Beyond Translation: Equipping Medical Trainees for Effective Interpreter Collaboration

Language is a cornerstone of the patient-provider relationship, shaping medical outcomes and influencing both patient and provider experience. Families who use a language other than English (LOE) face significant obstacles in navigating the health care system and the impact of language barriers on health care access, and quality has been well documented. When children from families speaking a LOE seek medical attention, they are 1.6 times more likely to be admitted compared with their English-speaking counterparts,1 and 1.7 times more likely to require intensive care unit transfer after admission.2 Patients speaking a LOE often experience longer hospital stays, up to 60% longer, and are twice as likely to suffer serious medical errors.3–5 Moreover, these patients and their families also report significantly lower participation in rounds and medical discussions.6Professional interpreters play a crucial role in reducing these disparities, improving patient outcomes, and enhancing health care experiences for both patients and providers. Working with qualified interpreters is associated with fewer medical errors, improved medical outcomes, better health care utilization, decreased hospital admissions, and increased satisfaction among all parties involved.3,7,8 Conversely, failing to partner with trained interpreters has been independently associated with increased adverse medical events, incomplete patient understanding of diagnoses and treatments, lack of informed consent, and an increase in unnecessary medical evaluations.7–9 Beyond their linguistic skills, interpreters often provide cultural context, helping clinicians navigate nuanced patient beliefs and values.9 The absence of professional interpretation services can exacerbate clinical biases, further widening disparities in prescriptions, pain management, diagnostic testing, and even the number of child abuse evaluations preformed.8,9 These findings underscore the profound clinical consequences of interpreter availability and appropriate collaboration.Moreover, the quality of interpretation matters, and there is extensive literature outlining best practices for providers when working with interpreters to improve successful communication. Importantly, this includes partnering only with trained, professional interpreters as this has been shown to have the largest positive impact on patient care.7,8 Compared with ad hoc interpreters such as family members and noncertified coworkers, professional interpreters have been shown to enhance patient satisfaction and significantly reduce interpretation errors, particularly those with clinical consequences.9 Additional considerations include speaking directly to the patient, positioning the interpreter in a triangular arrangement with the family, using short and simple sentences, pausing frequently for translation, seeking clarification when needed, preventing interpreter opinions from influencing discussions, and recognizing the proper scope and role of interpreter services.7Despite abundant clinical evidence supporting working with professional interpreters and best practices, medical trainees receive little to no formal education on how to effectively collaborate with interpreters. Historical survey data have indicated that nearly half of medical residents report never receiving any direct training on partnering with interpreters while an additional 35% of residents recall receiving “very little” instruction.10,11 This gap in education is also reflected in practice: more than 50% of nonfluent providers report using their limited foreign language skills “often” or “daily,” and a staggering 84% of residents admit to asking family members or friends, 77% relying on fluent colleagues and 22% turning to children as ad hoc interpreters.11,12 Alarmingly, most providers surveyed acknowledged that their families using a LOE “never” or “only sometimes” understand the diagnosis, treatment plan, or discharge instructions.12 Although the majority of the literature surveying trainees’ experiences is older, these same trends in inappropriate communication with patients preferring a LOE are still reflected in recently collected data and demonstrate a continued need for improvement in the care for this patient population.13Multiple barriers contribute to this underutilization of interpretation services including time constraints, perceived convenience of informal interpreters, institutional culture, and access issues.14 However, one of the most addressable and impactful factors is education. Studies consistently show that providers who receive formal training in interpretation best practices are significantly more likely to engage professional interpreters in their practice.15,16To truly transform care for families speaking a LOE within our institutions, we suggest a 3-pronged approach. First, incorporating formal education for trainees on working with interpreters is a critical step. Various educational models have previously been implemented, including online modules, in-person workshops, lectures, and simulation-based training. These programs integrate a variety of didactic learning, role playing, and discussion formats.17–20 Evaluation of these programs have shown positive increases in learners’ knowledge, confidence, and effectiveness in working with interpreters.11,19,20 Notably, studies