A critically important component involved in creating a culturally effective pediatric practice centers on identifying and responding to limited English proficient (LEP) patients' language preference.
Specific guidelines outlined in the National Standards on Culturally and Linguistically Appropriate Services (CLAS) can be used to make an individual practice more culturally and linguistically accessible to diverse patient populations. The CLAS standards were developed by 2 national project advisory committees that completed a thorough analytic review of relevant laws, regulations, contracts, and standards. In addition to federal, state, and payer requirements to provide linguistically appropriate services, a growing body of scientific literature has identified risk of medical errors if linguistic barriers are not addressed in the clinical setting.1
Options for Providing Interpreter Services
If the pediatrician does not speak or is not fluent in the LEP patient's primary language, there are several viable options to provide office- or hospital-based interpretive services such as language lines and trained independent interpreters. Using children, other family members, or untrained staff is not desirable in that these individuals may be unfamiliar with technical or scientific language, may inadvertently commit interpretive errors, or may editorialize patients' responses. Some community-based organizations provide a lower cost interpretive services option.
Pros and Cons Associated With Different Options
The cost associated with interpretive services is cited as a significant challenge in providing linguistically appropriate services to diverse patient populations.
- Language lines charge by the minute and depending on the length of the visit, may be the most expensive alternative. The lack of physical presence and visual contact of a telephonic interpreter can be viewed as problematic by some clinicians. On the other hand, if the pediatrician provides services to monolingual families from several different countries, language lines usually have a large cadre of multilingual interpreters available to provide needed language services. Finally, if the anticipated need for interpretation is only a few minutes in length or if the language is uncommon, language lines may be the most cost-effective option.
- Trained independent interpreters usually charge by the hour and would be more cost-effective if several patients needed interpretive services during a given block of time.
- Newer videoconferencing and mobile computer technology methods available in some hospitals offer promising options but are not yet widely available in office-based practices.
- The on-site interpreter's physical presence is often favored by providers and can be instrumental in assessing the patient's nonverbal language and visual cues.
Some community-based organizations offer training programs for laypersons to be certified as medical interpreters. Additionally, there are community-based programs that prepare individuals to serve as cultural brokers or patient navigators.
Beyond filling the immediate need for an interpreter, these community members (cultural brokers/patient navigators) can be instrumental in providing important information about cultural beliefs, customs, and trends. Trained interpreters from community- or faith-based organizations often offer a less costly option for interpretive services.
Cost and Payer Payment
In the United States, most payers do not pay physicians for the cost of interpretive services. Interpreter services are allowable Medicaid services. There is, however, variability in that some state Medicaid and Children's Health Insurance programs (CHIP) do pay the provider or contract directly with the interpreter.
Pediatricians will need to contact individual private and public payers to determine the scope of covered services in their state. If the interpreter expense is not covered by private or public payers, the pediatric practice pays for the services. Pediatricians can contact local hospitals to try to negotiate a discounted rate for interpreter services. Alternatively, practices can form physician networks to negotiate a more favorable rate.
Integrating Interpreter Services into Office Systems and Practice
Using interpreters, whether telephonic or in person, is likely to increase the amount of time needed for a patient visit. However, anticipatory planning can minimize disruption and delays in clinical practice. Scheduling interpreter-assisted visits as the first visit of the clinical session allows the practice to set the exact time when the interpreter will be needed. Patients and families should be advised to arrive at least 30 minutes prior to the interpreter's arrival time.
What to Look for in Hiring/Contracting for Interpreter Services
While there are currently no federal health care interpreter certification standards, pediatricians should inquire about the level of interpreter training, qualifications, and years of experience. At least one state (Washington) provides state-level certification. Additionally, preliminary steps have been taken toward the development of national standards.
Pitfalls to Avoid
Using untrained interpreters, including family, friends, and staff, can result in medical errors such as omissions, substitutions, or inaccuracies.1 Additionally, untrained interpreters may choose to editorialize sensitive information (eg, sexually transmitted infections, domestic violence). Using children as interpreters adds another set of challenges in that they are not mature enough and can be adversely affected by the clinical information being discussed.
Using untrained interpreters, including trainees who have superficial knowledge of a specific language, may result in a dangerous and false sense of security that accurate interpretation and meaningful physician-patient communication is actually taking place.
Tips for Working Effectively With Interpreters
- If possible, give the interpreter a quick summary of or an introduction to the patient and briefly share what is anticipated and will be covered during the visit.
- Even though the tendency is to establish eye contact with the interpreter, maintain eye contact with the parent or patient.
- Speak slowly.
- Use simple and easy-to-understand words and phrases; avoid jargon.
- Avoid interrupting the interpreter once the session has started.
- Invite the interpreter to share specific cultural practices or challenges that may arise during the encounter.
Assessing the Need for Interpretive Services
To determine the patient's or family's language of preference, they can be asked to read a brief "I Speak" document containing a single sentence in many different languages. Additionally, if patients say very few words during the clinical encounter and use a lot of nonverbal communication, such as nodding, pediatricians should suspect that there is a problem with language comprehension or literacy level.
1. Flores G, Laws MB, Mayo SJ, et at. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111:6–14
Chapter 5 Tools and Resources
Tool 5A: National Council on Interpreting in Health Care: National Standards of Practice for Interpreters in Health Care
A reference outlining best practices for use by interpreters and those who work with, train, and employ interpreters.
Tool 5B: Health Industry Collaboration Effort: Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Toolkit provides resources and tools for communications issues.
Resource 5A: US Department of Health and Human Services Office of Minority Health: National Standards for Culturally and Linguistically Appropriate Services in Health Care: Executive Summary
This report describes 14 national standards for providing culturally and linguistically appropriate services.
Resource 5B: La Clínica del Pueblo
This Web site provides a community-based example of a clinic providing interpretive services.
Resource 5C: National Council on Interpreting in Health Care
This Web site offers multiple resources for implementing interpretive services.
Resource 5D: "The Importance of Cultural Competency in General Pediatrics"
Brotanek JM, Seeley CE, Flores G. Curr Opin Pediatr. 2008;20:711–718
Resource 5E: What's in a Word? A Guide to Understanding Interpreting and Translation in Health Care
This guide describes the differences between oral interpreting and written translation, including the skills needed to competently undertake each.