Textbook

CORE MEDICAL INTERPRETER TRAINING®
Authors: Barry Fatland, Juan Gutierrez Sanín and Gerardo Lázaro

Core Medical Interpreter
Training® Program
CMIT®
"Communicating Without Barriers"
Textbook
©2020 Phoenix Language Services, Inc. All Rights Reserved. 1

ACKNOWLEDGMENTS
Writing this book summarizes decades of professional experiences, challenges, and the desire
for constant learning and improvement of the Medical Interpreter profession. We intend to
make every edition of this book better, more dynamic and adaptable.
We thank every person that has contributed with time and expertise to the publication of
this second edition.
PRINCIPAL AUTHORS
Barry Fatland
Gerardo Lázaro
CONTRIBUTING AUTHOR
Juan Gutierrez Sanín
SPECIAL THANKS TO
William R. Martin
Whose vision and commitment assembled this team to create our course and textbook to help
further the medical interpreting profession.

TABLE OF CONTENTS
ACKNOWLEDGMENTS .................................................................................................................... 2
INTRODUCTION .............................................................................................................................. 8
Chapter 1 AN INTRODUCTION TO MEDICAL INTERPRETING ..................................................... 11
Lesson 1: The Language Barrier ................................................................................................ 13
The Language Barrier ............................................................................................................. 13
Lesson 2: Other barriers and how to overcome them .............................................................. 17
Types of barriers to communication ..................................................................................... 17
The mission of the medical interpreter ................................................................................. 19
Roles of the Medical Interpreter ........................................................................................... 19
Lesson 3: Modes of Interpreting ............................................................................................... 23
Modes of Interpreting ........................................................................................................... 23
Lesson 4: Title VI of the Civil Rights Act of 1964 ....................................................................... 25
Title VI of the Civil Rights Act of 1964 ................................................................................... 25
Chapter 2 BASIC INTERPRETING SKILLS ....................................................................................... 27
Lesson 5: Consecutive Interpreting and the Conduit Role........................................................ 29
The Conduit role .................................................................................................................... 29
Lesson 6: The Message Clarifier role......................................................................................... 37
The Message Clarifier role ..................................................................................................... 37
Lesson 7: The Rules of Engagement .......................................................................................... 44
Rules of Engagement ............................................................................................................. 44
Lesson 8: Simultaneous Interpreting ........................................................................................ 52
Simultaneous Interpreting..................................................................................................... 52
Lesson 9: Sight Translation and Summarization ....................................................................... 55
Sight Translation .................................................................................................................... 55
Summarization ....................................................................................................................... 59
Lesson 10: Short written translation ......................................................................................... 61
Short Written Translation ...................................................................................................... 61
Lesson 11: Memory and Note-taking ........................................................................................ 65
Memory and Memory Development..................................................................................... 65
Note-taking ............................................................................................................................ 68
Lesson 12: Remote Interpreting................................................................................................ 71

Remote Interpreting .............................................................................................................. 71
Chapter 3 THE IMPACT OF CULTURE ON COMMUNICATION AND HEALTH............................... 75
Lesson 13: Introduction to Culture ........................................................................................... 77
What is Culture? .................................................................................................................... 77
Culture and Interpreting ........................................................................................................ 77
Cultural Competence ............................................................................................................. 81
Lesson 14: A brief history of the US Healthcare System ........................................................... 83
A brief history of the development of the US Healthcare System ........................................ 83
Lesson 15: The Culture of Western Medicine ........................................................................... 95
The Culture of Western Medicine ......................................................................................... 95
Lesson 16: The Cultural Clarifier role ...................................................................................... 105
Cultural Clarifier Role........................................................................................................... 105
Lesson 17: The Advocate/Systemic Clarifier Role ................................................................... 109
Advocate/Systemic Clarifier Role ........................................................................................ 109
Use of the Advocate/Systemic Clarifier Role....................................................................... 110
Guidelines for appropriate advocacy .................................................................................. 111
Chapter 4 THE CODES OF ETHICS ............................................................................................... 113
Lesson 18: Codes of Ethics ...................................................................................................... 115
Ethics.................................................................................................................................... 115
Chapter 5 GUIDELINES AND REGULATIONS .............................................................................. 139
Lesson 19: The CLAS standards and their significance............................................................ 141
Culturally and Linguistically-Appropriate Service (CLAS) standards ................................... 141
Lesson 20: The Joint Commission and standards on Language Access ........................... 145
The Joint Commission .......................................................................................................... 145
The Joint Commission on Language Access......................................................................... 145
Lesson 21: Overview of National Certification and Professional Development ............. 151
National Certification........................................................................................................... 151
Lesson 22: Self-care ................................................................................................................. 159
Stress.................................................................................................................................... 159
Self-care ............................................................................................................................... 160
Lesson 23: Infection control and occupational safety for medical interpreters .............. 165
Infections, occupational safety, and infection control ........................................................ 165
Infections ............................................................................................................................. 165

