DISCUSSION PAPER

Language, Interpretation, and A Clarifi cation and Reference Checklist in Service of Health Literacy and Cultural Respect

Marin P. Allen, PhD, National Institutes of Health (retired); Robert E. Johnson, PhD, Gallaudet University; Evelyn Z. McClave, PhD, California State University, Northridge; and Wilma Alvarado-Little, MA, MSW, New York State Department of Health

February 18, 2020

“The fi rst skill of a great translator is humbleness, to be a servant. Once you are a servant, you may be lucky to be called a master of your craft. And, you need the humbleness to understand your original, to be part of it—then also the practical humbleness to get someone who knows more than you to check your work. That collaboration is very enriching and very rewarding—a good way of ensuring you produce a decent translation.” — Marco Sonzogni, n.d.

“Translation is not a matter of only; it is a matter of making intelligible a whole .” — Anthony Burgess [8]

Introduction of the patient’s stressors. Using these two additional representations could provide a better understanding Language, interpretation, and translation are becom- of all factors at play. ing increasingly critical parts of practicing medicine During our careers in , communication, across the United States. However, these areas often and interpretation, and from our work in health lit- aren’t considered before the patient is sitting in front eracy, it has become clear to the authors that many of the clinician—and at that point, it is too late. Inter- health professionals lack a clear resource to help them pretation, translation, and regard for language need navigate the multilingual reality of health care in the to be incorporated across the clinical workfl ow and United States. In this manuscript, we off er linguistics, deeply considered and planned for well in advance of gesture, health literacy, health communication, and the patient seeking care. cross-cultural experience as lenses through which to This manuscript describes complex problems of consider cross-discipline communication. We also of- language, interpretation, gesture, and translation and fer a checklist to guide providers when they do not recommends solutions. Simply providing defi nitions share a common language with their patients. for the topics discussed does not provide an eff ective message for understanding the human context of lan- Scope of Language Challenges guage—especially in medical settings. Providing a free fl ow of accurate and a Recently, NAM Perspectives published “A Journey to clear understanding about how to improve human Construct an All-Encompassing Conceptual Model of health and prevent disease depends upon spoken, Factors Aff ecting Clinician Well-Being and Resilience” written, or signed words. Central to eff ectively sharing [7]. This constitutes an important eff ort to create a this knowledge is knowing how to meet people in a fair more holistic view of the provider. The authors of this and trustworthy way while respecting the complexities manuscript contend that this same 360-degree model and values within and among varying . of the clinician could be matched with a 360-model of A core principle underlies all communication: hu- an interpreter or translator and a 360-degree model mans communicate symbolically. Even the languages

Perspectives | Expert Voices in Health & Health Care DISCUSSION PAPER

people speak, write, or sign are, at their essence, sym- department with his mother and met with a physician bols. Burke described humankind as a “symbol-using who spoke little Spanish. Since an interpreter was not animal” whose reality has actually been “built up for us available, this minor “acted as his own interpreter.” through nothing but our symbol system” [9]. The physician misinterpreted when the mother stat- The issues of language access and eff ective com- ed that her son was dizzy, thinking the mother said that munication are much more complex and require her son looked yellow. When the physician asked the much more attention than what occurs when people boy about this, his mother responded, “You were dizzy, state that they need to “get someone to translate it” like pale,” and the boy reported to the physician that or “fi nd someone who speaks some Farsi or Spanish.” his mother said, “Like I was paralyzed, something like Communication is diffi cult, and communicating about that” [13]. often frightening and overwhelming health issues is The confused communication among the boy, his even more complex. When a health care provider does mother, and the physician presented very real safety is- not speak the same language as those being treated, sues and could have resulted in, for example, a missed relationships can quickly become strained, important diagnosis for juvenile diabetes. The authors encourage pieces of information can be lost, and gestures or turns readers to review Flores’ perspective in full. This excel- of phrase can be misinterpreted. These lapses in lan- lent resource demonstrates the challenges of, errors guage can change the course of someone’s life. in, and outcomes of, language services experienced by The number of languages spoken in the U.S. com- physicians and patients alike in the medical setting. pounds this complexity. Historically, 39 languages had The signifi cance of Flores’s paper was recognized in a been tracked through the American Community Sur- contemporaneous editorial in Oncology Nursing Forum vey of the U.S. Census Bureau. But, in 2015 the bureau by Caroll-Johnson, “Lost in Translation” [10]. Carroll- reported that more than 350 languages are spoken Johnson concluded that, “As the world shrinks and our and signed at home in the United States. These data communities become more diverse, we must be pre- also included more than 150 Native American languag- pared to address these dilemmas with real solutions es (such as Apache and Yupik) as well as additional and not rely on middlemen, women, or children lacking information about language use in 15 metropolitan in understanding to do our work for us.” areas. In the release, Erik Vickstrom, a Census Bureau Reporting on an additional medical setting, outpa- statistician, noted that “in the NY Metro area more tient practice, Jacobs and colleagues cite and describe than a third of the population speaks a language other the medical and fi nancial impact of one catastrophic than English at home, and close to 200 diff erent lan- missed interpretation [25]: guages are spoken.” He added, “Knowing the number of languages and how many speak these languages in On his initial medical history, a Spanish-speak- a particular area provides valuable information to poli- ing boy aged 18 years, of Cuban descent, pre- cymakers, planners, and researchers” [22]. These data sented with abnormal mental status complain- also help to give context to the increasing complexity in ing of “intoxicado.” An untrained interpreter navigating the health care system. understood this to mean that the boy was in- The challenge and necessity of translation and in- toxicated - though in the Cuban dialect, the boy terpretation in health care are illustrated in Flores’ was actually saying that he was “nauseated.” He concrete 2006 New England Journal of Medicine article received care for a drug overdose attributed to on language barriers and his systematic review of the substance abuse but developed paraplegia, impact of medical interpreter services on the quality subsequently found to be due to a ruptured of health care in the United States. In this perspective, intracranial aneurysm. The case led to a mal- Flores notes that “the provision of adequate language practice lawsuit with a $71 million award to the services results in optimal communication, patient sat- plaintiff . [26,27] isfaction, outcomes, resource use, and patient safety” [13]. The authors also review current law, regulation, and Flores describes, with direct quotations of the in- policy and the comparative costs of interpreter servic- teractions, the problematic exchanges that occurred es and systems in outpatient practice. when a 12-year-old Latino boy arrived at an emergency

