Improved Medical Interpreters: Solving the Language Barrier Issue in Healthcare Establishing a Model Medical Interpreter Certificate Program at Rutgers University New Brunswick that can be Adopted Nationally

Tag Words: medical interpreters, interpreter certification, undergraduate certificate programs, Rutgers University, language barrier, language, healthcare

Authors: Aaron Wu, Ife Aridegbe, Vincenzo Cimino and Julie M. Fagan, Ph.D.

Summary: The Patient Protection and Affordable Care Act has increased availability and access to health care in medically under-served communities; however, language barriers exist between patients and physicians, causing avoidable consequences such as malpractice lawsuits, unnecessary emotional and physical distress, unwanted procedures, and deaths (1). Currently, each state has its own legislated requirements for medical interpreters, yet in most cases training methods and supervision of practicing interpreters are lacking. In order to combat future problems, our project analyzed the financial cost and consequences that the current interpreter programs fail to address. The successes, failures, mission, goals and structures of existing national, regional, and local translator/interpreter certificate programs were reviewed and analyzed. The resourced information was used to construct a model of our proposed Medical Interpreter Certificate Program to be offered to Rutgers University New Brunswick students enrolled in the School of Arts and Sciences, School of Environmental and Biological Sciences, and Ernest Mario School of Pharmacy. The long term goal of the incorporation of this certificate program into the Rutgers University New Brunswick’s curriculum is to increase the marketability of Rutgers University and its students and to participate in the initiative to decrease the prevalence of language barriers in future healthcare services.

Video Link: https://www.youtube.com/watch?v=ppbGtL62Q8U&feature=youtu.be

The Issue: Language Barriers in Health Care (IA)

The United States is becoming more culturally and linguistically diverse. With an increasing number of individuals that have limited English proficiency and/or speak a language other than English residing in the United States, the language barriers in the nation’s health care institutions become even more prevalent and costly, both medically and financially. In 2008, approximately 20% of US residents spoke a non-English language at home, with 44% of this population lacking the ability to effectively communicate in English (1). These individuals, categorized as LEP or “limited English proficient”, would encounter additional communication issues with their primary care physician or medical specialist. The US Census Bureau’s statistics show that the number of individuals that have limited English proficiency and/or predominantly speak a non-English language at home has been increasing significantly since the 1990s (2). Yet contrary to these increasing percentages, with fast paced hospital environments and time restricted patient visits, there is often limited availability and access to interpreters in the clinical setting. Discouraging statistics of one study showed that in 46% of cases involving an identified emergency department, no interpreters were used with LEP patients (2). In most instances where no certified medical interpreter is available, bilingual clinical staff or ad hoc interpreters like family members or patients’ friends provide interpretation services. In either of these groups of individuals are not likely to be a trained or certified interpreter (2). With this use of untrained ad hoc interpreters, chances of misinterpretation and therefore, provision of inaccurate medical information involving diagnosis and treatment options to LEP patients are likely to increase. Often times, family members who are used as interpreters have different values, concerns and medical priorities than the patient, which may cause selective interpreting. Using children as interpreters can have even more disastrous results, since most are extremely unlikely to have an expertise on two different languages or medical terminology (2). Deleterious outcomes of ineffectively addressing language barriers include LEP patients having decreased compliance to medications regimens, not receiving the expected level of care, and having reduced opportunities for preventative services. Any of these outcomes can lead to an overall unnecessary increase in hospitalization and/or drug complications for these LEP individuals (2).

Florida Case (VC)

A specific case to note occurred in Florida when an 18-year-old man collapsed, fell into a coma, and was subsequently unable to convey his medical condition to paramedics. These same paramedics and emergency medical staff, failed to provide both the man’s girlfriend and his mother with an appropriate interpreter. In turn they conveyed to healthcare professionals, that the man had been “intoxicado”—Spanish for nauseated; however, those professionals misunderstood the word to mean that the man had taken drugs and had become high. He was subsequently treated for a drug overdose over the next thirty-six hours. The patient showed no signs of recovery so healthcare staff performed a neurological examination, but after the initial misdiagnosis excessive damage was done: the 18-year old was left a quadriplegic after enduring a severe subdural hematoma (3).

Responsibilities of Medical Interpreters Today (AW)

In order to fully understand the gravity of the situation and the concern that revolves around the quality of current medical interpreters, it is important to understand the full responsibility of this profession and the services they provide in the healthcare field. Currently there are two different types of interpreters: telephone interpreters and on-site interpreters. Both services are offered at a fee in many hospitals and are expected to provide high quality interpretation; however both differ in their effectiveness in enhancing patient-physician relationships. The primary role of medical interpreters is to support and strengthen the relationship between the patients and their assigned healthcare providers (4). This includes being the patient advocate and actively supporting change in patient health with clear rationale, being message clarifiers who facilitate communication between patient and provider, and being a message converter who follows standard health care practices along with upholding laws, regulations and policies. In conjunction, interpreters must provide some clarification about cultural norms, conveying such discrepancies to healthcare professionals in order to assure effective treatment (4). Charged with the responsibility of being the liaison between patient and healthcare provider, medical interpreters are trusted with vast amounts of personal information and the duty of providing a professional and unbiased line of communication to improve the patient’s overall wellbeing. Language Rights in Healthcare (VC)

According to Title VI of the Civil Rights Act proposed in 1964, no individual can be excluded from participating and/or benefitting from programs that receive federal financial assistance including health care (5). Furthermore the Supreme Court has rules that discrimination based upon language spoken is tantamount to discrimination based on nation of origin. Later, in the 1980s the Department of Health and Human Services issued requirements targeting health care providers specifically, completely banning discrimination in health service programs. (5).

There are many factors that influence which languages should be offered to persons with Limited English Proficiency (LEP), including but not limited to, the number of LEP persons speaking a particular language and the frequency of contact with each LEP language group in the healthcare system. Furthermore, the more funding an institution receives from the federal government the greater its obligation to provide services to LEP persons. Although legislation has been passed, there are few instances in which health care service providers (specifically larger institutions receiving the most federal funds) have been held accountable for inadequacies in such programs through the consistent failure in enforcement of these laws (5).

State Legislation and Their Attempts to Provide Language Access (VC)

As of 2006, at least 43 states had issued at least one legislative measure to deal with language access in the health care setting (5). However, it is important to note that half of these states enacted between one and four laws while the other half have enacted ten or more. California continues to be a leader in addressing these language access issues and, as of the same date, had issued over 70 of such legislations. These individual state legislations have proven beneficial to language access for people with LEP, yet they have also created an environment wherein different inadequacies have arisen from state to state (5). For instance, these legislative measures depend greatly upon the underlying political climate in each state, and which languages persons with LEP statewide speak (despite there being different needs between counties in the same state). These measures might attempt to address problems arising from such language barriers but results vary greatly between institutions (within the same state).

Most legislation deals with health care rights involving informed consent, patient education, or notification. Most of these attempts only concern themselves with particular medical conditions, healthcare settings, or languages (5). In New Jersey brochures regarding breast cancer awareness are provided to women in both English and Spanish, but no such program exists for lung cancer or other conditions, nor are other languages (i.e., Hindi, Mandarin, and Cantonese) addressed. Michigan has similar laws concerning HIV testing pamphlets being offered in only English and Spanish; however, abortion consent forms are printed in English, Arabic, and Spanish. Similarly, abortion risk pamphlets are offered in English, Spanish, and Arabic, but such information on parental care and parenting is offered in English and Spanish only. There is an underlying tendency for medical institutions to concern themselves more with the specific condition than the actual need for such translation in specific LEP subgroups. Interestingly, “Women’s Right to Know” acts have been passed in a range of states from Michigan to Nevada to Texas and tend to afford translational offerings at a much lower threshold than other programs. The main problem is that these acts are limited to adoption information and the detrimental effects of abortion (5).

Mental health settings provide a different set of requirements in varying states. For instance, trained interpreters are mandatory at all acute psychiatric facilities and emergency departments in Massachusetts (5). In contrast, Illinois requires that state mental health facilities provide professional interpreters throughout the process of patient intake and evaluation (5). Whereas, states like New Jersey, Colorado, and Rhode Island have provisions for language services that extend to linked facilities as well (i.e., not only state facilities like in Illinois). Here again, California seems to be spearheading new interpreting measures, aiming to provide services of a much broader scope. California legislation passed in 2003 mandates that all privately managed care plans as well as health insurers (both individual and group) provide members and clients with adequate access to language assistance and translated materials when obtaining medical care (5).

