Becoming a More Competent Medical Interpreter

On Saturday, April 20, the Michigan Translators/Interpreters Network (MiTiN) organized a workshop titled: “Becoming a More Competent Medical Interpreter” from 10:30am till 3pm at the Novi Public Library.

Angélica Snyder and Rita Galin, UMHS Spanish and Russian Interpreters respectively, were invited as the main speakers. Rita Galin presented the first part of the workshop, providing participants with the basics of Medical Terminology using word building and the very basics of Medical Science. All participants actively and enthusiastically participated in these word building exercises, brain storming of new concepts about the Nature of Medical Encounters, the Art of Prediction in Medical Setting, and Differential Diagnoses.

Angélica Snyder presented the second part of the workshop which gave participants an overview of the Standards of Practice, Code of Ethics, Cultural Competency, ethical decision-making, and advocacy in medical interpreting, among other topics. Participants partook in engaging discussions, while sharing their own experiences and providing feedback on some Ethical Dilemmas.

Angélica and Rita shared information with the participants about courses offered by UMHS Interpreter Services – Education Division. It was evident that the audience had a genuine interest in all Interpreter Services classes as well as the National Certification so Angélica provided them with information about the 2 national certification processes along with helpful hints and their respective websites. Lastly, Jeanette Kibler’s Medical Terminology book was a big success not only among Japanese speaking interpreters, but interpreters of other languages as well.

It was great to see our own interpreters among workshop participants.

Bridging the Gap – Summer 2013 Course

inge-and-fernanda-cvc-lobby-11.jpgBridging the Gap, created by The Cross Cultural Health Care Program (CCHCP), is the leading, nationally recognized medical interpreter training program in the United States. The quality of health care often depends as much on the interpreter, as on the provider. This foundation course prepares bilingual individuals to work as medical interpreters in hospital and clinic settings.

The University of Michigan Health System, Interpreter Services Program is Michigan’s first and largest licensed Bridging the Gap provider. The program offered by UMHS Interpreter Services is open to working and aspiring medical interpreters and is taught by an authorized Bridging the Gap trainer.

In this five (5) day/40-hour course, participants will learn:

  • Basic interpreting skills and communication techniques
  • Ethics
  • Basic medical vocabulary
  • Key health care information
  • Communication skills for advocacy
  • How to draft practical, working solutions

Information on the Summer 2013 Bridging The Gap course:

Dates: June 24 – 28

Times: 9:00am – 5:00pm

Location: UMHS Interpreter Services, 2025 Traverwood Drive, Suite A4, Ann Arbor, MI

Questions? Contact Jane Miller at 734-936-7021. To register, click here.

 

Work as a Team

As medical interpreters, we are never alone. We need at least one provider and one patient involved for us to do our job.

But then again, as interpreters, we are always alone. Providers often work as a team, making treatment decisions as a team. And patients may bring family members and decide treatment options as a family.

But, aside from some unusual exceptions, we are always alone. We could be physically surrounded by a bunch of people – a group of providers, a patient with their family members – but we stand alone.

Our work decisions – how we interpret what was just said – is a split second decision made entirely in our head. We don’t turn to a coworker after every sentence and discuss how we should interpret what the doctor just said. The decision is up to us and up to us alone.

Wordle: Team Of course we – belonging to a department with one of the country’s leading medical interpreter training programs – we have been given the knowledge and proper training to be able to make the right decisions when we are out there in the field all by ourselves. We study and practice so that we can make those split second decisions by ourselves.

But because we are trained and are confident in our abilities and can function so well alone out there at our appointments, it is easy for us to forget that we do belong to a department with other staff and coworkers.

Yes, you are sent out to the appointment all alone, but we never want you to feel alone. We never want you to forget that you are one of us – a crucial member of our team.

And “team” is the word often forgotten. Team is the word I want to remind you of today.

You are a team member of the Department of Community Programs and Services. You OLYMPUS DIGITAL CAMERAare a team member of the Interpreter Services Program. You are a team member of your language group.

Our department has progressed and changed so each of you can have a role and a voice as a team member of Community Programs and Services – so you can be an active team member of the Interpreter Services Program. In recent years, we have seen great changes in our department because we have seen changes in you and how you participate and interact with the department.

Now, I would like to urge you to move a little more forward and ask you to actively participate and communicate as a vital team member of your language group.

How often do you speak to your fellow interpreters in your language group? Sure we all have different lives and responsibilities and meeting face-to-face may not always be possible. But email can be a very useful, effective, and time-saving communication tool.