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As our nation becomes more multicultural, the chal- In interpretations between a signed language and a lenges will become only more complex. The time to ad- spoken language, simultaneous interpretation is com- dress language, interpretation, and translation as criti- mon, because the vocal-auditory channel and the ges- cal parts of the health system is now. tural-visual channel do not compete. In the health care environment, positioning of the patient, interpreter, Interpretation and Translation: Defi ning and provider are of great importance and should be Terms carefully planned. People often believe that interpretation involves spo- Under any conditions, simultaneous interpretation ken language and that translation involves written lan- presents linguistic and cognitive challenges. The re- guage. While these defi nitions may diff erentiate the sults sometimes suff er from inaccuracies not found two terms in a general way, there is actually a great in other forms of interpretation that allow for greater deal more to each concept, as we describe below. time delay between the produced utterance and the rendered interpretation. Interpretation These diffi culties occur not only in spoken involves two essential characteristics. interpreting but during sight translation (on-the-spot First, it involves the rendering of live utterances in translation from documents or directions provided one language to live utterances in another language. during the visit) that are also interpreted to the patient. The “source language” is the language of the speaker In all cases, the quality of simultaneous interpreta- (or signer). The “target language” is the language of tion will be improved if the interpreter has access to the receiver of the interpretation. Interpreting neces- the text or to accompanying electronic media ahead of sarily involves one of three possible dyads: (a) spoken the actual event. In medical settings, such access may source language and spoken target language, (b) spo- not be possible, so the pace of simultaneous interpre- ken source language and signed target language, or (c) tation may need to be slowed to ensure greater accu- signed source language and signed target language. racy.

Second, interpretation, being a live act, necessarily Consecutive Interpretation involves an immediacy not characteristic of translation. In an alternative form of interpretation, called consec- That is, the interpreter has to process a piece of utive interpretation, the sender produces (or signs) a and render it—either simultaneously or consecutive- short utterance (perhaps a sentence or two) and then ly—into the other language, without the opportunity to pauses while the interpreter renders these pieces into consider alternative renderings. the target language. Upon completion of the interpre- tation, the sender produces the next short piece of lan- Simultaneous Interpretation guage. In an example of simultaneous interpretation, the pa- Take this example passage: “I am going to explain tient speaks (or signs) in their source language, and the the side eff ects of this medication, which include possi- interpreter speaks aloud (or signs) what is being said ble shortness of breath, nausea, dizziness, and anxiety. in the target language for the health provider. The in- So, if you experience any of these, call me or go to the terpreter is, at the same time, comprehending the next emergency room.” Consecutive interpretation would part of the source’s message. create pauses that are helpful to both the patient and This is complex. Diff erent interpreters will vary in the interpreter. “I am going to explain the side eff ects their delay between the uttered (or signed) discussion of this medication [PAUSE], which include possible and their rendering of the message. The interpreter re- shortness of breath [PAUSE], nausea, dizziness, and ceives, produces, and converts at the same time. In this anxiety. [PAUSE] So, if you experience any of these, call example, the interpreter will reverse immediately to me [PAUSE] or go to the emergency room.” simultaneously interpret the information from health Consecutive interpretation can be more precise and care provider to the patient. Unlike in most health care accurate than simultaneous interpretation because it settings, in formal presentations, such as a conference, gives the interpreter more time to seek an appropriate this might involve the speaker using a publicly trans- rendering and does not involve the cognitive challenge mitted channel and the interpreter using a private of undertaking the two tasks of listening and render- channel that can be heard only through earphones. ing at one time (as in simultaneous interpreting). It can

