WORCESTER- But for Marisol Arzeno-McGill’s linguistic skills, Santos A. Delgado would probably not have understood a word Assistant District Attorney Timothy M. Farrell was saying as the prosecutor explained his predicament to the judge.
He could not go forward with the scheduled hearing on Mr. Delgado’s motion to suppressmotion to suppress n. a motion (usually on behalf of a criminal defendant) to disallow certain evidence in an up-coming trial. Example: a confession which the defendant alleges was signed while he was drunk or without the reading of his Miranda rights.
….. Click the link for more information. the drug evidence against him because a key police witness had inexplicably not shown up to testify, Mr. Farrell told Judge James R. Lemire during a recent Worcester Superior Court session.
Held on $50,000 cash bail and facing a minimum mandatory 10-year prison sentence if convicted, the 22-year-old defendant listened intently as Ms. Arzeno-McGill, the Spanish-speaking interpreter at his side, communicated Mr. Farrell’s comments in Mr. Delgado’s native tongue.
Citing the court’s heavy docket and the likelihood that Mr. Delgado’s case would not be reached anyway, Judge Lemire continued the matter to another date. Mr. Delgado, a Jamaica Plain man also known as James Pena-Guerro, was returned to the lockupSee hang and abend.
Ms. Arzeno-McGill rushed off to another courtroom where her services were needed.
It was one of more than a dozen times Ms. Arzeno-McGill would be called upon this particular day to assist Spanish-speaking parties to cases in the five court departments that make up the Worcester Trial Court at 225 Main St. She and Larry Smith
Larry W. Smith (born 1951 in Hudson, Quebec) is a Canadian athlete and businessperson. He is currently the president of the Montreal Alouettes. , the other Spanish-speaking interpreter assigned permanently to the Worcester courthouse, are among 28 certified language interpreters employed full time by the state Office of Court Interpreter Services.
They include 19 Spanish interpreters, five Portuguese and one each who speak Vietnamese, Khmer, Cape Verdean and Haitian Creole Haitian Creole
n.
A language spoken by the majority of Haitians, based on French and various African languages.
Noun 1. Haitian Creole , according to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. Gaye Gentes gen·tes
n.
Plural of gens. , manager of the office. Court interpreters are required to pass a test and undergo a tightly structured training program before becoming certified.
Ms. Gentes also uses the services of 188 per diem per diem adj. or n. Latin for “per day,” it is short for payment of daily expenses and/or fees of an employee or an agent. interpreters, independent contractors who speak both English and a combined total of 51 other languages, from Albanian to Vietnamese. A recent recruitment program added court interpreters in Hmong and several African languages African languages, geographic rather than linguistic classification of languages spoken on the African continent. Historically the term refers to the languages of sub-Saharan Africa, which do not belong to a single family, but are divided among several distinct , including Twi, Ibo, Dinka and Luganda, Ms. Gentes said.
State law mandates that non-English speaking and deaf or hearing-impaired parties or witnesses in legal proceedings All actions that are authorized or sanctioned by law and instituted in a court or a tribunal for the acquisition of rights or the enforcement of remedies. be provided the aid of an interpreter. In fiscal year 2008, the Office of Court Interpreter Services filled 96,737 requests for interpreters in about 140 courts statewide, up from 56,000 seven years earlier, according to Ms. Gentes.
The annual cost to the taxpayers is $1.5 million for the staff interpreters and $4.4 million for the per diems, according to Trial Court spokeswoman Joan Kenney.
Court interpreters have their own code of professional conduct covering such topics as accuracy, impartiality, confidentiality, proficiency, demeanor, case preparation, conflicts of interest, public comments and legal advice.
The code describes the role of the interpreter as that of a “communication facilitator” who helps protect the rights of non-English speaking people involved in the legal process.
Mr. Smith, a Michigan native, said he learned Spanish while attending Western Michigan University Western Michigan University, at Kalamazoo, Mich.; coeducational; founded in 1903 as Western State Normal School, became accredited in 1927 as a college, gained university status in 1957. and later became more fluent in the language while working in the tourism industry in California. A graduate of the University of Michigan Law School The University of Michigan Law School, located in Ann Arbor, is a unit of the University of Michigan. The Law School, founded in 1859, currently has an enrollment of approximately 1,200 students, most of whom are earning the degrees of Juris Doctor (J.D.) or Master of Laws (LLM). and a member of the California bar, Mr. Smith moved to North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures
Area, 52,586 sq mi (136,198 sq km). Pop. in the late 1990s, started doing
court interpreting part time there, then received his certification as a court interpreter.
He and his wife moved to Worcester “sight unseen” in 2001, after he accepted his current job here.
“I love it,” Mr. Smith said of his work.
“For me, it’s a natural. It’s a coming together of law and Spanish after all these years. It brings together what I like about both. I’m a people person. I think you have to be in this business. And I love language,” he said.
There’s more to court interpreting than the ability to speak English and another language, according to Mr. Smith.
There are two basic modes of court interpretation, simultaneous and consecutive, and each has its own set of challenges, said Mr. Smith. The former requires the interpreter to speak contemporaneously with the person whose statements are to be heard. In the latter, the interpreter allows the speaker to finish his or her statement before attempting its interpretation.
Mr. Smith likened simultaneous interpretation to a splitting of the brain’s lobes that enables the interpreter to listen and speak at the same time.
