Will greed win over quality medical interpreting in the middle of a pandemic?

September 9, 2021 § 4 Comments

Dear colleagues:

On May 15, 2021 the Certification Commission for Healthcare Interpreters (CCHI) released a study suggesting that an English-to-English exam might solve the shortage of healthcare interpreters in what they call “languages of lesser diffusion,” meaning languages other than Spanish, Arabic or Mandarin. The reason for this “sui-generis” affirmation is very simple: developing actual interpretation exams to test candidates on simultaneous and consecutive interpreting, and sight translation in both: source and target languages would be too expensive and therefore not profitable. Interesting solution: examine candidates’ English language skills (reading comprehension, medical concepts, fill-in the blanks, and what they consider can show the candidate’s “potential correlation with overall interpreting ability”: “listening comprehension.”) An English only exam will catapult an individual into an E.R. to perform as an interpreter without ever testing on interpretation!

What about native English speakers, who in the study scored an average of 87.9% compared to non-native speakers, who scored an average of 76.6%? No problem, says CCHI; passing score is 60% and Spanish language interpreters will continue to take the interpretation exam already in existence. I suppose the expectation might be that people who speak other “languages of lesser diffusion” in the United States have a higher academic background and their English proficiency is higher. Another point that makes this “solution” attractive is that most interpreter encounters in hospitals, offices and emergency rooms involve Spanish speakers, which brings the possibility of lawsuits for interpreter malpractice to a low, manageable incidence. I would add that many people needing interpreting services will not even consider a lawsuit because of ignorance, fear or immigration status. The good news: CCHI concluded that although this English-to-English exam option “is a promising measure…(it)…requires additional revision and piloting prior to use for high-stakes testing.” (https://slator.com/can-a-monolingual-oral-exam-level-the-playing-field-for-certifying-us-interpreters/)

Reading of this report and the article on Slator got me thinking about the current status of healthcare interpreting in the Covid-19 pandemic. How long will the American healthcare system ignore that the country is everyday more diverse and in need of professional, well-prepared healthcare interpreters in all languages? The answer is difficult and easy at the same time.

A difficult answer.

It is difficult because we live in a reality where every day, American patients face a system with very few capable healthcare interpreters, most in a handful of language combinations, and practically all of them in large and middle-sized cities. The two healthcare certification programs have poor exams. One of them does not even test simultaneous interpreting, and the other tests a candidates’ simultaneous skills with two 2-minute-long vignettes (one in English and the other in the second language). Consecutive skills are also tested at a very basic level with four vignettes of twenty-four 35 or fewer-words “utterances” each. It is impossible to assess somebody interpreting skills with such an exam after just 40 hours of interpreter training. (https://cchicertification.org/uploads/CHI_Exam_Structure-Interface-2020.pdf).

Except for those interpreters with an academic background or prepared on their own because they care about the service they provide, the current system provides a warm body, or a face on a screen, not a healthcare interpreter. Because the motivation is a robust profit, it is conceived and designed to protect the interests of insurance companies, hospital shareholders, and language services agencies. It has been structured to project the false impression these entities are complying with the spirit of the law; It is not designed to protect the physician or the patient.  

In 1974 the United States Supreme Court ruled that failing to provide language support for someone with limited English proficiency is a form of discrimination on the basis of national origin (https://www.federalregister.gov/documents/2000/08/30/00-22140/title-vi-of-the-civil-rights-act-of-1964-policy-guidance-on-the-prohibition-against-national-origin).  The ruling was later broadened and implemented by the Americans with Disabilities Act (ADA) (https://www.ada.gov/effective-comm.htm) and the Affordable Care Act (ACA) commonly known as “Obamacare.” (https://www.hhs.gov/sites/default/files/1557-fs-lep-508.pdf) This legislation specify that healthcare organizations must offer qualified medical interpreters for patients of limited English proficiency and those who are deaf or hard of hearing.

An easy answer.

Despite the reality we face, the answer to the question above is easily attainable because the healthcare industry has immense financial resources and a system that lets them capture money at a scale no other industry can.

