The Art of Working with Interpreters
A Manual for Health Care Professionals

Originally published by International Interpretation Research Center, Monterey Institute of International Studies, 1995.

by Holly Mikkelson

You've probably heard the story: The doctor asks the non-English-speaking patient how he's doing; the patient gives a lengthy response involving wild gesticulations and dramatic facial expressions, and the interpreter declares, "He says he's fine." Anyone who has to rely on an interpreter to understand what's going on is naturally mistrustful; putting your ability to communicate in someone else's hands means giving up a lot of power. But as the world continues to shrink, interpreters will become increasingly ubiquitous. Whether you're traveling for business or pleasure, conversing with colleagues in other countries, or interacting with patients right here at home, you'll find yourself relying on interpreters more and more frequently to bridge the language gap. The purpose of this booklet is to show you some steps you can take to communicate successfully through an interpreter.

What Do Interpreters Do?

The short answer is that interpreters convey oral messages from one language to another, that is, from a source language to a target language (as opposed to translators, who transfer written messages between languages). This seemingly simple task is actually quite complex. Every language has its own rules for putting together words, and if those rules are not followed, the words make no sense. Even a simple sentence like "Take the medication three times a day at mealtime" might end up as "At the time of eating daily three times the medicine you must in your mouth put." Interpreting is a lot like pouring water from a two-quart pitcher into a two-liter beaker: The water (the message) doesn't change; only the shape of the vessel (the words) does. The interpreter's job is to make sure no water is spilled during the transfer, and that no contaminants are introduced into the second container.

And that's not just a matter of changing word order: Suppose your patient comes from a country where it's customary to eat four times a day rather than three, and suppose the language doesn't have a generic word for "meal," but has only specific names for each meal. The interpreter would have to say, for example, "Take the medicine at breakfast, lunch, and tea, but not supper." And if the medical professional uses a colorful expression like "We'll have you up to snuff in no time," the interpreter must convey the idea that the patient will be brought back to health soon; a literal translation of that expression would probably leave the patient completely confused and wondering about the sanity of his health care provider.

Furthermore, human communication involves more than just words; messages are conveyed through posture, facial expression, tone of voice, and even silence. Imagine two different patients being informed of a course of treatment: The first patient slouches in her chair, looks at the floor or stares out the window during the explanation, and when asked if she understands, replies with a hesitant "yes." The second patient sits erect with her hands clasped in her lap, looks the provider in the eye, and responds to questions with a nod of the head and a firm "yes." Although both patients have used exactly the same words, they are clearly sending different signals. Even when both participants in a conversation share the same language and culture, they must be alert to these nonverbal cues if they are to communicate fully. When another language and culture are thrown into the mix, things get complicated. Although the nonverbal parts of the message can easily be seen and heard by anyone in the room, they may be misinterpreted because they vary from one culture to another (avoiding eye contact may be a sign of embarrassment, shame, or evasiveness, or it may simply be a way of showing respect for authority; and a patient may sit in an awkward position in the chair because she is insecure, in pain, or merely unaccustomed to sitting in chairs).

The goal of the interpreter is to convey all facets of the message so that it will have the same impact on the listener in the target language as it would have in the source language. He or she must bridge not only a linguistic gap, but a cultural one as well. Thus, there may be times when the role of the interpreter goes beyond conveying messages and encompasses some intervention to prevent misunderstandings. Suppose the interpreter is aware of certain dietary restrictions in the patient's culture that will hamper cooperation in treatment: The iron supplements recommended for prenatal care are considered a "hot" food, which pregnant women are supposed to avoid in the patient's belief system. It would be inappropriate for the interpreter to ignore that fact and simply interpret messages back and forth between patient and provider; it would be equally inappropriate for the interpreter to assume responsibility for persuading the patient to cooperate by telling her misleading things about the medication. The best course of action is for the interpreter to inform the obstetrician of the potential conflict and help provider and patient reach a mutually agreeable way to ensure cooperation in treatment.