Chapter 6 BASIC ANATOMY, PHYSIOLOGY, AND TERMINOLOGY ............................................ 171
Lesson 24: Introduction to Medical Terminology ................................................................... 173
Medical Terminology ........................................................................................................... 173
Lesson 25: Body organization, from cells to organisms ......................................................... 181
Levels of organization .......................................................................................................... 181
Body planes.......................................................................................................................... 183
Body cavities ........................................................................................................................ 184
Lesson 26: Integumentary, muscular, and skeletal systems................................................... 187
Integumentary system......................................................................................................... 187
Skeletal system .................................................................................................................... 188
Muscular system .................................................................................................................. 190
Lesson 27: Cardiovascular and lymphatic systems ................................................................. 191
Cardiovascular system ......................................................................................................... 191
Lymphatic system ................................................................................................................ 196
Lesson 28: Respiratory system ................................................................................................ 197
Respiratory system .............................................................................................................. 197
Lesson 29: Digestive and endocrine systems .......................................................................... 201
Digestive system .................................................................................................................. 201
Endocrine system ................................................................................................................ 204
Lesson 30: Reproductive and Urinary systems ....................................................................... 209
Urinary system ..................................................................................................................... 209
Reproductive systems.......................................................................................................... 211
Male reproductive system ................................................................................................... 211
Female reproductive system ............................................................................................... 212
Lesson 31: Nervous system ..................................................................................................... 215
Nervous system ................................................................................................................... 215
Lesson 32: Mental health ........................................................................................................ 221
Mental Health ...................................................................................................................... 221
Abbreviations and acronyms ................................................................................................. 226
Image credits ........................................................................................................................... 229
References ............................................................................................................................... 230

INTRODUCTION
This textbook has been written by and for medical interpreters. Textbook
written by
Its goal is to help explain the basic components of this relatively new medical
interpreters
profession using a variety of approaches, in a logical order, including some of the for medical
newest developments in the field, such as the incorporation of mobile devices for interpreters
interpreting services, as well as the trends in national certification. As of 2019, the
seven languages that are available for certification are Arabic, Cantonese, Korean,
Mandarin, Russian, Spanish, and Vietnamese.
While people have been interpreting for family, neighbors, and friends for
millennia, the medical interpreting profession is less than 40 years old. As the
latest wave of new immigrants started to arrive in the United States in large
numbers in the mid-1970s, interpreters and others involved in healthcare began
to realize that interpreting a message well is not the same as being bilingual.
Knowing two languages is just the starting point. It is crucial for the medical
interpreter to understand the meaning behind the words spoken by patients and
their families, and to study how to achieve the best results for patients and
providers of healthcare. And, from the beginning, interpreters pointed to the
importance of the innumerable variations of cultural approaches to health and
well-being that are in play in interpreted sessions.
National discussions around what this type of interpreting entails led to
regional and national meetings and the launching of the profession. In 1994,
groups of professionals from Boston and Seattle called for a national meeting in
Seattle to further the work started in the early 1980s. This led to the formation of
the National Council on Interpreting in Healthcare (NCIHC), which provided a
national platform for gathering opinions from people involved and starting the
national framework for the profession's standards of practice and code of ethics.
When healthcare interpreters explain what we do, most people are
astounded. For the most part, they have no idea what being a medical interpreter
entails. And as events throughout the world push more and more immigrants and
refugees towards the US, gaining broader recognition of the profession and
elevating the preparedness of medical interpreters becomes all the more
imperative.
Interpreting well takes expertise in at least two languages – English and a Interpreting
well takes
second language – and years of experience to become fast and accurate at expertise in
rendering a message in one language into another language. at least two
languages
and years of
experience
This textbook’s goal is to help the new or newer interpreter understand
what the profession as a whole has decided to be the best way to carry out our
job. We have tried to do this in plain English.
We include several of the profession’s codes of ethics, recognizing the

