AMA Journal of Ethics^®

Abstract

Spanish speakers make up 13.1% of the US population, and language barriers contribute to health disparities. Medical interpreters are essential for communication between patients with limited English proficiency (LEP) and their clinicians. However, there is a shortage of interpreters nationwide; free clinics, where a large majority of patients with LEP receive care, are especially affected by this shortage. Many medical schools are associated with a free clinic, and medical students who speak Spanish can help fill this gap. Loyola University Chicago Stritch School of Medicine, together with Interpreter Services at Loyola University Medical Center, created an interpreter certification program for medical students. Although there are challenges in certifying medical students as interpreters, doing so helps to build a workforce of well-trained, culturally competent physicians.

The Need for Certified Interpreters

According to the US Census Bureau's 2012-2016 American Community Survey 5-year estimate, 13.1% of the US population speaks Spanish, and 41.6% of these Spanish speakers report speaking English less than very well.¹ Language barriers contribute heavily to health disparities seen in limited English proficiency (LEP) populations. Indeed, studies document that patients with LEP often defer needed medical care; are at higher risk of leaving the hospital against medical advice; are less likely to have a regular health care professional; and are more likely to miss follow-up appointments, to be nonadherent with medications, and to be in fair or poor health.^2,3

A medical interpreter is an essential component of effective communication between patients with LEP and health care professionals. A systematic review of the literature revealed that the use of professional interpreters (ie, interpreters who have undergone a training and certification process) is associated with an overall improvement of care for patients with LEP.⁴ Specifically, use of professional interpreters "appear[s] to decrease communication errors, increase patient comprehension, equalize health care utilization, improve clinical outcomes, and increase satisfaction with communication and clinical services" for patients with LEP.⁴ A recent cross-sectional analysis of interpreter errors and their potential consequences in emergency department encounters in which professional interpreters, ad hoc interpreters, or no interpreters were present found the proportion of potentially consequential errors to be significantly lower for professional interpreters (12%) than for ad hoc interpreters (22%) and no interpreters (20%).⁵ Among professional interpreters, hours of previous interpreter training "were significantly associated with error numbers, types, and potential consequences" professional interpreters with at least 100 hours of training had a significantly lower proportion of potentially consequential errors than professional interpreters with less than 100 hours of training (2% vs 12%).⁵ For reference, the National Board of Certification for Medical Interpreters requires completion of a training course of at least 40 hours for candidate eligibility for the Certified Medical Interpreter credential for those who do not become certified through college courses.⁶

There is a shortage of certified interpreters nationwide. In 2015, for example, California had 738 certified medical interpreters to serve 1.7 million people who spoke poor English.⁷ Community health centers and free clinics, where many patients with LEP receive care, have a significant need for interpreter services.^8,9 Almost 50% of US allopathic medical schools operate at least one student-run clinic,¹⁰ and many others are affiliated with a free clinic. Although bilingual students often volunteer as interpreters and help to fill this gap, they are not necessarily formally trained.

The Icahn School of Medicine at Mount Sinai implemented a course providing training in interpreting techniques and language skills to bilingual students, which resulted in increased participant comfort level with and understanding of interpretation as well as high ratings by patients and student clinicians in these areas.¹⁰ Although this training program was rigorous, it is important to note that it was not an official certification program supported by a national organization. Knowing the patient care benefits of formally training and certifying interpreters, Loyola University Chicago Stritch School of Medicine (SSOM) funded and established an interpreter certification program for medical students with the help of Loyola University Medical Center (LUMC) Interpreter Services.¹¹ This program is expected to increase not only self-perceived interpreter efficacy but also patient and physician satisfaction.

Interpreter Certification Program Curriculum

Although any member of the care team—nurses, physician assistants, or administrators—can theoretically serve as an interpreter for a physician, staff who have other roles to fill are unable to provide this service. Bilingual medical student volunteers, therefore, provide a valuable service, helping to facilitate communication between physicians and their patients with LEP. Since three-fourths of student interpreter volunteers at LUMC reported that they had never received formal interpreter training, SSOM funded and established a certification program for medical students to ensure that patients receive quality communication that is standardized and meets hospitals' certified interpreter criteria.

It is important to note that Spanish interpreter certification is not the same as certification as a Spanish-speaking clinician. A professional interpreter knows and practices the principles and rules of interpretation and can facilitate communication between a clinician and a patient who speak different languages. A Spanish-speaking clinician is one who can safely provide care to Spanish-speaking patients with LEP without the use of an interpreter.

Purpose. The SSOM Interpreter Certification Program was established primarily to provide interpretation services for Spanish-speaking patients with LEP at Loyola's Access to Care (ATC) Clinic, which provides primary care services to a low-income, uninsured, underserved population. Although the number changes from year to year, approximately 50% to 60% of clinic resident physicians do not speak Spanish. At the same time, 80% of the roughly 1500 patients who receive health care services at the ATC Clinic list Spanish as their primary language.

