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#137 Nina Harkavy and Lorraine Way on Medical Interpretation

by Kira Dineen
December 18th 2020

This episode we are exploring medical interpreting in genetic counseling and other areas of healthcare. Joining me are Genetic Counselor Nina Harkavy and Inte... More

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Joining me are genetic counselor Nina Harkavy an interpreter. Lorraine Way Nina is a prenatal genetic counselor at Columbia University. She graduated from the johns Hopkins University, N. H. G. R. I counseling training program. Lorraine is a spanish instructor. She actually taught me at Sarah Lawrence. She's also a medical interpreter and the president of Language Way, a Language service company. She has a master's in France from Middlebury College where she also studied spanish. Thank you Lorena Nina for coming on the show. I'm really excited to dive into talking about interpretation and being able to use interpreters. I think we have a really good show ahead of us. So thank you so much for coming on. Thanks for having us. Yeah thanks for having us, kira. So, nina, how has your counseling experience changed? You previously didn't speak any spanish and now you have like a working proficiency. How has that experience change of going from knowing very very little spanish to now being able to communicate with spanish. Yeah. I mean it's a world of difference. I cannot even tell you. Um you know it's changed things in so many ways.

You know again the position that I was in when I didn't have any spanish you feel kind of disconnected from your patient. You're worried that the patient isn't getting the level of care that they might get if you understood them more clearly. You worry that there's a mistake in the interpretation that you won't be aware of. So you know, being now able to understand what the patient is saying, what the interpreter is saying and to some extent to make myself understood as well. I mean it's it's changed everything. It's changed the level of care that I think I provide because I'm able to understand more directly kind of what the patient is looking for without getting things lost in translation. Um I'm able to just make sure the session is as accurate as possible and correct mistakes as they come up and ask interpreters to clarify. Um and then I also it's interesting. I have some more like cultural insights now. There are things that I never would have picked up on without understanding the language that are very subtle that now that I understand my patients, I kind of get a little bit of a view into you know, what is more relevant for this patient that I might not have considered.

So everything more transparent there. Yeah, absolutely. And Nina, I'm just curious um when you say some insights culturally, can you think of anything specific that jumps out at you? Yeah. So I think, you know, it helps me connect with the patient, you know, one I guess one tiny example is that I had a patient recently I was asking her why she had a C section and her response was you know, suppressed the meant to suppress cement. So she was very much emphasizing supposedly and you know, then she said I was past my date. So the interpreter just said I was past my dates and I had a I had a student in the room right? And so the patient and I laugh because she's from a country where they do a lot of C sections that may not be medically necessary. So she and I now have this understanding of like I just had a C section because you know, and the student was like, hey, I feel like I missed something because you and the patient had this moment where you guys laughed about something but the interpreter just said she was past her dates. Like what was funny about that. So it's a little little stuff like that.

What a great example. And I'm sure that really helps you build rapport with patients instead of, you know, sometimes I've seen when genetic counselors and other health care providers, this kind of all applies to anyone in the healthcare field that everybody is looking at the phone and not each other. Whereas I'm sure now you're looking at each other and the interpreters kind of chiming in and helping making sure you're Your understanding at that 100%. But you're picking up on so many more subtleties in really having that human to human connection, whereas sometimes that's lacking when you're totally reliant on an interpreter for sure. I mean my patients might start by like kind of talking to the phone because the interpreter is by phone. But then as soon as they realized that I understand them, which they realized very quickly, even if I don't explicitly state that they realize that I'm understanding them. First of all, they're so happy um that I can understand them and then they look directly at me, they stop saying sentences like tell her meaning me. Um they just talk directly to me. I think they're more likely to disclose information to me because they know I'm going to understand what they're saying.

