Staff at Mid County Health Center, one of the most diverse clinics in Oregon, say they love their jobs for the same reason they find the work so challenging.
“What we like about the clinic is helping people from different cultures,” one provider said during a training last week on how to work effectively with interpreters.
“A lot of employees immigrated from other places, so they can share their experiences with patients,” another provider said. “We all have had chances to go other places, to fancy offices with better pay. And we decided to work here.”
For Diana Tavera, who was hired in January to help conduct the mandatory health screenings for all newly arrived refugees, the work is such a challenge and such a gift, that, at times, she struggles to keep her composure.
“I have to be professional because sometimes they cry, they’ve been burnt, or a bomb exploded on them,” she said. “And it makes you want to take such good care of these patients. I wish I could do so much more. I wish I could get in my car and drive them home so they don’t have to walk a mile to the MAX. I absolutely love my job.”
The language and cultural differences also make it harder to communicate. People at the busy center may feel pressed for time to fully explain their situation; especially patients who need the help of an interpreter.
Mid County uses interpreters more than any other county program; in the first three months of the year staff used interpreters more than 5,000 times. To be sure, the majority of those appointments are successfully because of the help of skilled interpreters. But staff say patients suffer when an interpreter lacks training or fails to follow professional standards. Providers and patients are frustrated by interpreters who arrive late or fail to show up at appointments; who lack the language or vocabulary skills; or fail to follow best practices.
A Workshop Revised
About 75 Mid County primary care health staff gathered last week to share their struggles and successes of working with interpreters, and learn ways to improve the experience for clients who rely on them.
“It’s such a beautiful thing to see the vulnerability, the excitement, the smiles,” said training facilitator Toc Soneoulay-Gillespie, director of refugee resettlement for Catholic Charities, after hearing providers talk about their jobs.
Soneoulay-Gillespie tailored the four-hour training for county staff based on a 16-hour version she developed on best practices for working with interpreters and how to deal with problems that arise.
Soneoulay-Gillespie was born in a Thai refugee camp and resettled to the U.S. as a child. She has spent much of her life acting as an interpreter, first for her Lao parents and then professionally. She said too often interpreters aren't regarded as professionals. Too often providers think any bilingual person can do the job. As a result, quality suffers.
“How can we raise the bar?” she asked. “Sometimes It’s as simple as getting the terms correct. There’s a big difference between an anesthesiologist and a gynecologist, but they’re both doctors. And there’s a huge difference between translating and interpreting. I can only interpret. I can’t translate. I don’t read or write in Lao.”
She said that change can start at Mid County. She said her introductory workshop isn’t a replacement for the required training in court or medical interpretation. Rather Soneoulay-Gillespie said, it is a practical hands-on training for bilingual individuals and providers alike to explore how to best work alongside one another.
It gives bilingual residents the basic ethical guidelines to step into the role of interpreter. And it gives English-speakers the skills to set expectations and better understand the challenges an interpreter faces.
“You as providers can set expectations,” she said.
Without agreeing on what standards interpreters should follow, it’s difficult to identify just what’s going wrong. But often it’s clear when something isn’t right.
Donna Chambers, Lead LPN at the clinic, said there are times during an appointment when a patient and interpreter are having a side conversation that she doesn’t understand.
“You can see the interpreter and patient are having a conversation you have no part of,” she said. “It causes me to lose confidence in the interpreter.”
Daisy Machic said sometimes when she asks a new Somali client about his or her history with drugs, alcohol and depression, the interpreter responds without input from the patient. “They just answer ‘No. No alcohol. No drugs. No depression. I know my people.’”
Susanna Kostanyan said she can tell if the interpretation is effective by looking at the patient’s face. “You can see if there’s understanding,” she said, “or if something isn’t translated the way it’s supposed to be.”
“You guys are describing a lot of poor practices. It sounds like interpreters who don’t understand their role,” said Amanda Wheeler-Kay, a Spanish interpreter and training co-facilitator. “Some interpreters think their role means, ‘I speak for you.’ They think they’re making it easier. You have to remind them, ‘that’s not your role.’”
Wheeler-Kay explained that companies providing language services hire contract interpreters who often work for multiple agencies at once. And those companies need to know when contractors fail to adhere to best practices.
“Hold us accountable,” she said. “Say, ‘here’s what you should expect.’ And when this doesn’t happen you need to give that feedback.”
Earlier this year, Multnomah County developed a form for providers and the public to give feedback on the performance of interpreters (and translators) who provide services for the county. Staff then work with providers to improve service and address specific concerns.
