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May is Mental Health Month, and we’re highlighting communities who need mental health support. Below, we discuss the emotional burden on medical interpreters in response to the recent article in The New Yorker, The Lonely, Vital Work of Medical Interpretation, by Clifford Marks.

In the article, Marks outlines the following points: medical interpretation is an emotionally taxing but vital skill; interpreters are failed by lack of regulation, lack of oversight, and lack of support; and patients are failed by inherent cultural ignorance and bias from providers. Marks outlines some of the many issues facing medical interpreters, but fails to provide any call to action. As a provider themselves (Marks is an emergency-medicine resident), the author has the opportunity to not only call for relevant changes to the field, but to change their own daily interactions to better support interpreters.

Articles routinely praise the “unsung heroes” of the medical field, but how many times can we feign surprise at the silent, dutiful work of interpreters before we admit we’re choosing to remain ignorant? Medical interpreting is an incredibly valuable and difficult skill that is thwarted by other healthcare professionals’ ignorance, patient distrust, and the government’s failure to provide further regulation.

Medical Interpretation is Emotional Labor

Marks reflects on the difficult conversations interpreters engaged in during the pandemic, but end-of-life conversations aren’t new. They’re a part of daily medical interpretations. While providers can specialize in physical therapy, emergency medicine, pediatric oncology, or plastic surgery, medical interpreters don’t choose a specialty. They interpret in any medical situation where they are required, which can lead to whiplash and emotional exhaustion. But the standard for interpretation, whether by contract or full-time employment, is to be paid by the minute, thus disincentivizing interpreters to take mental health breaks. By trade, interpreters cannot be emotional while working. Their job is to provide unbiased interpretation of everything that is said by all parties, giving them the most difficult job in the room, emotionally.

“We are trained as a profession to hold our emotions off to the side. But we are humans, too.”

Lourdes Cerna, The Lonely, Vital Work of Medical Interpretation

Healthcare professionals often experience what is known as vicarious trauma, and interpreters are no exception. It’s a huge part of the burnout equation. Not only does healthcare require long shifts, huge administrative workloads, and high-stakes focus – it also exposes its workers to traumatic experiences that they carry with them. A 2010 study found that more than half of interpreters working in mental health are negatively impacted by their work. That same study found that interpreters often thought about their sessions long after they had ended (Nimdzi).

“Interpreters do more than just witness a trauma. They channel it. During an assignment, interpreters have to visualize what is being said and then retell it with the same intensity, emotions, and intent as the speaker. In addition, by speaking in the first person and constantly repeating “I,” interpreters internalize the trauma and start to experience it as their own.”

The Cost of Caring – Vicarious Trauma in Interpreters

Healthcare as a whole needs to embrace the human experience on all sides of the patient/provider interaction. Connecting emotionally to one another unquestionably makes care better, and studies prove it. While compartmentalizing is necessary for those who deal with heavy emotional workloads, we also need to normalize regular debriefing sessions for providers, staff, interpreters, and other care team members. Stepping aside for 10 minutes to recompose or reflect should be as commonplace and structured as lunch breaks and shift limits.

“I’ll dig my nails into my hand,” she said. “I’ll do something to stop the tears, because if I fall apart then I won’t do a good job.”

Marta Rodriguez, Why a Medical Interpreter Felt ‘Disposable’ Amid Covid-19

Here’s a worksheet from NCHIC on debriefing for interpreters. 

Here are mental health resources for interpreters and patients that are available in multiple languages. 

The System Does Not Support Success

“Lax regulation, a lack of reimbursement, and variations in skills and procedures mean that many patients go without interpreting services. Researchers have found that, when patients do not have access to an interpreter, they are more likely to stay in the hospital longer and to be readmitted later on.”

Clifford Marks, The Lonely, Vital Work of Medical Interpretation

The government mandates accessible care, including language access, in a whole host of laws, executive orders, and regulations. That’s where guidance, and funding, stops. Language access falls under the requirement that care be accessible, but it is often up to individual providers or their organizations to gauge the accessibility of the care they provide. National medical interpreting certifications exist but there is no requirement for hospitals to use only certified interpreters. Despite interpreters being necessary to healthcare, there are few regulations on how these professionals should function as a part of the care team. This leaves the profession and its standards in limbo. Patient and provider opinions of interpreters vary wildly, because interpreter training and quality can vary so drastically. A foundation of inconsistency and distrust makes it difficult for interpreters to collaborate with patients and providers.

“Interpretation is what policy experts call an “unfunded mandate”: providers are required by law to offer language services but aren’t paid to provide them. Hospitals or clinics that serve mainly patients with limited English proficiency are already underfunded compared with those serving primarily English speakers.”

