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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Preparing to Interpret in Medical Settings

         What does an interpreter need to know?

The complex nature of interpreting in health care settings demands that practitioners be well equipped for the task. Napier et al. (2006) described medical interpreting as “diverse and unpredictable” as well as a “high stakes setting” (pp. 111-112). Clearly, preparation is key to working effectively in this setting. A review of writings that covered both sign and spoken language interpreting found general consensus on what interpreters need to know, and on personal characteristics that are important in medical settings. 

By far the most commonly cited need for medical interpreters was knowledge of medical terminology (Yaffe, 1999, pp. 1, 12; Barnard, 2005, p. 7; Goldberg, 2003, p. 6; Dower, 2003, p. 3; Napier, 2006, p. 112; Humphreys, 2003, p. 90; Frishberg, 1990, p. 119). The second requirement noted was knowledge of medical tests, treatments, procedures and equipment. Interpreters must be aware of the stages in medical processes, and the relative importance of communication at each stage (Humphrey & Alcorn, 2001, p. 13.35). Interpreters also need to be familiar with human anatomy and with the varieties of medical disciplines, roles of various medical professionals and hierarchies in the health care system. Lest interpreters find these requirements too daunting, Rogers (1999) pointed out that interpreters need not have a degree in medicine or in medical vocabulary to be effective, and should always be willing to ask both patient and doctor for clarification (p. 9). Barnum, quoted in Stewart et al. (2004), suggested that interpreters must be “educated enough in the field of medicine … not to be a doctor … but to be familiar with and comfortable in (the) medical setting…” (p. 110). Interpreters should have a general background in science, and knowledge of common illnesses, and be aware of safety issues that may affect them or their patients. Interpreters should be aware of the influence of culture and power dynamics in medical settings. Emotional issues, such as the ability to bring calm to a stressful situation, the capacity for “being present” for whatever the patient endures, and awareness of the possibility of vicarious trauma, are also important.

Many authors addressed issues specific to medical settings and suggested ways that interpreters could deal with them. One of the most commonly addressed issues was the need for patient privacy or “modesty,” and discussion included interpreter strategies for maintaining visual access with Deaf patients during physical examinations (Frishberg, 1990, p. 119; Humphrey & Alcorn, 2001, p. 31). Steinberg et al., addressing protocols for quickly identifying Deaf patients and providing interpreter services, stressed the importance of gender preference in choosing an interpreter for certain medical procedures (p. 739). Frishberg suggested that the interpreter could step out of the room during the actual exam or procedure, after explanations have been made (p. 120). 

Placement of the interpreter within sight of the patient but out of the way of medical professionals, equipment and procedures is often a challenge. As Humphrey and Alcorn (2001) pointed out, an “ideal” placement, with the interpreter near the health care practitioner and both within the Deaf patient’s sight line, is “virtually impossible” in some situations (p. 31). Frishberg (1990) agreed, pointing out that although interpreters are taught to place themselves near the source of information, the best placement in medical settings is not always near the practitioner (p. 120). Modifications in placement may need to be made to avoid hindering the procedure, or because of safety issues that may affect the interpreter. 

A few sources dealt with specific kinds of procedures. For example, Napier  (2006) explained the particular challenges that arise in eye care appointments: Some procedures, such as vision testing in a darkened room, removing a patient’s glasses, or dilation of the eyes, compromise the patient’s ability to see the interpreter (p. 113). Moxham (2005) discussed interpreting various types of medical procedures, including dentistry, physical therapy, home health care, nursing home care, and many more, pointing out challenges and suggesting ways interpreters may choose to deal with them (pp. 25-52).

Another challenge interpreters face in medical settings is working with Deaf patients who are stressed, worried, in pain, medicated, or physically compromised (Humphrey & Alcorn, 2001, p. 31). Frishberg (1990) suggested that health care providers sometimes need to be reminded that Deaf patients need to see to be able to communicate, and that interpreters need to be brief, clear and avoid fingerspelling with patients who are sedated (p. 121). A striking example of a physically compromised patient is provided in an article addressing end-of-life care needs of Deaf senior citizens (Allen et al. 2002). A Deaf person in hospice care suffering from a brain tumor was unable to sign clearly. A Deaf hospice visitor was able to understand what he was trying to communicate, even though an ASL-English interpreter with 20 years’ experience was not (p. 198). Although this incident did not involve an interpreted event, it highlights the difficulties a Deaf patient may have, as well as the need for Deaf interpreters in the medical settings.  

Safety is another topic that several authors addressed. Interpreters must protect themselves from exposure to illness as well as radiation from x-rays, and be careful that their own health does not negatively affect Deaf patients. Humphreys (2003) suggested that interpreters be aware that when health care providers don scrubs, masks, and shoe covers in preparation for a procedure, interpreters should as well (p. 90). Clear plastic masks are available that will allow the Deaf patient to see the interpreter’s face. Interpreters should also be sure that their routine vaccinations are current, and should have a TB test, hepatitis vaccinations, and tetanus shots. Moxham (2005) suggested an interpreter survival kit of sorts, which would include a nametag, hand sanitizer, sensible shoes, an identifying vest, and a copy of the ADA (p. 12).