Say a patient comes in to the Emergency Department and gets admitted. You know that somebody will be called to interpret for the patient the next day, and you know you’re not available. Why don’t you email your team to give them a heads-up? Of course, you cannot share patient detail to the whole group, and the whole group doesn’t need to know the details. You don’t have to write a novella about how the patient was injured and how the patient was feeling, etc., but just a few words like “hey, a little heads-up. We have a patient in 8C. They may schedule a test tomorrow. They will need an interpreter at some point. Let me know if you need more information.”

Although we don’t need to know the patient history, the fact that there is an inpatient – the fact that one of the interpreters will have to go interpret – is very useful information to know. We can all be prepared. We can all work to ensure smooth patient care.

Wordle: Untitled
Because that is why we are all here – for the patients and their families.

To provide the best and continuous service to our patients, we urge you to start thinking about your team and to start communicating with your language group.

Are you attending a staff meeting? Talk to your team so you can ensure someone will be available to cover appointments. Planning a vacation? Talk to your team and see if it won’t cause too much damage for you to be unavailable for an extended period of time. For example, “I’m thinking about going to Fiji sometime around October. Any conflicts? I have a few weeks of flexibility but I need to be back by October 25.” And someone else might say “I’m unavailable the first week of October, so if you can stay and work that week that’ll be great.” And now you know that if you take a vacation the first week of October there will be two interpreters gone. If you can, why don’t you try to avoid vacation that week so you can work and cover any appointments.

And sometimes you may have to juggle your schedules and make compromises. Holidays, for example. Of course you want to spend the holiday with your family, but guess what – we all have family. Don’t disappear each and every holiday because guess again, someone has to stay and interpret. Talk to each other. Compromise. Take turns.

When there is an event at the office – meeting, in-service, class – talk to each other and take turns so we can all attend them at some point. Take turns. If one month you attended an in-service and your colleague covered appointments for you, then the next month why don’t you let your colleague attend in-service and you cover the appointments. We all want to participate, and the department wants you to participate as well. But for everyone to participate someone has to be “not participating” in order to cover appointments and interpret. So, take turns “not participating” so we can all participate at one point.

Because at the end of the day it’s about the appointments – it’s about patient care. We went through Bridging the Gap and we continue to take trainings so we can be there for our patients and for this great hospital which strives for the best patient care.

And in order for all of us to be there for our patients and providers – although physically alone we may be in that exam room – we need to work as a team. Remember that you are never really alone when we can establish good communication among us. You are never alone when you are part of a team. Let us be a great medical interpreter team.

How I Became a Medical Interpreter

I recently returned home from the funeral of one of my patients. It is not part of my job. It is a part of my life now. During the funeral one of the attendees said, “Look, there are just a handful of us left. And we all are sooo old!” My heart sank. We have gone through so much together, we have learned so many things together, we are almost like a family now…

I became a medical interpreter 15 years ago. Our Russian community in Washtenaw County is small and I have known all of our patients for many, many years now. At first, I began as a volunteer at the Hospital. The University of Michigan Health System did not have an Interpreter Services department yet. There were only a few Russian-speaking patients in Ann Arbor at that time. However, they did not speak any English and they demanded proper medical care, so hospital administrators frantically searched for Russian-speaking interpreters; my friend told me about this. I have a medical degree from my country, so it was natural for me to become a freelance interpreter. I knew medical science and medical terminology. But everything else was so different.

So, I began to become accustomed to and familiar with the American Health Care System. I did not know about any training for medical interpreters or any other training except for English language classes, so I took as many as I could to hone my English skills. Of course I was interpreting from the third person and had absolutely no clue about any interpreting rules. I tried to do my best in relaying the message and establishing trust. All that I was doing in the room was trying to be a bridge between patients, their families and the medical providers, and that came from my own feelings and instincts.

I quickly realized that our patients, who were unfamiliar with the medical system and extremely suspicious about any decisions medical providers made, needed extensive education. “Why do I need this test? They probably would like to get more money from my insurance… And what is INSURANCE after all? And why do I need to sign a consent form that states that one of the complications of the procedure could be stroke, heart attack or death??? I will not sign anything!” Or it could be the absolute opposite—“The doctor does not want to send me for the test because my insurance will not pay for this… And what is INSURANCE after all?”

