Thursday, May 2, 2019

Five Pearls for Using Interpreters Ethically

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Author: Sara Urquhart, RN MA
Medical Student
Michigan State University College of Human Medicine
AAEM/RSA Publications and Social Media Committee

Imagine an unconscious 15-year-old male arrives at a downtown Miami trauma center. Paramedics say that before passing out, he told his Spanish-speaking girlfriend he felt “intoxicado.” “Intoxicated,” they say. The boy is stabilized and admitted to intensive care with a diagnosis of drug overdose. No one called an interpreter to interview his girlfriend. If they had, they would have learned that in Cuban Spanish, intoxicado is a word for nausea and that the boy did not take an overdose. Over 36 hours later, imaging shows a ruptured subarachnoid aneurism on the now paraplegic boy, who survives and later wins a $71 million malpractice lawsuit.[1]

Nearly 26 million people in the United States self-identify as Limited English Proficiency (LEP) on the Census.[2] Federal law requires all providers who receive Centers for Medicare and Medicaid Services funds to provide verbal interpretation services and translated written documents to LEP patients, and failure to do so has been deemed a form of discrimination in multiple legal cases.[3] Lack of professional interpretation leads to increased miscommunication, which exacerbates healthcare disparities and can lead to grave medical errors like the example above.

Research shows that interpreter use improves outcomes and patient satisfaction while reducing emergency department (ED) bounce-backs and unnecessary admissions.[4] A comparison study showed that using trained professional interpreters compared to ad hoc or no interpretation cut clinically significant communication errors with Spanish-speaking patients in half.[5] Using interpreters, however, is not a panacea for miscommunication. Keep in mind that a language barrier increases the risk for communication errors with LEP patients and this risk can be reduced, but not eliminated, by using trained professional interpreters.[6]

So, what do you need to know?

1. Know the laws.
Title VI of the Civil Rights Act of 1964 gives patients the right to communicate with healthcare providers in their own language. It is a legal responsibility and each state and healthcare entity has further interpretations.[7] Review the local laws and policies. Additionally, some health systems require all interpreters to be certified.

2. Know your limits.

Language fluency is not equivalent to command of the medical linguistics of a language. Run through the checklist below to test your ability.[8] If you answer “no” to any of these, you should use an interpreter:
  • Can you clearly understand the patient’s accent?
  • Can you understand the patient’s full responses?
  • Do you fully understand the cultural implications of the patient’s condition? Are you able to explain discharge instructions as well as you can in English?
  • Are you able to obtain informed consent, explain risks and benefits, and answer questions as well as you can in English?
  • Would you use your language skills in a court of law?
  • Are you sure that the patient can understand you?
3. Avoid using family members to interpret, especially children.
Even if the patient brought someone else to interpret for them, use a professional. This ensures you are not violating Health Insurance Portability and Accountability Act (HIPAA) or getting misinformation about symptoms. LEP patients are at greater risk for intimate partner violence, human trafficking, and HIV. It is impossible to screen for these conditions during emergency care if the patient’s trafficker is the interpreter.[8]

4. Avoid asking staff to interpret.
Medical interpretation is a separate specialty. Would you ask a respiratory therapist to do an x-ray for you? Don’t ask a staff member to interpret unless it is part of their job description and they have formal training. This exposes the patient’s privacy and puts you, the staff member, and the patient at risk for miscommunication.

5. Inform patients of their rights.
If a patient insists on using their own interpreter, inform them in their native language of their right to request an interpreter at any time during the visit and ensure that they understand that the necessary hospital interpretation services will not be at their expense. Include this in your documentation.

Take the time to learn how interpreting services function in any new clinical environment. Learn how to access the equipment yourself and who to ask for help. With this knowledge in your back pocket, you can take the best care possible of your LEP patients.


1. Price-Wise, Gail. An intoxicating error: Mistranslation, medical malpractice, and prejudice. Pennsauken, NJ: Bookbaby; 2015.

2. U.S. Census Bureau. Selected social characteristics in the United States. 2017 American Community Survey 1-Year Estimates. Accessed April 11, 2019.

3. Lawsuits. International Medical Interpreters Association website. Accessed April 11, 2019.

4. Karliner L, Jacobs E, Chen A, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007; 42(2), 727-54.

5. Flores G, Abreu M, Barone C, Bachur R, Lin H. Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med. 2012; 60(5):545-53.

6. Divi C, Koss R, Schmaltz S, Loeb J. Language proficiency and adverse events in US hospitals: A pilot study. Int J Qual Health Care. 2007; 19(2):60-7.

7. Regulations. International Medical Interpreters Association website. Accessed April 11, 2019.

8. Ortega, P. Spanish and the Medical Interview: A textbook for clinically relevant medical Spanish. 2nd ed. Philadelphia, PA: Elsevier, Inc; 2016.

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