National Council on Interpreting in Health Care (NCIHC) Code of Ethics as being
agreed to by all professional organizations of spoken language interpreters.
We also include two more, to show the broad agreement that exists within
our profession. Those two codes of ethics are from the International Medical
Interpreters Association (IMIA) and the California Healthcare Interpreting
Association (CHIA). They are all associations of professional medical interpreters
that have worked tirelessly for years to hammer out guidelines to help
interpreters who find themselves in difficult situations.
Understanding
As people from a growing variety of regions and countries of the world
a person's arrive, there is a broader recognition that understanding a person’s culture can
culture can have have an extremely important impact on our ability to understand the string of
an extremely
important words that any individual may utter. This textbook tries to help the newer
impact on our interpreter comprehend this in many different ways.
ability to
understand
As our profession has continued to progress, we have argued and debated
the best way to measure a medical interpreter’s ability to interpret accurately.
Efforts by hundreds of selfless individuals and countless thousands of hours
resulted in two nationally accredited certifying bodies by 2009, now able to certify
healthcare interpreters in 7 different languages: Arabic, Cantonese, Korean,
Mandarin, Russian, Spanish and Vietnamese. While this is a tiny fraction of the
world’s living languages, these seven languages cover a very large percentage of
those who need assistance in their medical encounters in the US.
The state of Oregon has stepped forward as the state with the highest
requirements for certifying medical interpreters (Oregon State, n.d.). Efforts
continue advancing in other counties and states.
With this new textbook, by offering information about professional

development, we also hope to encourage individual medical interpreters to join
with others in continuing to raise the profession’s profile, to join the professional
association of their preference, and to work to improve the possibility of
experienced interpreters being able to stay in the profession.

A person with years of experience as a professional medical interpreter in
different medical settings can offer better quality interpreting to limited English
proficient patients. Being able to earn a living doing this is part of being able to
stay in the profession, at least for most.
This textbook is
This textbook is designed for language-neutral courses. There is broad designed for
agreement that a language-specific course (for all Mandarin speakers or all language-
neutral courses
Spanish speakers) is the best learning environment for the interpreters. However,
the challenge that trainers throughout most of the US face is the difficulty in
enlisting enough speakers of any one language in the course at the same time.
We intend to make the development of this textbook a dynamic experience. If you

think you can contribute ideas, suggestions, changes, or improvements, please
share them with us.
Website: www.nichc.org
Email: info@nichc.org
Twitter: @nichealthcare
eLearning: https://elearn.nichc.org

Chapter 1
AN INTRODUCTION
TO MEDICAL
INTERPRETING

Lesson 1: The Language Barrier
GOALS
• To identify language as a barrier to communication between people who
don’t speak the same languages.
• To determine the consequences of linguistic barriers in healthcare settings.
The Language Barrier
Communication is one of the most notable aspects of human nature. When two Communication
or more people communicate, they use a combination of sounds, symbols, and is one of the
most notable
gestures to express a message that carries meaning.
aspects of
human nature.
This textbook will be dealing almost exclusively with spoken language barriers and
not with issues faced by the deaf and hard of hearing and the different signed
languages that are used to overcome their barriers. Rights and advances that the
deaf and hard of hearing have made over the past half-century have greatly
helped spoken language interpreters and our profession.
In a medical setting, when the two key people (patient and doctor) do not speak
the same language, it is clear that they will not be able to understand anything
beyond the simplest of communication, such as smiles, frowns, or other forms of
body language.
When nurses and doctors, in the profession commonly referred to as “providers,”

depend on answers to a long series of questions to help them understand why a
patient is in their office, not having a common language is a major obstacle or
barrier. Studies have shown that the questions that a doctor or nurse asks the
patient account for 60% to 70% of the information required for a provider to be
able to make the correct diagnosis (Young & Poses, 1983; Rich, Crowson, & Harris,
1987).
According to Flores (2003), untrained, untested bilingual people working as

interpreters make an average of 31 mistakes per interview, an interview being an
average length of 15 minutes. According to this same study, more than 77% of
these errors have negative consequences for the patient. Another study by Flores
(2012) indicates that 80 to 100 hours of training decreases the number of mistakes
from 31 to 12. And, more importantly, mistakes made by trained interpreters are
a lot less dangerous to patients’ health outcomes.