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also be more time consuming because each communi- ments can have varying lengths, and there is often no cator must wait for the interpretation to be completed opportunity for the interpreter to review them before before initiating the next “turn.” the interpreting encounter. Although this process can be eff ective for documents that are short and clear, Translation interpreters are sometimes asked to provide a sight Translation involves movement between the written translation for longer and more complex documents. forms of two languages. It is important to acknowledge These longer documents include such important items that there exist for unwritten languages as consent forms, forms for advance directives, and [e.g., the endangered tribal language of Coeur d’Alene detailed educational materials. Such forms should be or to American ]. There are also trans- translated prior to their use. lations between diff ering sign languages. Sometimes The challenges associated with sight translation in- misunderstood, it is important to note that sign lan- clude requiring the interpreter to speak and read in guage is not universal. two languages at the same time. Ultimately, this may More precisely, translation tends to involve move- threaten the accuracy, clarity, and thoroughness of ment between a recorded form of one language into a communication for the patient and the health care recorded—not necessarily the same form— of another provider. language. In this sense, “recorded” could include writ- ten text, audio recordings of spoken language, or video Why Skilled Interpreters are Key to Eff ective recordings of either spoken or signed languages. Health Care The essential characteristic of translation is that it It is important to point out that—while all interpreters, tends not to be “live.” It involves longer time spans be- by defi nition, are bilingual—not every bilingual per- tween the source production and the rendering into son can interpret. Professional interpreters undertake the target language. The time diff erence provides the substantial training in both languages and in moving opportunity for consideration of alternative transla- between them. These days, many interpreters have tions, research into previously produced translations, master’s degrees, refl ecting the years of practice neces- assistance from automatic translators by computer, sary to become profi cient at rendering the product of and revision of the fi nal target production. Translation one language into another in an effi cient, accurate, and diff ers from interpretation not because it produces meaningful way. In addition, for a limited number of diff erent materials, but because it off ers the opportu- languages, national certifi cation programs are in place. nity to consider the input and output provided since However, certifi cation is not available for all spoken the target production is “unglued” or separated in time languages. from the source material. Bilingual ability diff ers from person to person. Most As Youdelman notes, “The most qualifi ed transla- bilingual individuals have diff erential levels of compe- tors are those who write well in their native language tence in their two languages, often more so if they have and who have mastered punctuation, spelling and not formally studied both languages and learned how . Translators know how to analyze a text and to translate and interpret in each of the two languages. are keenly aware of the fact that translation does not This requires more skill than being conversationally fl u- mean -for-word replacement, but that context is ent in two languages. the bottom line for an accurate rendition of any text” While it is convenient and not uncommon to use [24]. The best translators understand the nuance and family members, friends, or passersby as interpret- connotative power of both languages and understand ers, the appropriateness of this practice diminishes the level of diction that is appropriate to the texts and as the stakes of the event become greater. Whereas a the audiences. person’s sister might function well in assisting in the Sight Translation communication between persons at an informal din- Sight translation is the “translation of a written docu- ner, the same sister may be seriously unqualifi ed to ment into spoken/signed language. An interpreter function as an interpreter in a health care setting. The reads a document written in one language and simul- fact that a patient might feel more comfortable with a taneously interprets it into a second language” [19]. family member should not outweigh the need for an In a health care setting, this usually occurs when a accurate interpretation of what the health care profes- spoken language interpreter is handed a document in sional says and how the patient responds. the moment during the interpreting assignment. Docu-