Furthermore this article mandated that all health plans and insurers comply with the aforementioned standards by 2009. This legislation aimed to provide a statewide provision for language assistance services to all Californians who are privately insured (5). Table 1: Methods for Reimbursement of Medicaid/SCHIP enrollees and Interpreter Competency Requirements (5)

State/District Entities Reimbursed Amounts Paid Interpreter Competency Requirements DC Language agencies $135-$190/h (in-person) No HI Language agencies $36/h Language agencies monitor quality and assess the qualifications of interpreters ID Providers $12.16/h Provider determines competency KS Medicaid fiscal agent Spanish--$1.10/m other No administers language line languages--$2.04/m MN Providers Lesser of $50/h or usual and Provider determines competency customary fee MT Interpreters Lesser of $25/h or usual and Provider must hire a “qualified” customary fee interpreter (no definition) NH Interpreters $15/h No although interpreters must $2.25/15 min after first hour enroll as Medicaid providers UT Language agencies $28-35/h (in-person) Language agencies monitor quality and assess qualifications of interpreters VA Area Health Education Reasonable costs reimbursed Interpreters must meet Center & 3 public health proficiency standards, including departments 40-h training VT Language agencies $60/h No WA—non-public Brokers: language agencies Brokers receive administrative State agency certifies interpreters entities fee Language agencies receive $34/h WA—public Public entities 50% allowable expenses State agency certifies interpreters entities WY Interpreters $45/h Interpreters must abide by NCIHC Code of Ethics ME Providers Reasonable costs reimbursed Provider determines competency: interpreter must sign Code of Ethics

More Recent Language Access Policy Developments—Executive Order 13166 & the OCR Policy Guidance (VC)

Back in 2000, then President Clinton issued Executive Order (EO) 13166, Improving Access to Services for Persons with Limited English Proficiency, which attempted to cope with insufficiencies in the system. It makes it compulsory (or rather reinforces Title IV) for institutions receiving federal funding and federal institutions to provide equal access to LEP persons. To ensure its success OCR issued an exhaustive Policy guidance so as to outline obligations healthcare providers and other federal institutions have to LEP individuals. This legislation dictates that language services are more likely to be in demand when there is a large population of LEP persons (5). It proceeds in guiding institutions to provide interpreting and translation for specific languages as more members of that language group are encountered (5). There has been little improvement in federal regulation since EO 13166 was first issued alongside OCR Policy Guidance, in improving provisions for language access (5). Thus, individual state legislatures have been burdened with the task of managing such issues, some of which have proven successful, and include:  Continuing education for health professionals  Healthcare interpreter certification  Compensation for language services provided for Medicaid/SCHIP enrollees

Current Global Standards Made to Standardize Healthcare Terminology (AW)

Though it is important to have a program that encompasses the cultural awareness aspects of branches and topics of healthcare, it is important to note and take into account the resources the global community already has. Currently, the World Health Organization has a guidance system for International Nonpropriety Names (INN) database. Used to identify active pharmaceutical ingredients/substances (5), each name is recognized by the global community as public property and works across borders. Mostly used for pharmaceuticals as a guideline to follow for naming drugs and prescribing the correct medicines to patients, it is reasonable to leave out drug naming out of this program due to the guidelines and intricacies already set in place thanks to the World Health Organization (5).

Malpractice Cases Resulting from Language Barriers (IA)

In many situations in which patients suffer medical complications due to these language barriers in the clinical setting, malpractice lawsuits are filed against their physicians or the hospital (2). Claims may include the medical institution's failure to translate important documents like discharge papers and consent forms. Malpractice cases often times are initiated due to the irreparable harm or death of a patient. This exact outcome occurred in the Tran malpractice case where lack of provision of a medical interpreter at the medical facility was deemed a significant causal factor in the death of the patient (1). In the Tran case, through the family’s entire encounter with medical professionals, no competent interpreter was used even though both of the female patient’s parents were LEP and primarily spoke Vietnamese. Instead, the 9-year old patient and her 16-year old brother were used as the sole interpreters of all medical information throughout the Tran family’s experience. The 9-year old girl subsequently died from a reaction to the prescribed drug Reglan (1).

This case further illustrates the tragedies that can occur when untrained and uncertified individuals like family members, friends and even worse, minors are used as medical interpreters. Unfortunate medical cases such as the Tran case can be avoided by increasing the accessibility and use of certified medical interpreters (1).

Medical Interpreter Certification Exams (IA)

The category of competent interpreters often includes both professional interpreters and bilingual medical staff whom take on the role of an interpreter. To be deemed competent in interpretation of medical information, the individual must be knowledgeable in ethics-related issues, confidentiality agreements, medical practice standards, and the role of the interpreter in health care as well as be proficient in English and the non-English language including specialized medical terminology in both languages (1). According to the National Board of Certification for Medical Interpreters, the process for getting certified first involves registering and paying a $35 nonrefundable fee which is waived in states like Oregon that are funded by grants. The subsequent step requires interpreters to take and pass a National Board Written Exam, which alone cost $175 after which individuals must take and pass an oral exam that ranges in cost from $235 to $275 (state-dependent) (1). Currently, only a handful of states have both written and oral certification exams available for medical interpreters, New Jersey is not one of them (having only written exams available) (7).

Unlike New Jersey, Oregon is a member of the small group of states that have oral and written medical interpreter qualification and certification exams. Despite this, a large percentage of interpreters are neither qualified nor certified. In Oregon, medical interpreters are organized under three different levels of proficiency: registered (the basic level), qualified (tested in the language) and certified (tested in medical terminology). According to statistics of the Oregon Health Care Interpreters Certification Program, of the estimated 3,500 employed interpreters in the state, only 25 are certified and 16 are qualified (8). That’s over 3,400 interpreters in the state of Oregon alone working while unqualified and uncertified. One stated reason for this large number of uncertified yet employed interpreters is the high cost of training. The average cost to get qualified and certified in Oregon is over $1,500. Another plausible reason is the lack of a standard national medical interpretation testing process. With unqualified individuals working as medical interpreters the possibility of medical liability and malpractice lawsuits increase (8). Legal and Financial Consequences (AW)

Language barriers often bring about both monetary and non-monetary damages and various types of avoidable lawsuits and allegations against the hospital and its physicians. The need for effective language services in hospital settings is critical to provide the utmost care for an increasingly diverse population of LEP patients. Many preventable problems caused by language barriers can stem from the patient, the physician, or even the hospital. Many LEP patients withhold their complaints for many reasons including the fear and unfamiliarity of navigating through policies and legal systems, finding a competent attorney that speaks the primary language of the patient and is willing to take the case, and overcoming the social barriers of being less educated in these situations. Most often these cases are due to the hospital and physicians inability to provide competent oral interpretation, provide translated versions of vital documents and instructions, inadequate documentation, and probably cases of discrimination against LEP patients (1).

The National Health Law Program (NHeLP) analyzed thirty-five claims (this constituted only 2.5% of malpractice claims received by malpractice insurance carriers) where the Carrier paid $2,289,000 in damages or settlements and $2,793,800 in legal fees (1). The lawsuits’ claimants (patients or family of the deceased) demanded reparations for damages ranging from $1 to over $10 million. The malpractice Carrier covered cost of legal expenses in 25 of the cases where $0 damages were awarded. Upon further analysis, the healthcare providers spoke the patients’ primary language only rarely. Of the twelve languages spoken by the patient and their families in these cases, only 5 of the physicians actually spoke the primary language directly to the patient (1).

Table 2: Amount of Damages Paid (1) Table 3: Amount of Legal Fees Paid (1) 35 detailed cases Legal Expenses Paid by Carrier $0 to $50,000 17 $50,001 to $100,000 11 $100,001 to $200,000 5 $200,001 or $400,000 0 $400,001 or more 2

35 detailed cases Damages Paid By Carrier $0 25 $1 to $100,000 4 $100,001 to 2 $200,000 $200,001 or more 4 From a study made by The Office of Management and Budget in 2002, inpatient interpreter visits cost $78 million, $12 million for outpatient visits, and $8.6 million for emergency department visits (9). Along with those costs, it costs around $150 or more for interpreter services. These services often exceed physician’s payments, presenting a challenge or what the American Medical Association calls a significant adversity for practices (9). It is important to note the consequences of these cases encompass not only the patient, but also the hospitals and the physicians whom the hospitals hire. An example is in the Garcia Case where a Spanish-speaking female patient in her second trimester died from complications due to pork tapeworm while she was under the care of her neurologist. The neurologist spoke limited Spanish and claimed, in the case, that he spoke medical Spanish and could take a medical and neurological history in Spanish. Even though both the patient and physician were able to communicate, the patient still complained that she was incapable of successfully explaining her condition to her physicians being that an interpreter was not provided (1). This ended with the Malpractice carrier paying $40,000; however the lawsuit for the physician ended up in $3.25 million in damages. Another case involved both patient and physician who were both of Korean descent. The male patient had an infection and lost the use of his eye. The issue was that the physician lacked adequate documentation and failed to state whether the conversations they had were in Korean or English. Due to the lack of documentation and, clarification about the need/use of an interpreter’s assistance in the medical charts, the case was settled for $450,000. In addition the carrier paid over $61,000 in legal fees (1). Litigation often becomes a downward spiral for both parties they both must pay either physical or monetary damages, there is a loss of reputation in both parties, legal fees build up and are not always covered completely by insurance and malpractice carriers, and there is a concurrent distraction because of the long litigation process. All of these issues lead to a heightened risk of reduction in quality of care for the patient. This is the ultimate and most unacceptable cost in the hospital. As one can see from these two cases, these issues could have been avoided if competent interpreters were staffed and offered, with patients and physicians made aware of such services (9).

