Communication via Medical Interpreters and Translators

Introduction 

Millions of people in the United States of America (USA), especially in California, have limited English proficiency. Throughout the country, this figure sits at 10% [1]. Whereas in California, it rises to 20% [2]. As English is the language primarily used in American healthcare, people who have limited proficiency are unable to effectively communicate with and understand healthcare staff. The resulting miscommunications and lack of understanding between healthcare professionals and patients can lead to improper treatment and other health inequities [1]. It was found that 49% of malpractice claims involved miscommunication, where 53% of these claims were specifically between healthcare providers and patients [3].

Healthcare today aims to mitigate this issue through the use of both medical interpreters and medical translators. Though tasked with a similar job of translating between the patient’s language and English, each title emphasizes different aspects. Medical interpreters orally translate spoken words between patients and healthcare providers during their interactions, while medical translators translate written documents [2].

The importance of medical interpreters and translators for facilitating social justice in healthcare is reflected in the law as well as in the tragic consequences that arise from insufficient medical interpreters. The Civil Rights Act of 1964 requires hospitals that receive federal funds to provide access to professional interpreters so patients can make informed decisions [1]. However, a current shortage caps resources–there are only 738 medical interpreters for every 6.8 million residents with limited English proficiency in California [2], and many of the federally funded hospitals do not provide access to professional interpreters altogether [1]. Consequences have already occurred. In a seminal incident known as the “Tran case,” a Vietnamese child was rushed to the emergency room with parents who could not speak English [4]. There were no Vietnamese interpreters at the hospital [4]. Amidst severe miscommunication with the family, the physician misdiagnosed the child’s condition and sent the family home with medication with potentially dangerous side effects–providing instructions about them in English only [4]. The child experienced a severe reaction to the medication and, with the parents unable to understand the instructions, died [4]. Avoiding tragedies like such can be attempted when multilingual family members are available to serve as interpreters. However, proficiency in languages alone does not lead to effective medical translation; it also requires careful understanding of the nuances embedded in healthcare interactions. Unless the interpreter had prior training on these aspects, critical errors in communication will still occur [1]. 

This report will discuss the communication and writing employed by medical interpreters and translators for undergraduate students who are interested in this field and in healthcare. This draws from both medical literature and an interview with Elsa Figueroa, a certified Spanish medical translator and former interpreter at the UC Davis Medical Center since 2015 (Interview questions in Table S4). The goals of this report are to inform fellow peers on how to effectively communicate across different languages so patients can make informed decisions, to inspire more people to consider medical interpreting and translating as careers, and to help reduce the health inequities that result from using nonprofessional interpreters and translators.

The Risks of Using Family Members as Interpreters

Even though healthcare professionals should use professional interpreters, they tend to rely more on family members when they are present [5]. This is a problem because family translators are prone to mistranslation and often omit or add information that healthcare staff said or did not say [6]. For example, one patient was ill-informed by their family member about the available treatment options for their illness, and as a result could not make the best decision and suffered needlessly [1]. Miscommunication also occurs through personal bias; family members are often found to construe staff based on their own views and struggle to properly convey uncomfortable topics like death [5]. For example, a husband entrusted as an intermediary between his wife and their doctor had to inform his wife that she was diagnosed with cancer, but could not find the words to do so, which strained their relationship [1]. Such difficulties can lead to conflicts within families, especially when involving end-of-life care [5]. Therefore, family members should not be used as interpreters and translators with such risks of miscommunication. 

Interpreters 

Communication by Interpreters 

While medical interpreters and translators ultimately draw from similar communication strategies, medical interpreting can be complex. Many different factors exist, but primarily it is due to the interpreter’s value as a bridge between the patient and the healthcare provider (E. Figueroa, pers. comm., Feb. 22, 2024). This goes beyond raw translation; they also must make sure that patients and healthcare providers can communicate effectively and understand each other [7]. Interpreters need to communicate in a way in which the meaning of what was said can be conveyed in the most understandable way (E. Figueroa, pers. comm., Feb. 22, 2024). They do this by being calm, reassuring, and neutral when interpreting, all while speaking in the first person (E. Figueroa, pers. comm., Feb. 22, 2024). Interpreters speak as though they are the patient (when speaking to the healthcare provider) and they are the healthcare provider (when they are speaking to the patient), essentially acting as though they are not present (E. Figueroa, pers. comm., Feb. 22, 2024). Furthermore, when interpreting, interpreters remain objective and do not impose their own opinions [7]. Moreover, interpreters can be called on to translate a variety of topics, ranging from explaining procedures to conveying bad news, in numerous different situations (E. Figueroa, pers. comm., Feb. 22, 2024). Figueroa mentioned that if she does not know what something means, she usually asks the medical professional for an explanation to use when interpreting (E. Figueroa, pers. comm., Feb. 22, 2024). 

