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The Voice On The Other End Of The Phone
A MIDDLE-AGED, SPANISH-SPEAKING WOMAN has just been wheeled into the emergency room (ER) of a major hospital in metropolitan Boston. Her anxious twenty-one-year-old son is with her. He describes, in hurried Spanish, how his mother was injured in a machinery accident at a factory. As I listen closely for a pause in his speech or an intake of breath (my opportunity to jump in and interpret his words into English), I concentrate not only on retaining and conveying all of the information he is providing, but also on how to render all of the nonverbal information—his inflection, his emphasis on specific words, his concern for his mother, and of course, his sense of urgency. I can’t see them; I close my eyes as I listen. The ER nurse, thankfully, is accustomed to working with an interpreter over the phone, which means that I won’t have to give her the basic instructions: speak directly to the patient, pause after every few sentences to allow me to interpret, ask one question at a time, and so on. She waits for the young man to stop speaking so that I can begin interpreting. I hear her sigh; I know she’s anxious to receive the information quickly. Unfortunately, they have me on speakerphone. The various background noises from machines beeping, equipment being moved around, and people coming in and out of the room are difficult to contend with. I block out the external noise and focus on the two voices that are communicating, but I wish that the son and nurse would pass the receiver back and forth or use a phone with two handsets, either of which would improve the quality and speed of communication. But I mustn’t let my own feelings or frustrations show in my voice—and I don’t. Impartiality is one of the core ethical principles of interpreting, no matter what the setting or mode of delivery. An interpreter’s opinions aren’t to influence either speaker in even the smallest or subtlest of ways. The hospital’s staff interpreter arrives on the scene, and I’m told that I’ll be disconnected. The nurse thanks me quickly before ending the call, a rare but appreciated treat, especially coming from someone in an emergency setting where seconds count. A few hours earlier, I interpreted for a patient who was in a setting far removed from the hectic pace of an urban ER. A nurse was at the home of a seventy-four-year-old, Spanish-speaking man in rural Kansas to teach him how to care for a wound. Slowly and carefully, she explained to him how to change the bandages, walking him through every step, from disinfecting the wound to applying the gauze and tape. During one pause, while we waited for him to repeat the instructions back to her, there was such stillness I heard a cow mooing in the distance. This morning I also interpreted for a Spanish-speaking woman with diabetes during a call to a mail-order equipment supply company; along with her monthly order, she wanted to redeem a coupon for lancets and test strips. During the call, the company rep told her about a blood-glucose meter with new features that would make it easier for her to test her blood. The caller was interested, and requested a copy of the company’s latest catalog. Joking with the company rep, she asked if he’d send her one of the meters for free if she agreed to let them use her photo on the cover of the next catalog. At age sixty-five, a height of five feet, and a weight of 230 pounds, clearly she’d be the perfect cover model, she told him.
AS A TELEPHONE INTERPRETER FOR SPANISH SPEAKERS, I need to be a quick-change artist. The diversity of settings—and terminology—that I encounter in a single day sometimes is mind-boggling. To start with, I contend with twenty-four different regional varieties of Spanish. Then, to be certified for health care calls, just one of the specialized areas I handle, I had to commit thousands of medical terms to memory as part of proving my ability to interpret in medical settings. Among such terms are ones dealing with anatomy and physiology, medications, and medical procedures. The most challenging terms, however, are neither the regionalisms nor the ten-syllable words of Latin origin. Among the most difficult to convey are ones that, to be properly understood, require prerequisite cultural context and knowledge. These include terms such as "HMO," "deductible," "coverage," and "copay"; although commonplace in U.S. culture, they don’t exist in