The healthcare sector deals with the lives and quality of living of all individuals present in the United States. Their reason to exist is to save lives, not to produce ever-growing dividends to its shareholders every year. This is an industry that spends unimaginable amounts of money in medical equipment, state-of-the-art technology, physicians, surgeons, nurses, therapists, researchers, attorneys, and managerial staff salaries. New expensive hospitals, medical office buildings, clinics, laboratories, and rehab centers are built all the time. This industry can spend top money in those sectors because it is good for business. It is an investment that produces a profit. I am not even scratching the surface of these expenses, but even if we ignore the money spent in food, gear, vehicles (land and air), utilities, clerical staff, janitorial staff, and medical aide positions, we can safely conclude this is an industry that knows how to spend money when an expense is viewed as an investment that will produce a financial benefit.

Designing good medical interpreter exams in many languages is expensive, paying professional-level fees to healthcare interpreters will cost money, managing a continuing education program will not be cheap, but the healthcare sector cannot cry poverty. They have the funds to do it. It is incomprehensible how a business that bankrupts its patients after one surgery or a chronic disease can argue with a straight face, they can only pay 30 to 50 dollars an hour to a medical interpreter. This is an industry that charges you fifty dollars for a plastic pitcher of water or twenty dollars for a box of tissue they replace every day.

Quality interpreting, and living up to the spirit of the law, cannot happen when an organization spends money to look for shortcuts such as testing English-to-English in an interpreting program. Only the promise of a professional income will attract the best minds to healthcare interpreting. Current conditions, including low pay, an agency-run system, and searching for shortcuts to go around the law will never produce quality interpreters.

If those deciding understand good professional healthcare interpreters are an investment as valuable as good physicians, surgeons and nurses, the solution can begin immediately. Designing and administering a quality interpretation exam will take time, getting colleges and universities to start interpreting programs that include medical interpreting will not be easy, but there are steps that can improve the level of interpreting services right away.   

A higher pay, comparable to that of conference interpreters will immediately attract top interpreters in all languages, at least temporarily or part-time to the field. Many top interpreters see the need for quality services during the pandemic, and they feel a need to help, but they have to make a living and healthcare interpreter fees do not meet the mark.

Instead of thinking of English-to-English exams to create an illusion they are forming interpreters, stakeholders should recruit native speakers of languages where interpreters are hard to find, but they must stop looking for “ad-hoc” interpreters in restaurant kitchens and hotel cleaning crews, and start talking to college students and professors, to scientists and physicians from those countries who now practice in the United States. With current technology, hospitals should look for their interpreters among the interpreter community in the country where a language is spoken and retain their services to interpret remotely, instead of opening massive call centers in developing countries, using the technology to generate a higher profit instead of better quality.  

Hospital Boards must find the money and allocate it to interpreting services. In these cases, such as Medicaid and others, the cost of interpreter services should be considered an operating expense. Insurers do not reimburse for nursing and ancillary staff. Hospitals and practices pay their salaries.

Payers may also benefit by covering interpreter services. Although data are limited according to the Journal of the American Medical Association Forum, studies suggest that when physicians struggle to communicate with patients, they are more likely to order unnecessary tests and treatments. This not only puts patients at increased risk, but also directly increases payer spending. Limited English proficiency patients may need care more frequently or seek treatment in more expensive settings, such as the emergency room, when they cannot communicate with primary care providers. Similar to insurers in fee-for-service arrangements, risk-bearing provider groups in alternative payment models face a similar incentive to curtail unnecessary or wasteful utilization. Poor interpreting services will also result in malpractice lawsuits against hospitals, language service providers, insurance companies and medical staff. In the long run, by far, this makes investing in quality interpreter services and interpreting education/certification programs a smaller expense. “Paying for interpreter services, from cost-based reimbursement, to their inclusion in prospective payment models, to insurer-led contracting of remote interpreters, would not only address the disparities exposed by the pandemic, but also help support practices facing financial peril due to the pandemic.” (https://jamanetwork.com/journals/jama-health-forum/fullarticle/2771859) It is time to grow up and stand up to the stakeholders in the healthcare sector; it is time to unmask the real intentions of language service providers who take advantage of often-poorly prepared interpreters to get a profit. It is time to have a serious healthcare interpreter certification exam that really tests the candidate’s interpreting skills. We need university and college programs, and a different recruitment system led by hospitals and insurance companies not multinational interpreting agencies, or ill-prepared small local players. Interpreters cannot be made in 40 hours and we can’t have newly trained interpreters learning at the cost of real patients’ safety. The pandemic showed us the importance of healthcare interpreting, let’s seize the opportunity to professionalize it.

When being politically correct hurts your rendition.

