Should the company also attempt to make it a recognized certification?

Comments are welcome. Please send to editor@multilingual.com

It is not only the interpreters who make the client relationships successful, however. This training program will be a vital component of an intricate structure that includes project management staff who are highly attuned to the needs of clients. The NYU observership is only possible because of the relationship already established. Carolina Vallecillo, coordinator of the LEP Depart-ment at NYU, says, “If I subcontract freelancers on my own, I don’t have a guarantee that they are qualified, and I don’t have the time to screen the interpreters and verify their knowledge. The account manager does it for me.” While there are several parts of an LSP’s QA process that clients do not see first hand, such as the project management software that has been developed over several years, the training is something that clients can concretely understand. It also assures them that should they have unique needs, training can easily be tailored so that they receive the best interpreters at no additional cost to them.

Many LSPs are committed to keeping abreast of technological, legal and medical developments that may impact the quality of their services. The medical interpreting profession is evolving. The need is more visible, there are more recognized solutions, and momentum is growing to move towards more solid steps such as a national certification for medical interpreters. We must all strive to continue creating awareness about what we do.

Interpreters, health-care providers and LSPs all face similar challenges on a day-to-day basis. Tapping the resources that are available and developing meaningful initiatives to enhance our services will strengthen our profession. For our company, it is clear that pursuing continuing education opportunities and working actively to train interpreters is the best way to provide quality services, to increase our clientele and to aid our cause.

LSPs cannot sit on the sidelines, statically acting as the middleman. By actively addressing these questions together, perhaps we can raise the bar in our profession. We’re eager to begin this training, but it’s important to get it right. M

Alexandra Farkas is communications manager at Eriksen Translations. Natasha Bonilla is vendor manager at Eriksen Translations and teaches interpreting at NYU’s School of Continuing and Professional Studies. Questions or comments? E-mail editor@multilingual.com

This article reprinted from #78 Volume 17 Issue 2 of MultiLingual published by MultiLingual Computing, Inc., 319 North First Ave., Sandpoint, Idaho, USA, 208-263-8178, Fax: 208-263-6310. Subscribe