The Australian population speaks over 300 languages. However, according to the 2016 Census, 4.5% of the NSW population report that they do not speak English well or at all. People from culturally and linguistically diverse (CALD) backgrounds tend to have different understandings of health care, and different expectations of the doctor-patient relationship. Those with limited English proficiency also face poorer health outcomes and limited access to care due to cultural and language barriers. Migrants, refugees and asylum seekers may face additional issues related to isolation, trauma and loss.
If you’re ever unsure whether your patient understands enough English, even if partway through a consultation, the best course of action is to engage an interpreter.
The responsibility for booking an interpreter always lies with the health care provider. It can be done in one of two ways:
- The Translating and Interpreting Service (TIS National) is free for private medical practitioners when providing Medicare-rebateable services to anyone in Australia with a Medicare card. It delivers 24/7 access to over 3000 interpreters across Australia who are proficient in over 160 languages. Once you have registered online, call the Doctors Priority Line on 1300 131 450 and you can be connected to a telephone interpreter within minutes. You can also book a telephone or onsite interpreter in advance of a consultation.
- NSW Health Care Interpreting Services (HCIS) offer 24/7 access to professional interpreting services onsite and by telephone in over 120 languages, including Auslan. There are five local HCIS in NSW which are free to use for consultations in the public health system, including public hospitals, community health centres, early childhood centres and some non-government organisations.
Why engage an interpreter?
A patient who confidently speaks conversational English does not necessarily understand the medical terminology, pharmaceutical terms, or health concepts used during a consultation.
Interpreters should especially be involved when:
- gaining informed consent for a procedure
- assessing the patient’s decision-making competence
- delivering sensitive information
- relaying complex treatment plans (such as starting or adjusting medications)
- discussing matters that are psychologically complex or distressing; and
- performing mental health, cognitive or neuropsychology assessments.
To ensure patient safety and reduce the risk of miscommunication, it is best to err on the side of caution when assessing whether an interpreter is needed. Ensuring a patient has provided informed consent to a course of treatment or surgery is a fundamental professional obligation every doctor has under the Medical Board of Australia Code of Conduct.
Dr Miriam Brooks, a GP with the NSW Refugee Health Service, suggests “Even if you're in the consult and you start to realise that actually, the patient understood a lot of what you said, and the interpreter is only needed every now and again, they still do need to be there because you need 100% understanding in the conversation.”
If a patient is reluctant to use an interpreter service, you may be able to allay their concern by explaining that interpreters are bound by confidentiality or by offering to book an interpreter of the same gender as the patient.
Risk of relying on patient family members
Agnes Lauder, a Polish speaking interpreter with the Sydney Health Care Interpreter Service, explains it is inherently risky to rely on family members as interpreters and it should only be done in dire circumstances.
Family members may not have the health literacy to accurately convey advice and diagnoses or may exercise their own judgement on which parts of the consultation to interpret. Asking a family member to interpret also places an unfair burden on them, as they may be processing their own feelings about the patient’s health and want to ask questions of their own.
Additionally, the patient may feel uncomfortable having their privacy compromised and their own role in shared decision-making with their doctor eroded.
The interpreter’s role and scope of practice
The majority of professional interpreters are certified by NAATI. Where a language test is not available, the interpreter’s prior professional experience may see them granted recognition by NAATI. Those who speak rare or new emerging languages undertake mandatory training through the NSW Health Care Interpreter Service Professional Development Committee. All Interpreters must abide by the Australian Institute of Interpreters and Translators (AUSIT) code of ethics. Under this code, interpreters must relay everything that is said in the consultation without altering, adding to, or omitting anything from the content and intent of the source message.
As an experienced health care interpreter, Ms Lauder says, “I try to convey [the patient’s] tone of voice whether it's flat or it's very excitable and sort of tie in the interpreting with the patient’s body language... so the health professional gets a better idea because it's not just about the words.”
Language isn’t the only barrier for a patient with limited English proficiency; the difference in cultural background and communication styles can also be a challenge.
Culture plays a significant role in a person’s understanding of health. Some cultures may have specific stigma related to certain illnesses, or traditions that prevent a patient from wanting to hear their diagnosis. Your CALD patients may also have varying levels of exposure to concepts such as shared decision making, which can affect how comfortable they are to participate and ask questions.
Dr Brooks says, “I find the interpreters can help me understand the culture and religious aspects to the conversation that are important to be aware of.”
How to work effectively with an interpreter
When working alongside an interpreter, it is best to book a longer consultation with the patient as communication may take more time than usual. You can bill longer consultation items in instances where the need for an interpreter results in a longer consultation, provided the requirements of the relevant item descriptor are met.
Ms Lauder advises, “Sometimes it’s good to have a briefing if the doctor is expecting the dialogue to be difficult, or if the information is sensitive.” Simultaneous interpreting (where the interpreter listens and interprets in real time as the patient speaks) can be helpful, or you can let the interpreter know if you prefer them to speak between sentences.
Throughout an interpreted consultation, the doctor remains in control of the encounter. The best approach is to sit directly facing the patient so you can speak to them as usual, while the interpreter is positioned to one side as an aide.
You can make the interpreter’s role easier by:
- speaking slowly and clearly with a measured pace and with adequate pauses
- ensuring the physical setting is private, comfortable, and quiet
- being aware of patient and interpreter fatigue in long consultations; and
- letting the patient and interpreter know in advance if you need to say something that doesn’t require interpretation (such as summarising history for a medical student).
From Dr Brooks’ perspective, empathy makes a world of difference. "I try to imagine: how would I go if I was in another country and unfamiliar with the health system and the language?" You may also need to proactively and verbally check whether the patient has any concerns with the treatment plan. For example, in some cultures nodding is a sign of respect, but it doesn’t necessarily mean the person feels comfortable to follow a treatment plan.
More tips for working with patients and interpreters
When you’re working alongside an interpreter, it is helpful to:
- address all your questions to the patient and continue to look at the patient when you're listening to the interpreter
- signpost the elements of the consultation (e.g., “I will ask you questions first and then examine you”)
- thoroughly explain the patient’s follow up actions rather than assume their familiarity with the health system
- confirm your patient’s understanding by asking them to repeat back to you what you’ve said
- proactively ensure you have the patient’s informed consent before starting a treatment, procedure or other intervention, and
- offer health resources in the patient’s language through the NSW Multicultural Health Communication Service.
Free Interpreting Service for private medical practitioners | Translating and Interpreting Service (TIS National)
NSW Health Care Interpreting Services - Interpreting/translating and multicultural health services
Consumer needs and preferences: Perspectives of culturally and linguistically diverse and Aboriginal and Torres Strait Islanders (safetyandquality.gov.au)
Does your diagnosis get lost in translation?
Phillips, C. (2010) ‘Using interpreters – a guide for GPs’, Australian Family Physician, 39(4), pp. 189-195. Available at: https://www.racgp.org.au/getattachment/d59afe23-3f3f-4039-af1b-81d172a7b486/Using-interpreters-a-guide-for-GPs.aspx (Accessed: 28 February 2022).
User Guide for Health Service Organisations Providing Care for Patients from Migrant and Refugee Backgrounds (safetyandquality.gov.au)
Culturally Responsive Clinical Practice: Working with People from Migrant and Refugee Backgrounds (culturaldiversityhealth.org.au)
Multilingual health resources:
The NSW Multicultural Health Communication Service
Multilingual content - COVID-19 (Coronavirus) (nsw.gov.au)
Multilingual information | Embrace Multicultural Mental Health (embracementalhealth.org.au)