August 5, 2013 § 17 Comments

Dear Colleagues,

A few weeks ago I was on a plane from Atlanta to Chicago. We were ready to take off and I planned to prepare during the flight for an assignment I had that very same evening at my destination.  Then, as we were turning our telephones off to pull back from the gate, the voice of the pilot came over the speakers.  He informed us that there would be a delay because we had to wait for a last-minute passenger who had just booked a seat on our flight.  At that point I thought that we would probably be there for another ten or fifteen minutes so I turned on my phone and began to answer emails. About thirty minutes later the pilot informed us that it would take a little longer. By now some passengers started to question the rationale behind the delay; after all there were at least another ten flights from Atlanta to Chicago later that same day.  About fifteen minutes later the pilot announced that they were asking for volunteers to move from the front to the back of the plane because the last-minute passenger was in a wheelchair.  Some passengers volunteered and moved to the back, a couple of the airline’s ground crew members helped the passenger, who turned out to be an elderly woman, onto the aircraft and into her seat. We assumed we were ready to go.  Unfortunately, at this time the pilot announced that there was some bad weather over Indiana and our flight plan had been altered. The problem: because we had been sitting at the gate for more than an hour, we now did not have enough fuel to go through the new route we had been assigned, so the plane had to refill before take-off.  Re-fueling was going to take about thirty minutes so we deplaned. As I was exiting the plane, I overheard a couple of guys saying that although there were plenty of flights to Chicago, the delay was due to the fact that this elderly woman was covered under the Americans with Disabilities Act (ADA) and therefore, the airline had decided not to offend her by asking her to wait until the next plane where she would board before the rest of the passengers. The second person remarked: “it’s just that nowadays everything is decided based on its political correctness.”  I don’t know if these passengers were right or not, but that made me think of what we, as interpreters, face sometimes when somebody wants us to say, do, or omit something that should be said, omitted or done as part of the interpretation, just because it is not politically correct.

Some years ago, but already within this era of political correctness, I was working as a court interpreter in a criminal trial where a person was accused of murder. It involved Hispanic gang members and that meant that it involved plenty of nicknames.  As the trial progressed, and many witnesses testified before the jury, it became clear that a key player in this murder was a gang member known as “el negro” (the black one) who apparently had witnessed the killing.  All witnesses, one after another, kept referring, in Spanish, to “el negro” as a key witness for the prosecution.

Eventually, there was a recess for I don’t remember what reason, and during the break, one of the prosecuting attorneys, an Anglo woman who was not the lead prosecutor and did not speak Spanish, approached me and told me: “You know, I’d much appreciate it if you stopped referring to Mr. Sánchez (I made up the name for this posting) as <el negro> It would be better if you refer to him as the <African-American> so please do it. I don’t want to offend anybody” I looked at her in amazement. In all my years as an interpreter nobody had asked me to do such a bizarre thing before.  I explained to her that nicknames, just like proper names stay in their original language.  I even explained that it is common for Hispanics to give a nickname to an individual as an expression of sarcasm, thus, the tallest guy could be nicknamed “chiquilín” the fattest man could be called “el flaco” and so on. I even told her that as a prosecutor she should be concerned about the identity issue, and that the correct nickname could be the difference between acquittal and conviction. She understood that I was not to honor her request, but did not like my answer, and so we continued with the trial after the break.

After other two or three witnesses, the bailiff called the name of another witness who entered the courtroom. This was a tall young white man. He was ushered to the witness stand, placed under oath, and asked to have a seat. Next, the prosecutor asked the first question: “Can you please tell us your name and spell your last name for the record.” The witness complied and I interpreted for the jury. Second, the attorney asked: “Sir, do you go by any other name?” The white young man answered in Spanish: “Si, me dicen el negro” (Yes, they call me “el negro”) I interpreted for the jury as I looked at the prosecutor who had requested I be politically correct and refer to the witness nicknamed “el negro” as the “African-American” and with an inner sense of satisfaction I looked at him and then back at her as if telling her: “you see, I did the right thing. Referring to this man as the “African-American” would have been ridiculous and odd.”  From that day I always question political correctness in those situations. My belief is that when someone wants to have a politically correct event, they should talk to the speaker, not to the interpreter; after all, we interpret what others say. We are not the ones who are speaking.  I would like to hear your comments regarding this issue. Please feel free to share any stories you may have that are similar to the one I just told you about.

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