Um and it just again, tiny little things that you wouldn't think about Like my patients again, culturally some of them are more likely to use terms of endearment or like pet names. Um and so I hear frequently patients say maya moore and I think that that's nice in the sense that they maybe that means they know I'm being sincere. So even if they're about to decline everything I'm offering them and they're like, no, but thank you, Maya moore. I really appreciate you taking the time the interpreter has never ever translated that. I've never heard an interpreter translate that phrase. So it's like, I'm so glad that I know that they're saying that. And I think that that means they feel a little bit more connected to me than they otherwise would. You're not missing those subtleties that are really important that yeah, maybe when you're um being able to interpret that direct language, it's like, okay, yeah, we covered this. We covered this. But it's like counseling is not just the information given. Otherwise we would hand people a packet. Do you have a comment to what Nina just said? Which I find very interesting that the interpreters are not interpreting those terms of endearment um as as a trained interpreter.

We are, we have pretty much a code of ethics to interpret everything that the provider is saying including hums, you know, hmm. And pauses and non verbal forms of communication and tone. Um you know, we're we have that's what our job is to interpret all of that too. So I'm a little surprised that they're always admitting that it's curious to me. Um but I'm thrilled that because of your knowledge of spanish, you're able to pick up on those subtleties and build the report with the patient. What are some general tips you have for working interpreters for the china, counselors, listening, the healthcare providers? Um well some may be obvious to people who are currently working with interpreters on a regular basis. Um but we actually are in our pre session, we are also trained to ask you to speak to pause frequently. That's a big one. Um it's easy to get caught up in what you're trying to convey to a person and especially in an emotional situation and start speaking more rapidly and with longer sentences that are always harder to interpret with a high level of accuracy.

So I would say the pausing frequently is one um speaking in somewhat shorter sentences um somewhat not always. Um and then um if you can at all avoiding idiomatic jargon, slang and idiomatic expressions are harder, harder to be highly accurate in an interpretive environment. It's not that it can't be done, it's just that it gets harder because um any form of familiar language is deeply rooted in the specific country and sometimes the specific town. So um there's just too many variables there. So um if you speak more in standard language plain terms um commonly used vocabulary. Those are some good things that are helpful in interpretation. So staying away from, oh I was so engaged, my eyes were glued to the tv because that's not going to translate very well using something like that.

That's what you mean. Yeah. Yes and no that's um that's a pretty good example. Um And just to know that interpreters are required to interpret meaning and not words right? Um So glued to the tv, we might we might say attached to the T. V. And that the the interpretation and spanish might sound like attached to the T. V. And not use the word glue because that's not probably what they would be using. So um that's that is actually very important in the turn in terms of interpretation it's not words it's meaning. Um and I think that's where you get at what the differences between translation interpretation. Because we've been talking about interpretation. But can you differentiate the two for our audience? Yes. Um translation is the written word only. Um interpretation is oral only. So they're not interchangeable translation is going to have a more exact quality because you have time to research if you're actually translating a written page or a book or an article or anything that somebody is doing or medical notes.

Um if there's something that you don't know, you look it up, you have multiple dictionaries and you get very very exact um interpretation. Um when I say meaning and not words um we'll go back to one of the examples of you use a somewhat slang expression, but if somebody says, oh I'm just pulling your leg, that's like an idiomatic slang expression. Um but the interpreter might might interpret that as I'm just teasing and there is no loss in the interpretation because you have accurately conveyed meaning. Whereas in a written document, a translation that's not acceptable. You need to go back and find that as close to an equivalent. If there's sometimes there's no equivalent but often there is um so you have to find that and correctly translate that in writing. Yeah. Along those lines. What are a few concepts that are challenging to interpret spanish nina? Is there a concept that you come across a lot that you're like this? I always have to phrase very specifically or I have to say it very different than I would in english?