Table 4: Amount of Damages Demanded (1) 35 detailed cases Damages Demanded in Lawsuit

$1 to $1,000,000 13 $1,000,001 to 2,000,000 2 $2,000,001 to $3,000,000 2 $3,000,001 to $4,000,000 2 $4,000,001 to $5,000,000 1 $5,000,001 to $10 million 0 $10 million or more 2 Unspecified “according to proof” 13

Table 5: Languages Spoken By Patient (1)

33 detailed cases* Primary Language of Patient # Times Physician Spoke Primary Language of Patient Spanish 17 2 Cantonese 2 0 Vietnamese 3 2 Mandarin 2 1 Korean 1 1 Punjabi 1 0 Thai 1 0 Tagalog 2 0 Farsi 1 0 Russian 1 0 Amharic or Arabic 1 0 Armenian 1 0

Current Problems with Medical Interpreters in the Hospital Setting and Current Solutions Implemented in the Field (AW)

Though many hospitals have put in their best effort to cater to the increasing population of diverse communities that visit the hospital for nonemergency and emergency situations, there has not been a national standard that is strictly abided by throughout the US and internationally due to regional differences in demand for different languages and the amount of time and money layered onto the process of providing care to the patient. Currently, companies such as Status Video provides professional interpreter services that cost $1.50 a minute with trained interpreters to video-call patients through an iPad attached to an IV pole that can wheeled to patients rooms and provide on-demand attention (9). The cost however builds up as the demand for aid increases. In 2013, the hospital had 83,000 total interpretation interactions, with 230 daily encounters (9). Though thirteen states and the District of Columbia directly reimburse providers for language services used by patients on Medicaid and the Children's Health Insurance Program, costs do still add pile up for the patients.

Physicians and hospital staff often ignore and do not follow these policies because of time pressures of incoming patients, lack of knowledge about the availability of interpreter services, or procedural difficulties in arranging for interpreters. These issues include: the failure to provide language access on multiple fronts, failure to utilize competent interpreters that are not of relation to the patient, use of a minor child and family members as direct interpreters, lack of translated informed consent forms and vital documents, failed advising of side effects, warnings, and directions from the physician due to lack of understanding and proper translation of documentation, and overall failure to meet and abide by the standards of care and protocol applicable for the physician and facility (1). The Lin Case analyzed by NHeLP is a prime example of the blatant disregard for language barrier protocols. In this case, a 17-year old, Taiwanese high school girl was hit with a tennis racquet two weeks prior to visiting the hospital. The patient showed signs of fever lasting three days and a painful headache. The physician used the patient herself as the interpreter. The patient later entered respiratory arrest and later died due to delayed treatment of a brain abscess. The problem in this case was that an interpreter was not present and offered to the patient and the patient, who was a minor was reliable for her sole interpretation of her ailment. This ultimately caused the delay in treatment, the patient’s death, and a lawsuit for medical negligence (1).

According to the Agency for Healthcare Research and Quality, 9% of the U.S. population is at risk of malpractice due to language barriers (9). Though efforts have been made through contracting interpreters of languages within the community, telephone, video call, and direct staffing of interpreters, many rural hospitals have difficulty finding the necessary resources to help their patients. Through evidence compiled in the American Journal of Managed Care, it has been found that patients who did not speak English has their primary language were more likely to have multiple 30-day remissions at a Los Angeles Hospital. It was also found that Patients speaking Russian, Farsi and Spanish each represented about 5% of patients with three or more hospital stays between July 2009 and December 2010 (9).

Even though multiple studies have been made about this issue, there have not been much follow through in improving the process of helping patients in a more proactive manner. Until further improvements are discovered and offered to hospitals, in order to prevent these avoidable issues, hospitals and malpractice carriers are urged to set objective standards of performance for staffed medical interpreters, develop specific codes and protocols to track specific language barrier issues, educate and bring awareness to physicians and patients of language services, and provide proper documentation and instructions of understanding for LEP in-patients and out-patients alike in order to protect both parties from allegations caused by miscommunications or a breakdown in communications through 3rd parties (10).

Current Attempts to Combat the Issue of Cross-Cultural Communication and Medical Illiteracy: Domestically and Internationally (AW)

Problems stemming from language barriers are not exclusively found in the United States. Due to international travel becoming more common and accessible. Hospitals and their healthcare providers are expected to prepare, accommodate and provide the same quality of care to foreigners as native-born citizens (11).

Currently, there are many international organizations worldwide dedicated to proactively combatting the issues of language barriers in their own special focus groups and professions. Domestically in the United States, the International Medical Informatics Association (IMIA) is the oldest and largest medical interpreter organization in the country (11). The goal of this organization is to standardize educational requirements and qualifications for medical interpreters, establish professional standards of practice for interpreters, promote professionalism in healthcare fields which require interpreters, promote the dissemination of medical informatics and awareness of medical interpretation-translation and current issues, promote research on cross-cultural communication issues in the healthcare setting, and promoting the medical interpreting profession (11). With members and associated interpretive and translative medical and health informatics organizations, the IMIA deals with language barriers in the healthcare field at a global scale.

Rather than combating the challenges of cross-cultural interpretation as a whole and at a global approach through policy and promotive tactics, Wolter Kluwer, market-leading global information services company, has developed and introduced the smart-device app for mobile devices called UpToDate to various international, local, and teaching hospitals throughout Japan (12). Utilizing current research and evidence-based clinical answers and recommendations to aid in diagnosis and treatment, UpToDate acts as a multi-tool for physicians and healthcare providers throughout Japan. With a built in multi-language search and navigation tool, it enables clinicians to pose clinical questions in multiple languages. It has an auto-complete feature that predicts medical terminology for quicker results. Currently, making up more than 1 million clinicians in 174 countries and almost 90% of academic medical centers in the United States (12).

In order to correctly combat the issues caused by language barriers, it is important to note two factors: that (1) the responsibility of handling language barriers does not completely fall into the hands of healthcare professionals as well as their patients, and (2) language barriers and medical literacy is nondiscriminatory to socioeconomic level, age, and education level. Therefore, it is important to create universal precautions and tests in order to determine how medically literate and prepared for these situations healthcare professionals are. Beyond that it is important to analyze how people might react throughout the process of being a patient or being discharged from the hospital and having to navigate through bills and insurance policies. Pfizer, a pharmaceutical corporation, among other researchers have created several tests, surveys, scales, and screening tools to help measure current health literacy for research used in potential health policy changes. Policy makers and researchers utilizing: Newest Vital Signs (NVS), Rapid Estimate of Adult Literacy in Medicine (REALM-S), Short Test of Functional Health Literacy in Adults (S-TOFHLA), The Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), Brief Health Literacy Screen (BHLS), or Subjective Numeracy Scale (SNS) (13). And so are able to pinpoint key areas in which policy changes may have a positive impact in improving cross-cultural communication issues in the medical field. Currently, research that is gaining the most attention in regards to policy change is using the media and health information technology to broaden and improve medical literacy and familiarity in low literate populations as well as creating a more culturally-tailored and patient-centric approach to cater not only to patients but their families as well (13).

Medical Interpreter Programs on the East Coast and in New Jersey (IA)

There are currently an encouraging number of certificate programs for medical interpreting at universities along the East Coast of the United States. Such certificate programs have been noted in undergraduate schools, from Ivy League universities to community colleges. Centers for higher learning like New York University, Cambridge College and Bunker Hill Community College are discussed below. Rutgers University, the State University of New Jersey currently has translation and interpreting programs and courses, but all focus on basic interpretation skills and/or skills specific for court interpretation.

