
The Value of Presence: The Role of In-Person and Virtual Medical Interpretation on Patient Care
Assistant Professor Katie Freeman, MD, practices full-spectrum family medicine including obstetrics at Bethesda Family Medicine Clinic in St. Paul as part of the Woodwinds Hospital Family Medicine Residency Program. Dr. Freeman spoke with us about a research project exploring the impact of different interpreter modalities (virtual versus in-person interpreting) on patients.
Can you tell us about the focus of your medical interpreter project?
We started from a place of experience working with non-English language preference (NELP) patients. Seeing patients who utilize an interpreter feels different depending on the format of that interpreter: whether they're present with you in person, whether they're on the telephone or on video, or it's a family member that's interpreting. In many ways that affects how the visit is going to go, what the flow looks like, how much information you're able to gather, how many different issues or tasks you're able to take on and how you feel, and how the patient feels at the end of the office visit.
For me, working with an interpreter in person is just worlds better than when they're remote. I was excited to use research to capture whether that's a real thing or not. I previously worked on a different group project looking at the outcomes of patients with diabetes depending on whether they had a telephone-based or in-person interpreter. This research indicated that diabetic outcome data were not affected by the type of interpreter. But this didn't match with the reality that I can do a lot more when interpreters are there in person, that patients better understand the plan, and I can provide more education.
After that, we decided to move away from quantitative data and instead use qualitative stories that focus on what the experience looks and feels like to participants. Ultimately, we hope to talk to patients about how the experience feels for them.
Previous research shows that patients appreciate both virtual and in-person interpreting, and that both forms are positively viewed. But again, that's not how it feels for me when I’m seeing patients.
How did you go about gathering data?
Initially, we wanted to speak directly to patients. But research with NELP patients is challenging—so many different languages, so many different backgrounds, and providing interpretation for all of these conversations. We thought it would be simpler to start by talking to interpreters both because they all speak a shared language (English), which makes it easier for us to host focus groups, and because they are also present in the room or on the phone for these visits. We were hoping to better capture the experience in the exam room, and how it differs between the two different formats.
We hosted virtual focus groups with interpreters. There were four to six interpreters in each group, and they reflected a whole range of different languages and places where they practice and the type of healthcare environments that they work in. About 50% of them were Spanish interpreters, but we also had Japanese, Hmong, Russian, and Arabic, as well as other languages. We developed a set of focus group questions based on the roles interpreters play, looking at observed benefits and challenges in a virtually interpreted environment versus in an actual in-person interpreting situation.
What were your takeaways from those focus group sessions?
The biggest thing I came away with was an immense respect for the interpreters and the professional way they approached their work. The amount of nuanced information they take into account when they're interpreting is impressive: not just what the words are, but the cultural context, the non-verbal cues, and the way they're able to coordinate movements and gestures and meaning alongside the words.
Participating in focus groups was wonderfully therapeutic for the interpreters. It was great to watch them interact with each other and share the pride and quality of their work. They also appreciated the opportunity to give feedback to healthcare providers on things we could do better both individually and as a system, as well as the ways we could better support them professionally, including skill development as well as respect and honor for the work that they do. It was a real honor to be present for these conversations.
We noted how interpreters weave their multiple roles together throughout a visit, and how it's so much easier for them to use their entire skill set and do their job well when they're in person because they have more tools at their disposal. The visual, emotional, and coordination of movements provide a more comprehensive picture. This is especially true for those interpreters who have been doing this for a long time; they are able to pull together so much more information when they're in person. Additionally, they are better able to manage the timing and flow of information between multiple participants: patients, families, and clinicians.
Interpreters frequently mentioned that being in person builds more trust because they're better able to convey information to patients and clinicians. Patients feel like they're more fully heard. Physicians feel like they're getting the information that they're looking for. Both are better able to get on the same page and come together with a plan.
What do you think accounts for this difference?
Our interpreters reflected on how multiple aspects of a healthcare visit are non-verbal. How do you talk through the right positioning for a wrist x-ray to capture the right images without being able to see the physical space, the location of the arm, and coordinate words with gestures? Or consider how challenging it is for phone-based interpreters during pulmonary function testing, where a patient has to breathe quickly and forcefully through a tube in a very specific way at a very specific time. It’s extremely challenging to do this when folks are not physically present together.