Yeah, there's two in particular. So one that comes up in every session, actually both come up in every session, but one would be carrier, the term carrier. And I think that especially in interpreting for genetics and I thought this was maybe my bias because I'm in genetics. But I talked to a couple other health care providers and they said one of the hardest things with using an interpreter and genetics is that many words don't have a synonym, You just have to define the word. Um And so the word carrier for example has its own connotation. We know what we're saying. You know, if I say the phrase, if you and your partner are carriers of the same thing, you may have a child who has the disease. Uh, that does not get translated correctly because there is inherent context that we're not explaining. Right. The word carrier has its own context. So what happens is the translation ends up being if you have a disease and your partner has a disease, your child may have a disease. And that's obviously not what I'm saying. So I've learned to be super careful about, you know, saying if you are a carrier of a genetic condition, meaning that you don't have any symptoms and you are healthy and your partner is a carrier of the same condition.

It's also healthy. There is a chance that both a healthy mother and a healthy father may have a child who does have symptoms and is not healthy and it sounds kind of repetitive. You know, I'm using a lot of the same words over and over, but I'm trying to get meaning across. Um rather than relying on the word carrier to include meeting because otherwise, again, it just it gets lost. Um, So that's one that is constant. I really have to define carrier in order to use it. Um, The other one that comes up a lot is is it's really tricky to do a pregnancy history. Um, Lauren and I definitely talked about this a lot because um the word Alberto is non specific. It doesn't tell me whether that was a miscarriage or a termination. Um And so when a patient answers a question with, oh that pregnancy resulted in Alberto. I don't I don't know what that means without um further clarification. And that being said. You know often what I've noticed is if I ask if a patient has had any terminations there automatically like yep four terminations 40 weeks and you're like Um Okay and by that you mean terminated, completed the pregnancy.

So it's like that often also gets lost in translation where they're saying, yeah I have four complete 40 week pregnancies term pregnancies, not termination, which we know to mean abortion. Right? So they're confusing the word uh termina with a termino, right? God is um to end. Um But a termino is the is what you're looking for for something going to term, right? And your right to avoid confusion in case your interpreter is not picking up on the nuance there more than clear meaning there. Um Then you would definitely need to add that follow up question. Absolutely. Wait, you're still drawing pedigrees by hand in 2020. Don't worry, we have a solution for you. Finna tips, complete genomic health record. Not only has intuitive pedigree drawing tool allowing you to capture complete family history 2.5 times faster than pen and paper. It has a pre visit patient questionnaire that auto draws your patients pedigree customizable into multiple languages on top of pedigrees that draw themselves?

You can capture all relevant patient information and get diagnostic insights in six different languages. This ensures clear communication with your patient, no matter what language they're comfortable with as we're learning in this episode, clear accessible communication is the heart of empathizing, understanding and supporting your patients see it for yourself. You can book a short demo at fino tips dot com Again find them at fino tips dot com. I'm also the host of the few native speaker series where I have interviewed genetic counselors about topics like telehealth, digital tools, leadership and precision medicine. You can watch all these free webinars on demand at you know tips dot com. Just click the stories tab and you can stay tuned for future installments in 2021 and nina do you have a way of checking with patients that their understanding the information? I mean there's ways that you know sometimes in english you can really sense if someone is understanding and sometimes you can and that's a whole another another area but with spanish there is more of a barrier there you're taking down the barrier quite a bit of understanding and be able to communicate in spanish but is there certain ways that you're able to check in with them without feeling like maybe you're quizzing them.

Is there an approach that you've learned to kind of finesse? Yeah. You know that that idea of quizzing them is so damaging. You don't want them to feel like you're giving them a pop quiz, especially if they're from a culture that really does not want to be seen as incorrect or or stupid unintelligent. Um so I think you know, some of it is context, right? So if you ask a question and you get an answer that doesn't quite make sense. Like have you had a termination yet at 40 weeks? You're like no wait something went awry there. Um and then also so um you know occasionally the questions that they ask me like okay, so if this is positive, I need my partner to come in for testing. Like great that shows me at least got something about the carrier screening aspect that it's for both parents. Um and my favorite is actually if they have someone with them or somebody on the phone that they're interpreting to in spanish like if their partner is like wait I'm confused and then the patient explains to the partner what they're doing. I love that because then if I hear the patient explain it correctly usually in like a very kind of basic level because they're just talking to their partner, it's amazing because I'm like, oh you absolutely got it, I can hear you explaining it.