Clifford Marks, The Lonely, Vital Work of Medical Interpretation

Did you know that Medicaid provides reimbursement for interpreter services in 15 states? 

What’s the difference between qualified and certified interpreters? 

Providers Can Lend Support

“Research suggests that it’s not uncommon for doctors to overestimate their own language abilities. In one study, researchers compared medical residents’ self-reported Spanish proficiency with their proficiency as measured by an objective test. They found that 1 in 3 residents who classified themselves as proficient did not test as such. Despite this, residents at all proficiency levels reported sometimes discussing clinical care with patients and families in Spanish without the aid of an interpreter.”

Mimi Zheng, Op-Ed: Does your doctor speak your language?

In her op-ed for the LA Times, Mimi Zheng urges hospitals to institute language proficiency testing for providers, to establish a clear line for when doctors are equipped to speak with patients directly and when they should involve an interpreter.

Provider/Interpreter interactions can be tense, often exacerbated by providers’ lack of cultural competency. Interactions with LEP, Deaf, or hard of hearing patients can be just as frustrating for providers as for patients. Providers require more comprehensive cultural competency training to be better prepared to work with both interpreters and minority patients.

It is important for providers to engage with interpreters as the peers that they are, to establish confidence and comfort in the patient. Without provider support, interpreters are set up for failure.

This website explores racism & medicine and provides tools for staff. 

Resources from the AHA on building a culturally competent organization. 

Opinions Aren’t Enough

“But, while interpreters can provide important cultural context, their code of ethics is also clear: they are there to translate, not editorialize.”

Clifford Marks, The Lonely, Vital Work of Medical Interpretation

Advocacy for interpreters has a long way to go. Marks, despite being a medical professional, uses the word translate as a synonym for interpret in his article. Marks isn’t the first to make that mistake and won’t be the last, but in actuality interpretation and translation are completely different skills used in different situations. It is this kind of ignorance that perpetuates the mythos that interpreting is some unknowable art that is both vital but often below providers’ notice; that interpreters are unsung heroes despite dozens of opinion articles about them each month; that the world of medical interpretation simply cannot improve.

The reality is that by constantly othering interpreters as some small, suffering subset, we refuse to properly acknowledge the hugely important role they play in our healthcare system. Interpreters deserve recognition, support, and respect – not just opinion pieces that further mystify and obscure their profession. Interpreting is emotionally taxing, but the burden can be lessened with systemic change and the support of providers on an individual level.

In the end Marks’ article seems to shrug at the problem. Rather than deciding to address the issue or further educate themselves and their peers, Marks simply recognizes that interpreting is a tough gig with a host of problems. That’s not enough.

Review the following to learn how to best engage with interpreters: 

Hear from other healthcare providers on the importance of interpreters: 

References

Becker, R., & Bowles, R. (2004). Stuck in the Middle: Debriefing for Interpreters. NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors. https://www.startts.org.au/media/Refugee-Transitions/Refugee-Transitions-Issue-15-stuck-in-the-middle-debriefing-for-interpreters.pdf.

Becoming a Culturally Competent Health Care Organization: AHA. American Hospital Association. (n.d.). https://www.aha.org/ahahret-guides/2013-06-18-becoming-culturally-competent-health-care-organization.

Goldberg, E. (2020, July 20). Why a Medical Interpreter Felt ‘Disposable’ Amid Covid-19. The New York Times. https://www.nytimes.com/2020/07/20/us/medical-interpreter-covid-hospitals-coronavirus.html.

Karandysovsky, G. (2020, April 10). The Cost of Caring – Vicarious Trauma in Interpreters. Nimdzi. https://www.nimdzi.com/the-cost-of-caring-vicarious-trauma-in-interpreters/.

Marks, C. (2021, May 4). The Lonely, Vital Work of Medical Interpretation During the Coronavirus Pandemic: The New Yorker. During the Coronavirus Pandemic | The New Yorker. https://www-newyorker-com.cdn.ampproject.org/c/s/www.newyorker.com/science/medical-dispatch/interpreting-during-a-pandemic/amp.

MH Cross Cultural Mental Health. (n.d.). https://www.ncihc.org/index.php?option=com_content&view=article&id=57.

Race & Medicine. (n.d.). https://www.raceandmedicine.com/.

Zheng, M. (2021, April 19). Op-Ed: Does your doctor speak your language? Los Angeles Times. https://www.latimes.com/opinion/story/2021-04-19/doctors-language-interpreters-medicine.