Additional studies also indicate that professionally-trained medical interpreters
Professionally-
trained medical spend less time in face-to-face medical encounters than telephonic interpreters
interpreters and bilingual employees (Grover, Dekayne, Bajaj, Roosevelt, 2012).
spend less time
in face-to-face
Language is an integral part of who we are
medical
encounters than
telephonic Some areas of the brain that are strongly associated with emotions, also manage
interpreters,
and bilingual language. These areas are the insula (temporal lobe) and the left inferior frontal
employees. gyrus (frontal lobe).
Figure 1. The cerebral cortex
In its 2017 estimate, the American Community Survey projected that more than
64 million people (21%) of the total U.S. population speaks a language other than
English, and 25.6 million speakers (40%) are limited-English proficient people
(United States Census Bureau, n.d.). This figure includes those who do not
understand or speak any English, as well as those who may understand English on
a very basic level but who do not feel comfortable expressing themselves in
English.

This estimate is based on census figures, and it does not reflect the reality given
that many people who do not have documents authorizing them to be in the US,
tend not to participate in the census process, causing data to portray an inaccurate
reality.
The vast majority of LEP people speak Spanish (16.5 million), followed by Chinese
(1.5 million) (U.S. Census Bureau, 2013). This enormous gap between the first two
LEP languages is a fact that may affect the profession in many ways, including the
availability of jobs and the common misconception along the US/Mexico border
that “everyone speaks Spanish here, so why use an interpreter?”
LEP patients are significantly more likely to lack access to health care, to visit the
emergency department repeatedly, to have more readmissions to the hospital
than the general population, to have more surgical complications, longer hospital
stays, and be vulnerable to more medical errors (Agency for Healthcare Research
and Quality, 2013).
Therefore, the lack of effective communication between people who speak The lack of
different languages can trigger a series of events that can compromise the effective
communication
patient’s care and safety. between people
who speak
different
The Case of Willie Ramirez and “Intoxicado” languages can
trigger a series
of events that
Case Study: The case of Willie Ramirez, an 18-year old Cuban immigrant, has can compromise
the patient's
become the most well-known case of the grave consequences of not using a care and safety.
professionally-trained medical interpreter.
After Willie had started feeling sick, friends and family members took him to the
emergency department of a hospital in Florida.
A series of misunderstandings led the providers to miss important signs and

symptoms to be able to diagnose what Willie was suffering from. His family
members and friends did not speak English.
One of the main terms used by Willie's family members was intoxicado (a term in
Spanish commonly used to describe food poisoning). The similarity to the English
word intoxicated (drug or alcohol poisoning) misled clinicians in their first
response and line of treatment.

The doctors concluded that the patient was suffering from a drug overdose and
proceeded accordingly. Willie's health deteriorated rapidly. He suffered brain
damage that left him a person with quadriplegia.
A wrong Wrong Diagnosis

diagnosis of a This is just one example, although important, of the wrong diagnosis of a health
health problem
led to a wrong
problem that led to a wrong treatment plan and disastrous consequences as a
treatment plan result of a hospital not understanding the importance of using professionally-
and disastrous trained medical interpreters.
consequences,
as a result of not
understanding Summary
the importance
of using
The tragic end to this error was one quadriplegic patient and a high-profile lawsuit
professionally- that ended in the court ordering the hospital to pay $77 million in damages.
trained medical
interpreters.
This is a very serious issue for 25.1 million people who do not speak English well
enough to communicate effectively in a healthcare setting, and for the millions of
healthcare providers who need to have accurate communication with their
patients.