Cambridge College: Medical Interpreter Certificate Program (IA)

Cambridge College located in Cambridge Massachusetts has a medical interpreter certificate program available to its undergraduate students. The program teaches topics that span from prescription medicines, diagnosis, treatment and human anatomy to cultural belief and patient values. It also prepares enrolled students for an internship under a professional interpreter’s supervision. The certificate program’s curriculum consists of a wide range of courses that total 18 credits (14).

The application process requires a high school transcript, recommendation form, personal statement, $50 nonrefundable fee ($100 for international students), proficiency in English as well as another language, and a passing grade on oral and written exams. In addition, there is a $110 graduation fee charged in the last term of undergraduate study and a health Insurance fee required for residents of Massachusetts. The certificate program has two options: degree credit or non-credit (14). Degree credit options incorporate the certificate program into student’s bachelor degree program and therefore are charged bachelor’s degree tuition. Non-degree credit option allows for non-traditional students not pursuing an undergraduate degree to still obtain the certificate but with appropriate non-degree credit fees (14).

Outcomes of the program include a greater proficiency in providing effective interpretation in a medical setting and a well-developed skill in cross-cultural communication. Individuals that finish the Cambridge program are successful in obtaining jobs as medical interpreters in medical practices, clinics, hospitals and interpreter agencies (14). Medical Interpreter Anatomy and Pathophysiology INT 100 • 3 credit(s) This course surveys the human body in health and disease in order to expose students who plan to work in health care to the major systems of the body, common diseases, diagnostic tests, pharmaceuticals and treatment options. Students learn how to define complex medical terms, concepts and abbreviations, and apply this knowledge according to their area of interest. The Role of the Interpreter INT 415 • 3 credit(s) This course focuses on the history of health care and social work, various cultures within our society, and the role of medical interpreters in the United States. Issues about advocacy that often impinge upon the interpreter-client relationship are examined. Students learn about confidentiality, patient rights, ethical and legal issues, as well as laws governing federal and state human-service agencies. Interpreting Skills I Multilingual INT 352 • 3 credit(s) Prerequisite: proficiency in other languages. Students already fluent in the language will learn the theoretical basis of interpretation and translation, and applied interpreting skills and techniques for medical or human service settings. Emphasis is placed on bilingual vocabulary and phraseology, and practice of interpreting skills through role-play. Interpreting Skills II Multilingual INT 355 • 3 credit(s) Prerequisites: Interpreting Skills I, LLIC010/INT100. Students integrate and apply the interpretation and translation theory learned in Skills I through extensive practice of simulations, predominantly in the consecutive mode. Students learn self-monitoring and coping strategies. They continue to develop bilingual medical and human service vocabulary and phraseology as well as explore the challenges of simultaneous interpretation. Cross Cultural Communications INT 412 • 3 credit(s) This course provides the participants with the opportunity to identify cross-cultural issues and their impact on the medical interpretation encounter. Students will analyze concepts such as communication, culture, cultural identity, non-verbal communication and cultural context related to interpretation. Readings of selected short stories that illustrate cross-cultural concepts will provide the basis for cultural contextual analysis. Interpreter Internship INT 300 • 3 credit(s) Students strengthen and refine their interpreting skills at a local internship site. They are evaluated for ability to work with providers and clients and to demonstrate understanding of service protocols in their field. In addition to completing the internship in the field, students also participate in debriefing seminars at the college to share and reflect on the meaning of the internship experience. Bunker Hill Community College: Medical Interpreting Certificate Program (IA)

Another college in Massachusetts known as the Bunker Hill Community College also has a certificate program for medical interpreting. The 18-credit curriculum is offered as a part-time evening program that trains students to become medical interpreters capable of working in various health care settings (15). A high school diploma, placement in college level English and reading courses, and health insurance are some of the program’s admission requirements. Since the program also involves placement in clinics or hospitals, criminal and sex offender background checks are also performed. Program graduates qualify for employment in chronic care facilities and health maintenance organizations as well as hospitals and clinics. Subsequent to the completion of the program, graduates are also able to take a certification exam offered by the National Board of Certification for Medical Interpreters (15).

COURSE TITLE COURSE SEMESTER CREDITS PREREQUISITES NUMBER TAKEN Medical Interpreting I AHE101- Fall 3 ESL099 or ENG090 and ESL099 see note* or RDG095 or placement Health Employment AHE104 Fall 3 Issues Medical Terminology NHP180-see Fall 3 note** Computer Course CIT Fall 3 Medical Interpreting II AHE102 Spring 2 AHE101 Medical Interpreting AHE299 Spring 1 AHE102 Internship Communication Skills for AHE117 Spring 3 Health Care TOTAL CREDITS 18

NYU Certificate in Medical Interpreting

The Certificate in Medical Interpreting: Chinese/English, Russian/English, and Spanish/English at New York University is a 120-contact hour program that consists of two non-credit courses that train entry-level medical interpreters in Spanish, Russian, or Chinese (Mandarin and Cantonese) (16). Students also have the opportunity to volunteer in a New York hospital during the program. Prior to registration, students must pass written and oral entrance exams, which test their proficiency in English, and one of the three other language options. Completion of only two courses, ‘Introduction to Medical Interpreting and Terminology’ and ‘Medical Consecutive Interpreting’ with a grade of B or higher is required to be eligible to receive the certificate (16). The courses are priced at a range of $740 to $795 each for a maximum total of $1590 required to obtain this certificate at NYU (16). Upon completion it is claimed that students will have gained the following:  Interpreting skills  Knowledge of English medical terminology  A vocabulary of language-specific medical terms and expressions  Training in cultural competency  Ethics and confidentiality training  Skills in professional conduct for various clinical settings  Preparation to work in any hospital setting (16)

The New Brunswick Community Interpreter Project (IA)

With the goal of improving the Latino community of New Brunswick, NJ’s access to health care, Robert Wood Johnson Medical School’s Office of Community Health created The New Brunswick Community Interpreter Project. This project addresses the needs of the recently increasing number of Latinos living in the New Brunswick area, many of whom are LED and lack insurance (17). The program works in collaboration with Rutgers University to give bilingual students the unique opportunity to play the role of medical interpreters at various New Brunswick medical institutions (17). Funded by grants from New Brunswick Tomorrow and Johnson and Johnson, the program is able to strive towards its 3 missions:

1. To increase health care access and quality in the New Brunswick Community 2. To offer an outlet for personal growth, community service, and language skills development for the Rutgers Community 3. To contribute to the development of the medical interpreting profession (17)

Rutgers: Translation and Interpreting program and courses (IA)

Rutgers’ Institute for Global Language currently has translation and interpreting courses available for its students. These courses, which run from four to eight weeks depending on the number of credits, include Computer-Assisted Translation (1.5 credits), Introduction to Court Interpreting (3 credits), Translation workshop (1.5 credits), and The Language of Justice (3 credits) (18). Note that though judicial-related interpreting courses exist, we have no such class in medical interpretation available. The downside of these courses is that it seems to only be available for educators and other professional proficient in language that want to increase their opportunities of employment and/or are seeking interpreting/translation careers (18).

The translation and interpreting program spearheaded by Rutgers University’s Department of Spanish and Portuguese allow individuals to earn BA, MA or certificates in Spanish-English Translation and Interpreting (19). The program, which is known to be one of the first translation/interpreting programs in the United States, has molded graduates who have received wide recognition over the past 20 years. Graduates of the Translation and Interpreting program have moved on to hold job titles like federal or state court interpreters and translators at Fortune 500 companies (19). A branch of the program is the Spanish-English Translation/Interpreting Certificate, which is offered to students who complete the following core, and prerequisite courses totaling 19-21 credits (20). The success of the program is mirrored in this certificate, with students who complete it having more job opportunities upon graduation.

Spanish-English Translation Interpreting Certificate Courses (20):

Prerequisite Course 01:940:401 Advanced Translation I 3 credits Core Courses 01:940:402 Advanced Translation II 3 credits 01:940:471* Internship in Translation/Interpreting 1-3 credits 01:940:475 Interpreting 3 credits 01:940:476** Legal Translation 1.5 credits 01:940:477 Court Interpreting 3 credits 01:940:478 Theory & Practice of Translation 3 credits or 01:940:479 Translation Workshop 01:940:486** Medical/Technical Translation 1.5 credits 01:940:487** Hospital/Community Interpreting 1.5 credits Linguistics Courses 01:940:363 Bilingualism in the Spanish-Speaking World 3 credits or 01:940:419 Dialectology of the Spanish-Speaking World 01:940:364 Contrastive Analysis (Spanish/English) 3 credits

Community Action: Proposing the Establishment of a Medical Interpreter Certificate Program at Rutgers University (AW)

For our community action project, we designed a model of a Medical Interpreter Certificate Program that can be initiated and tested at Rutgers University. By promoting cultural awareness and continuing education options for students, this program opens career opportunities and helps promote the improvement of the field of healthcare as a whole. The long-term goals of this model include its adoption by other schools to create a standard national certificate program for interpreting medical terminology in various languages. In order to gain faculty and school wide support and initiate the program’s start-up, we have decided to create a mailing list and send our research, thoughts, concerns, and ideas to Rutgers University and Medical School departmental heads, administration, and local newspapers in the tri-state area.

