Blia Yang Moua is in surprisingly good spirits as his doctors help him out of his hospital bed.
"We want you to do the two-step transfer, so roll," his doctor said. "Not off the bed! Oh, he's joking with me!"
Just a few days earlier, Moua was suffering from severe kidney failure. He needed medical attention immediately, but Moua speaks almost no English.
Through his interpreter, Ted Xiong, Moua explains that the idea of going to the hospital scares him.
"Yes, you don't have total confidence because of the language barrier," Moua said. "You might say something wrong, and then you might have surgery and it might cause death. So of course you are afraid."
Now, Moua has Ted Xiong at his side. Xiong translates what Moua says from Hmong into English.
Xiong is part of the language services staff at the Fairview Clinic of the University of Minnesota. He translates for several southeast Asian languages, but to him the hardest part of the job has nothing to do with words.
"It's being in the middle," Xiong said, "between the patient and the provider. You cannot advocate for them, you can't give them advice. It's like... you are just a voice."
Some estimates say that only one-quarter of U.S. hospitals have trained interpreters on staff.
Larger urban hospitals, like the Fairview clinic at the University of Minnesota, often have whole departments dedicated to language services. But in smaller clinics interpreters are scarce, and not all of them are as neutral as Ted Xiong tries to be.
Dr. Elizabeth Hebl agrees that interpreters need to be passive translators.
"What you want is a two-way conversation between the clinician and the patient, with the interpreter there to help with communication," Hebl said.
Far too often, Hebl explains, they aren't. That's because in many smaller clinics professional interpreters aren't available.
Hebl has been in countless situations where she's had to rely on ad-hoc interpreters like bilingual staff, or friends, family and even children of the patient, often with unnerving results.
"There is a bit of fear," Hebl said. "You wonder, 'What am I missing?' There are times someone walks out of there and you think, 'How much better of a job could I have done if we only had a common language?'"
There is good reason to worry.
A 2003 study conducted at the Boston Medical Center and published in the journal Pediatrics, found interpreters make an average of 31 mistakes in the course of one medical appointment.
Non-professional interpreters are much more likely to be the ones making those mistakes.
The most common was leaving out important information, but some interpreters even edited the doctor's words, adding their own take on the situation.
These are the problems that keep Mursal Khaliif up at night. He directs the language services program at Fairview, and has completed a fellowship on the topic of medical interpretation.
Khaliif points out that for most jobs in the health care field, there's rigorous testing done before someone is allowed to work.
"If someone wants to be a licensed nurse, they have to complete a set of exams or tests that would then certify them as a nurse," he said. "There isn't an exam or a test or a certification process that someone has to go through to become a medical interpreter."
This lack of training has led to some serious mistakes.
Khaliif remembers one case at a Twin Cities' hospital where a Hmong cancer patient was told she needed radiation therapy. But the interpreter translated the treatment to mean a "fire in the body." The patient refused the procedure until a more competent interpreter could give her a better explanation.
Khaliif says testing interpreters on basic medical knowledge could prevent situations like this one.
But he says a big part of the problem is that there are roughly 150 languages regularly needed at hospitals.
Coming up with a way to test both medical and cultural fluency in all of them would take a mountain of resources, something that limited English speakers may have trouble mustering.
"Many of the people that are represented by these languages are usually people that have little voice in our political and social context," he said. "Partly, I think that has been why there is little advocating for moving this forward."
But Khaliif is optimistic. Nationally, there are several groups working on a standard code of ethics for interpreters. In Minnesota, a bill was recently passed creating a commission to look at standardizing and testing language workers.
Mursal Khaliif says when it comes to training and certification for medical interpreters, it's only a matter of time before everyone in the field is finally speaking a common language.
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