Alfredo Lorente left Puerto Rico in 1988, and after graduating from Macalester College vowed not to use his Spanish to find work — he felt “like it was cheating.” But after years of living as a “bohemian” and bouncing from job to job, Lorente took the advice of a friend and looked into medical interpreting.
In a little more than a month, Lorente found himself on call to interpret in some of the Twin Cities’ largest hospitals after only four hours of training.
Non-English speakers put their health in the hands of interpreters every day around the Twin Cities. The only training many interpreters get, especially freelancers, is through the private, often tight-budgeted agencies that contract them. In many cases, the only requirement the interpreters have to meet is a written test after a one-day seminar. The state has no enforceable standards for interpreter training, and patients pay the price.
“There was no language test. They took it on faith that I spoke Spanish. … They took it on faith that I would behave in a professional fashion. I don’t know if there was a background check,” Lorente said about his first interpreting position.
MinnPost conducted dozens of interviews, and sent questionnaires to thousands of interpreters and nurses, receiving more than 500 responses. Many had little confidence in the medical interpreting industry. They said the criteria for selecting interpreters is insufficient, and that interpreters lack professionalism and often become emotionally involved with patients. Many don’t understand medical terms, lack formal training and are unfamiliar with standards of practice.
Some say, and studies confirm, that such problems put patient health at risk.
By law, health care providers that receive federal funding must provide language services to Limited English Proficiency (LEP) patients, but no enforced training requirements exist on either a state or federal level. An organization called the Interpreting Stakeholder Group (ISG) is working to change that, and some discussion is likely to begin in the upcoming legislative session.
The ISG is advocating stricter requirements for medical interpreters in Minnesota, and its work has led to recent changes in legislation. But with problems to iron out and a possible lobbying battle approaching, many Minnesota interpreters will continue to assist with sensitive medical work without checks and balances.
A first step
Before this year, no one knew how many medical interpreters worked in Minnesota.
“You could ask one person and they’d say 500,” said Michelle Chillstrom, manager of interpreter services at Hennepin County Medical Center (HCMC) and ISG chair. “Other people would say it could be as many as 5,000.”
In 2008, legislation passed that established a roster, and interpreters must now be registered through the Minnesota Department of Health (MDH) to be paid for their services. Based on that roster, an approximate figure on the number of interpreters working in Minnesota is now available: 3,100.
The legislation was championed by then-Rep. Cy Thao (DFL-St. Paul). Thao had the motivation and political support to fight for a state standard, and for him the roster was just a first step toward making certification mandatory for Minnesota interpreters.
The next step was going to be a registry with a universal certification standard. The plan would have to be created from scratch, as no national standard exists.
But when Thao chose not to run for re-election in 2010, the push to develop a statewide standard lost its momentum.
For interpreters who want fulltime jobs at hospitals or clinics, there is a monetary incentive to be certified, as they’re more likely to be hired.
“The training proved to be invaluable with me,” said Melissa Schroeck, who graduated from the University of Minnesota’s interpreting program and works at Children’s Hospital. “I think it got me the job at HCMC and definitely got me the job at Children’s.”
But HCMC and other hospitals and clinics must also hire outside interpreters through agencies on a case-by-case basis. Agencies normally pay all workers the same rate regardless of training or expertise.
“You can’t say, ‘I have X number of years of experience, I’m certified or I’ve worked here,'” Lorente said. “The agency says: ‘The rate is $20, like it or leave it.'”
Since the government reimburses providers for each interpreter encounter at at a maximum of $50 per hour, Thao was working to ensure that it gets what it pays for.
“If we’re going to pay you the same as an RN, we’re going to ask that you have credentials,” Thao said.
As it sits now, the MDH roster does not ensure that interpreters are competent; it just means they’ve paid the yearly $50 fee. Just as the luck of the draw can send a knowledgeable interpreter to a suffering patient, a lack of standards makes it possible to draw a wild card.
‘There really is a risk for the patient‘
The non-English speaking population in Minnesota is rising. The percentage of households speaking a language other than English at home rose from 8.5 percent in 2000 to 10.5 percent in 2010, according to U.S. Census data.
HCMC alone tended to more than 120,000 cases with non-English patients in 2010, Chillstrom said, and poor communication is risky.
“If [patients] have an interpreter who’s not qualified, what is the impact on their experience?” Chillstrom said. “What is the risk to that patient? What if they’re told that they have a problem with their liver instead of their kidney? If they’re not able to describe medical terminology, complex topics – there really is a risk for the patient.”
In a MinnPost questionnaire sent to interpreters on the MDH roster, 38 percent of the 224 respondents said that they felt their peers were not qualified to interpret in a life-or-death situation.
Patients with Limited English Proficiency (LEP) often have increased medication complications, poorer adherence to treatment and follow-up for chronic illnesses, and decreased comprehension of their diagnoses and treatment, according to a 2007 study published in the peer-reviewed journal Health Services Research.
According to a 2003 study conducted at the Boston Medical Center and led by Dr. Glenn Flores, common interpreter errors include:
•Omission, in which the interpreter leaves out an important piece of information.
•False fluency, in which the interpreter uses words or phrases that don’t exist in a specific language.
•Substitution, in which a word or phrase is replaced with another word or phrase of a different meaning.
•Editorialization, in which the interpreter’s opinion is added to the interpretation.
•Addition, in which a word or phrase is added by the interpreter.
Flores, who is now a professor of pediatrics at the University of Texas Southwestern Medical Center, said one of his subsequent studies showed that interpreters with at least 100 hours of training made fewer errors overall, and made fewer errors of consequence. “There are some that are advocating 40 hours of mandatory training, but we’re saying 100,” Flores said.
Interpreters or advocates?