The interpreter isn't working in a vacuum, after all. The goal of interpreted communications is to eliminate linguistic and cultural barriers and allow the participants to carry out their business as if there were no interpreter present. But the corollary to this is that any problem that would have existed between a provider and an English-speaking patient will not be solved by the interpreter. You can't expect the interpreter to improve on your articulation of ideas. If you want to explain a complicated procedure to an unsophisticated person, speak plain English so that the explanation can be put in simple terms in the patient's language. By the same token, don't expect the interpreter to clean up a patient's rambling, disjointed statements and turn them into concise answers.

Two Modes of Interpretation

Two modes of interpretation are used in the medical setting: consecutive and simultaneous. The more common mode is consecutive, in which the interpreter waits until the speaker has completed a statement before beginning to interpret it; thus, only one person is speaking at a time. A communication event that is interpreted consecutively generally takes about twice as long as one that doesn't require an interpreter. Consecutive interpreting requires a good short-term memory. Some interpreters take notes, but many simply rely on their memory, especially for short utterances.

The second mode of interpreting is simultaneous, which, as the name suggests, involves two people speaking at the same time. The interpreter, not being a mind reader, must wait until a complete idea has been expressed before interpreting it, but then continues to interpret, lagging one thought behind the speaker and finishing a few seconds after the speaker. This type of interpreting can save time, but it requires a lot of concentration on the part of the interpreter, and the other people in the room may find it distracting to hear two voices at once.

A number of factors come into play when deciding between consecutive and simultaneous interpretation. Some interpreters have not been trained in the simultaneous mode and find it difficult to perform. It may be inappropriate for some patients, especially if they know some English and become confused by trying to listen to both versions at once, or if they are hard of hearing. Some practitioners prefer simultaneous, however, not only because it saves time, but also because a skilled simultaneous interpreter can fade into the background and not intrude on the provider-patient relationship. The decision as to which mode of interpreting is to be used should be made by the medical professional and the interpreter together, taking these factors into consideration.

When Communication Breaks Down

Sometimes things don't go smoothly when working with an interpreter. It may be that the interpreter is untrained or inexperienced; perhaps the patient is saying things that are particularly difficult to interpret into English. Or maybe you're just having a bad day. Working with an interpreter does require an extra dose of patience. Here's a list of some problems that may arise in interpreted situations, and some suggestions for solving them:

I. Linguistic Problems

1. Technical terms: Although health care professionals usually try to avoid using technical jargon when speaking to patients, occasionally it will be necessary to use a technical term that the interpreter may not know (e.g., the name of a chemical or an instrument). If you find yourself in this situation, give the interpreter an opportunity to look up the term in a dictionary, or accompany the term with a description or an explanation of its purpose. Showing the patient pictures is always helpful.

2. Idioms: An idiom is a figure of speech that expresses an idea in a way that is unique to the language in question. Examples of English idioms are "under the weather," "to shake hands," and "so long." Sometimes the interpreter can find an equivalent idiom in the target language ("to shake hands" might become "to squeeze hands" or "to greet with the hands"), and sometimes there is no equivalent turn of phrase, so the interpreter just conveys the meaning ("under the weather" becomes "not feeling well," for example). It is especially important to be aware of the context in which a phrase is used. A seemingly simple idiom like "make out" could mean to decipher (as in "I can't make out his handwriting"), to pretend ("She is making herself out to be much more important than she really is"), to fare ("How did you make out?"), to prepare ("I am making out my will"), or to fondle ("They were making out in the back seat"). So the same English phrase would be translated completely differently in another language in each of these different contexts. Clearly, idioms are the hardest thing to translate from one language to another, yet it is impossible to speak without them. You can't eliminate all the idiomatic expressions from your speech, and a good interpreter should be prepared to deal with them, but just bear in mind that the more colorful your speech, the longer it may take for the interpreter to come up with an appropriate equivalent in the patient's language.