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Moreover, untrained interpreters may balk at expla- lot of technical vocabulary. Technical words may have nations involving bodily functions or critical injuries. to be spelled out if there is not a sign in the language Due to cultural beliefs or an age diff erence between a corresponding to that concept. younger family member and an elder, it might be con- In addition, when two spoken languages are involved, sidered disrespectful for a younger person to present it is easy for the health care practitioner to notice when many types of questions to an elder. This is especially the interpreter’s turn at speaking is fi nished. It is not true when dealing with personal or sensitive topics. always so easy for a hearing person with little experi- In addition, legal issues related to privacy come into ence in such situations to know when the interpreter play when employing an interpreter in a health care is fi nished with their utterance if they are interpreting setting. Professional health care interpreters will have spoken utterances into sign language. learned how to discuss these issues in their training. With a sign language interpreter, there may be a sub- Finally, it may not be suffi cient to have a good inter- stantial delay between when the practitioner is fi nished preter. In many settings, especially those involving very speaking and when the interpreter fi nishes interpret- specialized vocabulary (such as clinical settings and re- ing the utterance. This can lead to overlaps that hinder search environments), interpreters may need to have the quality of the communication. A certain amount of special experience with fi elds of health care, the vocab- fl exibility and patience may be required of the medical ulary used in those fi elds, and the indications that are practitioner in order not to overlap excessively with the under discussion. interpreter. Although appropriate and in-person interpreters Lastly, as a clinical event involving an interpreter will may not always be readily available, the authors of this almost certainly require more time than one in which manuscript believe they are necessary for eff ective the patient shares a language with the practitioner, it is communication with individuals who speak a diff erent advisable that practitioners adopt fl exible scheduling language from their health care provider. Providers practices to accommodate patients who require inter- may feel that the absence of an interpreter is equiva- preters. lent to the absence of eff ective communication, and Earlier in this discussion, the authors of this manu- the patient, without an interpreter, is not participating script noted the immediacy of the process in which an in their own health care. No one is served in this situ- interpreter takes a piece of speech or sign and renders ation. it—simultaneously or consecutively—into another lan- To demonstrate the high stakes of such a situation, guage without the opportunity to consider alternative Fadiman’s classic study of cross-cultural communica- renderings. This focus applies to formal interpretation tion in medical settings, The Spirit Catches You and You between two diff ering languages, but diff erences with- Fall Down: A Hmong Child, Her American Doctors, and the in the same language regarding health literacy terms Collision of Two Cultures, provides an extended descrip- should also be considered. The patient and the health tion of interactions involving a Hmong child over many professional may both speak English or Spanish or years [12]. Urdu, but their comprehension may not be equivalent. The specialized medical terminology and complex con- Interpretation Challenges and Signed cepts for describing disease or treatment processes Languages often hamper understanding. Signed language interpreting and spoken language in- Further, in an interpreted consultation, there are two terpreting have almost everything in common except potential sources of misunderstanding. An interpreter the channel of the signals. Signed languages, such as may misunderstand (and misinterpret) the patient, , can fully discuss any medical and the doctor (or the patient) may misunderstand the or scientifi c topic that can be discussed in English or interpreter. Teach-back is a very eff ective method for another spoken language. identifying trouble spots in interpretation. The primary diff erences in interpreting between a signed and a spoken language and interpreting be- Cultural Appropriateness of the Interpreter tween two spoken languages tend to be practical diff er- Because interpreters are the “voice” of the person for ences. Interpreting an English utterance into a signed whom they are interpreting, more should be consid- language may take a bit more time than the equivalent ered than just the technical message to be transmitted. spoken language interpretation, especially if there is a A patient in a medical encounter wants the best, most

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accurate representation. In general, it is considered ap- If the patient is back-channeling using nods asso- propriate for the cultural and ethnic characteristics of ciated with affi rmation, it can be very tempting for the interpreter to match those of the patient. overworked health care personnel to ignore vacant Overall, it is important that the individual’s voice, expressions in a patient’s eyes and facial expressions whether spoken or signed, be presented clearly and of confusion. Such nods, however, do not signal under- accurately by a qualifi ed interpreter, especially in clini- standing—they signal only attentive listening. cal and hospital settings, where information must be Research has shown that speakers often request lis- transmitted accurately and completely. tener back channels by nodding while they themselves When scheduling an interpreter, those charged with are speaking [16]. Listeners often respond with their hiring should consider the nature of the visit and its own nods almost immediately if the speaker is nodding content. Sharing this information in advance provides as well. Such back-channel requests are beneath the the spoken or sign language interpreter the opportu- level of conscious recall, so health care professionals nity to prepare. Preparation includes such activities may unwittingly be triggering back-channeling in pa- as identifying terms that might not exist in both lan- tients, which is then misinterpreted as understanding guages. In addition, recruiters should consider ethnic or assent. This challenge works both ways. and gender characteristics, especially when the gender of the interpreter is relevant to the health care visit, Additional Challenges for Interpreters such as in reproductive health care for either men or The authors have identifi ed many what might be women, or other issues that the individual perceives as called traditional or technical challenges for interpret- intimate, e.g., physical or psychological trauma. ers working in medical settings, but much needs to be Of course, considering all these factors is not always learned about the full range of interpersonal challeng- practical, and at times, the match will not be perfect. es for these professionals. In a 2016 qualitative study For example, because proportionally there are more of the experiences of interpreters who supported the women in the fi eld of interpreting than there are men, transition from oncology to palliative care, researchers it is not uncommon for a male client to have a female identifi ed the study aims: interpreter. Medical consultations focused on managing the Gesture and Miscommunication transition to palliative care are interpersonally Gestures are movements of the hands, arms, head, challenging and require high levels of communi- and other parts of the body that convey meaning and/ cative competence. In the context of non-English or serve interactive functions. Research has focused on speaking patients, communication challenges spontaneous gestures that co-occur with speech and are further complicated due to the requirement are beneath the level of conscious recall [17]. Unlike of interpreting; a process with the potential to conventionalized gestures, spontaneous gestures do add intense layers of complexity in the clinical not have prescribed, predictable forms, yet they reveal encounter, such as misunderstanding, misrepre- aspects of thought that are not verbalized. sentation and power imbalances [15]. One fi nding of gesture research especially relevant for clinician-patient interaction, with potentially the The sensitivity of this specifi c example seems to be biggest impact on patient health, is back-channeling. a likely proxy for all such emotional and complicated “Back-channeling” refers to the recipient’s signals of at- interactions. The investigators conclude: tention to the conversation. Often, they are verbal and overlap with the doctor’s speech, including utterances The results suggest that interpreters face a such as “uh-huh,” “oh, really,” and similar listening cues. range of often concealed interpersonal and in- Equally common gestures, however, include head terprofessional challenges and recognition of nods in American and many other cultures [23]. The such dynamics will help provide necessary sup- rate of nodding varies across cultures, and some coun- port for these key stakeholders in the transition tries, such as Bulgaria, use lateral shakes (akin to the to palliative care. Enriched understanding of in- American head movement for negation) as back chan- terpreters’ experiences has clinical implications nels instead. Cultures use whichever head movement on improving how health professionals interact (if any) is associated with affi rmation to back-channel. and work with interpreters in this sensitive set- ting [15].