Yeah, it's a good feeling when you can say okay, I really, you know during counseling sessions aren't super super long. Usually you have a lot of patients that are moving in and out and so to be able to teach them that information and then seeing that they actually have it is like you have that teacher moment of like, wow, okay, my patient got it. I'm proud, I'm glad that that could come across well and I'm sure using translators to that sometimes there's miscommunication with them, not even the patient, but just between you and the translator. What have you found to be some sources of that miscommunication and then we can hear from Lorraine side. Yeah, so again, I think a lot of it has to do with like you know where you're going with these questions and some of your words have context inherent in them. The interpreter does not know where you're going with things. So sometimes it's just an issue of there not even translating incorrectly or poorly, it just didn't get across like in the carrier example. But I've had these kind of disturbing examples that have come up where if I didn't understand spanish, like I'd be really concerned for how that session would have played out because you know, in one session for example, I had a patient we had diagnosed a fetal heart defect and so I knew the patient was in a little bit of denial and I started the session by saying, you know, we know that there is a problem with the baby's heart, but right now we don't know why and that was translated as we don't know if there's a problem with the baby's heart and that right, that kind of killed me.

And I don't it's like I don't know exactly what happened there. I don't know why that was the translation per se. If I wasn't clear, but you know, immediately had to jump on that and be like actually interpreter, that's incorrect, I'm sorry, but it's really important that you clarify there is definitely a problem with the heart. The only part I don't know is why. Um you know, so sometimes I don't know why there's a miscommunication. Um but I appreciate when the interpreter tries to resolve it. I appreciate when the interpreter pauses to ask for clarification. Um and I struggle with when an interpreter maybe doesn't understand what I'm saying but doesn't ask. So sometimes what happens is I'll say a word that they aren't familiar with like amniocentesis. The majority of them will ask me, you know, for more information about that word. But some people just kind of like make up a word. Like I'll say amniocentesis and they'll be like, yeah, and I'm like what just happened? Like why? So I've learned to you know if there's a word that I want them to use carefully. I will spell it for them or I will provide them.

The word that I want carriers should be translated as Porta door or Porta Dora if it's anything else, it's typically like incorrect. Um And so I've gotten really careful about spelling words for people so that they're giving the correct word or about providing them with the word that I want them to use. And Lauren did you want to jump in on your side of where miscommunications can go wrong? Um Well I do want to comment on a couple of the example um examples Nina brought up and um also to her point of um sometimes the interpreter doesn't know where the provider is going. Um So as you know, medicine is a huge field, so when you are receiving somebody as a medical interpreter um they're definitely not going to have the expertise in every area that you that you might need them to or want them to. So it's common for certain certain medical terms that uh an interpreter may not have come across.

Um Amniocentesis is not one of those words that I feel. Um Although in quite a number of countries they don't even have access to an amniocentesis or may have even heard of it. Um which for our world is um sounds very unusual but um in my interpreter course there were many countries that didn't have the test at all and there was no word in their language for that test. Um So you can have that that arises but to the specific um alarming example that Nina did give. Um I do not see any um reason for that to not have been interpreted exactly accurately. Um and fortunately she does speak quite enough spanish to know the difference and intercede and um ask for a correction um for sure. Um I myself have an enormous exposure to medical um experience having grown up with a mother who is a nurse and a number of doctors in my family and have been um teaching medical spanish for over 20 years.

