A Musing on Interpreters in the Pediatric Exam Room

L. Gregory Lawton, MD


March 21, 2018

When I practiced pediatrics as an Air Force officer, every one of my families spoke English. During residency rotations at Children's Hospital Oakland or University of California, Davis, I am certain that I made use of an interpreter as needed to conduct a history and physical exam, but I cannot specifically recall an encounter. It was not until I moved to Chester County, Pennsylvania, that I started to have more regular and memorable encounters that necessitated the use of interpreters.

Chester County is home to Kennett Square, the mushroom capital of the world, where over a million pounds of mushrooms are produced daily. The industry employs many farm workers, the majority of whom speak primarily Spanish. In my Children's Hospital of Philadelphia (CHOP) practice, I saw many a child brought in by a parent for whom English was a challenge, making conveying their questions and concerns difficult. Enter the interpreter.

Since a move to another practice in a different county, I hear Korean, Arabic, and Russian, with the occasional Spanish for good measure. At CHOP, we are very fortunate that for the vast majority of our encounters, we have live interpreters in the room. An alternative, interpretation over the phone, is certainly better than no interpreter at all, but it is devoid of nonverbal cues (which contributes to individuals speaking over or past one another) and complicated by poor-quality phone equipment.

Alejandra Duran Arreola, a second-year student who intends to practice obstetrics and gynecology, works as a translator for Dr Matt Steinberger at the Access to Care clinic at the Loyola Center for Health.

Often, the same interpreter is present on multiple occasions for the same family. Because my brain tends to group families by faces in an exam room, my inclination is to think of interpreters almost as family members. Interpreters become familiar with the families, the children, their medical problems, and the unique personalities of each of the members. Likewise, they become familiar with me as a physician—my style, humor, and mannerisms.

Over the years, I have learned a great deal of medical Spanish. This is thanks, in large part, to having studied Spanish in high school and college. But it is also due to the style of one Spanish interpreter, as well as perhaps the close relationship the Spanish language structure shares with English.

Me: For how many days has there been a fever?
Interpreter: ¿Por cuantos días ha habido fiebre?
Parent: Tres días.
Interpreter: Three days.

Perhaps is it my ear for Spanish, but I learned to take a very focused sick-visit history as a result of asking a question in English, hearing it turned into Spanish, then having the Spanish to English answer returned to me.

Sometimes, even when the interpreter is in the room, I would try my hand at a simple Spanish comment or observation—"muy guapo" for "very handsome," or "Lo siento" for "I'm sorry" when my probing otoscope results in protest from a feverish 1-year-old.

Along the way, I have discovered some humorous word relationships. Once, when trying to tell a parent that their toddler was very strong, rather than using the word fuerte, I said fuente—"Your child is a fountain." The interpreter laughed, as did the parents, realizing my mistake, but they appreciated the effort. My favorite Spanish phrase to employ, especially with small children, is "poco loco"—a little crazy. Pointing to the colorful socks I routinely wear, it is a phrase that is both apropos and rhymes.

My experience with Spanish is that the question/answer exchanges tend to be highly focused: English(q) → Spanish(q) → Spanish(a) → English(a).

It is not always so with Korean or Arabic. Many a time, I have sat helplessly as the parents and interpreter engage in a back and forth that looks like this: English(q) → Arabic(q) ↔ Arabic ↔ Arabic ↔ Arabic ↔ Arabic ↔ Arabic ↔ Arabic ↔ Arabic ↔ Arabic ↔ Arabic(a) → English(a)

Between my initial question and the eventual answer, there has been a long exchange in Arabic between the parent and the interpreter before resulting in a response I can understand. A question that I anticipate can be answered in a relatively simple way (for example, as a number or a binary response, such as yes/no or better/worse) can spark a long conversation while I am left hanging. Even as I try to get the interpreter to hone in on a specific piece of needed information, I recognize that language has its limits. And parents want to be sure I know what they think I need to know, even if I haven't asked for it.

Such exchanges can be frustrating for both parties, leaving the interpreter in the middle trying to straddle the linguistic nuances between two parties who, while sharing a desire to help the patient, have little to no means of communicating.

Although it might be tempting to consider interpreters as "neutral" intermediaries in the exam room, they too are subject to the personalities and circumstances within the room. An interpreter has cried as a diagnosis of cancer was discussed, or manifested frustration as a family persisted in asking the same question repeatedly, hoping for a different explanation or answer.

Recently, an 18-month-old with preternatural pulmonary capacity and vocal range registered her displeasure with me while I examined her abdomen. So effective was she that the entire office (and possibly beyond) knew of her feelings on the matter. In the small exam room, it was loud. The frazzled interpreter took in what the parents said in response to my question, turned to me, and with an earnest but exhausted expression, gave me the answer in Korean. I stared back at her for a couple of seconds. " English?" I finally asked, with a raised eyebrow. We both cracked up.

As the great American experiment of a nation of immigrants continues, our country will continue to benefit from an influx of peoples, customs, foods, and languages. Medicine, and in particular pediatrics, will continue to be the leading edge of this trend. Successful assimilation of a family and their children into the United States requires access to the possibilities and opportunities in this country. Access to healthcare is a significant part of this process. Our willingness to use and engage with interpreters in the medical realm is integral to making families for whom English is not their first language comfortable seeking out our services and advice.

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