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The authors of this perspective urge attention to the Translation, Interpretation, and Quality Im- needs of the interpreter in addition to the needs of the provement patient and the medical team. Quality improvement in all programs dealing with pa- Interpreters and Translators in Health Care tients and medical staff across languages constitutes an important element of understanding the full impact It is possible to approach the problems related to in- of language access and services. One model for discus- terpreting and translating more comprehensively and sion of the quality of services is based on the National systematically, but doing so requires strategy, organi- Academies of Sciences, Engineering, and Medicine’s zational commitment, planning, training, and budget. six quality domains of safety, timeliness, eff ectiveness, Two examples of such comprehensive and systematic effi ciency, equity, and patient-centeredness [18]. Each of approaches are those provided by Language Line Solu- these domains can pertain directly to opportunities to tions and the Health Care Interpreter Network (HCIN). improve the quality of translation and interpretation in Language Line Solutions, originally known as Com- medical settings. munication and Language Line (CALL) was founded in As an example of how quality improvement in inter- 1982 in San Jose, California to help police communicate pretation can be implemented is provided in a modular with some 65,000 Vietnamese refugees in the area. resource from the Agency for Healthcare Research and Language Line provides interpretation and translation Quality (AHRQ). The free and multifaceted TeamSTEPPS services for law enforcement, health care organiza- Limited English Profi ciency module trains health care tions, legal courts, schools, and businesses. teams to work with interpreters [2]. It also prompts HCIN was originated by Contra Costa Health Services interpreters to speak up if they discern a safety issue. in California. HCIN is focused on medical interpreting As the site notes, citing Divi and colleagues, “Recent re- and off ers an instantly accessible interpreting network search suggests that adverse events that aff ect limited- and cost-eff ective videophone medical interpreting in English-profi cient (LEP) patients are more frequently 38 spoken languages and in American Sign Language. caused by communication problems and are more HCIN provides by-appointment video or phone health likely to result in serious harm compared to English- care interpreting in approximately 60 additional lan- speaking patients” [11]. guages. Both organizations provide continuing education for Teach Back and Interpretation professional interpreters through online platforms. For In Sudore and Schillinger’s article on interventions to example, HCIN Learn off ers a three-hour course cov- improve care for patients with limited health literacy, ering interpreting for prenatal genetic counseling that they operationalize the teach-back method [21], which is described as covering concepts in human genetics, can also be used to ensure quality during interpreta- the work of counselors who advise about prenatal ge- tion sessions: “The teach back method is a technique in netics and, specifi cally, guidance on the challenges in which the clinician asks patients to restate or demon- interpreting that arise in this setting. The course also strate the knowledge or technique just taught” [21]. A provides technical language and practice elements for patient-centered strategy includes assessing how well interpreters. the patient understands the information the physician In the introduction to a manuscript examining HCIN, provides, using a methodical and sensitive approach Jacobs et al. argue that “providing health care in a lan- that requires the medical professional to be alert to the guage that the patient can understand is a moral im- needs of the patient. Important elements of the teach- perative. Allowing patients with limited English profi - back method include (a) confi rmation of understand- ciency to receive sub-standard care and consequently ing, (b) reinforcement, and (c) numeracy and present- be at risk for disparities in care, health, and well-being ing risk information. is unacceptable, especially in light of the breadth of lin- The authors note that asking “Do you have any ques- guistic access services available, even in remote areas” tions?” or “Do you understand?” does not confi rm un- [14]. HCIN has been successfully adopted by Contra derstanding. Instead, the authors recommend asking Costa Health Services, and is now utilized in 50 health “What questions do you have?” In an earlier work, Schil- clinics and hospitals throughout the system. linger and colleagues also recommend that the physi- cian destigmatize interactions by putting the respon- sibility back on themselves, stating, for example, “I’ve just said a lot of things. To make sure I did a good job