Qualifications and training. First-year and second-year medical students with fluency in Spanish are eligible to participate. The certification process consists of 4 parts, which can be completed at any time according to student availability. During the 2-hour preassessment, the student shadows an LUMC professional interpreter, and the interpreter assesses the student's Spanish proficiency. If deemed proficient, the student takes the ALTA Language Services Qualified Bilingual Staff (QBS) Assessment via phone, which consists of 5 sections: conversational/social, customer service, nursing diagnosis and instructions, medical terminology, and sight translation.¹² This national exam is designed to assess the examinee's ability to communicate directly with target language-speaking patients in a medical setting by measuring interpreting skills for a range of medical terminology and tasks. Once the student achieves proficiency at Level 2 ("ability to provide services in the target language in various healthcare settings"¹²), he or she proceeds to the next step, which consists of a 3-hour QBS training session. This workshop, offered by LUMC Interpreter Services for both student and community interpreters, reviews the principles of medical interpreting. In addition, time is allotted for practice, with the instructor providing supervision and guidance. Following this training, the student participates in 4 hours of direct demonstration, during which an LUMC professional interpreter observes the student interpret during a number of encounters in the hospital. (Of note, the interpreters who assist with this program are senior interpreters who receive program-specific training and instruction from the director of LUMC Interpreter Services.) The interpreter performs a final evaluation of the student, and if the student is deemed safe to serve as an interpreter in an unsupervised setting, he or she receives a certificate of completion as well as a Level 2 qualified medical interpreter badge. The student is then certified to serve as a volunteer interpreter at Loyola hospitals and clinics.

Growth and impact. Approximately 20 students serve as volunteer interpreters each year, of which a small percentage have undergone the certification process. During the 2015-2016 academic year, 4 students were certified as interpreters; during the 2016-2017 academic year, 6 students were certified. Of note, during the 2016-2017 academic year, 28 students attended a QBS training workshop, as the curriculum did not yet include a preassessment.

The impact that student volunteers have on patient care is significant, especially given that LUMC Interpreter Services is unable to meet the clinic's interpreter needs; the clinic does not have any LUMC interpreters onsite and only has access to phone interpreters. During the 2016-2017 academic year, SSOM students provided more than 550 interpreter volunteer hours and served roughly 400 Spanish-speaking patients (see Table). Due to the significant need for in-person interpretation, the time it takes to complete the certification process, and medical students demanding academic schedules, the ATC Clinic has continued to welcome noncertified student interpreters.

Ethics of Certifying Students

There are both benefits and risks to certifying medical students as interpreters. On one hand, permitting students to serve as interpreters increases in-person interpreter availability. Clinicians and interpreters prefer in-person interpretation over phone and video interpretation because this arrangement allows for improved nonverbal communication and greater physician satisfaction.¹³ Furthermore, serving as interpreters provides students with additional experience as well as opportunities to observe patient care during their preclinical years. Student volunteers gain perspective through participation in a multidisciplinary clinic team, and routine exposure to an underserved population helps to build their cultural competency through interactions with patients from different backgrounds. On the other hand, maintaining a distinction between their clinician and interpreter roles can be a challenge for medical students. As physicians in training, medical students are taught to conduct medical encounters: they know what questions to ask, what to clarify, and what the next steps are. As interpreters, their duty is to translate what the physician and the patient say verbatim. As medical students advance in their training, following the rules of interpretation can become increasingly difficult as a result of their urge to use their clinical training. If having medical knowledge interferes with the principles of interpretation, certifying students as interpreters can create ethical dilemmas for students and could be a legal liability if the conversation is edited in any way, such as through additions, omissions, or assumptions. Moreover, student interpreters are more likely to have limited skills compared to professional interpreters due to their relative inexperience, even after meeting the basic standards of interpreter training and certification.

Although asking ever-busy medical students to complete a 9-hour certification process is certainly demanding, doing so is best for the vulnerable patients who require interpreter services. The need to provide quality patient care must be balanced against the risks of volunteer interpreters applying their clinical training to the detriment of their interpreter role. By certifying medical students as interpreters, the SSOM Interpreter Certification Program is creating a path for students to become well-trained, culturally humble, Spanish-speaking clinicians.

Next Steps for the Interpreter Certification Program

After 3 years of pilot programs, an optimal certification curriculum was developed, as presented above. Evaluation of the 2018-2019 program is underway based on satisfaction surveys from interpreters, physicians who use student interpreters, and patients. Moving forward, SSOM plans to expand the Interpreter Certification Program with the goal of certifying a higher proportion of student interpreters. Since it is widely documented that patients with LEP receive inferior quality of care and that more interpreter errors occur with untrained ad hoc interpreters,¹⁴ making certification mandatory for student volunteers could be considered in the future if doing so does not significantly decrease the number of interpreters available to the clinic. Finally, curriculum improvement will continue, perhaps with the addition of follow-up training, practice, and evaluation after certification.