“The world is small now, we come from different backgrounds and different languages. We need interpreters,” says the patient's orthopedic surgeon, Nishitkumar Patel. “It is an indispensable part of delivering healthcare for Mount Sinai.”
Yet Mendoza, like the vast majority of medical interpreters in the U.S., does not possess a nationally recognized credential in her profession. That's because until just a year ago, no national certification was offered by any group, despite more than 25 years of effort to offer one in the field.
Today, two separate Washington-based organizations are beginning what insiders say will be a long process of offering national credentials and then upgrading the expectations for medical interpreters across the country.
The quicker of the two groups to offer a medical interpretation credential, the National Board of Certification for Medical Interpreters, has granted more than 80 for certified medical interpreters. Meanwhile, the Certification Commission for Healthcare Interpreters began offering testing through a pilot program in October, with plans to accept its next class of prospective nationally certified interpreters in January.
Mendoza's manager, Noemi Carrillo—director of the interpreter service at Mount Sinai—says she's anxious to start the process of getting her staff of 14 full-time and 11 part-time interpreters fully credentialed.
Currently, the only options available are those that have long existed, such as certificate programs at colleges and universities. Graduates of those programs may then also be subject to varying levels of state-based certification efforts. Experts say the intensity of the training and the thoroughness of the state-based certifications vary widely between organizations, prompting the need for national standardization.
“It's way, way past due. We interpreters have been waiting for the longest time for something like this,” says Edgardo Garcia, director of Language Access Services at Children's Medical Center in Dallas, where human resources officials recently agreed to pay expenses for its staff interpreters who take and pass the exam offered by the National Board of Certification for Medical Interpreters.
The staff of 25 full-time and 22 part-time interpreters handled 160,000 patient encounters in 2009 between the hospital's main campus in Dallas and another location in Plano, Texas, Garcia says. Garcia declined to say how much the department currently costs to operate. At Mount Sinai, the language department was budgeted for $791,906 in fiscal 2009 for its staff of 17.5 full-time-equivalent positions, Carrillo says.
Yet commercial and government payers typically do not increase their reimbursements just because a hospital or clinic had to employ an interpreter to communicate with a patient in a language other than English. So why would a hospital spend even more money on training and salaries for newly credentialed interpreters when they don't bring money into the hospitals?
Many reasons exist, but often the first one mentioned by experts is this: Hospitals are mandated to provide interpreter services.
Although no official agency keeps tabs on the number of interpreters or their patient-interaction in the U.S., the Census Bureau says about 9% of the U.S. population has limited English proficiency.
In 1974, the U.S. Supreme Court ruled in Lau v. Nichols that Title VI of the Civil Rights Act requires federally funded public agencies to provide linguistic accommodations such as interpreter services. The court said that its ruling derived from the law's prohibition of discrimination on the basis of national origin. Subsequent federal regulations have made clear this applies to hospital interpreters. Regulators also use mandates in the Americans with Disabilities Act to require interpreters for American Sign Language.
“Bottom line, if you take Medicaid, Medicare, federal research grants, any federal money at all, you have to provide equal access to people who don't speak English,” says Cynthia Roat, a healthcare language access consultant and trainer based in Shoreline, Wash.
But it's not just the federal and state regulators enforcing the legal requirements. By following the law, hospitals also can work to protect themselves from civil liability, which can be a large consideration in some cases. For example, in 1984, a hospital in Miami paid a $71 million settlement after hospital and emergency staff relied on the interpretation from a boy's mother and treated him for a drug overdose instead of the stroke he actually had. The boy ended up quadriplegic, according to news accounts.
“You could have provided a whole lot of language access for $71 million,” Roat says.
And then there's the marketing aspect. Patients with limited English proficiency are more likely to return to the hospital if they know they'll be able to see someone speaking their language—which can help hospitals that want to increase their census numbers, says Elizabeth Colon, president of Metaphrasis Language & Cultural Solutions, Frankfort, Ill.
Another financial incentive—which also happens to align with social-justice goals—is the improvement in the quality of medical services when an interpreter is used. For instance, experts say the most common medical task performed in any hospital or clinic is the taking of a detailed medical history, which can be fraught with potential miscommunications that lead to problems later.
“We waste money when we work across a language barrier without a qualified interpreter,” says Eric Hardt, a geriatrics physician at Boston Medical Center and associate professor at Boston University School of Medicine. “We waste more money than we would spend by having a qualified interpreter in the room.”
Mendoza, the Mount Sinai interpreter, recalled a time when initial miscommunications led a medical team to believe that an emergency patient was having chest pains—when in fact the interpreter eventually discovered that it was the woman's breast, not her heart or her chest, that hurt.
Interpreters say they often act as “cultural brokers” to patient populations, training them on the best ways to interact with the American healthcare system while also explaining cultural differences to doctors. Art Liebl, president of Interpreters Associates, Charlestown, Mass., says members of the local Brazilian community often need to be coached to use primary-care doctors instead of emergency departments for many health needs.
“We are there as cultural brokers,” Liebl says. “It's a large role that the interpreter plays, it's not just a mechanical translation.”