Certificate Program’s Target Audience & Requirements (21):

1) Science majors with a background and proficiency in the designated languages**  Rutgers Language Proficiency Test competency (level intermediate and above) 2) Language majors/minors with fulfilled science/technical prerequisites 3) Students enrolled in the School of Arts and Sciences (SAS), School of Environmental and Biological Sciences (SEBS), Ernest Mario School of Pharmacy, School of Engineering (Biomedical Engineering Majors) 4) Overall GPA requirement of 3.0 and above 5) Criminal background check required 6) Submission of medical history and record of recent PPD skin test required for internship portion of program * Program details are subject to change at University’s discretion due to number of enrolled students, resources, etc. ** Spanish will be the first language offered; with success of the program we will have the program (Arabic, Azerbaijani, Bangla/Bengali, Chinese (mandarin and Cantonese), Hindi, Indonesian, Japanese, Korean, Persian, Punjabi, Russian, Turkish, and Urdu)

Proposed Medical Interpreter Certificate Program Model for Rutgers University (IA)

Ideally, our proposed Rutgers University Medical Interpreter Certificate Program will combine essential requirements and courses of both the existing Translation and Interpreting Program under Rutgers University’s Department of Spanish and Portuguese and the very successful Medical Interpreter Certificate Program at Cambridge University. Formatted below is our model curriculum for the certificate program amended for Rutgers University. Following the model are projected resources needed to support the certificate program such as course instructors, lecture halls and classrooms, and financial and administrative support. Model Curriculum for the Proposed Rutgers Medical Interpreter Certificate Program (22 & 23)

Prerequisite Course 01:940:401 Advanced Translation I* (3 credits) Prerequisites: With grades of B+ or better: 940:325, 326 and 01:355:101, or equivalent. --Not open to freshmen and sophomores.-- Introduction to the theory of translation and guidance in the use of materials essential to the translation process. Intensive practice in the translation of short texts in various fields from Spanish into English and English into Spanish. Core Courses 01:940:402 Advanced Translation II* (3 credits) Prerequisite: 01:940:401, or equivalent. Intensive practice in the translation of short texts in various fields from Spanish into English and English into Spanish. 01:940:471 Internship in Translation/Interpreting* (1-3 credits) Rec. 1 hr., field work 2 hrs. per credit. Maximum of 3 cr. Prerequisite: Spanish 401 with a grade of B+ or better. Pre- or co- requisite, Spanish 402 or Spanish 475 and permission of department. Supervised training in a business firm, social service agency, or government office. Weekly discussions of specific texts and problems arising from the fieldwork experience. Supplementary written and laboratory assignments. 01:940:475 Interpreting* (3 credits) Prerequisites: 01:940:401 or 402. With permission of department Spanish 402 may be taken as corequisite. Introduction to theory and practice of liaison, consecutive and simultaneous interpreting. Spanish-English and English- Spanish. Intensive classroom and language laboratory exercises. 01:940:478 Theory & Practice of Translation* (3 credits) Prerequisites: 01:940:401, 402 with a grade of B+ or better. With permission of department Spanish 402 may be taken as a corequisite. Introduction to translation studies. Application of linguistic theory and computer technology to translation. Intensive practice in non-literary and literary translation, including narrative and theater. or 01:940:479 Translation Workshop* (3 credits) Prerequisites: Spanish 401, 402 with a grade of B+ or better. With permission of department, Spanish 402 may be taken as corequisite. Intensive practice in advanced translation, Spanish to English and English to Spanish. Non-literary and literary texts. Individual and group projects, with emphasis on translation into the native language. 01:940:486 Medical/Technical Translation* (1.5 credits) Pre- or co-requisite: 01:940:401 or permission of department. Practice in translation in such areas as medical, pharmaceutical, communications, computers and science textbooks. Development of specialized glossaries. Spanish-English and English- Spanish. 01:940:487 Hospital/Community Interpreting* (1.5 credits) Pre- or co-requisites: 01:940:402 and 475 or 486, or permission or department. Theory and practice of hospital, medical and other sensitive community interpreting roles. Development of specialized glossaries. Field assignments in area hospitals and clinics. INT 100 Medical Interpreter Anatomy and Pathophysiology** (3 credits) This course surveys the human body in health and disease in order to expose students who plan to work in health care to the major systems of the body, common diseases, diagnostic tests, pharmaceuticals and treatment options. Students learn how to define complex medical terms, concepts and abbreviations, and apply this knowledge according to their area of interest. INT 412 Cross Cultural Communications** (3 credits) This course provides the participants with the opportunity to identify cross-cultural issues and their impact on the medical interpretation encounter. Students will analyze concepts such as communication, culture, cultural identity, non-verbal communication and cultural context related to interpretation. Readings of selected short stories that illustrate cross-cultural concepts will provide the basis for cultural contextual analysis. *Existing course at Rutgers University New Brunswick School of Arts and Sciences Department of Science and Portuguese **Existing course at Cambridge University that should be created and established at Rutgers University New Brunswick. Possible Instructors of Certificate Program’s Courses (24) (IA)

To guarantee the success of the proposed medical interpreter certificate program, course instructors with experience teaching translation/interpreting courses are needed. It is believed that the credentials of the individuals below make them great candidates as instructors of one or more of the nine courses listed in our program model. The instructor candidates are:

1. Miguel A. Jimenez-Crespo, PhD  Director of Rutgers Translation and Interpreting Program at the Department of Spanish and Portuguese  Instructor of the summer course Computer-Assisted Translation 2. Hank Dallmann, PhD  Coordinator of the New Brunswick Community Interpreter Project  Staff interpreter for Robert Wood Johnson Medical School  Professor of interpreting and translation at Rutgers University 3. Betty Dallmann  Instructor of Rutgers University summer courses Translation Workshop and The Language of Justice 4. Margarita Smishkewych  Masters degree in Translation and Interpretation  faculty member of the Rutgers Translation and Interpreting Program 5. Margot Revera  Masters degree in Translation and Interpretation  faculty member of the Rutgers Translation and Interpreting Program 6. Beatriz Viera  adjunct instructor of the summer course Legal Translation  faculty member of the Rutgers Translation and Interpreting Program

Additional Projected Resources Needed for the Program (IA)

Apart from instructors and faculty members, the certificate program is projected to also require lecture hall/classroom sites, placement testing sites, supplies, and student recruitment. Being that seven out of the nine courses our program’s model curriculum already exist at Rutgers, the establishment of the additional two courses modeled after two Cambridge College courses should be the only difficult process. We confirm that obtaining resources for the program should not be difficult since testing/classroom sites and supplies are already available through Rutgers’ SAS Institute of Global Languages and Department of Spanish and Portuguese. If the program is successful, we hope to garner the financial support needed to promote our program’s mission and expand the curriculum to include other Rutgers language departments.

Scholarships & Further Incentives to Enroll into this Program (AW)

To attract perspective student enrollment for this certificate program financial aid is offered through many different scholarship awards for those who have a strong interest in sustaining their native language and are willing to pursue and explore future career paths involved in topics pertaining to language and cultural studies. This certificate program is aimed at the practicality of applying cultural awareness and language proficiency to improve the medical field. It is also an experience for students to create opportunities for themselves and explore the possibilities of starting their post-graduate careers abroad. Studying abroad offers valuable medical interpreting experience through communicating with people from different backgrounds. Students’ emersion into different cultures forces them demonstrate effective communication and social skills. Currently there are four main scholarships offered by Rutgers University pertaining to language studies, cultural awareness, and studying abroad. These scholarships include: The Critical Language Scholarship (25), The Boren Scholarship (26), The Benjamin A. Gilman International Scholarship Program (27), and The Fulbright Grant (28).