The tone and body language also play a huge role in interpreting and need to be used effectively (E. Figueroa, pers. comm., Feb. 22, 2024). For example, when interpreting bad news to a patient, Figueroa tends to copy the body language and tone of the physician (E. Figueroa, pers. comm., Feb. 22, 2024). It is also important to look at body language and the way things are said because they can contribute to the meaning of what was communicated (E. Figueroa, pers. comm., Feb. 22, 2024). 

Communication can be slightly different in more serious settings, like in palliative care [5]. In palliative care, interpreters are involved in family meetings to discuss how to manage symptoms, aims of treatments, and end-of-life care [5]. Additionally, it was recommended that healthcare providers and interpreters meet before talking to the patient to discuss whether culture should play a role in the interpretation and the topics that will be discussed with the patient [5]. This is to make sure that healthcare providers and interpreters have the same understanding, which is crucial in serious settings [5]. 

Successful interpretation requires all of the intricacies mentioned above. Nonprofessional interpreters, like family members, do not know of all of these skills which are essential when interpreting [7]. This can result in the patient and the healthcare providers not having all of the information, which can heighten risks for the patient and affect the quality of care they receive [7]. 

Roles of Interpreters 

There are three main roles of interpreters: verbatim interpretation, health literacy guardian, and cultural broker [7]. Verbatim interpretation is when the interpreter translates exactly every piece of information from the patient to the healthcare provider and vice versa [7]. In this role, the interpreter is trained to refrain from offering their own opinion or advice [7].  There are two different strategies in verbatim interpretation. The first is direct translation, which translates word-for-word. The second is translating by meaning, which focuses on conveying the point that the speaker is intending to communicate. Both strategies have disadvantages to consider: direct translation can fail when a word with multiple synonyms in another language is encountered, while information can be omitted by the interpreter when translating by meaning [6]. 

Figueroa personally supports translating by meaning because a word-for-word interpretation can be harder to understand (E. Figueroa, pers. comm., Feb. 22, 2024). For instance, when family members interpret, they tend to do a verbatim interpretation, which can lead to misunderstandings because family members could either omit or complicate the choice of words, which can cause parts of the translation to lose their original meaning [6].

However, there is evidence that assisting patients in understanding the healthcare professional usually requires more than verbatim interpretation [6]. To account for this, an interpreter can take on the second role of health literacy guardian. Here, they advocate for the patient and their family by informing the healthcare professional the best way to treat the patient [7]. This could mean letting the physician know that it would be helpful for the patient to have medication instructions written down [7]. This also means making the patient feel comfortable to ask questions [7], and interjecting when a misunderstanding occurs (E. Figueroa, pers. comm., Feb. 22, 2024). Additionally, being a health literacy guardian means regularly communicating with the healthcare providers and the patients to make sure the latter are receiving the best possible care [7]. Moreover, while this role grants more freedom of discretion than verbatim interpretation, Figueroa believes that interpreters should advocate for patients without imposing their own views and opinions (E. Figueroa, pers. comm., Feb. 22, 2024). From my personal experience working in hospitals, I saw that this role was difficult for family members to take on because it required the interpreter to be objective while considering their bond with the patient. As a result, this can disproportionately affect the type of care patients receive. 