“You’ve got to develop that ability of incoming and outgoing, in two different languages. And it’s in real time,” he said “It takes practice. It doesn’t come naturally. You just have to learn.”
Surprisingly, Mr. Smith said he and most of his colleagues find consecutive interpreting more difficult because it is so taxing on the memory.
Spanish is Ms. Arzeno-McGill’s first language. Born in San Juan, Puerto Rico San Juan (IPA: [saŋ hwaŋ]) (from the Spanish San Juan Bautista, “Saint John the Baptist”) is the capital and largest municipality on Puerto Rico. , she studied English in grade school.
A former bilingual elementary school elementary school: see school. teacher with a master’s degree in communications from Boston University, Ms. Arzeno-McGill worked as an account executive in
public relations public relations, activities and policies used to create public interest in a person, idea, product, institution, or business establishment. By its nature, public relations is devoted to serving particular interests by presenting them to the public in the most
before becoming a medical interpreter at Brigham and Women’s Hospital Brigham and Women’s Hospital (BWH) is a hospital in the Longwood Area of the Boston, Massachusetts neighborhood of Mission Hill. With Massachusetts General Hospital, it is one of the two founding members of Partners HealthCare. in Boston, a position she held four years.
She has been a court interpreter for 20 years, the last seven on a full-time basis, and said she has enjoyed every minute of it.
“I think I have the best job in the world,” she said.
Being assigned to five different courts – superior, district, juvenile, probate and housing – exposes her to a wide range of legal issues and keeps the job interesting, according to Ms. Arzeno-McGill.
“Each court has its own style, its own way of doing things. I never know when I walk through the door what’s waiting for me that day,” she said. Ms. Gentes said the system developed by Ms. Arzeno-McGill and Mr. Smith to cover the Worcester Trial Court is used as a model for court interpreters statewide.
“What I enjoy the most is that what I do, it’s an instrument to the limited-English speaker to have a voice and have full understanding, participation and access to our legal system,” Ms. Arzeno-McGill said.
Contact Gary Murray by e-mail at gmurray@telegram.com.
ART: PHOTO
CUTLINE: Spanish-speaking court interpreters Larry Smith and Marisol Arzeno-McGill are assigned permanently to the Worcester Trial Court. They are among 28 certified language interpreters employed full time by the state Office of Court Interpreter Services.
Background. About 19 million people in the United States are limited in English proficiency, but little is known about the frequency and potential clinical consequences of errors in medical interpretation.
Objectives. To determine the frequency, categories, and potential clinical consequences of errors in medical interpretation.
Methods. During a 7-month period, we audiotaped and transcribed pediatric encounters in a hospital outpatient clinic in which a Spanish interpreter was used. For each transcript, we categorized each error in medical interpretation and determined whether errors had a potential clinical consequence.
Results. Thirteen encounters yielded 474 pages of transcripts. Professional hospital interpreters were present for 6 encounters; ad hoc interpreters included nurses, social workers, and an 11-year-old sibling. Three hundred ninety-six interpreter errors were noted, with a mean of 31 per encounter. The most common error type was omission (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). Sixty-three percent of all errors had potential clinical consequences, with a mean of 19 per encounter. Errors committed by ad hoc interpreters were significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters (77% vs 53%). Errors of clinical consequence included: 1) omitting questions about drug allergies; 2) omitting instructions on the dose, frequency, and duration of antibiotics and rehydration fluids; 3) adding that hydrocortisone cream must be applied to the entire body, instead of only to facial rash; 4) instructing a mother not to answer personal questions; 5) omitting that a child was already swabbed for a stool culture; and 6) instructing a mother to put amoxicillin in both ears for treatment of otitis media.
Conclusions. Errors in medical interpretation are common, averaging 31 per clinical encounter, and omissions are the most frequent type. Most errors have potential clinical consequences, and those committed by ad hoc interpreters are significantly more likely to have potential clinical consequences than those committed by hospital interpreters. Because errors by ad hoc interpreters are more likely to have potential clinical consequences, third-party reimbursement for trained interpreter services should be considered for patients with limited English proficiency.
Key Words: language • interpreters • medical errors • children • pediatrics • Hispanic Americans • quality
Abbreviations: LEP, limited in English proficiency • SD, standard deviation
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METHODS |
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 TOPABSTRACTINTRODUCTION METHODS RESULTSDISCUSSIONREFERENCES |
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We audiotaped pediatric encounters in which a Spanish interpreter was used in the pediatric outpatient clinic of an urban Massachusetts hospital over a 7-month period. All study parents had identified themselves as LEP. A bilingual research assistant was present during the encounter only to record the interaction, and did not act as an interpreter, nor take part in subsequent production of transcripts or data analysis. A bilingual verbatim transcript was prepared from the audiotape of each encounter by a professional transcriptionist fluent in both English and Spanish. To ensure accuracy and reliability of the transcripts, each transcript was reviewed 3 times for errors, once by a bilingual physician whose first language is English (G.F.), a second time by a bilingual sociologist whose first language is English (M.B.L.), and a third time by a bilingual physician whose first language is Spanish (M.A.).