In addition to all of that, our patients are absolutely non-compliant no matter what. Medical providers who had no idea about those issues, medical care, and expectations in the former Soviet Union also needed extensive education. This is how I slowly made it my mission to be a patient’s advocate and cultural broker. I prepared and presented lectures about specifics in working with Russian-speaking patients, differences in medical care, grief, and loss in Russian culture, and so on to medical providers at UMHS. I also educated our patients about various aspects of American Health Care, insurance, referrals, refills, consent forms, Living wills and Powers of Attorney.

I am a lead interpreter now in our large department of Interpreter Services. We have all completed Bridging the Gap training for medical interpreters, and now I know how to properly interpret in the medical setting. I also teach a course “Medical terminology and Body Systems” for medical interpreters. We have staff interpreters that cover 8 languages and contract interpreters who cover another 100+ languages.

I am so proud to be the first interpreter who was hired as a staff interpreter at the University of Michigan Health System. I always say to our new interpreters, “Isn’t it great? We help people and we are getting paid for that! Not very many people can say that about their jobs.”

Challenges & Best Practices for Interpreters – Summary from Diversity Rx

Interpreting in Emergency Services: Challenges and Best Practices for Face-to-Face and Telephonic Interpreters

Presenter: Jason Roberson, MA, Cyracom

This presentation focused on Emergency Services encounters and how they present unique challenges for both face-to-face and telephonic medical interpreters. The presenter explained how conditions may force interpreters to push the limits of the National Standards of Practice in order to provide the most complete and accurate interpretation, and offered measures to help ensure maximum effectiveness and the best possible outcome in Emergency Services interpreting.

Key ideas or suggestions for UMHS – ISP

  • Challenges for interpreting in the ER setting include
    • Positioning
    • Multiple providers
    • Critical timeframe
    • Flow of communication
    • Background noise
    • Emotional nature of the clients
    • Personal needs of interpreter
    • Understand who does what in a ER trauma – example – recording nurse and the role of the physician in charge
    • The recording nurse is a key point person for the interpreter to know – he/she can be your liaison to the trauma team
    • “Mechanism of injury” – how the injury occurred eg. Fall, auto accident etc.

 

Culturally & Linguistically Appropriate Materials and Training Refugee Interpreters

Ensuring Culturally Sensitive and Linguistically Appropriate Materials for a Low-Literate Medicaid/Medicare Population

Presenter: Nai Kasick, L.A. Care Health Plan

  • Use of fotonovelas to improve health literacy for Spanish-speaking patients
  • You can test your ER IQ http://www.anthem.com/eralt/va/urgentcare.swf - not captioned and in spoken/written English but great simple information about when to go to the ED and also what are other options

Training Refugee Interpreters: A Refugee Resettlement Agency Approach

Presenter: Natalya Mytareva, MA, International Institute of Akron, Inc.

This presentation explored challenges of and approaches to training interpreters who are recently resettled refugees themselves. It discussed the program’s content as well as instruction and assessment methods. The presenter share her successes and lessons learned during the existence of this program.

Key Ideas or suggestions for UMHS-ISP

  • Shorter trainings are better – 4 to 5 hour trainings vs all day
  • Repeat the foundations of interpreting at each training
  • Peer review is helpful
  • Between training provide “homework” or self guided study
  • Pre and post tests
  • When ranking or rating use Low – medium – high vs a numbers scale

Impressions from Diversity Rx – Equitable Mental Health Services

Partnering with Interpreters to Provide Equitable Mental Health Services

Presenter: Marla Lipscomb, MSW, LCSW, Saint Alphonsus CARE-Culturally Appropriate Resources and Education Maternal Child Health Program

This workshop discussed how one of the most influential and critical roles in providing equitable mental health services to LEP populations is the role of the interpreter. It was designed to strengthen knowledge and awareness about the unique skill set that is required of interpreters in the mental health setting.

Key ideas or suggestions for UMHS – ISP

  • relationships between therapist, client, interpreter – “triad” is a dynamic opportunity to create safety and build trust
  • In order to restore choice and voice for the patient it’s important that :
    • Patient chooses preferred interpreter
    • Interpreter is the same throughout all treatment
    • If there is a change in interpreters, patient needs to be informed before appointment
    • “Heart Language” – the language that was used when the trauma occurred. When talking about the trauma, the patient needs to discuss it using their “heart language”.
    • Trauma is like a slow drip (always there).  It is often triggered in healthcare settings due to cultural misunderstandings.
    • Vicarious Trauma – very common among interpreters of the same immigrant group who have experienced the same trauma in the past and/or have the same traumatic experiences eg; abuse, rape.  Tips for prevention include:
      • Do not sit too close to the trauma survivor when they are telling their story
      • Do not mirror body language of the trauma survivor
      • Speak in the 3rd person when the survivor is talks about their past

Summary from Diversity Rx – Promoting Health Equity

I attended the Diversity Rx conference in March along with several colleagues. Below are my summaries and impressions of the workshops and presentations I attended.

