Medical interpreters in short supply as health coverage grows
This article orignally appeared in the San Francisco Chronicle
Vietnamese interpreter Siu Williams and her fellow linguists are in such demand at Stanford Hospital that the sprawling campus has become like a trampoline and the hallways like treadmills.
“We bounce from one building to another building. Sometimes at the main hospital, we run,” said Williams, describing a typical day helping a blur of limited-English-speaking patients at the medical center communicate with health care providers. “At the end of the shift, I don’t need to go to the fitness club.”
When it comes to one of California’s most overlooked medical needs Williams is essential — and perilously rare.
She is among only 738 certified medical interpreters in the state just when federal health reform has extended coverage to 1.7 million Californians with limited English skills. Overall, 6.8 million Californians — 20 percent of the state’s potential patient population — aren’t proficient in English, according to the 2010 census.
Both federal and state law make access to a medical interpreter the right of all patients who need one, just like the courts must offer an interpreter to a witness or defendant in need. But unlike the uniform qualifications required to become a court interpreter, California law doesn’t say how qualified medical interpreters must be.
Certified vs. noncertified
Certified interpreters are the only medical linguists in California who have been tested by one of two independent bodies, the Certification Commission for Healthcare Interpreters or the National Board of Certification for Medical Interpreters. The shortage of certified interpreters has health care providers scrambling to use creative methods to comply with language access laws. They include the routine use of noncertified interpreters, which critics say amounts to using linguistic second stringers.
“This is one of the most important medical issues confronting California,” said John Pérez, a member of the UC Board of Regents who as California Assembly speaker proposed laws in 2013 and 2014 that would have bolstered the number of certified interpreters. “We have so many different languages spoken, and we don’t have the medical interpreting depth to address the need.”
And when separating certified interpreters by language usage, the disparities become startling.
Spanish speakers with limited English number 4.6 million in California, according to the census, and they are relatively fortunate to share 594 certified medical interpreters.
Vietnamese speakers with limited English skills, numbering 282,000 statewide, must make do with nine certified interpreters, including Williams.
For the Philippine Tagalog-speaking community, which includes about 228,000 limited English speakers, there is only one certified medical interpreter in the state. And there is only one for the Hmong-speaking community which includes 35,000 with limited English skills.
A 2010 report by the UC Berkeley School of Public Health and National Health Law Program examined 1,373 malpractice claims and found 35 cases in which death, dismemberment, brain damage, and other cases of severe medical harm were traced to inadequate medical interpreting.
The cases, compiled over four years, involved multiple languages, and patients of all ages.
In one case, involving a 9-year-old girl, the report found that emergency room doctors neither “provided competent oral interpreters, nor translation of important written” consent forms in prescribing the drug Reglan for what was diagnosed as stomach flu.
The drug is not recommended for pediatric use, but the girl’s Vietnamese-speaking parents were not informed of the risks in their native language. The doctors also used the child herself and her 16-year-old brother as ad-hoc interpreters, relying on them to inform the parents about side effects that would require them to immediately return to the hospital.
The girl died from a heart attack brought on by an adverse reaction to the drug, the report said.
Report editor Mara Youdelman, senior attorney at the National Health Law Program and a commissioner on the interpreters certification commission, said she believes such cases are “vastly underreported.”
Poor, immigrants hit hard
Many of those impacted by poor interpreting are undocumented immigrants who do not want to call attention to themselves, or legal immigrants unaware of their language rights at the hospital, she said. Or, they are low-income patients overwhelmed with navigating the health care safety net.
“It’s an uphill battle to identify these cases,” Youdelman said.
Hanh Nguyen, 65, a kidney patient, and her son Xuong Luu, 35, who often interprets for her during treatment, have experienced the consequences of having too few medical interpreters.
Nguyen recently visited Stanford Hospital for a kidney transplant consultation and received assistance from Williams, the certified Vietnamese interpreter.
But at the DaVita dialysis clinic in San Jose, where Nguyen has received treatment three times a week for nearly a year, there is a drop off in interpreting quality and access, Nguyen’s son said.
Frequent communication between caregivers and patients is critical during dialysis, a life-sustaining treatment that is especially exhausting for older patients like Nguyen.
Nguyen must provide caregivers detailed feedback on how she feels during the hours-long sessions in order for them to determine how often she needs treatment and if her body is reacting safely to the drugs involved. And caregivers must be able to communicate clearly with Nguyen about what she must do between sessions, including adhering to strict dietary rules.