The purpose of The Critical Language Scholarship Program is to expand the efforts of the US government in increasing the number of American citizens interested in studying and mastering foreign languages deemed critical. Critical languages include: Arabic, Azerbaijani, Bangla/Bengali, Chinese, Hindi, Indonesian, Japanese, Korean, Persian, Punjabi, Russian, Turkish, and Urdu (25). This 7-10 week program provides structured cultural enrichment at language institutes located in Azerbaijan, Bangladesh, China, Egypt, India, Indonesia, Japan, Jordan, Morocco, Oman, Russia, South Korea, Tajikistan, Tunisia, Turkey, or other countries where the target languages are spoken. It covers a list of amenities that would make those participating have an easier time (25).

The purpose of the Boren Scholarship (similar to the Boren Fellowship) is to provide funding for US undergraduate students that are interested in pursuing and interested in adding an international and language components into their undergraduate education. Providing up to $20,000, the scholarship funds students to study abroad in countries important to US interests that are often underrepresented and overshadowed by conventional study abroad programs (26). Locals include countries in: Africa, Asia, Central & Eastern Europe, Eurasia, Latin American, and the Middle East. The countries of Western Europe, Canada, Australia, and New Zealand are excluded. In exchange for accepting these funds, US undergraduate students must agree to the NSEP Service Requirement and work in a Federal Government position with national security responsibilities for the duration dictated under the program (26).

Funded by the Bureau of Educational and Cultural Affairs at the US Department of State, the purpose of the Benjamin A. Gilman International Scholarship is to fund students who are interested in pursuing academic study abroad programs (27). The scholarship targets those underrepresented in the study abroad programs, such as students with high financial need, STEM majors, diverse ethnic backgrounds, and the disabled. Encouraged to study abroad in non-traditional this scholarship aims to afford opportunities to those students least likely to study abroad otherwise (27).

Funding bachelor's degree recipients, master's candidates and recipients, doctoral candidates, and young professionals and artists, the Fulbright Grant aims to provide opportunities for eligible individuals to pursue individually designed study/research projects. Such projects may include but are not limited to: research, field work, university coursework, classes in music conservatory or art school, business internships, English Teaching Assistantship (ETA), community service, or a combination of these different services (28). Providing funding for various amenities, the Fulbright Grant experience is invaluable to those who have a strong background in other languages as well as English. This enables grantees to practice teaching languages and experiencing the cultural awareness aspect of studying and working abroad whether it is in the healthcare field or any other field of research (28). How the Certificate Program fits into the Rutgers University- NB Mission (IA)

The objective of our proposed program is to incorporate the ethnical, cultural and linguistic diversity present at Rutgers University into the undergraduate and graduate education of students pursuing a career in the health sciences. Our proposed medical certificate program is a great fit for Rutgers University New Brunswick whose threefold mission involves providing for the instructional needs of New Jersey’s citizens, contributing to the well-being of the state, and aiding the national and local economy.

The short-term goal of this proposed certificate program is to train undergraduate Rutgers New Brunswick students to strengthen and apply their linguistic backgrounds to their education. If the program proves to be successful with the Rutgers undergraduate population, long-term goals include incorporating the medical interpreter certificate into graduate and continuing education programs and eventually programs at other United States universities. Being that Rutgers is intertwined with many businesses in the New Brunswick community, the program strives to effectively train students in the program's internship course to successfully interpret in the New Brunswick located Eric B. Chandler Health Center. By doing so, students will be able to strengthen their skills while providing much needed interpreting services to residents of the New Brunswick community. Though this program will not be research related, it will improve the quality of education of participating students and contribute to the cultural, social and medical wellbeing of New Brunswick.

Benefits of the Certificate Program (IA)

1. Graduating students with the certificate will have more employment options 2. Quality of Rutgers health-sciences and language related academic programs will be enhanced 3. Surrounding New Brunswick communities will be provided with high quality interpreting services from students of the program 4. Rutgers will be part of the small group of innovative universities with medical interpreting certification programs

Looking into the Future (VC)

We initially designed this program for use locally, here at Rutgers New Brunswick. It is our intention to incorporate this program into perspective students’ undergraduate curriculums. After students and professors have become acclimated, we hope to incorporate a greater number of students (both traditional and non-traditional). This task will require some assistance from the Department for Continuing Education and will allow non-traditional students with the option to earn a certificate in medical interpreting. The same basic classes will be compulsory and non- traditional students will be able to place out of the introductory language courses. Looking further, we hope that this medical interpreter program will set a new statewide standard here in New Jersey, with a greater number of universities offer such programs, perhaps even across the country. Letter (sent to Rutgers University New Brunswick department heads and administration)

Dear (insert name here),

As undergraduates here at Rutgers University New Brunswick, we have come across an innovative approach being undertaken nationally and globally to enhance the education of undergraduate and graduate students, and improve the quality of future healthcare given by our rising generation of health professionals. Please read below to see how Rutgers University and you can be a part of this pioneering educational approach.

Since the incorporation of the Patient Protection and Affordable Care Act (PPACA) into the US legislature on March 23, 2010, there has been an influx of patients who are now able to access healthcare. New Brunswick, like most of the United States, is a diverse community with many inhabitants having immigrated to their new homes. As a result, a large proportion of New Brunswick's population consists of individuals with Limited English Proficiency (LEP). With the growing availability of and access to health care in medically under-served communities, language barriers that exist between patient and physicians become a great detriment. Currently, many states have legislated requirements for medical interpreters, however in almost all cases, management and enforcement of these requirements is lacking. Often times, unqualified individuals like family members and friends of patients are wrongfully used as convenient replacements for certified medical interpreters. This should not be the ‘go-to’ solution to cultural and language barriers existing at medical institutions. When patients have little to no English- speaking ability and uncertified interpreters are used, healthcare professionals fail to provide the standard quality of care these patients deserve to receive. As a result, patients often have a lack of trust for their doctors and misunderstand their ailments, treatments, dosages, and financials. To combat these common issues of interpreter access and availability, an innovative method has been established at institutions and universities globally, nationally and locally.

Medical Interpreter Certification programs have been successfully launched at institutions across the globe and universities across the nation. As witnesses of the linguistic and cultural diversity at Rutgers University and the New Brunswick Township, our team passionately believes that Rutgers should incorporate a Medical Interpreter Certificate Program into its growing repertoire of programs and make such training available to undergraduate students. The success seen in schools like Boston University, NYU and Cambridge College can certainly be replicated and perhaps magnified here at Rutgers. By analyzing the methods and structure of these programs and courses at other universities, we have constructed a model medical interpreter certification program that takes into the account existing resources at Rutgers University New Brunswick such as a culturally and linguistically diverse student body, dedicated departments, and language labs. Since general translation/interpreting programs and court interpreting courses are currently available at Rutgers New Brunswick, we are hoping to use these same resources to create a program more tailored for the medical and health care field; a Medical Interpreter Certification Program.

Financially, this model program would bring in a lot of funding to Rutgers University and its departments from many different sources. Current and future in-state students of Rutgers University would be paying tuition to fund their undergraduate education as well as their enrollment and participation in this certificate program. There would also be a large influx of financial support coming from international students with a desire to expand their multilingual talent and out-of-state students having such a novel program, Rutgers would be one of the first in the area to offer a new, promising program that combines science, healthcare, and a student’s cultural background together to enhance overall education. By establishing such a distinct and unique program at a well-known institution like Rutgers, the university, its departments and faculty members would quickly become financially able to expand its connections and network within the medical field not only nationally, but globally.

Furthermore, with the incorporation of this proposed certificate program into Rutgers curriculum, graduates will have additional employment options after graduation, students will be able take on a more personal approach to their education, and our future healthcare providers become more culturally competent and linguistically diverse. Being that a large majority of our student population is in medical, pharmacy, nursing, or physician assistance programs, this certificate program will have widespread application. As Rutgers undergraduates, we are hoping to first change the way our healthcare system manages patients who speak English as a second language, at a local level, here in New Brunswick. This program would not only benefit undergraduate and eventually graduate and non-traditional students at Rutgers University New Brunswick, but also residents of the local Piscataway/New Brunswick area through student provided interpretation services.

We are writing to you in the hopes that you would, with others at Rutgers, entertain the possibility of developing a medical interpreter certification program at Rutgers. We would be happy to share with you our proposal and model program curriculum as well as a short video presentation https://www.youtube.com/watch?v=ppbGtL62Q8U&feature=youtu.be. Contact Dr. Julie Fagan to request a full copy of our proposal. We could also present our proposed program to you and others if you would like to learn more about our proposed medical interpreter certificate program.

Continuing the theme of the Rutgers motto: Sol iustitiae et occidentem illustra (Sun of righteousness, shine upon the West also), we feel that this program will create many new opportunities with each coming year for a rapidly growing and diverse student body. Adding Rutgers University to the short list of undergraduate institutions providing this novel and successful approach to incorporate cultural and linguistic competency into science and health education will help bring Rutgers to the forefront of improving healthcare in NJ and across the US as well as bring a new stream of income to the University.