Promoting Health Equity – Two Perspectives

Presenters: Sue Schlotterbeck, MS, RD, LD, Edward M. Kennedy Community Health Center and Elizabeth Walker Anderson, JD, System Director, Equitable Care, HealthEast Care System -Cross Cultural Services

The 2 presenters discussed their successes and lessons learned in promoting health equity. The presentations included sharing techniques, evaluation tools, and resources used to discuss the following six areas: organizational commitment, training and education, workforce diversity, language services, community engagement, and measuring and addressing health disparities.

Key ideas and take-aways for UMHS – ISP

Below are examples of strategies that UMHS Interpreters could utilize in our work to promote understanding and health equity for our patients. Ideally the heath care provider would present the materials this way, but if not, we as Interpreters could use the following techniques:

Ways to encourage questions:

  • Ask “What questions do you have?” This will let the patient know you would like him or her to ask questions.
  • Do not ask “Do you have any questions?” This often results in a quick “no” even if patients do have questions.
  • Encouraging Questions:
  • Lets patients know that their role in their own health care is important
  • Decreases the number of call-backs or questions after the patient leaves
  • Increases patient satisfaction and patient safety

What is “Teach Back”?

  • Technique that confirms the patient understands what the provider has ‘explained.’
  • Asking patients to repeat in their own words what they need to know or do, in a non-shaming way.
  • A chance to check for understanding and, if necessary, re-teach the information.
  • Demonstrates that the burden for effective communication is on the provider not the patient.

Why use “Teach Back”?

  • Asking that patients recall and restate what they have been told is one of 11 top patient safety practices based on scientific evidence.
  • Everyone benefits from clear information.
  • Research shows that patients remember and understand less than half of what providers explain to them.
  • Many patients are at risk of misunderstanding, but it is hard to identify them.
  • National Healthy People 2020 goals include: “Increase the proportion of persons who report their health care provider always asked them to describe how they will follow the instructions” (“Teach Back” relates to this goal).

Examples of “Teach Back” – Ways you can ask patients to demonstrate understanding, using their own words:

  • “I want to be sure I explained everything clearly.  Can you please explain it back to me so I can be sure I did?”
  • “What will you tell your _____ (partner, family…) about the changes we made to your blood pressure medicines today?”
  • “Instructions can be confusing.  I want to be sure I was clear in how I explained this medicine.  Can you tell me what it is for and how you will take it?”

**Excerpt from workshop handout – Edward M. Kennedy Community Health Center Contents of Online Training

**Health Literacy, “Teach Back” and Encouraging Patients to Ask Questions (rev 8/10/2011)

Additional information/suggestions

  • Studies show that there is an 88% increase in patient understanding when the “teach back” method is used. – WOW!!!!!
  • 50% of American adults (93 million) do not understand healthcare information
  • There is a feature in Microsoft Word that will check language grade level for documents that you write.
  • Someone from Interpreter Services/community health could attend the monthly new manager’s meetings and present on topics such as using interpreters, LEP patients, racism, white privilege, LGBT patients etc.
  • Annual staff training online (like our mandatories) includes a rotation of the following topics: 1) Working with the LGBT patients, 2) Working with interpreters, and 3) Understanding Racism

Diversity Rx Conference – Part II

My impressions and lessons learned from the Diversity Rx conference as a representative of the UMHS Interpreter Services Program continued…

Engaging the Patient: Strategies for Practice and Provider Training:

  • There is a virtual world called “Second Life” which we can use to create an on-line based classroom. Participants can use their Avatar to interact with each other, engage in role-plays and review each other’s performance.
  • In Second Life, people can make presentations using the actual Power Point materials and participants can have small group discussions. They can also video-record their Avatar’s performance.
  • In order to run this program, people have to have high level of technical support.

Innovations in Health Equity and Health Systems Transformation:

  • Researchers are trying to compare hospitals in various countries in Europe and North America to develop a better model to achieve equity in the health care.
  • We can review regional differences and similarities with “America’s Health Rankings” website.
  • It is important to conduct a large-scale survey to gain information on regional characteristics. Such information helps policymakers to review and modify existing policies. However, it is often impossible to understand details of personal experiences by assessing large-scale survey results. We need to examine both quantitative and qualitative data to provide the best service available to people in need.