The encounters analyzed for this study represent all pediatric visits with Spanish interpreters that occurred in a larger study of patient-physician communication, which consisted of a convenience sample of 153 audiotaped visits in the pediatric outpatient clinics of an urban Massachusetts hospital. Of the 153 participants in this larger study, 110 of the children and their families were Latino. Among these 110 Latino participants, there were 74 mothers/adult caregivers who were LEP, for which 38 visits occurred in Spanish with Spanish-speaking clinicians, 13 visits included a Spanish interpreter, and 25 occurred in English without an interpreter. Although this larger study used a convenience sample, the sample was obtained to reflect a reasonable spectrum of outpatient pediatric visits experienced by Latino families, and has no obvious selection biases other than respondent refusal, which was rare (only 2 potential subjects refused to participate). Participants from the larger study were sampled to capture visits from the full range of daily office hours and all 5 clinic days (Monday-Friday) during the work week. Pediatric encounters included walk-in, sick, and routine health care maintenance visits at the pediatric primary care clinic, and initial and follow-up visits at the outpatient lead and failure-to-thrive clinics. Both pediatricians and pediatric nurse practitioners provided care to study patients, and patient care was in no way altered by the study, except for the presence of the research assistant and tape recorder. The patients and their families, clinicians, and interpreters were told only that this was a study of patient-physician communication, and they were not aware that errors of medical interpretation would be analyzed.
Personnel who provided medical interpretation were classified as: 1) hospital interpreters, professional interpreters (ie, those receiving financial compensation) employed by the study hospital’s department of interpreter services; and 2) ad hoc interpreters, who could include family members, friends, nonclinical hospital employees, strangers from waiting rooms, and hospital clinical staff (including nurses and social workers) who had received no formal medical interpreter training or screening. During the period when the study was conducted, all Spanish hospital interpreters who had been hired had undergone some level of screening and evaluation for language proficiency in Spanish and English. There was, however, no ongoing training or formal performance evaluation in the hospital for interpreters. Low-intensity, voluntary formal interpreter training was sporadically available at various community sites, but it was not known what proportion of interpreters took advantage of these voluntary community opportunities.
For each audiotaped encounter, analysis consisted of identification of the frequency and categories of interpreter errors. An “interpreter error” was defined as any misinterpretation of an utterance that occurred in the clinical encounter, including those committed by the designated medical interpreter, as well as those made by health care providers (such as when a physician with limited Spanish proficiency made errors in Spanish while talking to the mother after the designated interpreter had departed). Errors by health care providers were classified as interpreter errors because the study focus was on errors of interpretation made by any staff member acting as a medical interpreter during a clinical encounter, and we found that certain providers often would attempt to interpret when the designated medical interpreter departed or was temporarily unavailable.
Five categories were used to classify interpreter errors, based on 4 categories used in previous work,10,11 supplemented by an additional category (false fluency). These categories are as follows:
Omission: The interpreter did not interpret a word/phrase uttered by the clinician, parent, or child.
Addition: The interpreter added a word/phrase to the interpretation that was not uttered by the clinician, parent, or child.
Substitution: The interpreter substituted a word/phrase for a different word/phrase uttered by the clinician, parent, or child.
Editorialization: The interpreter provided his or her own personal views as the interpretation of a word/phrase uttered by the clinician, parent, or child.
False Fluency: The interpreter used an incorrect word/phrase, or word/phrase that does not exist in that particular language.
In addition to being classified into 1 of these 5 categories, an interpreter error was also considered to have potential clinical consequences if it altered or potentially altered 1 or more of the following: 1) the history of present illness; 2) the past medical history; 3) diagnostic or therapeutic interventions; 4) parental understanding of the child’s medical condition; or 5) plans for future medical visits (including follow-up visits and specialty referrals).
Medical jargon, idiomatic expressions, and contextual clarifications may occasionally require medical interpreters to not interpret a phrase word-for-word. Thus, any deviations from word-for-word interpretation in transcripts that were attributable to jargon, idioms, or contextual clarifications were not classified as interpreter errors. Because medical interpreters may also act as a cultural broker or advocate, any utterances that could be interpreted as cultural explanations or patient or family advocacy were not classified as interpreter errors. A separate analysis of the relationship of the number of verbal exchanges, the interlocutor, and the quality of the interpretation will be reported elsewhere in a separate paper.
The validity of the analytic method for identification and classification of interpreter errors was assessed as follows: 2 transcripts (cases 26 and 153) were first subjected to preliminary error analysis using simple definitions of each error type and category. The 2 transcripts were scored by 3 observers, a bilingual physician whose first language is English (G.F.) and 2 bilingual physicians (M.A. and L.M.) whose first language is Spanish. To avoid the introduction of bias, the latter 2 observers were blinded to the study goals and hypotheses. Each of the observers was assessed as being highly fluent in their second language based on years of experience providing primary care to Spanish-speaking patients in a Pediatric Latino Clinic (G.F.), 7 years as a research associate on studies of English-speaking populations in the United States (M.A.), and years of teaching high school to English-speaking students in the Massachusetts school system (L.M.). Interobserver variability for the 3 observers was assessed using agreement matrices and by calculating the percentage of agreement in 2 separate analyses, 1 for overall interpreter errors, and the second only for errors of potential clinical consequence. The Kappa Index was also determined for errors of clinical consequence. It was not possible to derive a Kappa Index for overall errors, as transcripts could not be accurately scored for 1 of the 4 cells (cell d): when neither observer identified an error, there was no reliable way to determine whether one should count by words, phrases, transcript lines, or utterances.