Thank you for your time and consideration

Sincerely,

Aaron Wu

Ife Aridegbe

Vincenzo Cimino Julie M. Fagan, Ph.D.

Mailing List:

A list of individuals in the Rutgers New Brunswick community who are believed will play a pertinent role in the establishment of the certificate program was compiled. The individuals below are either directors or administrative heads of science, health, and language departments related to the proposed certificate program. We have sent the above letter to:

Robert L. Barchi Rutgers President [email protected]

Brian Strom Chancellor of Rutgers Biomedical and Health Sciences [email protected]

Marion Yudow Director of Institute for Global Languages [email protected]

Carolyn Burger Senior Academic Program Coordinator of Institute for Global Languages [email protected]

Peter March SAS Executive Dean [email protected]

James Masschaele SAS Executive Vice Dean [email protected]

Michael Beals Vice Dean for Undergraduate Education [email protected]

Kenneth Breslauer Dean of Biological Sciences, Vice President for Health Science Partnerships [email protected]

Hank Dallmann Coordinator of the New Brunswick Community Interpreter Project [email protected] Robert M. Goodman Executive Dean of SEBS [email protected]

Gail Alexander Chief of Staff, Office of the Executive Dean [email protected]

Richard D. Ludescher Dean of Academic Programs, School of Environmental and Biological Sciences [email protected]

Barbara J. Turpin Dean of Undergraduate Education for the George H. Cook Campus [email protected]

Joseph A. Barone PharmD – Dean and Professor II of the Pharmacy Practice [email protected]

Donald K. Woodward PharmD – Associate Dean for Academic Services [email protected]

Jeannette M. Decker Senior Program Coordinator [email protected]

Arthur D. Casciato, Ph.D. Director of Office of Distinguished Fellowships [email protected]

References

1.) Quan, K. JD MPH., & Lynch, J. (2010). The High Costs of Language Barriers in Medical Malpractice. Retrieved February 25, 2015, from http://www.pacificinterpreters.com/docs/resources/high-costs-of-language-barriers-in- malpractice_nhelp.pdf

2.) Flores, G. MD. (2006, July 20). Language Barriers to Health Care in the United States — NEJM. Retrieved March 29, 2015, from http://www.nejm.org/doi/full/10.1056/NEJMp058316 3.) Ludden, J. (2009, July 27). Patient Interpreters Save Money, But Who Pays?. Retrieved March 29, 2015, from http://www.npr.org/templates/story/story.php?storyId=111066555

4.) Lee, H. Y., Ph. D., (2015). Working with Interpreters - Part II. Retrieved March 29, 2015, from http://www.cehd.umn.edu/ssw/ContinuingEd/Documents/Module5/Module-5-Working- with-Int

5.) Chen, A. H. M.D., (2007, Oct 24). The Legal Framework for Language Access in Healthcare Settings: Title VI and Beyond. Retrieved March 30, 2015 from http://link.springer.com/article/10.1007/s11606-007-0366-2

6.) World Health Organization. (n.d.). Retrieved March 20, 2015, from World Health Organization website: http://www.who.int/medicines/services/inn/en/

7.) Get Certified. (2012). Retrieved March 29, 2015, from http://www.certifiedmedicalinterpreters.org/getcertified

8.) Castillo, A. (2013, May 5). Lack of standards for Oregon medical interpreters raises issues about training. Retrieved March 29, 2015, from http://www.oregonlive.com/pacific-northwest- news/index.ssf/2013/05/lack_of_standards_for_oregon_m.html

9.) Rice, S. (2014, August 30). Hospitals often ignore policy on using qualified medical interpreters, patient safety is endangered. Retrieved March 29, 2015, from http://www.modernhealthcare.com/article/20140830/MAGAZINE/308309945

10.) Smith, S. (2012, June 8). Professional Interpreters Communications with LEP Patients Have Fewer Errors. Retrieved March 29, 2015, from http://health.wolterskluwerlb.com/2012/06/professional-interpreters-communications-with-lep- patients-have-fewer-errors/

11.) IMIA - International Medical Interpreters Association. (2015). Retrieved March 29, 2015, from http://www.imiaweb.org/about/default.asp

12.)Rebelo, A. (2015). Wolters Kluwer Health Announces Launch of UpToDate Anywhere in Japan. Retrieved March 29, 2015, from http://www.uptodate.com/home/wolters-kluwer-health- announces-launch-uptodate-anywhere-japan

13.) Current Research in Health Literacy. (2012). Retrieved March 29, 2015, from http://www.pfizer.com/health/literacy/healthcare_professionals/public_policy_researchers/curre nt_research_in_health_literacy

14.) Medical Interpreter Certificate. (2013). Retrieved March 29, 2015, from http://cambridge.cambridgecollege.edu/degree/medical-interpreter-certificate 15.) Medical Interpreting Certificate Program – Bunker Hill Community College. (2015). Retrieved March 29, 2015, from http://www.bhcc.mass.edu/programsofstudy/programs/medicalinterpretingcertificateprogram/

16.) NYU School of Professional Studies. (n.d.). Retrieved March 20, 2015, from NYU School of Professional Studies website: http://www.scps.nyu.edu/academics/departments/foreign- languages/academic-offerings/noncredit/certificate-in-medical-interpreting.html

17.) New Brunswick Interpreter Program. (2014). Retrieved March 29, 2015, from http://rwjms.rutgers.edu/community_health/nbinterpreter_pgm.html

18.) Translation and Interpreting. (2015). Retrieved March 29, 2015, from http://languageinstitute.rutgers.edu/translation-interpreting

19.) About the Translation and Interpreting program. (2015). Retrieved March 29, 2015, from http://translation.rutgers.edu/-program-info-mainmenu-38/about-mainmenu-75

20.) Certificate in Translation. (2015). Retrieved March 29, 2015, from http://translation.rutgers.edu/certificate-in-tai-navmenu-135

21.) Essential Medicines and health products: International Nonproprietary Names. (2015). Retrieved March 29, 2015, from http://www.who.int/medicines/services/inn/en/

22.) Undergraduate Spanish Courses. (2015, January 1). Retrieved March 29, 2015, from http://span-port.rutgers.edu/spanish-program/200-spanish-courses

23.) Medical Interpreter Certificate. (2013, January 1). Retrieved March 29, 2015, from http://cambridge.cambridgecollege.edu/degree/medical-interpreter-certificate

24.) Faculty / Staff. (2015, January 1). Retrieved March 29, 2015, from http://translation.rutgers.edu/faculty-staff-directory-mainmenu-107/91-faculty

25.) Casciato, A. D., Ph. D., (2015, January 1). Critical Language Scholarships. Retrieved March 29, 2015, from https://fellowships.rutgers.edu/fellowships/critical-language-scholarships

26.) Casciato, A. D., Ph. D., (2015, January 1).Boren Scholarship. Retrieved March 29, 2015, from https://fellowships.rutgers.edu/fellowships/boren-scholarship

27.) Casciato, A. D., Ph. D., (2015, January 1).Benjamin A. Gilman International Scholarship. Retrieved March 29, 2015, from https://fellowships.rutgers.edu/fellowships/benjamin-a-gilman- international-scholarship

28.) Casciato, A. D., Ph. D., (2015, January 1).Benjamin A. Fulbright Grant. Retrieved March 29, 2015, from https://fellowships.rutgers.edu/fellowships/fulbright-grant

29.) About the University. (2015, January 1). Retrieved March 29, 2015, from http://www.rutgers.edu/about/about-university

Letters to the Editor

Letter #1 sent to West Windsor and Plainsboro News on 3/25/2015:

Dear Mr. Rein,

I was hoping you could please consider publishing my letter to the editor. Currently an Undergraduate (junior) at Rutgers University I, along with my friends, want to enhance and personalize the educational experience of the diverse community who attend Rutgers University from West Windsor and neighboring towns as well as combat medical illiteracy and language barriers in the medical field.

Since the incorporation of the Patient Protection and Affordable Care Act (PPACA) into the US legislature on March 23, 2010, there has been an influx of patients who are now able to afford the care they need and take advantage of this national healthcare policy change. West Windsor and close by communities such as Piscataway and New Brunswick contain large diverse community with many inhabitants having immigrated to their new homes. As a result a large proportion of these long-term residents speak English as their second language–assuming that they speak English at all. With the growing availability of and access to health care in medically under-served communities, language barriers that exist between patient and physicians become a great detriment. Having been a volunteer EMT at the Twin W First Aid Squad since my high school career at West Windsor Plainsboro High School South, I have had many experiences with interacting with patients who have had a difficult time understanding and explaining what they are feeling during their time of emergency even when we have transferred them to the hospital.