Another example is the frequent screening questions that need to be read off a piece of paper or computer screen at every visit. It’s much more efficient for an in-person interpreter to read those questions to the patient in their preferred language, versus the physician having to read the questions into a phone, when they are then translated and read back to the patient.
What are your plans for sharing your research findings?
We're excited to take all these conversations and use the findings to create multiple papers. The first paper shares how a clinical experience looks different between virtual and in person.
The second paper is going to be about the interpreter experience in COVID, as interpreters were often not considered essential workers in the same way as healthcare providers. They are not actually often employed by the health system, and so at times didn't have access to PPE or a voice in development of new COVID processes and protocol. They often felt isolated, forgotten, despite doing important, essential work.
We anticipate the third paper will discuss the scope of the interpreter role, including how it's defined and integrated within healthcare systems. What potential impact might it have if medical interpreters were to be treated as interdisciplinary team members and critical experts—not just individuals who communicate language between two people?
Why is this work about medical interpreters important?
Within an interpreter’s defined role and scope, they are to interpret word for word between two parties, and not insert themselves into the conversation. But many interpreters have learned so much along the way about effective ways to describe various medical situations; diagnoses, procedures and medications, as well as cultural situations, and really develop into experts in their field.
I want to find a way to honor that knowledge and elevate the role that they play in providing high-quality care. Maybe even compensate them more appropriately and help get more people into these types of roles in the long term.
What made you want to study this?
I practice family medicine at M Health Fairview Clinic - Bethesda, in St. Paul’s Frogtown neighborhood, where we do a significant amount of refugee and immigrant health. At Bethesda, over 40% of our patients require an interpreter. We practitioners work alongside interpreters all day, every day. And what we've been hearing from the health systems and insurance companies is that in-person interpreters are too expensive and that doing virtual interpretation is a more cost-effective, equally high-quality, way of providing language support for patients.
The health system is encouraging us to move away from in-person interpreters, and there are some good reasons behind that. The timing to get everyone in the right place at the right time is hard. Having interpreters travel between different locations can be complicated and time consuming, and coordinating the right language in a timely manner, especially in emergencies, is hard.
But I wanted to better understand what we may be losing by moving to virtual interpretation. Does it affect the quality of care for patients? Does it affect patient satisfaction? Does it affect my ability to provide the same high-quality, patient-centered care I give my English-speaking patients? Does it lead to increased clinician frustration and burn out? Because when you don't have critical information to help support your patient appropriately, that feels awful. Interpreters matter, especially in person.
Who is on your project team?
We have a whole group that's been working on this project together. Sherri Fong, MPH, has been our amazing research coordinator. Lauren McPherson, MD, MPH, a postdoctoral cancer disparities research fellow, has been with our group from the start and has great insights on research and care.
And we have a stellar fourth-year medical student from Ohio University, Faiza Aziz, DO. Faiza worked as a Somali and Swahili interpreter at Hennepin Healthcare before she started medical school. She is a wonderful interpreter and medical student and will be a wonderful doctor. We have another outstanding medical student, a current third-year UMN student, Marin Melloy. Chloe Botsford, MPH, is another great public health researcher who helped lead focus groups and has been a part of the writing process too.
We were lucky to build our focus group guide and participant materials off previous work by Maura Shramko, PhD, and Maria Veronica Svetaz, MD, researchers with Aqui Para Ti, a program for Spanish-speaking youth. It's been a full group effort because most of the team is new to qualitative research and focus group design and implementation, and I feel so lucky to be working with such a smart, flexible and overall great team.
What are the findings of your research at this point?
Building relationships, trust, and understanding between people is better when all parties, including the interpreter, are in person (especially if a patient might be in distress, has mental health concerns, or is acutely ill). People feel calmer. They feel better. They feel more heard. The way that the clinician and the patient connect is enhanced when interpreters are in person.