‘I feel neglected’
“They set me up and wander off somewhere else, and there are so many times where I am not feeling well,” Nguyen said in Vietnamese that was translated by her son. “I feel neglected.”
DaVita dietitian Linda Huie said she used a Vietnamese-speaking administrative assistant from a nearby center to interpret Nguyen’s initial consultation and said she recalled using a noncertified telephone interpreter “a handful of times.”
Justin Forbis, a spokesman for DaVita, the largest dialysis chain in the country, confirmed Huie’s account. He said Nguyen, who has hepatitis, must be placed in an isolation area, and regularly using a speakerphone there for telephone interpreting “could cause echos.”
“It is a requirement that we are able to speak to patients in a language that they understand,” Forbis said in an e-mail. “How the translation is provided is not regulated, however, so that means translation can come from teammates who speak the language, family members of the patients or, if those options aren’t available, phone translation.”
With so few certified interpreters, health providers routinely turn to noncertified interpreters, tested and trained in weeks, often with no previous medical background.
The largest such provider, CyraCom of Tucson, is at the other end of the Blue Phone, a language service standby at California hospitals, and the service DaVita used occasionally for Nguyen. The patented landline features two blue-colored receivers for doctor and patient, and a company interpreter on the line.
“They are not certified. They are qualified,” CyraCom spokeswoman Regina Little said in defense of the company’s linguists. “What that means is they have three weeks, or 120 hours of personal training.”
Leon Vang, the state’s only certified Hmong interpreter, said he could not imagine meeting the linguistic, cultural and medical complexities of his job with such modest training. He has seven years experience in the field, and uses videoconferencing to interpret for patients when he can’t be where they are.
“In mental health, there is no word in Hmong for bi-polar. I have to explain the entire medical concept,” said Vang, 34, who works in Orange County for Language Access Network, which requires its interpreters to be certified.
“If it’s a car accident with 10 ER providers around the patient, all speaking at once, and the patient is too injured to speak, I’ve had to interpret instructions from the doctor for the patient to wiggle his finger if he can hear them.”
Vang said when he leaves his shift, there are still cases left to take. “Obviously, I can’t take them all, but I do all I can,” he said.
Facing such demand, some larger providers have tried innovative methods to fill the void.
Attempts to fill the void
Kaiser Permanente, for example, trains their bilingual medical professionals to act as interpreters during intake and other situations. Kaiser does not require these employees to be certified, but does require them to pass an internal exam.
Kaiser has also established “module” primary care and OBGYN clinics in which everyone, from the receptionist to the nurse to the physician, is bilingual and has taken the Kaiser test in a target language.
The company, nevertheless, keeps a cadre of independently certified interpreters in-house for its most serious medical cases.
Don Schinske, executive director of the California Healthcare Interpreting Association, a nonprofit that has lobbied for uniform certification in medical interpreting, applauded Kaiser’s efforts, but pointed out they still fall short of a uniform standard.
“It’s a mishmash out there, no question,” Schinske said. “A lot of health systems race to find the lowest possible cost solution.”
Certified interpreters told stories of having to clarify misunderstandings at various hospitals that originated from a patient’s interaction with a noncertified interpreter. If the medical stakes weren’t so high, some could make for comedy skits.
Williams, who interprets at Stanford under a freelance contract, said one phone interpreter once told a doctor that an elderly patient was suffering from ongoing “hand pains.” The woman was actually complaining of head pains. Another certified Vietnamese interpreter said a noncertified counterpart told a woman to experiment with a “nipple” when her newborn cried. The doctor actually had said pacifier.
Pérez, who has termed out of the Legislature, pushed through bills in 2013 and September 2014 that would have tapped health reform funds to certify interpreters who worked with Medi-Cal patients, and increase the numbers of interpreters statewide.
Governor vetoes funds
After fronting $200,000 in startup funds, the state ultimately would have received $270 million in Affordable Care Act funds to implement the certification program. Interpreters would have been required to pass a national certifying exam and a state test.
Gov. Jerry Brown vetoed the bills both times, saying the state already had its hands full with the larger implementation of health reform.
Pérez’s successor as Assembly speaker, Toni Atkins, D-San Diego, introduced more modest legislation in February that would require the state to seek federal funds to establish a uniform certification for interpreters.
The goal is to provide “reliable access to language interpretation for Medi-Cal beneficiaries who are limited English proficient,” Atkins’ bill says.
Pérez said that with Atkins’ bill, California would come out ahead.
“Besides the human costs of poor medical outcomes … there is a financial cost every time poor interpreting creates over-treatment,” he said. “Quality health care often gets lost in translation.”