Unique Training Approaches in Medical Interpretation:

  • At the Memorial Sloan Kettering Cancer Center in NY, they offer a medical interpreter training program for unemployed or underemployed people. This course is a 120-hour course and includes job coaching. This is a completely free course.
  • International Institute of Akron (OH) also offers a training program for people who are willing to serve as an interpreter in their own ethnic communities. This is also free for participants.
  • It is important to screen applicants for their bilingual skills and employability early in the application process.
  • There was also a research project at the Memorial Sloan Kettering Cancer Center in which researchers investigated the level of fluency of bilingual providers.
  • It is important to make sure bilingual providers are proficient enough to practice using their non-English language.  When they say they are planning to use the language, an appropriate assessment should be conducted.

Diversity Rx Conference – Part I

I participated in the Diversity Rx conference as a representative of the UMHS Interpreter Services Program. I staffed the information table at the conference Expo, and also had opportunities to attend plenary sessions and workshops. The followings are the highlights of what learned from this conference.

From Welcome and Introductions session:

  • The city of Oakland has a Chinese-American female mayor and there is a very high percentage of the Asian population.
  • There is an organization called, “Asian Heath Services” in Oakland and currently 5000 people are on their waiting list to receive health care. I was aware that historically there has been a much higher number of Asians living in the West coast regions, but I didn’t imagine the city of Oakland had that large an Asian population.
  • I have never heard of a word, ‘patient of color,’ and I wondered if I am considered one of them. (In the US context, ‘people of color’ is often used to describe the African-American population, so maybe not. I need to study more.)
  • The word ‘disparity’ is used to describe inequality in health care. This usage was completely new to me.
  • LEP patients are considered to be one of the disadvantaged groups. I’ve always thought my role as an interpreter is to make a bridge between people who do not share languages. I certainly do not consider our Japanese patients as a disadvantaged group. This is a positive thing, but has always limited the way I think about things more critically.

From Certification for Medical Interpreters: Updates from Two Programs:

  • CMI certification is valid for 5 years while CHI is valid for four years.
  • The next language groups for the oral exam are Korean and Vietnamese for CMI and Russian and Vietnamese for CHI.  (I was hoping they would make Japanese available next.)
  • CCHI written exam seems to assess the role of interpreter more than CMI exam does.
  • CCHI oral exam includes simultaneous interpretation, but CMI does not have that component.
  • CCHI will have CEAP (Continuing Education Accreditation Program) available in August 2013 for people to get their training sessions accredited.
  • CCHI employees rate CCHI oral exams.
  • In Oregon, they do not recognize CMI or CCHI.  Interpreters have to complete 60 hours of training and have 40 hours of work experience.

From Plain Language to High Tech: Communication Strategies Across Language Barriers:

  • “Mobile Wave” by Michael Saylor (2012) talks about how the development of mobile technology will change our lives. I think the development of the mobile technology has already influenced how UMHS Interpreter Services interpreters work every day. I use my phone almost all the time while I am at the clinic. It has dramatically increased my productivity at work.
  • Companies such as “Verbalizeit” and “Sendboo” offer instant translation services, but the accuracy of their translation is questionable. People using this type of service need to know when it is appropriate to utilize it.
  • I did not know the President Obama signed the Plain Language Act in 2010.
  • Voice for Health CEO, Michelle Scott, in Grand Rapids uses the concept of plain language editing in their translation process.
  • There are four components in the concept of ‘health literacy’ – visual literacy, computer literacy, information literacy, and numerical literacy.
  • Health literacy is not correlated to the level of education and the type of occupation. It is influenced by the patient’s stress level, illness (types of illness and the degree of severity?), age, and experience.
  • When assessing LEP patient’s health literacy, we have to look at 1) education level, 2) country of origin, 3) literacy rate, 4) health system, 5) access to education, 6) access to information.
  • In the process of plain language editing, elements such as sentence structure, logic gaps, unnecessary concepts or phrases, colloquialisms, cultural expressions, abbreviations, acronyms, word choices, and units of measurements should be reviewed.
  • The best person for plain language editing is someone with teaching experience and cultural knowledge.
  • The best way to assess whether the translation is culturally and medically appropriate is to have both cultural and medical reviews and have a focus group check the translated material. Of course, this will be time consuming and costly….
  • Currently, no certification is available for medical translators. Even if someone has the ATA certification, we should always check his or her experience as a medical translator before assigning a project.