The second thing is that there's understanding between parties, including improved accuracy and lower error rates because of the many nonverbal inputs like body language, gestures, and pacing. Interpreters are really good at identifying when patients are confused. Clinicians should be good at this too, but interpreters are even better because of their enhanced communication training. When you're explaining a new concept or a medication or what happens next or what to watch for, being able to effectively clarify and make sure patients understand decreases risk of complications and helps ensure timely and appropriate follow up.
The third theme was around access: the importance of having professional interpreters in all situations. The option of virtual interpreting fills an important need. Sometimes virtual interpreters improve efficiency and flow.
On the other hand, if you have a clinic with a good interpreter and a consistent language, visits actually go faster and you can see more people if the interpreter is in person. In-person interpreters eliminate the process of finding the technology, logging in, getting the right person, the right language, ensuring everyone can hear and is connected, and completing all the introductions. This can happen three or four different times in one office visit as patients travel through the clinic. In the right setting, having an interpreter in person who travels with the patient through their visit is actually faster than doing virtual, which I think people often forget.
Our last theme centers on health equity and the importance of elevating the patient’s voice. Interpreters hear frequently from patients comments like, “I don't trust the system” and “I don't want to go in.” But when they have a high-quality professional interpreter that they work with, and they know that person is going to be there to meet them and help figure out where in the building to go and walk through the different steps of the visit, and promote their voice and their needs, that's going to increase the likelihood they seek care.
Is it always better to have in-person medical interpreting?
At first my inclination was that we should always have in-person interpreters—that it is the gold standard and best option always. I found that's not true. There are definitely clinical situations where virtual works really well. These findings helped our team develop a framework for selecting an appropriate interpreter format to help clinicians, and hopefully guide healthcare system policies as well.
Because, for example, in a situation where you have an established relationship and routine chronic disease follow-up visit, where participants know each other well, using a virtual interpreter works fine. But there is a big difference in complexity for interpreters working the ER or in labor and delivery or when explaining a new diagnosis of heart failure. Compare that to a fifth or 10th diabetes visit between patient and provider, one where we're just reviewing labs and adjusting medications. For that, virtual interpreting works pretty well once the education and the relationship-building has been established on the front end.
As you look to the future, what are your hopes with regard to the next steps with this research?
We definitely want to get this information and our learnings out there. We're working on that right now. We also have meetings set up with different professional organizations, such as the Minnesota Academy of Family Physicians and the Minnesota Medical Association to discuss opportunities for advocacy and policy changes. Interpreters also have their own professional organization, the Upper Midwest Translator and Interpreter Association (UMTIA), and meeting with them provides opportunities to partner and work together.
One goal is to seek out opportunities to bolster the number of interpreters working here in Minnesota. There used to be multiple interpreter training programs in Minnesota, and now there's only one degree program, at Century College, and a few scattered certification programs. Opportunities exist online as well, but we need to think more critically about how we might develop opportunities to train additional interpreters. That includes considering the value of interpreters and ensuring compensation, support, and education that honors their professionalism and the complexity of the work. This needs to be a sustainable long-term employment option. We hope to advocate for providing educational opportunities and enhancing this area of the workforce.
Additionally, we plan to meet with local health systems to consider ways to integrate and implement some of the things we've learned. The goal is to get the right interpreter, in the right format, in the right place, at the right time. We'd love to do patient focus groups and hear that perspective—it's something we’ve been excited about from the beginning. We’d like to see if what we've heard from the interpreters matches the patients’ desires, concerns, and needs.
Do you have any other thoughts you’d like to share?
I always felt like I understood what interpreters did and the complexity of their role. But after doing these focus groups and listening directly to interpreters themselves, the respect I have for the complexity of their work and how they do it has increased so much.
It's an impressive skill set; they have to work fast and can't always anticipate what's going to happen. They have to know a complex medical terminology as well as have a deep understanding of multiple languages. They have to figure out how to stay calm and support the patients’ emotions at the same time. It's a hard job. When interpreters are working over the phone or over video, it's much harder because they are missing inputs and information. They're not there. They have to insert themselves into the room, and they get paid significantly less to do virtual work. Essentially, virtual interpreters get paid less to do work that's harder and more complicated.
Interpreters do complicated and emotionally challenging and vital work. I think a lot of us take them for granted, including myself. I am less likely to take them for granted now.
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