One point not often addressed in the literature, and often not covered in interpreter education, is the existence of almost 200 types of genetic hearing loss, about one-third of which are part of a syndrome that can produce major health problems (Harmer, 1999, p. 75). Patients whose deafness falls into this sub-category may need more complex health care than other patients.

These are only a few of the challenges interpreters face in health care interpreting, and for which they need preparation. In the next section, resources for medical interpreters and curricula for medical interpreter training and education will be reviewed.

         Education and resources for interpreters.

Dealing with the vast array of medical procedures and terminology can be daunting. A number of resources are available for working interpreters who are either actively involved or interested in medical interpreting. One of the most comprehensive is Tamara Moxham’s 2005 book, Deaf Patients, Hearing Medical Personnel: Interpreting and Other Considerations. The book is intended and written for interpreters, Deaf consumers and their families, and medical staff and administrators, and covers protocol for hiring interpreters, including Deaf interpreters; HIPAA; interpreter roles; emergency coverage; ethics; medical context and culture; and specific types of medical scenarios. 

In an article published in the Journal of Deaf Studies and Deaf Education, Harmer (1999) has provided an overview of Deaf people and medical care entitled “Health Care Delivery and Deaf People: Practice, Problems, and Recommendations for Change.” This broad-ranging article examines factors affecting Deaf people and health care, reviews literature on the subject and recommends changes.

The Interpreting Handbook for Diagnostic Procedures (1998, 40 pgs.), by Cathy Cochran of the Olathe Medical Center, describes common radiologic diagnostic procedures, such as chest x-rays, bone studies, ultrasounds, and angiographies, giving information that interpreters need to interpret them successfully. For each procedure, the author has explained the purpose of the exam, how the patient is prepared, the position of the patient, appropriate placement of the interpreter, precautions, and special considerations. She has also provided specific information on how interpreters can protect themselves during these procedures, and included a list of common medical abbreviations. 

Writing in the RID Views, Barnard provided a very brief list of terms associated with sexually transmitted diseases, giving a definition of each and suggesting that interpreters attend lectures or read up on STDs (January 2005, pp. 1, 15). Goldberg suggested low-cost training options such as workshops and college courses in anatomy and physiology or in Greek and Latin affixes, and further recommended that interpreters watch medical programs on television, particularly those on public or educational channels, paying particular attention to the social dynamic among professionals (January 2003, pp. 6-7). The author also suggested medical dictionaries and laminated pages from medical study guides as useful resources. 

Although written primarily for spoken language translators and interpreters, materials available from the American Translators Association (www.atanet.org) can also be helpful to sign language interpreters. This organization, which has a medical section for members, publishes Medical Translating and Interpreting: A Resource Guide: A comprehensive resource for translating and interpreting in the medical field. Among the articles in issues of recent conference proceedings are discussions of specific medical topics. For example, two papers written by a doctor who is also a translator define coronary heart disease, giving symptoms and risk factors and describing the diagnostic procedure and treatment (Rivera, 2004, pp. 141-146); and explain issues and terminology associated with palliative medicine (Rivera, 2003, pp. 161-173). Another summarizes classifications, terminology and treatment of epilepsy (Rosdolsky, 2005, p. 177ff). Philips and Araujo-Lane (2005) offered ideas on how to request clarification in medical interviewing and walked readers through options for interpreting a specific medical term, describing the ramifications of each interpretation (pp. 197-205).

Other resources include Barnum and Siebert’s (1987) Interpreting in Medical Settings: A Student Manual, written for the program in Medical Interpreting at the College of St. Catherine, and Bridging the Gap: A Basic Training for Medical Interpreters (1999) from the Cross Cultural Health Care Program (http://www.xculture.org/). Language-specific resources include Trabing and Metivier’s (1995) Training Manual for Spanish/English Interpreters in Health Care Settings from the North Carolina Primary Health Care Association, and Mikkelson’s (1994) The Interpreter’s Rx: A Training Program for Spanish-English Medical Interpreting.

Swabey et al. (2006) wrote, “Although health care interpreting is one of the most common forms of community interpreting, effective practices for the education of interpreters working in health care have yet to be identified” (p. 59). A few sources suggested topics that might be included in such a curriculum. A survey of medical interpreter training options available for spoken language interpreters in California in 2002 found that programs ranged from 30 to over 360 hours, with most 40 hours long. Two-thirds of these programs required no practicum experience as part of the training. Typical courses included role and ethics, basic interpreting techniques, controlling the flow of the session, medical terminology, professional development and the impact of culture in medical interpreting.  Longer programs included more practice interpreting and more analysis of the conversation process (Dower, 2003, p. 3).