Lesson 2: Other barriers and how to overcome them
Goals:
• To describe the different barriers to effective communication that can
hamper access and quality of care for LEP patients.
• To be aware of and describe the four roles that medical interpreters can use
to overcome the four barriers to communication.
Types of barriers to communication
In Lesson 1, we discussed in depth the importance of the language barrier in a Two people that
medical encounter. Two people that don’t speak the same language cannot don't speak the
communicate effectively without help from a professional healthcare same language
cannot
interpreter. The patient cannot be precise in describing to the provider what their communicate
health concern is, and the doctor cannot even ask the questions that he or she effectively
without help
needs answers to come up with the best diagnosis. from a
professional
This barrier is the basic one and is (or should be) obvious to all. But there are other healthcare
interpreter
barriers, and here we offer a complete list:
Barriers to communication that can affect a patient's health outcome:
1. Linguistic barriers: The patient and provider don’t speak the same language
2. Register (technical) barriers: This is an additional linguistic barrier, but of a

special type, where there is the use of complicated terms by the provider or
slang by the patient.
3. Cultural barriers: They are cultural differences between the provider and
patient, including, but not limited to, beliefs and approaches to health and
healthcare.
4. Systemic barriers: They are the products of the complex nature of the US
healthcare system and its failures in care coordination.

Linguistic barriers
When the patient and provider do not speak the same language, as interpreters,
we convert the meaning of the message from one language to the other.
Register (technical) barriers
The word “register” is used in the profession to refer to the level of complexity
Register, refers
to the level of used by people when they speak using complicated, technical terms. In medical
complexity used settings, it is also referred to as doctorese or medicalese.
by people when
they speak using
complicated, Simple language, or plain English, also referred to as Standard English, is the
technical terms.
standard speaking form of English that everyone who speaks English can
understand.
Technical jargon or very elaborate speech full of “fancy words” is called “high
register.” Street slang is an example of a “low register” speech.
Cultural barriers
People perceive things differently depending on their life experiences. Some

things that are intended to mean one thing can be misunderstood to mean
something else, becoming unwillingly offensive, or causing discomfort.
Systemic barriers
Systemic barriers refer to the problems most patients have trying to navigate the
complex US healthcare system. Difficulties arising from systemic and social factors
that can make it difficult for patients to access the right resources of care at the
right time.

The mission of the medical interpreter
"To ensure effective communication during interactions between a patient and a
provider who speak different languages for the purpose of protecting the
patient’s safety and contributing to the best possible outcome."
We just explained the four main barriers to communication in an appointment

between a patient and a provider who don’t speak the same language.
Roles of the Medical Interpreter
Now, we will describe the basic aspects of each of

the roles interpreters use to address the barriers
mentioned above in preventing negative health
outcomes.
There will be separate lessons later in this

textbook to develop each role and how we use
them in more detail.
The way roles are represented to the right is an

attempt to help the interpreter visualize this, with
the Conduit role being in such large font size to
emphasize that this is the main role the interpreter
uses for the vast majority of time in an interpreted
encounter. There are separate lessons on each of
the four roles that are shown above and briefly
Figure 2. Roles of the medical interpreter
described below:
1. The Conduit:
The interpreter addresses the language barrier with the Conduit role. This is
the basic role of an interpreter. We will learn later why it is best to stay in this
role as much as possible and then how to switch briefly to another role, and
then back to the conduit role.

In the conduit role, the interpreter will render the whole message as faithfully as
possible without additions, omissions, or changes to the meaning of the message.
Figure 3. The conduit role of the interpreter
When we say that we want to stay in this role as much as possible, it is because it
keeps us in the background and emphasizes the messages being exchanged
between the doctor or nurse, and the patient.
If the conversation requires us to switch to a different role to make sure that the
meaning of the message is accurately conveyed between the provider and patient,
we try to switch back to this role as soon as possible.
2. The Message Clarifier:
The interpreter addresses the register (technical) barrier by switching to the

Message Clarifier role. With this role, the interpreter clarifies the linguistic
nuances that can get in the way of understanding words such as medicalese, slang,
idiomatic phrases, symbolic language, etc. It is also used frequently when the
interpreter cannot hear what the provider or patient says and asks them to repeat.
This role is the second most commonly used role and is fairly self-explanatory. If
you, as the interpreter, don’t hear what is said, or you don’t understand a word or
phrase, either from the provider or the patient, you then ask them to repeat, or
perhaps to repeat in shorter phrases or simpler terms.
Once the patient or provider repeats as requested, you go back to your role as a
conduit, your main role.