The preliminary error analysis of the 2 test transcripts revealed a mean percentage of agreement (± standard deviation [SD]) among the 3 observers on the overall errors of 60% ± 19, with a range of 31% to 82%. Disagreements were primarily attributable to either overlooked errors or unintended differences in the line numbering of the transcripts analyzed by different observers. After line numbering corrections, refinements, and meeting for consensus purposes, there was complete agreement among the 3 observers on the number and type of overall interpreter errors. The mean percentage of agreement (± SD) among the 3 observers on errors of potential clinical consequence in the preliminary analysis was 83% ± 12, with a range of 72% to 97%. The mean 
(± SD) for errors of potential clinical consequence in the preliminary analysis was 0.57 ± 0.3 (considered a moderate strength of agreement by the guidelines of Landis and Koch12), with a range of 0.21 to 0.97 (from fair to almost perfect agreement by the Landis and Koch guidelines12). Because the mean percentage of agreement and were considered unacceptably low, the error categories and types were further refined. After refinement, there was mean agreement of 99% ± 1.7 (range: 97%–100%) and a mean of 0.99 ± 0.03 (range: 0.94–1.0 [almost perfect by the Landis and Koch guidelines12 for both the mean and range]) regarding interpreter errors of potential clinical consequence on the 2 test transcripts. The remaining 11 transcripts were analyzed by the first author, using the refined error categories, types, and analytic approaches.
To analyze the statistical significance of differences between hospital and ad hoc interpreters in the proportion of errors made, the Yates-corrected 
2 test was used, with P < .05 considered statistically significant.
Institutional review board approval was obtained from the participating institution to conduct this study, and written informed consent was obtained from each participating parent.
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RESULTS |
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| TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Thirteen clinical encounters with Spanish interpreters present were audiotaped, yielding 6 hours of audiotapes, 474 pages of transcripts, and 49 513 words that were exchanged. Hospital interpreters were present in 6 of 13 encounters; in the remaining 7 encounters, the ad hoc interpreters included a nurse for 3 encounters, a social worker for 3 encounters, and an 11-year-old sibling for 1 encounter. The number of words uttered per encounter averaged 3781, and there was no statistically significant difference in the mean number of words uttered per encounter by interpreter type (mean words uttered = 3919 when hospital interpreters were present vs 3663 when ad hoc interpreters were present, with P > .5 by the 2-tailed Student t test). The visit type, clinician present, patient age, and number of interpreter errors in each clinical encounter are summarized in Table 1.
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There were 396 interpreter errors noted in the 13 clinical encounters (Table 2). The mean number (± standard error) of interpreter errors per clinical encounter was 30.5 ± 3.6, with a range of 10 to 60. There was no statistically significant difference between hospital and ad hoc interpreters in the mean number of errors committed per clinical encounter.
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The proportions of interpreter errors by category were: omission, 52%; false fluency, 16%; substitution, 13%; editorialization, 10%; and addition, 8%. There were no statistically significant differences between hospital and ad hoc interpreters in the proportion of errors by specific category (Table 2), except for false fluency errors, which occurred more often during encounters with hospital than ad hoc interpreters (22% vs 9%, P = .001). Additional analysis of false fluency errors occurring in encounters with hospital interpreters revealed that health care providers made 76% of the false fluency errors, and 58% of these errors occurred while the interpreter was out of the room or on the phone, whereas the remaining 42% of errors were made by the provider without any correction by the interpreter. Health care providers were >11 times more likely (relative risk: 11.4; 95% confidence interval: 1.7–76.2) to make false fluency errors when a hospital interpreter was involved, committing 76% of the false fluency errors with trained interpreters, compared with only 7% of false fluency errors when untrained interpreters were involved (P < .001). Nevertheless, health care providers committed only 
10% of all errors observed in this study. About three quarters (73%) of the false fluency errors committed by hospital interpreters involved medical terminology, including not knowing the correct Spanish words for “level,” “results,” and “medicine,” and using the Puerto Rican colloquialism for mumps, which could not be understood by a Central American mother.
There were 250 errors (63% of all errors) that had potential clinical consequences (Table 2). The mean number (± standard error) of errors with potential clinical consequences per encounter was 19 ± 3.2, with a range of 5 to 49. Errors made by ad hoc interpreters were significantly more likely to have potential clinical consequences than those made by hospital interpreters, at 77% vs 53% (P < .0001). When an 11-year-old sibling was used as an interpreter, for example, 84% of the 58 errors she committed had potential clinical consequences, and when an untrained staff nurse interpreted, 90% of his 10 errors had potential clinical consequences. Indeed, the lowest proportion of errors of potential clinical consequence committed by an ad hoc interpreter was 62%.
Interpreter errors of potential clinical consequence included: 1) omitting questions about drug allergies; 2) omitting key information about the past medical history (a mother’s statement that her child had been hospitalized at birth for a renal infection); 3) omitting crucial information about the chief complaint and other important symptoms (Fig 1); 4) omitting instructions about antibiotic dose, frequency, and duration; 5) instructing a mother to give an antibiotic for 2 instead of 10 days (Fig 2); 6) erroneously adding that hydrocortisone cream must be applied to an infant’s entire body, instead of solely to a facial rash (Fig 3); 7) telling a mother to give soy formula to her infant, instead of a physician’s instructions to breastfeed only; 8) omitting instructions on the amount, frequency, and type of rehydration fluids for gastroenteritis; 9) editorializing to a mother that she should not answer personal questions asked by her physician about sexually transmitted diseases and drug use; 10) explaining that an antibiotic was being prescribed for the flu; 11) omitting a mother’s clear explanation that a child had already been swabbed rectally for a stool culture; 12) omitting and substituting for a mother’s description of her child’s abnormal behavioral symptoms (Fig 4); and 13) instructing a mother to put oral amoxicillin into her child’s ears to treat otitis media (Fig 5).