NAM.edu/Perspectives Page 7 DISCUSSION PAPER

and explained things clearly, can you describe to me . Resilience” [7]. This important eff ort to have a holistic . . ?” [20]. In that same study, Schillinger notes that the view of the provider might well be matched with a simi- method “does not result in longer visits and has been lar model for the patient and for the interpreter. The associated with diabetic patients having better meta- conceptual model presented in the Brigham paper, bolic control” [20]. These techniques also allow the which considers clinicians, patients, families and care- provider to emphasize important health information, givers, and all of the aspects that infl uence all of their conveyed via the interpreter, in a culturally sensitive behaviors, provides an important starting place for the manner. eff ort to provide a holistic view of the provider and the health care system. Universal Precautions and Health Literacy The second edition of the AHRQ’s “Health Literacy Uni- Measuring Patient Experiences with versal Precautions Toolkit” describes health literacy Interpreter Services universal precautions as “the steps that practices take Since 1995, AHRQ has off ered the Consumer Assess- when they assume that all patients may have diffi cul- ment of Healthcare Providers and Systems (CAHPS) to ty comprehending health information and accessing advance scientifi c understanding of the patient’s expe- health services” [4]. The precautions include the follow- rience with health care [3]. AHRQ has developed a se- ing elements: (a) simplifying communication with and ries of resources to be used in medical settings, includ- confi rming comprehension for all patients to minimize ing specifi c, freely-available supplemental surveys that the risk of miscommunication, (b) making the offi ce en- assess patient and provider experiences with inter- vironment and health care system easier to navigate, preter services in medical settings [1]. AHRQ data are and (c) supporting patients’ eff orts to improve their a rich resource for internal analysis and shared data health. comparisons. Among other items, patients are asked AHRQ also provides its rationale for this approach: about their needs for services, the services provided, the timeliness of the services, and the quality of the in- Experts recommend assuming that everyone terpreter. Sample survey questions include may have diffi culty understanding and creating an environment where all patients can thrive. • “How often did this interpreter treat you with Only 12 percent of U.S. adults have the health courtesy and respect?” literacy skills needed to manage the demands of • “Using any number from 0 to 10, where 0 is the our complex health care system, and even these worst interpreter possible and 10 is the best in- individuals’ ability to absorb and use health in- terpreter possible, what number would you use formation can be compromised by stress or ill- to rate this interpreter?” ness. Like with blood safety, universal precau- • “How often did you use a friend or family mem- tions should be taken to address health literacy ber as an interpreter when you talked with this because we can’t know which patients are chal- provider?” lenged by health care information and tasks at • “Did you use a child younger than 18 to help you any given time. It is important to bring this same talk with this provider?” principle of assuming the likelihood of diffi cul- ties in comprehension into any interpretation Diff erent CAHPS surveys use slightly diff erent ques- between language settings. This will help lessen tions about interpreter services [5]. For example, Hos- the risk of miscommunication. [4] pital CAHPS includes the question, “During this hospital stay, did hospital staff tell you that you had a right to Not all medical interactions are in hospitals or of- interpreter services free of charge?” fi ces. In a discussion of patient communication in pal- liative care and hospice settings, Alves and Meier note: Pitfalls of Electronic Interpretation as a “Doctors practice as we are trained” [6]. Solution The competing and stressful pressures on clinicians The introduction of handheld, speech-driven electronic are complicated by a myriad of elements, outlined in interpretation devices seems, at fi rst, to address many Brigham and colleagues’ National Academies article of the problems that arise when providers and patients “A Journey to Construct an All-Encompassing Concep- do not speak the same language. However, these de- tual Model of Factors Aff ecting Clinician Well-Being and vices lack the precision and fl exibility required for