3. Inarticulate patients: Sometimes patients are not able to express themselves clearly, or they may not respond directly to your questions. It may be that they are nervous, or on medication, or just not very adept at conveying information clearly. If you get a non-responsive answer to a question, don't automatically assume that the interpreter is at fault. Try to keep your questions simple, and ask the patient directly, "Do you understand?" You may want to ask the interpreter to suggest other ways of eliciting the information from the patient. It takes a little more patience to deal with an inarticulate patient when there is also a language barrier, but don't give up.

4. Dialectical or regional differences: Some languages are spoken in several different countries, and there may be regional variations in usage. Even within the United States, there are significant regional differences in English vocabulary and usage. Imagine the variations that can exist in a language like Spanish, which is spoken in some 20 different countries! Obviously, you can't expect to get an interpreter who is from the same country as the patient in every instance; a trained interpreter should be able to deal with dialectical differences. But if you are aware that the patient and the interpreter are not from the same country, you can avoid problems by giving the interpreter a little extra time to resolve any misunderstandings that may arise. Again, patience is the key.

II. Cultural Problems

1. "Lost in the translation": Some concepts just don't translate very well from one language to another because the cultures are so different. For example, the concept of allergy is not known in Navajo culture. The question, "Are you allergic to any medications?" can't be translated directly into Navajo. If an interpreter informs you that what you are saying doesn't translate very well into the patient's language, try reaching your goal by another route. You might ask, "Has a medicine ever made you sick? Have you ever had trouble breathing after taking a medicine? Have you ever had a rash?" etc. Specific questions are always easier to translate than abstract ones. Similarly, the patient's words may not translate very well into English. If something a patient says sounds strange to you, follow up with questions such as, "Is this a common custom in your country? What is the purpose of this practice? What do you think causes this symptom?" etc. You may want to ask the interpreter some questions about it after the patient has left. Try to find out as much as you can about relevant aspects of the patient's culture.

2. Mistrust, embarrassment, shame: Some patients have a very difficult time revealing personal information through an interpreter, especially if the interpreter and/or the provider are of the opposite sex from the patient or are significantly younger than the patient. It may be that the interpreter is from the same neighborhood as the patient, and it is a tight-knit community; alternatively, the patient may mistrust the interpreter because he or she is from a different tribe or ethnic group. You certainly can't change your age and sex, and you may not have any choice in interpreters, but try to be sensitive to these concerns and reassure the patient that the interpreter is impartial and that everything will be kept confidential.

3. Family members: In some cultures, families are extremely close. Family members may want to accompany the patient in the examining room, and may insist on interpreting for the patient. The patient may find it comforting to have a relative present for the examination. Family members don't make good interpreters, however, even if their language skills are strong, because they can't remain impartial. If you do allow a relative to remain in the examining room, make sure you communicate directly with the patient, rather than letting the relative speak for him or her, and use a neutral, professional interpreter.

4. Informed consent: In our society, there is a very strong sense of the "need to know." We believe that patients should be informed every step of the way and should actively consent to treatment. Other societies don't share that belief, however, and you may find that a patient is reluctant to participate in decision-making. The patient may even view such consultation as a sign of indecision or lack of authority on the part of the medical professional. Try to be sensitive to such different viewpoints, and ask the interpreter to suggest ways of bridging the gap to enable you to meet your legal obligations while respecting the patient's concerns. Perhaps a trusted family member, elder or clergyman can be designated to represent the patient's interests.

5. Unintended offense: As stated earlier, we attach meaning to nonverbal elements of communication like posture, facial expressions, and tone of voice, and we may make judgments about people based on these factors. Bear in mind that the same is true in other cultures, and you may unintentionally be giving offense. Sitting with your foot pointed at someone is considered an extremely rude gesture in Southeast Asia, for example; calling someone by his or her first name without asking permission is inappropriate in Latin America. Ask the interpreter how you should greet the patient, what the proper form of address is, and if there are any postures or gestures you should avoid. Again, learning as much as you can about the patient's culture will help you avoid difficulties.