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DISCUSSION |
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| TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Implications for Practice, Training, and Research
Errors in medical interpretation were found to be alarmingly common in this study, averaging 31 per clinical encounter. In addition, there was no statistically significant difference between hospital and ad hoc interpreters in the mean number of errors committed per encounter. Although errors made by hospital interpreters were significantly less likely to be of potential clinical consequence than those made by ad hoc interpreters, over half of hospital interpreter errors had potential clinical consequences. These findings support the conclusion that most hospital interpreters do not receive adequate training at their institution.13 Fewer than one fourth of hospitals nationwide provide any training for medical interpreters.13 Only 14% of US hospitals provide training for volunteer interpreters, and in half of these hospitals, the training programs are not mandatory.13 Even when hospitals provide training to medical interpreters, the training may be limited to short orientation sessions or shadowing more seasoned interpreters.13 Our study findings and these national data suggest that additional research and policy work is needed to determine what type of medical interpreter training is most effective in reducing interpreter errors. Specific issues that need to be addressed include whether training of medical interpreters should be mandatory, and which training approaches are most effective in eliminating common errors of potential clinical consequence and in improving accuracy and understanding medical terminology.
The categories of interpreter errors noted in this study indicate areas where more training is needed for medical interpreters. Omissions by far were the most common type of interpreter error, accounting for more than half of all errors. This finding suggests that a principal focus of interpreter training should be the faithful transmission of each and every utterance by clinicians, patients, and patients’ families. Simultaneous remote or on-site interpretation (as is done in the United Nations) has the potential to increase the number of utterances and reduce the number of errors,11 but concerns can be raised about the costs of training and implementation, and difficulties with acceptance by interpreters. Most false fluency errors committed by hospital interpreters (73%) involved medical terminology. This finding indicates that medical interpreter training should include a detailed review of medical terms, with attention to linguistic issues such as variation among cultural subsets of a single linguistic group. In addition, periodic performance evaluation, including monitoring of false fluency errors, may be an important means of quality improvement for medical interpreter services, indicating when additional training in medical terminology is needed.
The categories of interpreter errors noted in this study also indicate that more training is needed for clinicians in the use of medical interpreters. Clinicians commit most false fluency errors when the interpreter leaves the room or is taking a telephone call, and clinicians are 11 times more likely to make false fluency errors when hospital interpreters participate in the clinical encounter. These findings are consistent with studies that show that most hospital staff receive no training on working with interpreters,13 and most medical schools do not provide adequate instruction on linguistic and cultural issues in clinical care.14 For example, only 23% of US hospitals provide any training for their staff on the use of medical interpreters, and such training may consist of nothing more than policies and procedures for requesting interpreters.13 These studies and our results suggest that clinicians should receive skills training on the proper technique for working with medical interpreters, especially the risk of false fluency errors associated with clinicians with limited foreign language fluency. It is recommended that interchanges between such clinicians and patients (and their families) in a foreign language should be limited to when the medical interpreter is present and not distracted; if such interchanges occur without an interpreter, the clinician should consider repeating the interchange when the interpreter is available once again. The limited foreign language skills of a clinician can prove to be an asset, however, in that they can provide a means of verifying the quality of medical interpretation. For example, if the clinician hears a patient utter a word or phrase that was not translated by the interpreter, the clinician could bring this to the interpreter’s attention, and reemphasize the importance of faithful message transmission of each and every utterance. Conversely, because 42% of false fluency errors committed by clinicians occurred in the presence of an interpreter and went uncorrected, medical interpreters probably should be taught that it is reasonable and appropriate to correct clinician false fluency errors.
Medical Errors and Quality of Care
The study findings suggest that interpreter errors of potential clinical consequence could be a previously unrecognized possible root cause of medical errors. Although a recent Institute of Medicine report15 has drawn much attention to medical errors, errors of medical interpretation have not generally been included in the discussion of sources of medical errors. In this study, several documented common mechanisms for medical errors16,17 were observed among the interpreter errors of clinical consequence, including being told to use the wrong dose, frequency, duration or mode of administration of drugs and other therapeutic interventions, and omitting relevant clinical information on drug allergies and the past medical history. These findings suggest that for LEP patients, providing qualified, trained medical interpreters may be an important means of reducing medical errors and improving the quality of medical care. It also seems reasonable that as part of ongoing quality improvement efforts, medical institutions might consider periodically audiotaping or videotaping a representative subsample of clinical encounters where medical interpreters are used, to identify and monitor the overall number and categories of interpreter errors, the number of interpreter errors of potential clinical consequence, and medical errors that result from interpreter errors.
