Friday, November 14, 2014

Medical Interpreting: the Ideal and the Reality

My own experience as a medical interpreter was brief and limited to a single patient. To find out about it, enter cullera in the Search box on the right.

The organizations of professional medical interpreters always emphasize the dangers of translation errors between patients and their doctors. They often cite the tragic case of Willy Ramirez, an American Latino baseball player who was left paralyzed because of a misunderstanding over the Spanish word intoxicado. (It means poisoned and may have nothing to do with alcohol.) When children are pressed into service, it may become even more dangerous as well as very stressful for the kids. Well, those organizations are right.
"A study by the American College of Emergency Physicians in 2012 analyzed interpreter errors that had clinical consequences, and found that the error rate was significantly lower for professional interpreters than for ad hoc interpreters 12 percent as opposed to 22 percent. And for professionals with more than 100 hours of training, errors dropped to 2 percent."
Hardly surprising. Ad hoc here means untrained and inexperienced. In some countries, like Britain and the United States, training is now available to those who have the time and money. What should the training cover, assuming the students are already competent as general interpreters?

1. Medical terminology and phraseology. Everyone thinks of this first, but there's more to it than they usually realize. There are different levels of medical language. There's the technical level used by health professionals between themselves; then there is the level they use to communicate with lay people who only know a popular 'register' of it or don't know it at all. Take the following example.
Technical: coronary thrombosis
Popular: heart attack
Uneducated and children: sharp chest pain.
A friend of mine at the University of Valladolid has just co-authored a paper about how medical language uses metaphors to translate between the technical and popular levels.
Expert Interpreters should know all the registers and how to use them. Many local health administrations now issue glossaries in the languages most spoken in their communities.

2. Basic knowledge of medicine, first aid and anatomy in both languages at Wikipedia or nursing level. If the doctor says, "I think your meniscus is torn. Does it hurt?" the patient will likely not know where the meniscus is, but the interpreter must.

3. Dealing with people (and with oneself) in stressful and even dangerous circumstances. Patients mustn't be made more nervous than they already are. Quite the contrary. Sometimes it's the medical personnel who are the problem, because they won't listen quietly and with an open mind for example. (In my own case I had trouble convincing the doctors that the patient wasn't drunk but suffering from dementia.) And of course we can't have the interpreer fainting at the sight of blood.

4. Medical ethics. The interpreter is part of the medical team and must respect the same rules about, for instance, what can or cannot be revealed to a patient's family.

Ideally, therefore, most medical interpreting would only be done by trained and qualified interpreters. But there are some 'flies in the ointment'. Where do you find such interpreters speaking the required languages, and how do you ensure they're available when and where needed?

Here's where we hit the reality.
"Thirteen years ago, the state of Oregon recognized the problem and required doctors and hospitals to start using professional interpreters. The Affordable Care Act also has expanded the kinds of materials that hospitals and insurers are required to translate for people who don't speak English. But more than a decade after its state law passed, Oregon still has trouble getting all patients the medical interpretation help they need."
"Eby [Helen Eby a certified medical interpreter in Oregon] says Oregon has about 3500 medical interpreters [i.e, interpreters who can be called in on medical assignments]. But only about 100 of those have the right qualifications. So, you have a 3 percent chance of getting a qualified or certified interpreter in Oregon right now,' she says, 'That's pretty low in my opinion'"
This comes in a report not from some underdeveloped country lacking medical infrastructures but from an American state with a highly developed hospital system.

Nor will the situation improve any time soon. I'm a supporter of telephone interpreting, which ought to make the limited supply of EMIs more widely available. But it turns out telephone interpreting has its own problems for medical interpreting: read the full report referenced below. Another solution ought to be to train more EMIs. However,
" She [Eby] says it takes a long time and costs a lot of money to become certified. And after going through all that training, a person may find that he or she can make more money or have a more stable lifestyle in another career – like being a translator for court reporting. That's because medical interpreters tend to be [classed as] consultants and don't get paid to travel. The hours can also be sparse and sporadic."
So part of the problem and its potential solution is financial. Upgrading courses should be directed first to working interpreters who already have general experience, and they should be low-cost and subsudized. EMIs need to be better paid, and there should be a large difference between their tariff and that of untrained interpreters so as to provide an incentive for the latter to upgrade.

Meanwhile I contend that the mass, the other 97%, must be recognized, studied and incorporated, not ignored. At very least, MS should be kept informed and given advice. Something along these lines:
"The interpreter assigned to you for this case is a competent general interpreter but has not qualified as an Expert Medical Interpreter (EMI). [Or in some instances, "The interpreter… has little or no experience of interpreting and has not qualified…] Be aware that the danger of mistranslations is substantially greater when the interpreter is not an EMI, just as the danger of misdiagnosis increases if the physician is not a specialist.

Here are some things you can do to help.

If you have a bilingual glossary or patient information material about the medical condition, get it to the interpreter as soon as possible.

Does what the interpreter is saying make sense and does it fit the clinical picture? If not, ask the interpreter to repeat, and if the inconsistency persists ask for an explanation of the translation.

Is the interpretation much shorter than the original? If so, check with the interpreter that nothing has been left out.

Do not use close relatives of the patient or children unless there is absolutely no alternative. Their translations are likely to be affected by their emotional involvement.

Interpreting is very tiring. Try to give your interpreter a break from time to time.

If the interpreter continually makes mistakes, ask for another.
And to the interpreters themselves:
You are a member of the medical team, subject to medical ethics. Do not attempt to intervene in the treatment or contest the doctors.

There are surely some things I've left out. But if the above advice were taken, it would at least be better than leaving the MS and the interpreter to sink or swim.

Kristian Foden Vencil. In the hospital, a bad translation can destroy a life. Shots, Health News from NPR, October 2014., or click here.

Beatriz Méndez Cendón et al. On the comprehension of common medical metaphorical terms / Las metáforas médicas: Un recurso para la comprensión de conceptos para el lego. Publication pending, 2014.

Doctor, patient and Spanish interpreter. Source: Shots, Health News from NPR.


  1. Kevin. Good post. Similar or worse situations prevail in most countries, which is clearly not good.
    On a slightly different note, re "On the comprehension of common medical metaphorical terms / Las metáforas médicas: Un recurso para la comprensión de conceptos para el lego," do you think that should be 'common medical metaphorical terms' or 'common metaphorical medical terms'? I think it should be the latter.

  2. Thank you, Steve. On the "common metaphorical terms," I agree with you because "medical terms" should be kept together as a compound. However, I think "medical metaphors" would be enough, as in the Spanish title.

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