Partnering with medical interpreter

1. Review medical records for any information about patient’s English proficiency.
2. Ask patient (or family) what language she speaks at home.
3. If English is not the primary language spoken, identify patient’s primary language and call the health facility interpreter support system to request an interpreter for the clinical encounter.

• Some patients may be unwilling to have a medical interpreter in a clinical encounter and prefer to have their family members interpret for them. It is important to remind patients and families that the medical interpreter is trained to work in conjunction with doctors to ensure that complex health messages.
• In some very small ethnic communities, patients may refuse the interpreter as the MI may be a friend or family member and they may be unwilling to discuss their health issues in from of the MI.
• In other cases, patients may feel very strongly that they do not want an MI. These situations have to be resolved on a case-by-case basis by gently exploring the MI refusal and respectfully negotiating a solution that is acceptable to all parties.

To learn more please watch Stanford Cross Cultural Medicine Microlecture Series

1. Brief the interpreter on the topics to be discussed and the time available for the encounter. If all the work cannot be accomplished in the given time, plan ahead to have a follow up encounter to complete the tasks.
2. Next, gauge the MI’s level of health literacy and comfort related to the topic being discussed in a non-judgemental fashion by asking open-ended questions “I am planning to tell the patient that her cancer is not responding to the experimental treatments and that she is not a candidate for the FDA Phase 1 trial. I want to first check in with you and determine if you are comfortable with the terminology related to cancer treatments and experimental studies”
3. If you are planning to deliver bad news to the patient inform the MI and identify a strategy to deal with requests for non-disclosure (please watch the video below)
4. If you are planning to make medical decisions, strategize with the MI about how best to engage the patient and the surrogate in shared decision-making.
5. Ask MI to do Conduit style interpretation i.e. literal interpretation in the first person, with no omissions, editing, summarization, synthesis, or interpretation.
6. Assure the MI that you will be speaking in short sentences and try to avoid medical jargon.
7. Encourage the MI to ask any clarifying questions as needed so s/he can interpret after fully understanding the context and the information.
8. If you expect to encounter strong emotions from the patient and family, be aware that the MI is not immune to emotions. It may be prudent to warn the MI so they can prepare themselves to maintain calm professionalism at all times.

• Never use a child
• If forced to use ad hoc interpreter (family member, employee) be aware of conflicts of interest that may exist.
• Instruct the ad hoc interpreter to use conduit style interpretation.
• Be aware that the ad hoc interpreter’s health literacy and English proficiency may be quite limited.
• It is hard for family members to serve as neutral interpreters as they have a role obligation and may not be immune to secondary gain issues.
• Telephone and video based medical interpreters offer ease of access and flexibility when available.
• Make arrangements for a regular MI for the next encounter.

Requests for non-disclosure are very common in many cultures:

To learn more please watch Stanford Cross Cultural Medicine Microlecture Series

1. Ensure that the patient and family are situated comfortably.
2. Assess the patient’s visual and auditory abilities. Make sure that the room is well lit. Ask for a pocket- talker if the patient is hard of hearing.
3. Sit down in a chair so that you are at eye level with the patient and facing the patient directly and between 1 to 2 feet from the patient.
4. The MI should be positioned so that s/he can have a direct and unobstructed view of both the patient and family as well as the doctor.
5. The provider should look directly and speak to the patient during the entire encounter
6. Have all persons in the meeting introduce themselves. Explain that you will be asking questions and giving information that the MI will interpret.
7. Do not direct your questions or inquiries to the MI. Address the patient at all times.
8. Speak in short sentences and pause for the MI to interpret in ‘conduit fashion’.
9. Avoid side conversations in English with the family members.
10. If doing a physical examination, ask the MI to turn away from the patient and draw the curtain around to protect the patient’s privacy and confidentiality. MI should be able to hear the questions you ask during the physical examination and interpret the patient’s responses.
11. Be extremely sensitive if the MI is a member of the opposite gender. In some cases (example during a pelvic exam or a rectal exam), the MI may need to step outside the room briefly during the physical encounter and have to interpret by phone standing just outside the room.
12. At the end of the meeting, ask the patient to use the ‘teach back’ technique to repeat the main point(s) through the MI
13. Summarize the encounter in short sentences and strategize for follow up.

• Remember that non-verbal communication comprises the majority of communication and is vital in being able to interpret the full meaning of the patient’s responses.
• Also, non-verbal communication varies across cultures. Thus, the cultural knowledge a MI has can be very helpful in gauging the patient and families responses in it entirety.
• While it is important to maintain eye contact with the patient, it is important to remember that in many Asian cultures, prolonged eye contact may be seen as intrusive and disrespectful, especially with a member of the opposite gender

Foreign medical practices may lead to misunderstanding:

Decision making process varies in different cultures:

To learn more please watch Stanford Cross Cultural Medicine Microlecture Series

1. Leave the room with the MI to (a) briefly debrief with the MI and (b) to prevent a conversation between the patient/family and the MI about medical issues just discussed.
2. Ask MI about her/his emotions and well being especially after a intense emotional encounter.
3. Thank the MI for their help.
4. If there are specific things identified that can be done better in the future, be sure to identify those and discuss with the MI.
5. Document the name of the MI used in the medical records.

• It is acknowledged that encounters using MIs will likely take more time. However, it is impossible to provide quality care to a patient with LEP without the assistance of an MI. Thus the lengthy encounters are not the fault of the MI. It is just intrinsic to the providing care for a patient across the cultural and language barrier.

To learn more please watch Stanford Cross Cultural Medicine Microlecture Series