Study Limitations
Several limitations of this study should be noted, along with their implications for future research. Our sample size was relatively small; studies of errors of medical interpretation on a larger scale are needed. Only 1 observer analyzed 11 of the transcripts, so interpreter errors potentially may have been missed that could have been identified had multiple observers analyzed these transcripts. Single-observer transcript analysis was performed, however, only after refinements of the analytic technique were instituted as a result of multiple-observer testing and validation. It also seems unlikely that identification and inclusion of potentially overlooked errors would have substantially altered the principal study findings, but additional study of this interpreter error analytic tool is warranted. This study was limited to pediatric encounters; similar studies of adult LEP populations need to be conducted, particularly given that interpreter errors may have an even greater effect on adults because of their generally greater morbidity, comorbidity, and mortality. Similarly, we examined only outpatient encounters with Spanish interpreters, and studies are needed of interpreter errors and their clinical consequences in other languages and in the emergency department and inpatient settings. The hospital interpreters in this study had little to no training (although the study institution has subsequently initiated extensive training of their hospital interpreters). Replication of this study with hospital interpreters who have received extensive, consistent training compared with ad hoc interpreters may reveal more substantial differences in the number and categories of errors. Because LEP patients who need interpreters sometimes obtain medical care without interpreters, more research is needed comparing health care quality and satisfaction with care when LEP patients have trained hospital versus ad hoc versus no interpreters.
Policy Implications
The study finding that errors made by ad hoc interpreters are significantly more likely to have potential clinical consequences—coupled with a fairly extensive literature documenting that LEP patients tend to receive poorer quality medical care—would seem to constitute a strong argument for third-party reimbursement for trained medical interpreter services. Studies demonstrate a wide range of adverse effects that limited English proficiency can have on health and use of health services, including impaired health status,6,18 a lower likelihood of having a usual source of medical care,6,18,19 lower rates of mammograms, pap smears, and other preventive services,20,21 nonadherence with medications,7 a greater likelihood of a diagnosis of more severe psychopathology and leaving the hospital against medical advice among psychiatric patients,5,22 a lower likelihood of being given a follow-up appointment after an emergency department visit,23 an increased risk of intubation among children with asthma,24 a greater risk of hospital admissions among adults,25 an increased risk of drug complications,26 longer medical visits,27,28 higher resource utilization for diagnostic testing,28 lower patient satisfaction,18,29,30 and impaired patient understanding of diagnoses, medications, and follow-up.31,32 Latino parents consider the lack of interpreters and Spanish-speaking staff to be the greatest barriers to health care for their children, and 1 out of every 17 parents in one study reported not bringing their child in for needed medical care because of these language issues.4 On the other hand, recent studies indicate that trained professional medical interpreter services are associated with improvements in the delivery of health care services to LEP patients,33 but do not increase the mean duration of medical visits.34
The lack of trained hospital interpreters is not uncommon for the millions of LEP patients in the United States: one study found that no interpreter was used for 46% of LEP patients, and when an interpreter was used, 39% had no training.31 In a guidance memorandum, the Office of Civil Rights stated that the denial or delay of medical care for LEP patients because of language barriers constitutes a form of discrimination, and requires that any recipient of Medicaid or Medicare must provide adequate language assistance to LEP patients.35 A Presidential Executive Order also has been issued on improving access to services for persons with Limited English Proficiency.36 Concerns have been raised by medical associations about physicians having to cover the costs of complying with the Office of Civil Rights guidance memorandum,37 but the issue could be resolved by having third-party reimbursement for interpreter services. Although additional research on the cost effectiveness of third-party reimbursement for interpreter services would be helpful, mounting evidence suggests that additional studies of the issue may not be needed, including a successful $71 million lawsuit over a misinterpreted word in the emergency department,38 a report of a prolonged hospitalization for perforated appendicitis that might have been avoided if an interpreter had been called,39 and a report of children placed in state custody for mistaken child abuse because of a misinterpreted word and failure to initially call an interpreter.39 Legal liability and medical errors may be important factors in considering whether investment in third-party reimbursement of interpreter services is a reasonable strategy for assuring that LEP patients receive high-quality, equitable care.
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ACKNOWLEDGMENTS |
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This study was supported in part by the Generalist Physician Faculty Scholars Program (to Dr Flores), the Minority Medical Faculty Development Program (to Dr Flores), and the Opening Doors Program (to Dr Laws) of the Robert Wood Johnson Foundation. Dr Flores is a recipient of an Independent Scientist (K02) Award from the Agency for Healthcare Research and Quality.
We thank Howard Bauchner and Paul Wise for their comments on earlier manuscript drafts.
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FOOTNOTES |
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Received for publication Jan 29, 2002; Accepted May 24, 2002.
Reprint requests to (G.F.) Center for the Advancement of Urban Children, Department of Pediatrics, 8701 Watertown Plank Road, Milwaukee, WI 53226. E-mail: gflores@mail.mcw.edu
Presented in part at the annual meeting of the Pediatric Academic Societies; May 2, 1999; San Francisco, CA.
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REFERENCES |
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| TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Read all eLetters
Guillen Clarifies Comments on Spanish-Speaking Players
On the eve of an important series with the Tigers, Ozzie Guillen waved reporters into his office Tuesday morning. This would be a clarification session for Guillen, the always colorful, never dull White Sox manager.
After Chicago’s 4-1 victory over Oakland on Sunday, Guillen made inflammatory comments that Asian players were given preferential treatment because they routinely had interpreters. He wondered why Spanish-speaking players, many of whom struggle with English, were not provided with interpreters.