The third role of an interpreter is to be a cultural broker, which means helping make sure the healthcare providers understand the culture of the patients, while patients understand the culture of the part of the hospital they are in [7]. By doing this, it helps make sure that healthcare providers are on the same page as the patients [7]. For example, pain is a subjective variable. It is dependent on culture and language, which can affect how patients report pain and how healthcare providers treat pain [5]. In this case, interpreters would need to make sure healthcare providers and patients have a shared understanding of the patient’s pain experience so the pain can be accurately assessed and treated. In addition, by acting as a cultural broker, an interpreter builds a relationship with the patient and gains their trust which is needed so patients can receive the best possible care [7]. Family members who are used as interpreters may not know the culture of the hospital and the healthcare providers, so they could find it difficult to ensure that healthcare providers and the patient are on the same page [7]. If healthcare providers and patients do not see to an understanding, patients will not receive accurate judgment for their treatment. 

Translators 

The translator’s role of translating written documents [2] is less complex than the cue-sensitive nature of interpreting, but it is by no means simple due to the emphasis on context (E. Figueroa, pers. comm., Feb. 22, 2024). Figueroa writes mostly educational materials and informed consent forms (E. Figueroa, pers. comm., Feb. 22, 2024). Sometimes there will be phrases, idioms, or words that cannot be directly translated into another language (E. Figueroa, pers. comm., Feb. 22, 2024). In that case, Figueroa focuses on the purpose of a phrase and tries to achieve that same purpose in the translation (E. Figueroa, pers. comm., Feb. 22, 2024). In addition, balance between making the translation easy to understand, but also accurate, comes with a strong understanding of the language’s discourse (E. Figueroa, pers. comm., Feb. 22, 2024). One thing to consider when translating is that some languages have different dialects. In this case, Figueroa looks at the area where translation is occurring, researches the common dialect of use, and incorporates the specific vocabulary (E. Figueroa, pers. comm., Feb. 22, 2024). For example, when Figueroa translates something for UC Davis, she uses terms often used in Mexican Spanish because most of the Spanish speakers in California are from Mexico and Central America (E. Figueroa, pers. comm., Feb. 22, 2024). In addition, similar to interpreting, culture should be taken into account because it can dictate word choice (E. Figueroa, pers. comm., Feb. 22, 2024). For example, in Figeuroa’s dialect, “coger” means “to take,” but in most of Latin America it means “to have sex,” so when translating she uses the word “agarrar” instead (E. Figueroa, pers. comm., Feb. 22, 2024). In contrast, if a family member is used as a translator, they may not know how to effectively translate because some words and phrases do not have a direct translation [6], which can form barriers to patient understanding. 

As a demonstration, Figueroa provided a sample informed consent form that she prepared in both English and Spanish (Fig. S1-S2). This form is to participate in a transplant program to receive a liver that has Hepatitis C (HCV/VHC) (E. Figueroa, pers. comm., Feb. 22, 2024). It also provides information on what an organ with Hepatitis C is, the risks and benefits of this procedure, the treatments, and the acknowledgement for patients to sign if they want to be in this program. I asked a friend’s mom, who is a native Spanish speaker from Guatemala but untrained in medical translation, to translate the Spanish version into English to compare with Figueroa’s official version (Text S3). Both Figueroa’s and the mom’s versions on the “Risks” section are shown below (Table 1).

When looking at the official English document and at the mom’s translation, I saw that the same meaning was conveyed in both documents, but the wording differed slightly. For example, in the official document it says, “The consequences of HCV infection include severe liver inflammation which can be life threatening.” In the mom’s translation, it says, “The consequences of the infection with VHC include serious inflammation of the liver, that could be possibly lethal.” Both translations convey a similar meaning–that deadly liver inflammation is a possible consequence of HCV infection–even though they use different words to do so. However, while “lethal” and “life threatening” are both used to mean “deadly,” they are different words that convey slightly different tones: “lethal” emphasizes death more directly than the “life threatening.” The official version’s use of the preceding verb phrase “can be” versus the mom’s “could be possibly” is another example of tonal difference, as the former conveys a more serious tone than the latter. All of these choices can affect how seriously patients perceive the risks of HCV infection. This shows that the meaning, purpose, and tone of a word or phrase is important, not necessarily the direct translation.