Um So and I still don't of course know everything but far from right. Um I'm learning all the time as we all are. Um but so from my own personal experience, I'm going to have a little bit of a better understanding of where the provider might be going with something. Um but absolutely don't hesitate to stop and ask. Or even if you find that that particular inter interpreter is struggling way too much or you find way too many inaccuracies to switch interpreters if it's on the phone or if it's face to face to ask for a different interpreter, you have every right to and you really have an obligation to the patient to say, you know what this, I can tell that this is not going right and say, I'm sorry, interpreter, I'm gonna have to get someone else and that really is your responsibility as a health care provider. And a couple of those points. The interpreter was breaking code of ethics, They are never so no one is ever supposed to make up a word if they don't know right? I mean that's that sounds obvious, but we do receive this training as part of our program, you know, in in a professional medical certificate or certification, you are trained in those ethics that um if you do not know, you ask the provider if it's a it's a word, you don't know, you ask the provider to explain what that word is.

You know, if I would end up in certain points of oncology, I may not know some words, I do a fair amount of mental health, i genetics and other specialties, but I might, they might elude me with some specialist term in oncology, so I might have to ask the oncologist, could you please explain what that is? Um Lauren, what is involved, you said a little bit of the training process but what is required to actually become a medical interpreter because I think a lot of people I I didn't know before, you know, being your student of what is required of medical interpreters to be able to be in this role. So um there is a very wide range that you're going to see and experience and you probably would know just by working with some of the interpreters, those that have the higher levels of trainings versus those who don't um so at the top level there is a national um a national organization that certifies medical interpreters.

Um this is going to become the golden standard but it is not yet the golden standard. The people that have that background are going to have um a bachelor's, a Master's degree. Um They may also have a degree in interpretation from one of the schools in this country or abroad. Um And then they would have to pass extensive examinations in this national um national certification for medical interpreters. Um That's a very high standard. Most of the interpreters that you're having work um that you use are not going to have that standard those that I have seen based on my small experience. Um in this field the reason is my primary field and languages has been um teaching translation and now interpretation. So I have experienced interpreting but not as much as translation and um and the teaching of medical spanish. Um So the access that I have to that right now is that those that have the higher, higher higher levels um might be one or two face to face hospital interpreters that are higher and they're also supervising the team of interpreters.

Um If you start going down the scale um sadly enough when I started to look for work to supplement my income in medical interpretation, almost all of the ads at high school diploma. Uh um And uh those people may or may not, they mostly if they're hired by an agency or by a telephone interpretive service, they have passed some kind of task to get hired. Um And that's usually an audio, a prerecorded audio test that they have to interpret and then that's graded, that's recorded and graded. It's that type of test not. Um I don't know if some of them have written tests, I haven't seen that yet. Um So you know, at the very low level, which could be um quite a number of the interpreters that you're that you have, you could have someone with a high school diploma that has maybe a certificate, a brief uh five weeks certificate and medical interpretation um at the top level Masters plus plus extensive certification experiences.

So the range is huge and I think that's part of what's going on in the profession that it's starting to um they're starting to work toward more higher level professionalism and more standardization. Um It's just to feel that interpretation by and large in this country has not been enormously standardized. Yeah, I think that's a really good point in just that health care providers may not know really the extent of like how much the interpreter has in their background of education. And I think beforehand, I thought that, oh, they must have a master's, that's kind of what I was thinking and that's not the case always. I think that's something to be aware of and all right, another point of just kind of throughout this episode that we've had is any amount of another language that you can learn is advantageous. And I hear this a lot in the field of from students saying our medical spanish class at Sarah Lawrence College, only some students took it, it's an elective and so, you know, some people were saying what's the point in just learning a little bit, I'm going to use an interpreter anyway.