many other countries and languages. Yet these aren’t the only cultural issues that prove challenging. On a call last week from Los Angeles, a visiting nurse was at the home of a teenage couple for a postnatal care visit. As the young parents spoke, it seemed from their grammar and choice of words that neither of them had much formal education. In spite of it being a summer day, the parents being dressed in warm-weather clothing, and the home having no air conditioning, the nurse quickly noticed that the baby was red-faced, sweating, and swaddled in multiple layers of blankets. She spoke reassuringly to the parents as she peeled off layer after layer covering the baby and then took the child’s temperature. The baby had a fever. Why, the nurse asked, carefully, in a nonaccusatory manner, had they had put so many layers on the child? I used the same gentle tone when asking the question in Spanish. The teenage mother answered quietly, "Well, that’s how the Virgin dressed Baby Jesus..." The nurse hesitated for several moments, and I could almost hear her searching for an appropriate response. She asked the parents if they knew how to take the baby’s temperature. They didn’t. The nurse moved into more familiar territory, demonstrating and explaining this seemingly simple process, only to be politely interrupted by the father in Spanish. "Excuse me, ma’am," he said, "but we do not know how to read." After I interpreted this to the nurse, she asked, audibly taken aback, "Not even numbers?" He replied, "No, we do not know how to read letters or numbers." In a truly stunned silence, the nurse didn’t say anything for a few moments. I could practically hear the parents, who uttered nary a word, worrying that their lack of education was affecting their ability to care for their child. I also could practically hear the nurse’s thoughts, wondering how she should deal with this as she helped them be parents. After a few minutes that felt as if we were approaching eternity, I finally piped in with a suggestion to help them communicate (that’s appropriate for me to do—it’s not the same as injecting a personal opinion). "This is the interpreter. Would it be possible to show them the red line on the thermometer?" The nurse immediately said, "Yes, of course! Thank you, interpreter!" and went back into action. From then on, the nurse was careful to pause more frequently, use visual aids, and verify that the parents understood. Although much of my work is serious, once in a while I’m able to help people laugh with each other. A few months ago, I was interpreting for a Spanish-speaking man who had come to a doctor’s office for a first-time visit. As he gave his medical history, I noticed his Colombian accent, as well as the way he referred to medical terms by their Latin names. To maintain accuracy when interpreting back into English, I rendered these terms in Latin, too, and the doctor commented, "Interpreter, you are doing a great job!" The physician seemingly hadn’t heard the patient’s use of Spanish-inflected Latin and was attributing the high level of the terminology to my knowledge. I clarified the situation by saying, "This is the interpreter speaking. It is actually the patient who is using the Latin phrases; I am only interpreting them." With that information in hand, the doctor asked the patient where he’d learned the Latin names. The patient revealed that he was an orthopedic surgeon in his native country. "Wow! Really!" the surprised doctor responded. The patient laughed and said, "Yes, my Latin good, my English bad." In equally broken Spanish, the doctor responded, "Mi Latin bueno, mi Español malo." The two were interacting directly with each other, as equals, for at least a few moments without any help from me. On the flip side, I’ve witnessed—by phone—some behavior by providers that is offensive or rude. I’ve interpreted for patients who ask, "Why is the doctor speaking so slowly to me? Does he think I am stupid?" I’ve also interpreted the words, "Please tell the nurse not to yell at me. I don’t have a hearing problem—I just don’t speak English." Recently I heard a physician say, in all seriousness, "Next time you come, you speak inglés, understand?" as if mastery of a new language would magically occur by the follow-up appointment. When those comments are made—and my job is to faithfully repeat them—I’m grateful that I can’t see the look on the patient’s face. I’m also grateful that no one can see the look on mine.