6. Folk beliefs: In the United States, we have a great deal of respect for modern science, and we have abandoned many of our traditional home remedies in favor of the latest medical technology. Not all cultures share our faith in contemporary medicine, however, and you may have patients who believe in spirits, consult healers, use herbal remedies, and engage in other practices not recognized by western medical specialists. Some of these customs may be beneficial, or at least harmless, but others may conflict with the course of treatment you have recommended. It's a good idea to address this issue in a non-judgmental way: Ask the patient if he or she has tried any home remedies (and if so, what the ingredients are) or is consulting a specialist in the community. If you suspect that a patient is not cooperating in treatment, probe further to find out what the problem is. It may be that the medication conflicts with cultural dietary restrictions, for example. You may be able to alter the form of medication or find some way of describing it that makes it more compatible with the patient's belief system. Consult with your interpreter if you have any doubts about the patient's understanding or acceptance of your recommendations.

III. Mechanical Problems

1. Memory: The act of interpreting involves listening to the source-language message, processing it for understanding, storing it in short-term memory, searching for target-language equivalents, and generating the target-language version, all in a matter of seconds. The longer your statement, the harder it is for the interpreter to recall it verbatim and interpret it accurately into the patient's language. If the interpreter interrupts you or asks you to repeat details, you may be speaking for too long. Short-term memory is limited in terms of both time and volume, so if you speak very quickly and cram a lot of detail into what you say, it will still be difficult for the interpreter to remember, even if you don't take very long to say it. Try to speak slowly and clearly, and pause frequently to allow the interpreter to intervene and interpret short segments, especially if you are giving a detailed or complicated explanation.

2. Physical distractions: Interpreting requires a great deal of concentration. If the interpreter is hampered by noise, constant interruptions, fatigue caused by long hours of standing and interpreting without breaks, or other distractions, it will be very difficult to interpret accurately. It is particularly difficult if the interpreter has other duties to perform, such as answering the phone and filling out forms. The interpreter should have a comfortable place to sit where he or she can see and hear both patient and provider. It is always advisable to have an interpreter who is able to devote all of his or her time and energy to the task of interpreting.

IV. Other Barriers to Communication

1. Emotional reactions: As you know from your experience in the health care profession, interactions with patients can be emotionally-charged events. Although interpreters are supposed to show the same professional detachment that medical practitioners display, emotional involvement with patients is hard to avoid, especially if the interpreter has come to know a patient well over time. If you have to deliver bad news to a patient or a family member, try to warn the interpreter so that he or she can prepare for the ordeal. A time-out may be necessary for particularly stressful situations. It is also essential for the interpreter to be able to turn to a supervisor or colleague for support or to vent strong emotions in a safe environment without violating confidentiality.

2. Interference by relatives: Sometimes a patient's family members have very strong feelings about the situation and want to take an active part in the treatment. They may mistrust the interpreter and insist on interpreting themselves. Because you need to have a neutral interpreter working for you, it is important that you stand behind your interpreter and reassure the family that he or she can be relied upon to do a good job.

3. Triadic communication: The presence of the interpreter turns the two-way communication between provider and patient, which is already complicated enough, into a three-way interaction with considerable potential for problems. Make sure you don't relinquish all control to the interpreter, allowing him or her to interview the patient directly and leave you out of the relationship. On the other hand, avoid getting into a power struggle with the interpreter: asking a question before the interpretation of the previous answer is completed, for example, or cutting off any attempts the interpreter makes to explain cultural issues. Ideally, the medical professional and the interpreter should work together as a team to communicate fully with the patient. This may entail adjusting your interview style somewhat. The more you work with interpreters, especially experienced and well-trained ones, the smoother your relations will be with non-English-speaking patients.

Tips for Successful Communication Through an Interpreter

Here are some steps you can take to make sure you and your interpreter collaborate effectively to communicate with your patients:

Prior to the Interview:

* Make sure you allow extra time for an interpreted patient consultation.