“Could I have a provider, a client and an interpreter?” Soneoulay-Gillespie asked the group.
Psychiatric Mental Health Nurse Practitioner Tina Walde raised her hand to play the role of provider. Daisy Machic settled into a chair to play the patient. And Operations Supervisor Berenice Dominguez-Vazquez sat down to interprete.
Two minutes into the fake clinical visit, Soneoulay-Gillespie interrupted.
“Knock knock,” she said and rapped her fist against an invisible door. “I’m so sorry to interrupt, Tina. There’s a really annoying patient out in the lobby whose demanding to see you and refuses to leave until he talks with you”
Dominguez-Vazquez turned to Machic.
“Someone is misbehaving outside,” she said in Spanish.
“Now what did she say?” Soneoulay-Gillespie asked the group, then furrowed her brow at the word “misbehaving.”
“Now, why did she change my word?” she asked.
“Autocorrect for impoliteness,” someone in the audience suggested.
“Is that why?” she asked Dominguez-Vazquez, who nodded.
“I was impolite,” Soneoulay-Gillespie said, her voice raising. “I used the word ‘annoying.’ I didn’t use the word ‘misbehaving.’
She asked the audience why it might matter to the patient. Someone said they would want to know if their provider talked about patients that way.
Soneoulay-Gillespie nodded again.
“It’s the same with curse words,” she said. “I have interpreters who have refused to curse. I tell them, ‘then you’re not interpreting.’
“Limited English Proficient people can lie. They can use profanity. Just like you or I. But the interpreter takes that away because they feel uncomfortable.”
Raising the Bar with CIFE
Soneoulay-Gillespie and Wheeler-Kay introduced CIFE to Mid County staff, a simple set of guidelines that can help visits go smoothly by making sure everyone knows what to expect.
“There are a lot of things an interpreter should and should not do,” Soneoulay-Gillespie said. “CIFE lays out the expectations up front.”
- C stands for Confidentiality. Interpreters sign confidentiality agreements, but in small communities, the person who interprets for a counseling session might also sit near the patient at mosque. Addressing confidentiality at the beginning of each session reminds all parties of this requirement and helps build trust with the patient. Also mentioned here is the protocol regarding any written notes that an interpreter might take during the session. Those must be shredded following the session. They are not the property of the interpreter.
- I stands for “I use first person.” Interpreters should speak in first-person, as is the industry standard. This cuts down on confusion, provides a more direct interpretation and honors the client’s voice.
- F stands for Flow. The interpreter might need to ask for a pause, a clarification, or -- if a session lasts more than 30 minutes -- a break. Providers can empower them at the beginning of each session by saying, “You control the flow of the this meeting. If I’m going too fast, slow me down. If you don’t understand something, or the client doesn’t understand something, ask me to clarify.”
- E stands for “Everything with be interpreted.” This best practice is frequently dismissed. Some interpreters fail to interpret what is announced over an intercom or said in a side conversation. An interpreter might summarize or omit the content of a provider’s or client’s words.
Soneoulay-Gillespie takes particular offense at the omission or softening of a client’s words.
“They’ll say, ‘he’s been repeating himself this whole time. He just keeps rambling on. Do you want me to interpret that?’” And her response? “I don’t care if he’s repeating himself. You should honor that. Why did you take that away from this person. They are not invisible, right?”
Nursing Supervisor Katie Thornton said establishing standards at Mid County and laying out those expectations to interpreters sounds like a great idea.
“This gives us power to say something,” she said. But Thornton feared interpreters might push back if providers implemented these standards. She wondered if some might just reply, “that’s not the way I work.”
“First person is an expectation. If that’s not happening, that information needs to get back to the company,” interpreter Wheeler-Kay explained. “As for Flow: It’s intimidating to come in and ask, ‘can you slow down?’ Giving them permission can make them feel more comfortable. And educating patients gives them power too. I have had patients say to me, ‘sometimes interpreters get mad if I don’t understand.’”
Lead LPN Chambers said she planned to cut out the CIFE definition and tape it to her wall.
“I think it’s very helpful, the whole thing,” she said. “CIFE. I really want to see us use this. I think this will really professionalize the experience.”
Soneoulay-Gillespie said she has given variations of this training for years.
“We have yet to see the level of enthusiasm, vulnerability, commitment, and willingness to sit with new concepts and tools for improving the work they do, as we've seen with your entire team,” she wrote to Mid County Director Tasha Wheatt-Delancy. “MCC [Mid County Clinic] is clearly giving voice to a community that would otherwise be overlooked.”