Use of Technology

Advanced technology has led to numerous translation services, particularly Google Translate, which could potentially assist in translating and interpreting. However, studies have shown that Google Translate can be inaccurate to a problematic level. For example, one study conducted in 2014 found that only slightly above 50% of the phrases were translated correctly and that sometimes Google Translate made grave errors in translation [8]. The technology has significantly improved since, but a more recent study in 2021 still found that only 82.5% of the translations made by Google Translate were accurate in meaning [9]. Individual comparisons of seven languages commonly spoken in emergency rooms in Los Angeles County also showed that accuracy varied widely for each language: Spanish and Tagalog had the highest accuracy of 94% and 90% respectively, whereas Farsi and Armenian had the lowest accuracy of 67.5% and 55% respectively [9]. Grave errors even persisted: the phrase “you can take over the counter ibuprofen as needed for pain” was translated into an Armenian phrase that actually means “you may take anti-tank missile [sic] as much as you need for pain” [9]. Therefore, even though the accuracy of Google Translate improved and will continue to improve, it remains too problematic for healthcare professionals to depend on [9]. Figueroa also mentions that she does not use technology to translate documents because she will then need to proofread the translation for its errors, which usually takes longer (E. Figueroa, pers. comm., Feb. 22, 2024).

Conclusion

There is a huge demand for professional interpreters and translators, especially in the USA where the number of people with limited English proficiency is growing [2]. It was found that the number of people with limited English proficiency in the United States increased by 80% from 1990 to 2010 [10]. By having more people become professional interpreters and translators who communicate effectively, patients with limited English proficiency will receive a more equitable quality of care. This can allow professional interpreters and translators to facilitate social justice, while also preventing family members from being used as interpreters and translators to reduce communication errors and health inequities. Therefore, I hope more people will choose to become medical interpreters and translators so they can reduce the health inequities that patients with limited English proficiency face.

About the Author: Sweta Tummala

Sweta Tummala majored in Neurobiology, Physiology, and Behavior with a minor in Public Health Sciences. She is interested in becoming a physician and making sure that everyone has access to healthcare. She volunteered with Joan Viteri Memorial Clinic, shadowed physicians, and interned in various departments at hospitals. As a result, she observed that there were not many professional interpreters and translators and more often than not family members were used for interpreting. When professional interpreters and translators and family members were not present, technology was used. Therefore, in this paper she wanted to examine the health inequities caused by the lack of access to professional medical interpreters and translators. She will also explore the profession of medical interpretation and translation, focusing on what makes successful interpreters and translators, in the hopes of encouraging more people to pursue this field and reduce health disparities.

Author's Note

I chose to write this piece because I have worked in numerous healthcare settings where patients and healthcare providers did not speak the same language and as a result could not understand each other. The majority of these cases used technology, family members, or nonprofessional interpreters and translators, which can lead to huge disparities. I wrote about communication via medical interpreters and translators so that those who want to go into this field can know the best way to communicate to reduce the disparities that can result from miscommunication.

Supporting Information

• Figure S1: Informed Consent Form in English
• 
• Figure S2: Informed Consent Form in Spanish
• 
• Text S3: Translation to English of Select Paragraphs in Spanish Informed Consent Form

• This document is an informed consent. It gives you the opportunity to participate in a program to receive liver transplant from a donor that has died who had a positive result of the virus of Hepatitis C or previously it was exposed to the infection of Hepatitis C. The Hepatitis C is a virus that certain people get by being exposed to dialysis, blood products, consuming of drugs by needles or sexual contact. If you participate in this program, you could receive liver transplant much faster than if you are in the waiting list to get one from a person that has died.

  Risks

  At risk of receiving a liver with positive results of Hepatitis C and liver stays contagious with VHC and it can cause damage to the liver if it is not treated. The consequences of the infection with VHC include serious inflammation of the liver, that could be possibly lethal, insufficient Hepatica through several years and cancer of the liver (that to produce after many years of the infection without treatment), and kidney damage. Also, exists a risk of developing diabetes after receiving the liver with positive results of Hepatitis C. Although it is not very common some patients can still develop complications like kidney damage, even though they receive successful treatment of Hepatitis C.