* Meet with the interpreter briefly before seeing the patient to discuss any cultural, emotional, or linguistic problems that may arise during the interview.

* Find out the proper form of address and the correct pronunciation of the patient's name.

* Agree with the interpreter on whether the simultaneous or the consecutive mode of interpretation is to be used.

* Encourage the interpreter to let you know if any communication problems arise.

During the Interview:

* Introduce yourself to the patient and explain the purpose of the interview.

* Sit in such a way that you can look directly at the patient.

* Address the patient in the second person ("When did you start feeling the pain?" instead of "Ask him when the pain began.").

* Throughout the interview, watch the patient's face for reactions. If the patient appears confused or doubtful, ask, "Do you understand? Do you have any questions?"

* If you need to consult with the interpreter on a matter, explain to the patient what you are doing. Similarly, make sure the interpreter explains to you any independent conversation he or she has with the patient.

* Speak slowly and clearly, with frequent pauses to allow for a phrase-by-phrase interpretation.

* Try to avoid using technical jargon or very colorful language with lots of slang, metaphors, or proverbs.

* At the end of the interview, summarize any decisions or recommendations that have been made. Encourage the patient to ask for explanations or clarifications.

After the Interview:

* After the patient has left, give the interpreter the opportunity to debrief you on any cultural or linguistic issues that may have arisen.

* If you are going to be seeing this patient again or will have a lot of contact with patients of this ethnic group in the future, ask the interpreter to recommend some reading materials about the patient's culture.

At All Times: Be Patient!

For More Information

Videos:

An excellent video series, The Bilingual Medical Interview, has been developed by Boston City Hospital in collaboration with the Department of Interpreter Services and the Boston Area Health Education Center. It comes with a very helpful discussion guide that includes a comprehensive bibliography. For ordering information, contact: Boston Area Health Education Center, 818 Harrison Ave., Boston, MA 02118, (617) 534-5258.

Another excellent video is Mental Health Interpreting: A Mentored Curriculum, developed by Dr. Robert Pollard at the University of Rochester School of Medicine and Dentistry. It can be obtained by contacting Dr. Pollard at the Department of Psychiatry, University of Rochester School of Medicine, 300 Crittenden Blvd., Rochester, NY, 14642, telephone (716) 275-3544, email Robert_Pollard@urmc.rochester.edu.

Interpreting in Refugee Mental Health Settings, part of the Refugee Mental Health series produced by the University of Minnesota. It can be ordered from Bruce Downing, PhD, Department of Linguistics, 142 Klaeber Ct., University of Minnesota, Minneapolis, MN 55455, (612) 624-4055.

Articles and Books:

Bloom, M. "The Use of Interpreters in Interviewing: Characteristics, Conceptualization and Cautions." Mental Hygiene. 50:2:214-17. 1966.

Downing, B.T. and Berg, C. "If You Don't Speak English." University of Minnesota Center for Urban and Regional Affairs, CURA Reporter, Aug. 1991, Vol. XXI, No. 3, pp. 9-14.

Harwood, A. Ethnicity and Medical Care. Cambridge, MA: Harvard University Press. 1981.

Kleinman, A. "Culture, Illness and Care." Ann Intern Med. 88:251-258. 1978.

Marcos, L.R. "Effects of Interpreters on the Evaluation of Psychopathology in Non-English-Speaking Patients." Am J Psychiatry, Feb. 1979, Vol. 136, No. 2, pp. 171-174.

Putsch, R.W. "Cross-cultural Communication: The Special Case of Interpreters in Health Care." JAMA, Dec. 20, 1985, Vol. 254, No. 23, pp. 3344-3348.

Ruiz, P. "Cultural Barriers to Effective Medical Care Among Hispanic American Patients. Ann Rev Med. 36:63-71. 1985.

Vasquez, C. and Javier, R.A. "The Problem With Interpreters: Communicating With Spanish-Speaking Patients." Hospital and Community Psychiatry, Feb. 1991, Vol. 42, No. 2, pp. 163-165.

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