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medical interactions. Devices render words that sound Additional questions to ask yourself and your team alike such as “oral” and “aural)” or “optic” and the suf- are: How will I manage the time in the appointment? Do I fi x “otic”), but have, often critically diff ering meanings. have a good resource for evaluating the credentials of any Words that are said out of context, or words that are interpreters? Are there going to be any special needs for unfamiliar can stymie eff ective rendering of communi- the interpreter, such as a gown or a mask? Has the inter- cation. Devices aren’t able to diff erentiate or under- preter been prepared for the interaction to make the most stand any miscommunication in the range of mean- eff ective use of their skills? (E.g., the following introduc- ings of a word such as “PAP,” which can vary from “the tion for an interpreter: “Today, the patient is going to common gynecological test of a PAP smear,” to “posi- be told he is going to undergo chemotherapy. This fact tive airway pressure,” to “a synonym for soft or baby sheet will be used by a patient who speaks Portuguese, food” lacking the cues for context. Such a device could and I will be explaining how the medication works and also have diffi culty relaying like-sounding words such what to expect.”) as dysphagia (diffi culty in swallowing) and dysphasia (a Remember, each time, to look at the individual (your brain injury that complicates communication or makes attention is important), not the interpreter. it impossible). Machines are improving, but they are not the solution in many medical settings. During the Patient Encounter: Clinical Setting Focus on the patient. Looking the patient in the eye will Looking Forward help in judging their level of understanding. Ensure that you are talking to the individual, not the interpreter or Having reviewed the many challenges related to lan- a family member. This will help ensure that the patient guage, interpretation, and translation in health care makes their own decisions in the encounter. settings, the authors of this manuscript believe that Ask yourself: Will embarrassment about topics, cul- improving communication via interpretation and/or ture, age, or the presence of family members in the room translation between clinicians and patients depends keep my patient from telling me the truth? Have I used the on (a) strategic preparation; (b) careful and consistent teach-back method to confi rm my patient understands implementation of rules; and, as with any signifi cant ef- me? (E.g., “Please, tell me what I’ve asked you to do? fort, (c) commitment to improvement through experi- How will you take this medication? When do you need ence. to be rechecked?”) Much research is needed regarding the intersections of language, interpretation, translation, and health lit- After the Patient Encounter: Clinical Setting eracy. Immediate research needs include comparisons Ask yourself: How did it go? Are there any adjustments I across varying methods of interpretation and transla- need to make for the next interaction with this patient or tion services and the eff ectiveness of specifi c methods any other individual who speaks a diff erent language? Are and tools. The impact of nonverbal cues and gestures there any adjustments I need to make in working with an in medical settings need greater attention. There is interpreter, either in person or by teleconference? also a need for better understanding of how to bring individuals from diff ering cultural perspectives into the References processes that directly aff ect them. 1. Agency for Healthcare Research and Quality The authors of this manuscript off er below a few sug- (AHRQ). 2017. Supplemental items for the CAHPS gestions for developing habits that health care provid- hospital survey: Interpreter services. Available at: ers may fi nd helpful. The suggestions are followed by a https://www.ahrq.gov/cahps/surveys-guidance/ short checklist (on the following page) that can be used item-sets/literacy/suppl-interpreter-service-items. in the clinical setting. html (accessed January 14, 2020). Planning Ahead: Clinical Setting 2. AHRQ. 2017. TeamSTEPPS limited English profi ciency If possible, prior to a fi rst encounter with a patient who module. Available at: https://www.ahrq.gov/team- communicates in a diff erent language than yours, con- stepps/lep/index.html (accessed May 9, 2019). sider: how might my staff and I determine what language 3. AHRQ. 2018. CAHPS hospital survey. Available at: preferences and accommodations are needed for eff ective https://www.ahrq.gov/cahps/surveys-guidance/ communication with the individual? hospital/index.html (accessed May 9, 2019). This is also a good time to think about what materials 4. AHRQ. 2019. AHRQ health literacy universal precau- might be provided and how they will be used. tions toolkit. Available at: https://www.ahrq.gov/ health-literacy/quality-resources/tools/literacy-

NAM.edu/Perspectives Page 9 DISCUSSION PAPER

Checklist: Considerations in Planning for Possible Translation and Interpretation Needs in the Clinical Setting

Planning

 Do I know what this patient needs to understand and what they need to take away from this encounter?  Is the interpreter prepared with enough information?  Have I planned the best way to focus on the patient?

The Patient Encounter

 Am I focused on the patient (making eye contact), not the interpreter or family member?  Am I remembering the teach-back strategy and not depending on head nods, which often mislead?

Refl ection after the Patient Encounter

 What could I do to improve the next interaction with this patient or a similar patient?  Have I made a note in the record to include the language and interpreting preferences of this patient?

toolkit/index.html (accessed January 14, 2020). US hospitals: A pilot study. International Journal for 5. AHRQ. 2019. CAHPS surveys and guidance: What Quality in Health Care 19(2):60-67. https://doi.org/ are CAHPS surveys? Available at: http://www.ahrq. 10.1093/intqhc/mzl069 gov/cahps/surveys-guidance/index.html (accessed 12. Fadiman, A. 1997. The Spirit Catches You and You May 8, 2019). Fall Down : A Hmong Child, Her American Doctors, 6. Alves, B. and D. Meier. 2015. Health Literacy and and the Collision of Two Cultures. 1st ed. New York: Palliative Care: What Really Happens to Patients. Farrar, Straus, and Giroux. NAM Perspectives. Commentary, National Acad- 13. Flores, G. 2006. Language barriers to health care in emy of Medicine, Washington, DC. https://doi. the united states. New England Journal of Medicine org/10.31478/201512c 355(3):229-231. 7. Brigham, T., C. Barden, A. L. Dopp, A. Hengerer, 14. Jacobs, E. A., G. S. Leos, P. J. Rathouz, and P. Fu, J. Kaplan, B. Malone, C. Martin, M. McHugh, and Jr. 2011. Shared networks of interpreter services, L. M. Nora. 2018. A Journey to Construct an All- at relatively low cost, can help providers serve pa- Encompassing Conceptual Model of Factors Af- tients with limited English skills. Health Aff airs (Mill- fecting Clinician Well-Being and Resilience. NAM wood) 30(10):1930-1938. https://doi.org/10.1377/ Perspectives. Discussion Paper, National Acad- hlthaff .2011.0667 emy of Medicine, Washington, DC. https://doi. 15. Kirby, E., A. Broom, P. Good, V. Bowden, and Z. org/10.31478/201801b Lwin. 2017. Experiences of interpreters in sup- 8. Burgess, A. 1984. Is translation possible? Transla- porting the transition from oncology to palliative tion: The Journal of Literary Translation XII:3–7. care: A qualitative study. Asia-Pacifi c Journal of 9. Burke, K. 1966. Language as symbolic action; essays Clinical Oncology 13(5):e497-e505. https://doi.org/ on life, , and method. Berkeley: University 10.1111/ajco.12563 of California Press. 16. McClave, E. Z. 2000. Linguistic functions of head 10. Carroll-Johnson, R. M. 2006. Lost in translation. movements in the context of speech. Journal of Oncology Nursing Forum 33(5):853. https://doi.org/ 32(7):855-878. https://doi.org/ 10.1016/ 10.1188/06.ONF.853 S0378-2166(99)00079-X 11. Divi, C., R. G. Koss, S. P. Schmaltz, and J. M. Loeb. 17. McNeill, D. 2005. Gesture and thought. Chicago: Uni- 2007. Language profi ciency and adverse events in versity of Chicago Press.

