Medical Interpreting: A Review of the Literature

Developed by J. Moore and L. Swabey
CATIE, College of St. Catherine/NCIEC
DRAFT ~ 2007

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Introduction | Deaf Patient Perspectives | NonDeaf Patient Perspectives | Settings and Types | Challenges and Issues | Interpreting Role | Preparing to Interpret | Summary and Implications | References | Bibliography | Download PDF

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Challenges and Issues in Medical Interpreting

            Legal issues.

Provision of sign language interpreting services in health care settings falls under two laws. Section 504 of the Rehabilitation Act of 1973 requires that access be provided in federally funded agencies, and the Americans with Disabilities Act, signed into law in 1990, requires access in “public accommodations,” including doctors’ offices. 

Despite these laws, Deaf people continue to encounter difficulties in gaining communication access. Steinberg et al. (2002) commented, “Despite a decade of legal mandates and case law supporting inclusion, as well as cost-benefit ratios that favor full access to care, continued difficulties are reported when deaf consumers attempt to access health care” (p. 740). Geer (2003) reported that Deaf people file many ADA complaints that they have received accommodations they felt were inadequate (p. 135). Examples include providers asking a Deaf patient to bring a friend or relative to interpret, using a staff member who can fingerspell to communicate, and hiring an incompetent interpreter. Both the ADA and Section 504 of the Rehabilitation Act of 1973 require that interpreters be provided to Deaf sign language users. Depending on the complexity of the issues under discussion, however, there may be situations in which an interpreter is not required.

Some sources in journals for medical professionals have reported on outcomes of lawsuits related to provision of interpreter services with Deaf patients. For example, one article reported on a successful discrimination suit against a medical facility that attempted to use a staff member who knew a little signing instead of waiting for a professional interpreter (Legal Eagle, February 2007). In this case, the patient collected damages for pain and suffering for the time during which the surgery consult went ahead despite the hospital’s refusal to provide a professional interpreter. The article pointed out that although courts have not made it entirely clear whether a certified sign language interpreter is always required, the federal regulations do say that the facility should “give primary consideration to the requests of the disabled (sic) individual” (p. 3). However, an article in another issue of the same nursing association newsletter reported a different case in which a Deaf patient’s teenaged children were asked to interpret for their father, but were unable to sign well enough to do so. The hospital tried to contact a professional interpreter, but could not locate one. The court held that in order to prevail, the complainant would have to prove that the lack of appropriate interpreter service resulted from the medical facility’s “deliberate indifference” (May 2007, p. 5).

Spoken language interpreting services for non-English-speaking patients are governed by Title VI of the Civil Rights Act of 1964. Some articles intended for the health care community have reported that non-deaf patients who speak languages other than English face some of the same barriers to care as Deaf patients do. For example, in a case involving a Spanish-speaking laborer, the court awarded damages for the loss of sight in one eye due to inadequate treatment of an injury. The doctor spoke with an interpreter by phone, but did not make use of the service to talk with the patient, resulting in inadequate communication (Legal Review and Commentary, 2003).

            HIPAA and privacy issues.

The Health Insurance Portability and Accountability Act (HIPAA) Public Law 104-191, passed in 1996, applies to health information created or maintained by health care providers, and limits who may see private health care information. The website www.hhs.ocr.hipaa gives information on this act as it applies to patients and health care providers. Two articles in the RID Views explain how this act applies to interpreters. According to Agan (2004), the law applies to health information in any form or medium. Patients must be notified of the law, and notification must be documented (pp. 1, 24). HIPAA addresses the patient’s right to have access to his/her own health records, and to request corrections or submit a written statement of disagreement with them if s/he wishes. The patient has the right to an accounting of how the information was used and to whom it was disclosed. Particularly sensitive information is subject to certain restrictions on access, and a grievance process is in place for patients to use if problems arise (p. 24). 

Thress (2005), who has experience as both a physician’s assistant and an interpreter, pointed out that interpreters who are not employees of medical facilities fall under the “business associate” part of the law, and have access to patient information only for the purpose for which the medical facility collected it, i.e., to provide health care. An interpreter or referral service may use the patient’s name, contact information, and generally identifiable health information for business purposes in the provision of service. Thress stated that interpreters need to sign a business associate’s contract, a sample of which is provided on the HIPAA website. 

            Logistical issues.

Accessing interpreters in a timely manner for medical needs is often an issue, particularly in areas where there is already a shortage of interpreters. Elkins (1993) discussed a process established for dispatching interpreters in emergency situations through the Sign Language Associates, Inc. Emergency Services Division. This service contracts with hospitals, which pay an administrative fee, to provide services in cases of immediate need and short-notice appointments.  Elkins’ article points out that, in order to create an effective emergency system, a critical mass of Deaf consumers and interpreters is required. Geographic area, agency structure and interpreter qualifications must also be considered. 