  The certification of the informed consent

  I have been informed of the purpose of this program, its procedures, possible benefits, risks, and alternatives to receive an organ from a donor that shows/has positive results of the infection of vhc/Hepatitis C. I have been given the opportunity to have questions and to make questions (ask) and I have been told what can I do with this questions at any time in the future. All of my questions have been answered satisfactorily at this moment.

• Table S4: Interview Protocol

• Interview Questions

  -What languages do you work with as a translator? -How would you describe your typical day at the office, including your daily activities? -What type of documents do you translate? -How would you translate phrases in English that might be hard to translate into Spanish, like idioms? Can you give me an example? How would you translate “break a leg?” -Have you encountered times when you had to be creative in translating? - Who do you communicate with when you are working? -What type of writing do you do over and over again? -Do you use AI to help with translation? -Do you also translate prescriptions and directions? -If I were to start working in your field tomorrow, what would I have to learn about writing in this field? -How does your writing change when the document is for an adult vs a child? - Do you have any advice for how to obtain a job in this field? -How would different dialects play a role in translating? -Do you take culture into account when translating? -How were you able to incorporate medical Spanish into your vocabulary? -How do you use punctuation when translating? -Do you have a sample that you could share with me? -How was communication used when interpreting? -What did you mean by advocating for the patient -How does setting affect the way you communicate? -How would you interpret idioms?

References

1. Eldred SM. 2018. With Scarce Access To Interpreters, Immigrants Struggle To Understand Doctors’ Orders. NPR. Accessed 2024. Retrieved from: https://www.npr.org/sections/health-shots/2018/08/15/638913165/with-scarce-access-to medical-interpreters-immigrant-patients-struggle-to-unders
2. Gonzales JM. 2015. Medical interpreters in short supply as health coverage grows. San Francisco Chronicle. Accessed 2024. Retrieved from: https://www.sfchronicle.com/health/article/Medical-interpreters-in-short-supply-as-health -6225291.php
3. Humphrey KE, Sundberg M, Milliren CE, Graham DA, Landrigan CP. 2022. Frequency and Nature of Communication and Handoff Failures in Medical Malpractice Claims. J Patient Saf [Internet]. 18(2):130-137. doi:10.1097/PTS.0000000000000937
4. Quan K, Lynch J. 2010. The High Costs of Language Barriers in Medical Malpractice. Berkeley (CA): National Health Law Program. Accessed December 11, 2024. Retrieved from: https://healthlaw.org/wp-content/uploads/2018/09/Language-Access-and-Malpractice.pdf
5. Silva MD, Genoff M, Zaballa A, Jewell S, Stabler S, Gany FM, Diamond LC. 2016. Interpreting at the End of Life: A Systematic Review of the Impact of Interpreters on the Delivery of Palliative Care Services to Cancer Patients With Limited English Proficiency. J Pain Symptom Manage [Internet]. 51(3):569–580. doi:10.1016/j.jpainsymman.2015.10.011
6. Labaf A, Shahvaraninasab A, Baradaran H, Seyedhosseini J, Jahanshir A. 2019. The Effect of Language Barrier and Non-professional Interpreters on the Accuracy of Patient-physician Communication in Emergency Department. Adv J Emerg Med [Internet]. 3(4):e38. doi:10.22114/ajem.v0i0.123
7. Suarez NRE, Urtecho M, Jubran S, Yeow ME, Wilson ME, Boehmer KR, Barwise AK. 2021. The Roles of medical interpreters in intensive care unit communication: A qualitative study. Patient Educ Couns [Internet]. 104(5):1100–1108. doi:10.1016/j.pec.2020.10.018
8. Patil S, Davies P. 2014. Use of Google Translate in medical communication: evaluation of accuracy. BMJ [Internet]. 349(7988). doi:10.1136/bmj.g7392
9. Taira BR, Kreger V, Orue A, Diamond LC. 2021. A Pragmatic Assessment of Google Translate for Emergency Department Instructions. J Gen Intern Med [Internet]. 36(11):3361–3365. doi:10.1007/s11606-021-06666-z
10. Maxwell LA. 2011. Limited-English-Proficient Population Rises 80 Percent Since 1990. Education Week. Accessed 2024. Retrieved from: https://www.edweek.org/leadership/limited-english-proficient-population-rises-80-percent-since-1990/2011/12