Telephone interpreters are less visible than our in-person counterparts and, perhaps because of this, not always fully appreciated. Yet within health care interpreting—and health care as a whole—we are a unique and important subset. Because our services are accessed easily, on demand, by phone, we often accompany a patient at various steps in the process of obtaining health care and services. (Granted, it’s rare for the same interpreter to be used at each step, but we do sometimes have repeat clients, especially with health plans that use case management.) From the time non-English speakers call 911—and as they are transported to the hospital in an ambulance and arrive at the ER—up until their final rehabilitation appointment and the last refill on their medication, a telephone interpreter is often "by the patient’s side"—well, in their ear, at least. Later, they’re likely to call again to decipher the final "explanation of benefits statement" from their insurance company. An interpreter’s job, on the telephone or in person, is filled with complexity, and, as many of us in the field will tell you, it’s a job where many people underestimate the skill that’s needed. Transferring information accurately and completely from one language to another language sounds much simpler than it is. It’s often especially complicated when the information is spoken. In reality, most people find it difficult to accurately repeat information to another person even in the same language; the typical botched results of the game "telephone" underscore the difficulty of the task. (As an aside on terminology, interpreters deal with spoken words; translators deal with written words.) Those of us who work within the interpreting field also face a lack of awareness within the health care community at large of the importance of professional medical interpreters, what it means to provide professional interpreting services, and the enormous effect that professional interpreters have on the delivery of high-quality health care services. A common—and potentially deadly—misconception is the belief that anyone who’s bilingual can interpret. That’s like saying that anyone who speaks English can become a professional speaker or that anyone who knows how to write can become a professional writer. The simple truth: skills required to interpret are far more complex than what’s needed merely to speak or write in a given language. Want proof? When fully bilingual speakers take interpreting tests, their passing rates are often in single digits. As a phone interpreter, I see this lack of understanding play out on a daily basis. I’ve often been replaced in the midst of an encounter by on-location "interpreters," including patients’ relatives and hospital staff members who aren’t qualified medical interpreters. Because the call usually is promptly disconnected in such situations, it’s not something I can prevent. Even as I hear the ominous sound of the dial tone, I realize that lives are being put in the hands of nonprofessionals whose language skills might not be sufficient. It’s unclear if they know medical terminology, it’s unlikely that they’ve had even minimal training, and they’re probably years away from providing interpreting services at a professional level. An additional role that professional interpreters are able to take on is being a competent cultural broker. This requires knowing a great deal about two or more cultures, as well as having the knowledge and foresight to prevent linguistic misunderstandings. Words in different languages might sound similar and, therefore, seem that they mean the same thing, but that’s not necessarily so. For instance, the Spanish word embarazada sounds like the English word "embarrassed," but it means "pregnant." False cognates such as these, if interpreted incorrectly, can set the stage for disastrous medical errors. Fortunately, for both interpreters and patients, in 1994 the National Council on Interpreting in Health Care (NCIHC) (http://www.ncihc.org) was founded, and it is contributing to the understanding and professionalization of the field. It describes its mission as promoting "culturally competent professional health care interpreting as a means to support equal access to health care for individuals with limited English proficiency." Among the NCIHC’s contributions is producing the first-ever national code of ethics and standards of practice for interpreters in health care here in the United States. One of the NCIHC’s strengths, I believe, is that it’s not made up solely of interpreters. Instead, it also counts health care providers, interpreting coordinators, researchers, and others interested in interpreting issues among its members, which in turn provides a widespread base toward understanding the need for and the role of professional medical interpreters. As I see it, it advocates so that I can do my job. Still, even with the efforts of the NCIHC and other organizations, such as the International Medical Interpreters Association (IMIA) and the California Health-care Interpreters Association (CHIA), there’s a long way to go. According to the 2000 census, there are forty-seven million patients in the United States who speak a language other than English at home—a number that’s grown even larger in the years since the census data were collected. It’s going to take a lot of understanding, bridge building, and collaboration—not just within the health care profession—to ensure that limited- and non-English-speaking patients are linguistically well served. These patients are also my patients. I hear them; I speak for them; I speak to them on others’ behalf. I get to see the U.S. health care system from the inside out. When a child frantically dials emergency services, I convey both his urgency and the dispatcher’s methodical questioning. I speak both for the woman nervously, whisperingly, calling the domestic violence hotline while a violent spouse sleeps in the next room and for the counselor who quietly assures her that she is doing the right thing and seeks to help her. On behalf of an organ donation bank, I speak with a tender and respectful voice to parents whose son just died in a car accident, and I convey the parents’ grief-filled desire to help others. I am the voice for the nurses yelling "Push! Push! Push!" during the final stages of delivering a baby. Then I carefully render, letter by letter, the baby’s name so that it appears correctly on the birth certificate. And some days, like today, I get to laugh (with my mute button on!) when a caller good-naturedly comments that she’d be the perfect cover girl for a catalog featuring a blood-glucose meter. As is the case with other health professionals, I live each day knowing that people’s lives are in my hands. I am the voice of both the patient and the doctor (or the dispatcher, receptionist, benefits coordinator, social worker, billing specialist, and everyone else along the provider chain). Even when I hear the words, "You’re going to be disconnected," I silently know that, in reality, I couldn’t be more connected.
Nataly Kelly (nataly{at}commonsenseadvisory.com) lives in New Hampshire and is now a senior analyst and cultural communications strategist at Common Sense Advisory, an independent research firm with a focus on language services, in Lowell, Massachusetts. Names and certain identifying details about people in the essay have been changed.
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