If patients do not speak English and there are no competent translators present, how can higher- level healthcare professionals provide the same quality of care to these patients and trust that the patients understand their ailments, treatments, dosages, and financials completely? Currently, each state has its own legislated requirements for medical interpreters, however, in almost all cases such requirements, training methods, and supervision are lacking. Malpractice suits due to language barriers are expensive and can be avoided easily with preparation and training.

Many students enrolled at West Windsor Plainsboro High School South and North come from many different ethnicities and cultural backgrounds and make up a large population of Rutgers undergraduates and graduates who enroll as students studying the field of Medicine, Pharmacy, Nursing, Physicians Assistance, and many more fields retarding healthcare and science. Many students, like me, put so much work in these fields of study that many unfortunately lose their cultural background and ultimately their multilingual skills and potentials are wasted. I believe that the best way to combat the issues of national language and cultural barriers is to utilize the large, diverse population of present and future students enrolled at Rutgers University New Brunswick and create a continual-education program/certificate program that students can enroll in to (1) take their education in a more personal approach by using their native tongue to expand their career horizons in health care, (2) be more culturally aware and open to a potential career path abroad, and (3) combat language barriers and improve the overall healthcare system. Being a student in a school with a student body of more than 65,000 students from all 50 states and more than 115 countries with a total of 47,000 undergraduates and more than 19,000 graduate students, it is easy to lose yourself in the competitive academic environment especially in those aiming to pursue a career in healthcare. Heritage and culture becomes the “go-to” method of identifying myself out of the crowd. This project is Important to me because it will allow busy pre-health students, whose shoes I’ve struggled in, add a personal flair into their “orthodox” education. Being an undergraduate life sciences do not have a “right-out-of-college- hire-able” degree such as engineering degrees and healthcare internships are often unpaid regardless of how much indent the students are, I feel that this program will significantly help students be more prepared entering the job market. With this program and certificate, students are eligible for niche careers right out of college that could help build-up funds to further their pursuit towards a career in healthcare.

In a project my partners and I have been working on, we have provided an overview for the proper preparation and training for medical interpreters. By analyzing the domestic and international methods of combatting language barriers and medical illiteracy, we have compiled and constructed a certification model program that takes into the account existing resources Rutgers University New Brunswick already has such as: eager students with various international backgrounds, dedicated, well-funded departments, and language labs.

Our goal for this project is to create a program in which students with an interest in a career in the field of healthcare can have a chance to utilize their cultural backgrounds to enhance their future experience in their given profession. Our long-term goal is to potentially develop nationwide undergraduate Medical Interpreter Certificate program that can be adopted into other schools across the US and in affiliated international schools. What we need now is administrative and public advocacy to initiate this plan.

As current undergraduates hoping to enter the healthcare field in the near future after graduating from Rutgers University New Brunswick and having been a student during the recent merge with the Robert Wood John Medical School, I feel that this program would benefit the Rutgers University–New Brunswick, Rutgers New Jersey Medical School, and the population of eager students as a whole. Continuing the theme of the Rutgers motto: Sol iustitiae et occidentem illustra (Sun of righteousness, shine upon the West also), I feel that this program will open many opportunities with each coming year for a rapidly growing and diverse student body. My partners and I ask for your help, support, and participation in the integration of this program into the growing legacy of Rutgers University.

Thank you for your time and consideration,

Aaron Wu Rutgers University the State University of New Jersey Letter #2 sent to the Daily Targum on 3/24/2015:

Dear Yvanna Saint-Fort (Daily Targum Editor),

Please consider publishing my letter to the editor- see submission below and attached. The issue and proposal have grown to be very important to my two partners and I. We hope that the proposal garners enough support that our proposed program is established at the University.

Making Medical Interpreter Certification an Option at Rutgers University By Ife Aridegbe --- 3/24/2015

Since the 2010 incorporation of the Affordable Care Act into US legislature, the population of individuals who can obtain affordable health care has expanded. Combine this policy change with the growing cultural and linguistic diversity in many areas of the US and we have the existing cultural and language barrier in modern healthcare becoming even more of a medical, legal and financial burden.

As much as these barriers exist on an international and national level, such issues are just as prominent here in New Brunswick. Rutgers University and the surrounding New Brunswick area have communities that are undeniable diverse. Why don’t we incorporate the cultural and linguistic diversity of many students here at Rutgers into our education? I am encouraging all Rutgers New Brunswick students and faculty members interested in health care to consider this question.

With responsibilities of a medical interpreters including translator of medical information, culture broker, and patient advocate, their presence is essential. Yet, individuals with limited English proficiency and/or who speak a primary language that is non-English often are not provided with certified medical interpreters. Whether this is the result of the limited number of interpreter services that are available at medical institutions or the lack of a standard procedure for incorporating medical interpreters into patient-doctor relationships, such occurrences are unacceptable. Unqualified individuals like family members and friends of patients’ are not acceptable replacements for certified medical interpreters. When the problem is often the limited access and availability of certified medical interpreters, why not train our future health care providers to be more culturally competent and multilingual at the undergraduate level?

My team members and I passionately believe that Rutgers should incorporate a Medical Interpreter Certificate Program into its growing repertoire of curriculums and make such training available to traditional and non-traditional students. The success seen in schools like Boston University, NYU and Cambridge College can certainly be replicated and perhaps magnified here at Rutgers. If you are a student in Rutgers’ medical, pharmacy, nursing, or physician assistance programs help us make this certificate program an option for you! Not only will this certificate program provide graduates with additional employment options post-grad, it will help students take on a more personal approach to their education and become more culturally competent in future careers. We have strong hopes that incorporating this Medical Interpreter Certificate Program into the undergraduate education of Rutgers students majoring in healthcare-related fields may launch a national initiative aimed at decreasing the prevalence of language barriers in future health services. All my team asks is for the support of our Rutgers community in bringing the need for a Medical Interpreter Certification Program to the attention of our institutions academic leaders.

Thank you for your time and assistance.

Best Regards,

Ife Aridegbe Rutgers University- SEBS Class of 2015 Major: Biological Sciences Minor: Public Health

Letter #3 sent to the Queens Courier, Queens Chronicle and Queens Forum on 3/25/2015:

Dear Lisa Licausi,

Please consider publishing my letter to the editor—see submission below and attached. I am currently a senior at Rutgers University New Brunswick enrolled in the Undergraduate School of Environmental and Biological Sciences. I am originally from North Flushing, Queens and recognize the diversity in my home community, where many individuals are immigrants whose proficiency in English is weak at best. My group members and I are hoping to change the way our healthcare system manages patients who speak English as a second language, at a local level, here in New Brunswick. However, this need is most prevalent in NYC, the melting pot I call home. In 2010 the US legislated the Patient Protection and Affordable Care Act (PPACA), which has made healthcare readily available to a new segment of our community (who previously could not afford treatment). Despite this new recognition and accessibility, management of cases where patients with limited English proficiency is desperately lacking. Thus, there is a predominating need to overhaul such protocols and establish medical interpreter programs in Eastern and Southern Queens especially, where there are large Hispanic and Asian communities.

Medical interpreter programs do exist (usually as continuing education programs), many of which may be studied at universities right here in the city. However, these programs lack national standardization, and are failing to adequately prepare students for the adversities they will deal with in practice. That is why my classmates and I are working to create a dedicated curriculum here at Rutgers, which addresses these shortcomings and will be made available to both traditional and non-traditional students. The ultimate goal, however, is for universities across many states to adopt this newer standard and assume a more stringent medical interpreter standards.

As a first generation Italian-American I have first-hand experience with the inadequacies prevalent in our current system. In many cases doctors fail to successfully communicate disease states, causes, and treatment regimens to their patients, often relying upon family members for translation. This method fails to consider patients’ unwillingness to discuss specific symptoms with family members who are most often younger than the patients. This unwillingness subsequently retards the treatment process and can even lead to misdiagnosis and/or insufficient treatment. That is why this issue is so important to both my classmates, and myself and so we have made it our goal to prepare medical interpreters to: (1) translate medical information, (2) establish proficiency as a patient advocate, and (3) understand possible differences in cultural norms and act as an intermediary between doctors and patients.

If these new processes are assimilated into current medical interpreter programs in the Queens and larger NYC area, we will successfully procure a higher standard of treatment for patients with limited English proficiency, while making students pursuing careers in healthcare more marketable.

Thank you for your time and consideration, Vincenzo Cimino Rutgers University the State University of New Jersey (SEBS Senior)