Monday, August 11, 2008

Alterations of content of family meetings by medical interpreters

Chest has a fascinating paper looking at how content can get changed by interpreters during family conferences. The data comes from an analysis of transcripts of ICU family conferences in which the family didn't speak English and a certified medical interpreter was used (the study took place in two Washington state hospitals and the interpreters were certified via a Washington state certification process). (All this comes from a larger study which involved tape recording ICU family conferences in which end of life issues/decisions were likely to be addressed - this is a subanalysis of 10 conferences in which an interpreter was used.) Essentially they hired certified medical interpreters (who weren't involved in the study and who didn't know the interpreters involved in the study conferences) to transcribe and translate into English the non-English portion of the tape recorded conferences. What the family 'actually' said was then compared with what the interpreters translated in the conference and vice versa for what the clinicians said. There was some quality control to check the accuracy of the hired interpreters.

They then schematized 'alterations' in content into omissions, additions, and substitutions, or editorializations, and further categorized these into positive or negative alterations in several categories (e.g. medical information - interpreter decreases certainty of prognosis vs. increases certainty of prognosis, interpreter makes an implicit prognosis more explicit or makes an explicit prognosis more implicit; emotional content - interpeter omits emotional language, makes harsh sounding clinician statements softer, etc.).

Major findings are as follows: alterations were common, in over 50% of translated statements. Most were editorializations (which they defined as an interpreted passage which combined at least two of either an omission, addition, or substitution) or omissions. 77% of these were judged to be 'potentially significant' alterations (which could affect the goals of the conference such as sharing accurate medical information, building rapport, eliciting patient values, establishing treatment goals, etc.) and almost all of these were judged to be negative - interfering with those goals. They note that an average of 16 alterations which could affect treatment decisions occurred each conference.

Yikes. Before you flip out, which is what I did when I read the abstract, it's helpful to see examples they gave of these - some are drastic and some are more subtle and (especially given the small sample size and relatively preliminary and potentially subjective nature of the interpretation of these alterations) one shouldn't make too much stock in those numbers. Saying that doesn't take away of course from the overall finding of the study: real-life interpretation is fraught with hazards, even with professional interpreters, and when there seems to be protracted conflict, lack of understanding, or that little voice in your head saying 'boy I don't think they're getting it' or 'something's wrong here' - consider problems in interpretation.

Anyway: the examples they gave ranged from just flat out 'wrong' interpretation to changes in emphasis which remove opportunities to build rapport, establish treatment goals, etc. .

Doctor: I don’t know. Um, this is a very rapidly progressing cancer. Interpreter (translating): He doesn’t know because it starts gradually.

Doctor: Have you spoken to your husband about these kinds of questions before he got sick, what his wishes might be in this sort of situation? Interpreter (translating): Did you talk to your husband before he got so sick about possible situations, what was awaiting him?

The authors recommend:

First, preconference meetings with interpreters might provide an opportunity to address some of the causes of alterations. These meetings might include a discussion of which interpretation approach would be most appropriate (eg, strict linguistic translations or a "cultural broker" approach), and might provide an opportunity to clarify the topics to be discussed and the terminology that will be used. Second, by speaking slowly and using short sentences, clinicians can prevent a situation in which the interpreter has to remember large blocks of information, thereby reducing the chance the interpreter will make alterations and particularly omissions. Finally, physicians should repeat important concepts and ask the family members if they have questions about those concepts to make sure key data are accurately conveyed to the family.

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