Carter et al. (2001) described an on-call system for dispatching medical interpreters in emergencies, developed in response to a class action suit against Connecticut hospitals by the Connecticut Association of the Deaf. The consent decree required that interpreters be provided “within one hour of identifying a patient or companion as needing the services” (p. 1). The system involves both recruiting and assigning interpreters, and providing initial and ongoing interpreter training. 

New technology offers other avenues for timely access to interpreters. Swabey and Laurion (2005), in a presentation at the 2005 RID Conference, reported the results of a study on the feasibility of video remote interpreting in health care.  Hirsch and Mirano (2007), writing in Health Management Technology, reported on the use of video conferencing to provide interpreting services. A New Jersey hospital that serves a high percentage of both non-English speakers and Deaf and hard of hearing people required interpreting services in 46 spoken languages and in ASL during a two-year period. In 2003, after exploring several solutions, the hospital contracted with an interpreting agency to provide interpreting via video conferencing. Among their requirements for the service were on-demand interpretation for both spoken languages and ASL, using one device to handle both. The service had to be easy to use, with information encrypted for HIPAA compliance, and the interpreters had to be “medically trained.” Hospital administrators found the service to be effective, particularly because it “helped realize large financial savings by not employing live interpreters with huge financial guarantees” . The hospital plans to include access to video interpreting with the in-room monitors used for TV viewing, and to extend its use to EMTs in the field. 

            Quality control: The case for professional interpreters.

Due to the relative scarcity, expense, and difficulty in scheduling associated with professional, medically trained interpreters, health care providers often resort to the use of ad hoc interpreters, typically staff members who know the patient’s language to some degree, or family and friends of the patient. However, the case for using professional interpreters trained in medical interpreting is strong in situations involving both Deaf individuals and non-English speakers.

Writing about sign language interpreting in medical settings, de Vlaming (1999) suggested that a common issue facing Deaf patients is the pathological view of deafness held by the majority of health care providers. The author stated, “…a professional interpreter acquainted with deaf culture can influence and introduce the perception that sign language is not the absence of spoken English…” (p. 14). 

As mentioned previously by Flores (2003), errors increase when ad hoc interpreters are used (as cited in Angelelli, 2004, p. 23). Chen (2006), writing about her experience relying on the husband of an Arabic-speaking traditional Yemeni woman to interpret, advocated for the use of professional interpreters, stating that untrained interpreters are “reliably unreliable” (p. 1745). McAleer (2006), discussing Deaf patients’ experiences with health care in Great Britain, stated unequivocally, “Nurses who are not trained interpreters but have some knowledge in BSL (British Sign Language) should not act as interpreters”. Fallat et al. (2007) reported on a survey of members of the American Pediatric Surgical Association, which posed the following ethical dilemma: A doctor must rely on a neighbor to interpret for Cantonese-speaking parents of a six-week-old baby in order to obtain informed consent for surgery on the child. Based on results of the survey, the report recommended the exclusive use of trained interpreters (pp. 129-136). Only one article supported the use of family members as interpreters.  Kuo and Fagan (1999), writing about a group of non-English-speaking patients, found that those non-deaf patients felt highly satisfied with and comforted by family interpreters, and may prefer them.

Even when professional interpreters are available, doctors may not avail themselves of their services. A 1996 survey of 165 doctors at a professional conference found that all were unaware of their legal obligations to provide access to Deaf people under the ADA (Harmer, 1999, p. 80). Iezzoni (2004) found that, “When hiring interpreters, physicians often do not seek persons trained specifically in medical sign language” (p. 359). Steinberg et al. (2006) referred to a study published in the Journal of the American Medical Association (Ebert & Heckerling, 1995), which found that doctors used interpreters with Deaf patients infrequently even though they recognized that communication was better when an interpreter was present. An increase in the use of professional interpreters was noted when health care providers were given training in working with interpreters (Karliner, 2004, p. 175).

Medical interpreting is most often done by community interpreters, rather than staff interpreters. Mikkelson (1999) noted in the RID Journal of Interpretation, “Whereas court interpreting is just beginning to emerge as a recognized profession in this country, … other types of community interpreting are far behind” . However, this is changing in the area of medical interpreting. 

Mikkelson (1999), a spoken language interpreter, pointed out that two states, California and Washington, have made efforts to require certification for some types of medical interpreting, and medical interpreter associations have been established in California, Washington and Massachusetts (p. 130). California has also taken steps to prohibit the use of children as medical interpreters in some circumstances  (Yee et al., 2003).

Not all states have such requirements, and even in states with specific laws requiring the use of professional interpreters, state laws often “do not define what constitutes adequate screening, testing, training and proficiency for interpreters”  (Baker et al., 1998, p. 1469). This points to the need for professional standards for interpreters in both sign and spoken languages, which is the subject of a later section of this paper.

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