Some say that language barriers aren’t even the largest problem. Many times interpreters do not know where to draw the line between being a voice and an advocate.
“Some of those boundaries start to blur, where the interpreter will say, ‘Oh sure, I’ll pick up this, or I’ll do that for you. I’ll pick up medications, or I’ll pick up this or that.’ Or start helping out in ways that isn’t their role as a medical interpreter,” said Jody Chrastek, coordinator for pain and palliative care for Children’s Hospital.
Chrastek has a delicate job. She goes into the homes of pregnant couples whose babies aren’t expected to survive, and to the houses of families that are trying to make life comfortable for their terminally ill children.
It’s not unusual for the meeting to stop because the interpreter is crying so hard.
She said it’s difficult for interpreters to avoid getting emotionally involved because often the people they’re interpreting for are in their own, close-knit community. Within some communities the issues of mental and sexual health are taboo, and without training, interpreters are unprepared to deal with these issues.
Chrastek recalled one case when the condition of a client’s daughter was getting worse, and she asked the mother whether, if her daughter’s heart were to stop, she would like Chrastek to pound on her chest. Without consulting the client, the interpreter said: “‘She will want that done. In our culture that’s what we do — she will want that done,'” Chrastek said.
Chrastek said it’s not acceptable for an interpreter to speak in place of the patient. She pressed him again to ask, but by that point, she questioned whether the interpreter delivered the question verbatim. “‘I don’t know what he said to her. He could have said, ‘If her heart stops, you want them to do something, right?'”
Interpreters are aware of the problems as well. Many interpreters who responded to the MinnPost questionnaire expressed concern about the quality of work in their industry. Dozens suggested that more training and stricter tests should be required.
One interpreter commented, “Too many people think that just because they speak two languages they can be interpreters. I have witnessed a lot of ‘interpreters’ who should be banned from doing it, because they do a less than mediocre job.”
Those surveyed were allowed to respond without providing their names, though many did. MinnPost emailed the surveys to interpreters listed on the MDH roster.
A Spanish interpreter who asked not to be named said she must repeatedly turn down jobs for specialties in which she has told her employer she has no experience.
“I have learned that this agency is not overseeing whether or not I am qualified to interpret medically, therefore I have had to make myself an advocate not only for myself to make sure I am qualified for a job, but for patients who deserve to have a competent interpreter,” she said.
Garden and Associates, an agency that connects care facilities with interpreters, has a session on cultural competency in its single day of training. When asked if he thinks that a one-day seminar is sufficient to train interpreters for difficult cultural interactions, CEO Tom Garden was quick to respond. “A year wouldn’t be enough to teach that,” he said.
An uneasy alliance
The ISG has led the fight to enforce stricter standards through a registry, but a rift in its own membership may kill new legislation before it’s even introduced. The ISG is a collective of doctors, interpreters, insurers, hospital administrators, interpreting agency owners and others.
A group of agency owners, some from ISG, formed its own group last year, called Interpreter Agencies of Minnesota (IAM). It’s a group working to protect the interests of the industry — owners see that certain regulations could affect their bottom lines.
“I don’t work 80 hours a week to not make a profit,” said Garden, who is also president of IAM.
The owners have reason to be uneasy about possible legislation: A mandatory registry could in theory eliminate interpreting agencies altogether. Hospitals could reach into the registry and choose interpreters they trust rather than going through agencies, which make their money by keeping a portion of what the client pays.
Thao, the former legislator, said that’s a sensible solution.
“I know a lot of the agencies keep about 50 percent of the fees,” Thao said. “I wish that the state would just have that registry and have hospitals reimburse [interpreters] half of what they’re doing now. Interpreters are still getting the same rate, and you cut off the middle man.”
Garden also said interpreters would rather leave the profession than pay for expensive training, and this exodus would create an access problem in the Twin Cities, where there are too many cases and not enough interpreters. Chillstrom said this is not the case, and it all boils down to patient care over profits.
“[The IAM is] a professional group that really has…their own goals and their own perspective,” Chillstrom said. “I think about it in a different perspective, which is the perspective of the patient.”
Garden said he strongly supports a registry with new interpreting standards, but he stipulated that the proposal for the Legislature should be realistic and should not create financial hardships for agencies and interpreters.
For now the ISG and IAM have an uneasy alliance — they’re both teaming up to fight for a pool of money that has accumulated through the annual $50-roster fees and is sitting in the state’s special revenue fund. Both want legislation in the upcoming legislative session that would ensure that the state doesn’t commandeer the more than $100,000 in roster fees, which it can do.
“We don’t want that money to end up in the state general fund to help solve the state’s deficit,” Chillstrom said.
With Thao gone, both the ISG and IAM are looking for another legislator to champion the cause. But even if they find that person, the divergent opinions between the two groups could mean that the legislator would have to eventually pick a side. It would take political will to put anything on the table given the lobbying on both sides, Thao said.
“If you don’t have a lobbyist, you don’t have votes,” he said.
Before any legislation can be put forward, several basic questions must be answered: How will the $100,000 in roster fees be used? What test would be taken, and who would administer it? Who would pay for testing? How would they determine the feasibility of training requirements for rare languages?
Until then, hospitals and clinics — not to mention patients — will continue to deal with inconsistencies from an unregulated industry.
Lorente is one interpreter who believes changes can’t come quickly enough. He said he’s on the roster of five agencies, including some of the Twin Cities’ largest and most recognized. Lorente said he’s not certain any of those agencies know the extent of his skills.
“I’ve never spoken in Spanish to the management of any of the agencies I work for.”
This article was produced in partnership with students at the University of Minnesota School of Journalism and Mass Communication, and funded in part with a grant from the Ethics and Excellence in Journalism Foundation.