assessing posttraining provider behavior show measurable improvements in patient communication while working with interpretation services.17,18 The evidence is clear: integrating structured education on interpretation into medical training can significantly enhance communication with patients and families speaking a LOE, improve clinical outcomes, and help reduce disparities.Previous educational programs provide a strong framework for the creation of an effective curriculum. Many of these programs have involved professional interpreters in both the planning and delivery of their training, ensuring accurate, firsthand information on effective collaboration.17,18 Additionally, interactive learning methods have been shown to have greater impact on creating lasting improvements in how participants use interpreters. Programs that include simulation, role playing, and group brainstorming have demonstrated higher participant satisfaction and better knowledge acquisition.18–20 Furthermore, it is beneficial for training to feel relevant to the daily experiences of providers, so using realistic patient scenarios and firsthand encounters can be very effective.18–20 Providing feedback for learners during the educational sessions on their own biases and practices can also be a valuable component for promoting lasting change and allowing for real-time adjustments and improvement in communication.20 Finally, making education as widely accessible as possible with dedicated time allotted for learners to participate, can help maximize its reach. Although each program should tailor its curriculum to its unique needs, abundant examples can be found in medical education journals, in the MedEd Portal, and through discussions at educational conferences.17–20Second, formal education should be supplemented by a supportive institutional culture that values and models effective collaboration with interpreters. Although education of trainees will likely gradually improve this culture, it also evolves through the everyday actions of all members of the care team, from trainees to senior attendings. Unfortunately, some trainees report that the normalization of not using interpreters can influence their own communication choices with patients.14 Importantly, this means that every interaction in which a patient’s language needs are not appropriately accommodated, especially by attendings and team leads, can play a role in furthering this normalization and heightening barriers for families speaking a LOE. On the other hand, consistent engagement of interpreters for all necessary conversations and deliberate efforts to include family members on rounds and in care discussions help shift the institutional norm and encourage a more mindful approach to language barriers.6 As role models for trainees, all physicians working with learners should be cognizant of the influence of their own communication habits and recognize the responsibility they have to model and encourage culturally mindful communication with all patients. To further counteract this normalization, those leading teams of trainees should not only exemplify effective interpreter collaboration but also set these behaviors as explicit expectations for their team members. Providing regular feedback on communication with families speaking a LOE is also valuable to continue trainee education on these skills. From an institutional perspective, hospitals should establish clear behavioral standards and policies and hold providers of all levels accountable to the expectation of effectively collaborating with interpreters and communicating in each patient’s preferred language. This may be aided by the inclusion of these topics on performance evaluations, incorporation into staff orientations and provider trainings, and the insertion of language discussions into routine safety and mortality reviews.Lastly, we should focus on improving the availability and convenience of interpretation services. Providers often note challenges with poor access and longer wait time as reasons for not involving interpreters or relying on less ideal alternatives.14,15 By ensuring consistent and timely access to interpretation, we can significantly reduce these obstacles. This might involve system-level improvements such as appropriate staffing for in-person interpretation services, expanded access to video interpretation technology, or partnerships with a reliable telephone interpretation service that cover a wide range of languages, including those used less frequently. On an individual level, providers can advocate within their system for this investment in increased interpretation resources, ensure they understand their hospital’s process for coordinating with in-person interpretation services to increase availability and proactively plan for the time necessary to involve interpreters for languages encountered less often.Given the diversity of our patient population, equipping medical trainees with the skills to collaborate effectively is not an option—it is a necessity. By prioritizing access to interpreters, modeling best practices, and providing formal education, we can take crucial steps toward delivering equitable, high-quality, and culturally competent care for all patients.The authors would like to acknowledge the language services department at Texas Children’s Hospital for their encouragement and engagement in discussions surrounding this project.