The White Sox, who lead the American League Central, were off Monday, so this was Guillen’s first opportunity to respond to angry criticism — the commissioner’s office was bombarded with calls from teams pointing out their programs designed to accommodate Latin players — including a statement from the White Sox saying that he was incorrect.
A number of players, including the Mets’ Carlos Beltran and Francisco Rodriguez, recalled their experiences early in their careers and agreed with Guillen.
Guillen explained himself in a 30-minute conversation that, in typical Guillen fashion, was a whirlwind of good points and contradictions.
He said the tempest began innocently enough when he was asked about Dayán Viciedo, the White Sox’ Cuban-born infielder.
Viciedo and his family defected from Cuba in 2008 by boat to Mexico. Once there he crossed into the United States and went to Miami. Baseball approved him as a free agent on Nov. 10, 2008, and a month later, Viciedo and the White Sox agreed to a four-year, $10 million contract.
Guillen’s point was how hard it was for Viciedo to come to the United States from Cuba and assimilate into a new culture.
“When a Japanese player is done playing major league baseball, they go back to their country and enjoy their life,” Guillen said. “When the Cuban player comes to this country, I don’t think they can go back to their country and see their families.”
Then Guillen expanded his comments, explaining how difficult it is for Spanish-speaking players without interpreters to communicate effectively.
Guillen made a similar complaint in 2004 about the Hispanic presence in baseball, the language divide and what he said was the apparent favoritism toward Asian players. He wondered whether greater accommodations could be made given the assistance that Asian players received.
He said: “I always make a joke that we bring a Japanese guy (as an interpreter) because (the Japanese players) don’t speak the language,” Guillen told USA Today. “Why don’t we bring a Latin guy to help? … I told Tony Bernazard (of the players’ union), we bring guys here who can’t speak the language and we don’t care. Then they tell us to learn the language.”
In the intervening years, baseball, largely in response to criticism and pressure from people like Guillen, has established programs to accommodate baseball’s phenomenal Spanish-speaking influx. Almost 30 percent of major league players are Latin American. Every major league team has multiple Latin players, and Hispanic players also make up a significant portion of minor league teams.
According to the commissioner’s office:
The basic agreement requires notices provided to major league players be translated and printed in Spanish and made available to all Spanish-speaking players.
All drug-testing program documents and presentations are in English and Spanish.
During the season, each club makes available an English as second language course — provided that at least one player on that club requests such a course.
At the minor league level, all documents provided to minor league players are translated into Spanish.
All club academies in the Dominican Republic provide educational programs in English to players under contract.
If a player wants to have an interpreter during pre- and postgame interviews, he can make arrangements with the team. In fact, there should be dedicated interpreters for every language. But on Tuesday, Guillen, in response to a direct question, said he did not want the league or the teams to supply interpreters. He wants the players to buckle down and learn English.
Freddy Garcia, a White Sox pitcher, said he didn’t have strong feelings one way or the other about Guillen’s comments.
“I’m one of the guys who doesn’t talk that much,” he said. “I don’t need a translator to say I feel bad and that I got my butt kicked. It’s no big deal for me.”
While he plays down the role, Guillen is the voice, the backbone and the conscience of Latin players. He is an advocate.
“I just want my people, these kids, to have a better life on the field, off the field,” he said. “That’s all we want. That’s what I was saying. I was saying I want to help Latino kids.”
The solution is that more reporters should learn Spanish and more Latin players, for their own sake, should take advantage of Major League Baseball’s bilingual programs.
The two sides will meet somewhere in the middle. Outside Ozzie Guillen’s office, of course.
UN Interpreters Make Sure Nothing Is Lost In Translation
Think you’re good at languages? Try applying for one of the toughest translation jobs on earth — working as a language specialist for the United Nations. RFE/RL takes a behind-the-scenes look at the world of interpreters.
By RFE/RL
UNITED NATIONS — When Libyan leader Muammar Qaddafi delivered his notorious 96-minute speech before the UN General Assembly last autumn, no one may have been more aware of each passing minute than his personal translator, Fouad Zlitni, whom he had brought along for the occasion.
Nearly three-quarters of the way into Qaddafi’s address, Zlitni collapsed, undone by the effort of translating the Libyan leader’s rambling, at times angry speech from Arabic into English for nearly 75 minutes straight.
Hossam Fahr, the Egyptian-born head of the UN’s interpretation service, says Qaddafi’s translator went far beyond the normal limits of what an interpreter can reasonably be expected to do.
“It was a very unusual situation, because every member state has the right to bring its own interpreter. [Qaddafi] had his own interpreters; they were already installed in the booths. So we let them do the work, and then unfortunately, one of them just collapsed a good 75 minutes into the statement,” Fahr said.
“I take my hat off to him — he did a very good job under the circumstances.”
The incident served to highlight the grueling nature of simultaneous interpretation, a profession which few ordinary people have occasion to observe.
But at the United Nations, which brings together 192 member states and a profusion of mother tongues in its day-to-day pursuit of international diplomacy, interpretation is at the very core of its operations.
The annual General Assembly — which every autumn brings together the entire UN membership for a massive two-week series of speeches and policy reviews — may represent the World Cup of professional interpretation.
But even on a day-to-day basis, the UN’s councils, committees, and publications produce enough work to keep its language staff of nearly 460 people busy on a full-time basis.
Barry Olsen, who heads the conference interpretation program at California’s highly respected Monterey Institute of International Studies — from which a number of UN translators have graduated — says UN language specialists are generally considered the best in the business.