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18. Institute of Medicine. 2001. Crossing the Quality A clarifi cation and reference checklist in service of Chasm: A New Health System for the 21st Century. health literacy and cultural respect. NAM Perspectives. Washington, DC: The National Academies Press. Discussion Paper. National Academies of Medicine, https://doi.org/10.17226/10027. Washington, DC. https://doi.org/10.31478/202002c 19. National Council on Interpreting in Health Care. 2005. National standards of practice for interpret- Author Information ers in health care. Available at: https://www.ncihc. Marin P. Allen, PhD, is the former Deputy Associate org/assets/documents/publications/NCIHC%20 Director of the Offi ce of Communications and Public National%20Standards%20of%20Practice.pdf (ac- Liaison in the Offi ce of the Director, National Institutes cessed May 13, 2019). of Health (retired). Robert E. Johnson, PhD, is Profes- 20. Schillinger, D., J. Piette, K. Grumbach, F. Wang, C. sor Emeritus, Department of Linguistics, Gallaudet Uni- Wilson, C. Daher, K. Leong-Grotz, C. Castro, and versity. Evelyn Z. McClave, PhD, is Professor Emerita A. B. Bindman. 2003. Closing the loop: Physician of Linguistics California State University, Northridge. communication with diabetic patients who have Wilma Alvarado-Little, MA, MSW, is Associate Com- low health literacy. Archives of Internal Medicine missioner, New York State Department of Health, and 163(1):83-90. Director, Offi ce of Minority Health and Health Dispari- 21. Sudore, R. L., and D. Schillinger. 2009. Interven- ties Prevention. tions to improve care for patients with limited health literacy. Journal of Clinical Outcomes Man- Acknowledgments agement 16(1):20-29. The authors would like to acknowledge the important 22. US Census Bureau. 2015. Census bureau reports at contributions of John P. Madison, PhD to this perspec- least 350 languages spoken in U.S. Homes. Available tive and to the larger discussion. We would also like to at: https://www.census.gov/newsroom/press- express our gratitude to Melissa French and Alexis releases/2015/cb15-185.html (accessed May 10, Wojtowicz for their support in the development of this 2019). document. 23. Yngve, V. H. 1970. On getting a word in edgewise. 1970, Chicago. Confl ict-of-Interest Disclosures 24. Youdelman, M. 2009. What’s in a word? Ms. Alvarado-Little has no relevant fi nancial or non- A guide to understanding interpreting and fi nancial relationships to disclose. She contributed translation in health care. Available at: to this article based on her experience in the fi eld of https://9kqpw4dcaw91s37kozm5jx17-wpengine. health literacy and cultural competency and the opin- netdna-ssl.com/wp-content/uploads/2019/01/ ions and conclusions of the article do not represent Whats-in-a-Word-FINAL.pdf (accessed May 13, the offi cial position of the New York State Department 2019). of Health. 25. Jacobs, B., A. M. Ryan, K. S. Henrichs, and B. D. Weiss. 2018. Medical Interpreters in Outpatient Correspondence Practice. Annals of Family Medicine 16(1): 70-76. Questions or comments about this manuscript should https://doi.org/10.1370/afm.2154 be directed to Marin P. Allen at marinpallen@gmail. 26. Ku, L. and G. Flores. 2005. Pay now or pay later: com. Providing interpreter services in health care. Health Aff airs (Millwood) 24(2): 435-444. https://doi. Disclaimer org/10.1377/hlthaff .24.2.435 The views expressed in this paper are those of 27. Harsham, P. 1984. A misinterpreted word worth the authors and not necessarily of the authors’ $71 million. Medical Economics. June: 289-292. organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, DOI Engineering, and Medicine (the National Academies). https://doi.org/10.31478/202002c The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Suggested Citation Academies. Copyright by the National Academy of Allen, M. P., R. E. Johnson, E. Z. McClave, and W. Alvarado- Sciences. All rights reserved. Little. 2020. Language, interpretation, and translation:

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