The College of St. Catherine established a Health Care Interpreting Program in 1983. According to Barnum (1989), students were required to take Human Anatomy and Physiology, General Psychology I and II, Lifespan Development, Psychology of Adjustment, and Medical Terminology as part of their general education courses. In addition to the language and interpreting skills classes typical of most programs, students were offered classes specific to the medical setting. “Introduction to the Health Care Interpreter Setting” consisted of lectures, tours and observations of medical interpreters, and was designed to help students understand the health care system. “Medical Interpreting” provided an opportunity for students to gain hands-on experience while they continued to learn about the health care system. Each unit also included vocabulary and role-plays related to the topic. Topics included placement, determining appropriate communication mode, job stress, medication, and safety issues. Students also completed practicum hours with a working medical interpreter during this course.  After taking “Medical Interpreting,” students took “Mental Health Interpreting,” which included such topics as therapy, sexual abuse and domestic violence, and chemical dependency. This course also included a practicum. The last course in the health care course sequence was a 90-hour practicum. In addition to these courses, the program included “Ethics and Decision-Making for Health Care Interpreters” in which students studied ethical issues in the health care setting  (1989, p. 85ff).

Reporting on the emergency dispatch system for sign language interpreters in Connecticut mentioned earlier, Carter et al. (2001) wrote that initial training of working interpreters unfamiliar with medical interpreting included safety and universal precautions, consent forms, radiology and pharmacology, working with deaf-blind people in medical settings, and “Rx for Effective Medical Interpreting" . Ongoing weekly small group classes included case studies, role-plays, films on specific medical topics and question-and-answer sessions. Mentoring on the job, individual weekly sessions, and classes for CDIs and oral interpreters were also provided. 

A unique training program was developed to prepare interpreters of spoken Navajo to interpret information related to diabetes, a major health problem among that population. Under the auspices of the Navajo Nation, the project developed a glossary of common terms and concepts, and used case studies to address four common situations: the newly diagnosed diabetic, the patient with poorly controlled diabetes, retinopathy screening, and nephropathology screening and treatment  (Nutrition Research Newsletter,  pp. 12-13).

Angelelli (2006) recommended that health care interpreter education should aim to develop skills in six areas: cognitive processing; interpersonal issues, such as role visibility/neutrality and power; linguistic factors, such as vocabulary and changing registers to accommodate patient needs; professional issues, such as ethics and certification; settings; and sociocultural issues, such as the impact of the institution and society (p. 25). The author stressed that the current model of interpreter education is based on preparing conference interpreters, but that new models need to “account for the role of the interpreter, so that students understand the agency that they have, how it falls within a continuum of participation or visibility, and what duties and responsibilities emerge from this agency that cannot be denied” (p. 29). Students need to be exposed to medical discourse so that they see the connections between settings, expectations and actual performance. Angelelli recommended “problem-based learning,” of the sort that is used in medical schools, and suggested that students might also benefit from health care communication courses offered in medical schools (p. 35). She suggested the following course sequence:  introduction to medical interpreting, language enhancement for medical interpreting, strategies for medical interpreting, the role of the medical interpreter, and a practicum in medical interpreting  (p. 38).

A problem-based learning strategy used in many in sign language interpreting programs is the “Demand Control Schema.” Dean and Pollard (2005) defined interpreting as a “practice profession,” like law or medicine, one that requires the practitioner to be able to consider the situation and human interaction in order to work effectively (p. 259). This is in contrast with “technical professions,” like engineering or accounting, in which one needs only knowledge and skills to function well. These authors echoed Roy , Metzger , Hsieh , Angelelli and Wadensjo in their statement, “Our teaching and practice experiences have led us to conclude that the field of sign language interpreting suffers from significant gaps in rhetoric versus defacto practice” (p. 265). In other words, interpreters in real life do influence the flow of communication, and must realize their agency in order to practice effectively. Dean and Pollard proposed the Demand-Control Schema as a framework for decision-making in interpreting. All situations, including medical ones, force interpreters to make decisions regarding the demands of the situation in four areas: environmental, interpersonal, paralinguistic, and intrapersonal. Interpreters may choose to deal with these in active (liberal) or inactive (conservative) ways. Moving too far to either end of this continuum may risk unethical behavior (p. 273). 

The Demand-Control Schema has been used in teaching interpreting in general and in teaching medical interpreting in particular (Dean et al. 2003, pp. 1, 10-12).  Davis (2005) explained how the interpreting program at the University of Tennessee, working with the University of Rochester, offered an introductory course in Demand-Control Schema followed by a course in medical interpreting (p. 40). In the second course, students shadowed health care providers at the University of Tennessee Medical Center, using the Demand-Control Schema to analyze the settings they observed. Through their observations, they were exposed to basic medical knowledge and terminology, doctor-patient interaction, and a variety of health care settings. Following each observation they researched related medical information, then participated in a “group supervision meeting” in which they discussed their experiences under the guidance of an instructor. Students benefited not only from the knowledge they gained, but also from the opportunity to gain empathy for patients and to understand the health care providers’ perspectives (Dean et al., p. 12).

Metzger suggested that one way to prepare students for future medical interpreting would be a team effort between an interpreter education program and a medical education program that pairs interpreting students with medical students (p. 200). This would also benefit medical students, preparing them to work with interpreters in their future careers, and might well have the effect of increasing usage of interpreting services. Kennedy and Rho (2004) have used professional interpreters in a formal curriculum to teach doctors “triadic interviewing,” that is, interviewing patients using an interpreter, and have found it very successful (p. 557).

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