“A translator or interpreter who works for the United Nations has reached what is very much one of the pinnacles of the profession. It is an organization that is respected and the linguistic work that goes on with the United Nations is of the highest order,” Olsen says.
Iron Nerves And A Sense Of Style
Although the official working languages at the United Nations are English and French, the UN has six official languages into which the bulk of its official documents and publications are automatically translated — English and French, plus Arabic, Chinese, Russian, and Spanish. (In instances where other languages are needed, the UN will hire freelance interpreters or country delegations will bring in their own translators.)
UN interpreters, most typically, translate from their acquired languages into their native tongue. With language like Chinese and Arabic — where accomplished translators are more difficult to find — interpreters will translate both into their native language as well as their adopted ones.
It’s an intense experience that can drain even the most accomplished interpreters — to avoid a Qaddafi-like marathon, in fact, the UN abides by a strict timetable in which interpreters work in teams of two, with one typically working no more than 20 minutes at a time before switching to his or her partner. (General Assembly speeches, moreover, are usually kept to 15 minutes or less.)
Mastering a language is only the start to being a good interpreter. In a UN guide for would-be language specialists, the job appears to be equal parts diplomat, rocket scientist, and traffic cop. “A good translator,” it reads, “knows techniques for coping with a huge variety of difficult situations, has iron nerves, does not panic, has a sense of style, and can keep up with a rapid speakers.”
Igor Shpiniov of the UN Training Section, Hossam Fahr, the chief of the UN Interpretation Service, and Stephen Sekel, the former chief of the UN English Translation Service.
Stiff Competition
Such people, it appears, are hard to find. Despite salaries that are among the highest in the profession — top-rank UN interpreters can earn $76,000 a year — the United Nations is suffering a severe shortage of qualified language personnel.
“We’re looking for people with good comprehension skills. Sometimes people who translate from French or English into Russian do not necessarily speak fluently in English or French,” says Igor Shpiniov, a Russian-born translator who runs the UN’s language training division.
“Sometimes, paradoxically, they can translate a text about atomic energy, but if you ask them to buy milk at a French supermarket, they’ll be at a loss.”
Competition for the jobs is stiff. Out of 1,800 applicants looking to work as Chinese interpreters last year, only 10 passed the UN examination. For Arabic, only two out of 400 made the cut.
Many UN language experts work as translators for the vast numbers of publications and documents that pass through the international body each year. But the most prestigious position is that of the simultaneous interpreters when language experts sit in soundproof booths and provide a running translation of often highly technical or politically charged speeches.
The Comma Affair
The profession was first developed during the Nuremberg trials of Nazi war criminals in 1946. Now both the General Assembly and Security Council have eight translation booths — one for each of the UN’s official languages, and two for alternate language translations. (According to UN rules, the media is barred from sitting in on live interpretation sessions.)
When working at important events like Security Council meetings, interpreters are often allowed to prepare with advance information about the proceedings, allowing them to familiarize themselves with the concepts and terminology of the debate. The agenda for the General Assembly is often planned months in advance, allowing the translation team ample time to estimate how many interpreters will be needed for scheduled talks.
Still, no amount of advance planning can completely protect interpreters from anxiety when the time has come for them to translate. Some studies have shown that during intense debates, interpreters often experience an increase in blood pressure and heart rate as they struggle to translate different terms, nuances, and arguments into smooth, comprehensible phrases.
Movies like “The Interpreter,” starring Nicole Kidman as a UN translator and filmed inside the United Nations compound, brought an aura of Hollywood glamour and intrigue to the role of interpreters. In reality, the job can be far more prosaic, although constant worries about involuntary bloopers and misinterpretations can keep tensions high.
In one instance, a firestorm was raised when a single comma was removed from the text of a UN resolution involving two unnamed former Soviet republics in the thick of a border dispute. One of the countries, angered by the omission, demanded it be replaced. But the UN translators, undaunted, said the comma had distorted the meaning of the text. Not everyone was happy, but in the end, the comma stayed out.
Mistakes And Applause
Interpretation head Fahr also recalls a mistake he made as an Arabic-English interpreter when the Egyptian diplomat Boutros Boutros-Ghali was sworn in as UN secretary-general in 1992.
“What comes out of my mouth is, ‘I congratulate you upon your election as secretary-general of the United States.’ And everybody in the General Assembly laughed,” Fahr said.
“So the president of the General Assembly asked the then-secretary-general, [Peru’s Javier] Perez de Cuellar why are they laughing, and he said ‘The English interpreter made a mistake.'”
In the end, Fahr says, he received a forgiving round of applause.
Stephen Sekel, former chief of the UN’s English translation service, says such mistakes are quite common and that UN staff only occasionally demand an interpreter be sanctioned for making a mistake. Overall, he says, the skill and professionalism of the UN translation team ensures any they remain an indispensible, behind-the-scenes asset — and that their errors will be few.
“We expect our language staff to bring a great deal of general knowledge to the job, a high level of education and a lot of intellectual curiosity,” Sekel said.
“They are expected to be continuous learners. They wouldn’t survive otherwise. Perhaps that explains why we don’t have too many examples of terrible mistakes that brought us to the brink of a major international crisis.”
| Frustrated crowd pleads for city interpreter rehire | |
| By: DAVID HENKE, dhenke@northfieldnews.com | |
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