And I think me taking this class, I've really seen, the other side of it is like the more I know, the more I'm able to see if the translator is accurately doing this and connect with my patients even just a little bit if I'm asking them how they are, what their name is. And so I think that's a really good point that I just wanted to pull out because I think you guys have really highlighted that a lot. I mean I'm sure you can agree with me on that, that really helped me. Yeah, and I think that that's so valuable because again, as somebody who was just learning spanish from beginning, you know, in my twenties and this is going to apply to a lot of training genetic counselors who are twenties thirties, whatever learning spanish for the first time. I don't want people to get discouraged by like, well I'm not fluent, I'm not going to be fluent for a long time. Like I don't care. It's so helpful. It is, it is so dramatically changed, you know, how I interact with patients and the level of care I provide that, you know, I would love for this to be standard genetic counselors should have training in spanish. So I just think no matter what, like any level of comprehension that you can get is better than none. Yeah, and I hope that too, I I'm sure in the future I don't know how soon, but we'll see this start to be part of, you know, the accreditation board saying, okay, programs need to have this offered.

Maybe students aren't required to take it, but have it be offered because not as far as I'm aware of programs that I've talked to other students, there's not a lot of schools that offer this, it's something that students seek outside of um, their curriculum. And so um yeah, I think the three of us are in agreement on that, that it's it's really important and I think that's kind of to myth bust a little bit of learn a little bit if you can, and kind of keep going from there. Right. Um, I do have something to say on that. It's absolutely amazing to me to see how far people actually progress in a short period of time. Um, so one of my current students has studied spanish for a year. She has been working um really working in the language after nine months at the nine month mark. She started to really work. I mean now, um I think her sessions mostly go with, she has the interpreter present on the line if she needs it, but she, she tells them I'm leading the session and I'll ask you if I need anything from you.

And so, I mean this is the type of thing that can happen. The other thing that I want to point out, especially since um since people are still in graduate school taking these classes, um you're at the point in your life where you might start with a little, you might start with three months or six months, which is a small amount of spanish that can get you quite far in um in some regards, but maybe not able to do your entire session in spanish spanish, right? But at that point in your career, oh my gosh. Um even if you end up studying spanish for two or three years effectively. Um you you will be working in spanish in your career in your lifetime because you're early on in your career, which is a beautiful thing. Um and I do I do hope that most programs start going toward the the the concept of including it as part of their curriculum because we're really at that point now and it's really exciting to see that happening very, very well said.

And I think we've left the listeners a lot to think about and hopefully start brushing up on their spanish or diving into other languages. So thank you both for coming on, really appreciate being able to dive into this different kind of episode in different topic for healthcare providers. Thank you so much. Thank you. You can check out Lauren's website, the language way dot com and DNA podcast dot com has all the information you're gonna need about DNA today. I have so many other interviews with genetic counselors, there, probably my most popular guests that come on the show. So you can check out interviews with Jenna counselors and many more types of guests all on D. N. A podcast dot com. The podcast players don't have all of the episodes because there's over 100. So in order to listen to all the episodes, you have to go to a website. DNA podcast dot com. If you're on twitter, I'd love to connect with you at D. N. A. Podcast instagram. I'm at D. N. A radio. Any questions for myself, Nina or Lorraine can be sent into info at D. N. A podcast dot com. There's also a contact form on the website. If that's easier for you.

We are happy to answer any questions that you thought of throughout the episode or if you have comments on what we discussed, if you have some insight to share that wasn't expressed during the episode or you want to echo something. We did say email in info at D. N. A podcast dot com if you haven't already, please drop a rating and review on the podcast app you listen to, especially if it's Apple. It's really quick and helps the show imagine a health record system that's actually designed for genomics available in six different languages and complete with pedigree drawing diagnostic insights and more. We'll stop imagining and start using because fino tips is nothing like yuri hr it's the world's first genomic health record system that captures family history seamlessly. Regardless of the language patients are comfortable with. Because clear communication is the root of supportive care. Visit fingertips dot com to learn more. Be sure to check out Gino bank. As I mentioned before, they are the first anonymous DNA storage and sharing platform that is completely controlled by you with Blockchain technology.

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#137 Nina Harkavy and Lorraine Way on Medical Interpretation
#137 Nina Harkavy and Lorraine Way on Medical Interpretation
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