3. The Cultural Clarifier:
This role addresses cultural beliefs or barriers that may cause confusion
between the provider and the patient. The California Healthcare Interpreters
Association (CHIA) also refers to this role as the Cultural Mediator in its
California Standards for Healthcare Interpreters, published in 2002.
This role is used much less frequently by the interpreter and only when the
interpreter feels that there may be confusion due to a cultural difference
between the patient’s culture and the cultures embedded in the medical
encounter (provider, hospital, neighborhood, city, etc.)
Patients and providers may use different “standard” concepts or processes The interpreter
within healthcare. In this case, the interpreter may need to provide a cultural may need to
framework of reference to mending the potential misunderstanding between provide a cultural
framework of
patient and provider. reference to mend
the potential
misunderstanding
Once the cultural difference is clarified, the interpreter switches back to the
between patient
conduit role. and provider.
4. The Advocate/Systemic Clarifier:
The systemic barriers are addressed by the Advocate/Systemic Clarifier role.
The interpreter speaks not as the interpreter but on behalf of the patient, with
the patient’s agreement, usually to guide the patient to the person in charge
that can help.
This role is infrequently used and requires the agreement of the hospital or
clinic where you are working, as well as sound judgment based on experience.
And that is also why it is in such small font size in the depiction of roles above.
Transitioning between roles
Interpreters often switch from one role of interpreting to another. This

transition must be done following transparency.
Transparency entails informing all involved parties of the actions to be taken

by the interpreter to clarify any message, cultural or systemic issues.

Transparency is the part of the interpreting protocol that avoids having a side
conversation with the patient or the provider, leaving the other party
uninformed.
The interpreter's goal is to return to the conduit role as soon as possible after
completing whatever clarification is deemed necessary.

Lesson 3: Modes of Interpreting
Goal:
• To identify the four modes of interpreting
Modes of Interpreting
Modes are different ways of interpreting which professional interpreters use in

different situations, to facilitate communication more effectively.
Some of the modes entail materials from a written source. Because of this, they
are called “translation.”
Consecutive Interpreting
Consecutive interpreting is considered the standard and is the most-used mode in

the medical field. It used to be called “pause” interpreting because it Involves
pauses with time for the interpreter to interpret. The provider speaks, and then
the interpreter interprets. The patient speaks, then the interpreter interprets. Two
people are not talking at the same time.
When there are only three people involved in the medical encounter, it is too
difficult for either the provider or the patient to understand if two people speak
at the same time, which is the mode that is described below.
The interpreter
must be
The interpreter must be involved in managing the flow of communication as the involved in
provider, and the patient will tend to speak for long periods unless they are very managing the
used to communicating through a professional interpreter. flow of
communication
Sight Translation
Sight translation is the act of reading a written text in one language and giving an
oral rendition in the other language. Since it is an oral skill, it should be called ‘sight
interpreting,’ but the accepted professional term is ‘sight translation.’

Simultaneous Interpreting
Simultaneous interpreting involves processing both languages at nearly the same

time. The interpreter is interpreting what the speaker is saying just a few seconds
after hearing the words.
Speakers don’t pause to allow the interpreter to interpret unless pauses are part
of their natural speaking rhythm. Speakers determine the pace of interpreting,
which for interpreters new to the simultaneous mode, can be a major challenge,
especially if the pace is fast and without natural pauses.
Short written Translation
This is not a mode of interpreting, but it is a task that is increasingly a part of what
spoken language interpreters are asked to do and to do it accurately. In the past,
spoken language medical interpreters had been urged to turn down requests to
do a written translation, unless they were translators certified by the American
Translators Association (ATA).
We have included a short lesson on short written translation later.
__________
Summarization
Summarization The interpreter's summarization is the oral rendition of the gist of the message. It
is not is not considered a mode of interpreting as you are putting into your own words
considered a
the main idea or ideas, but not the words of another person.
standard mode
of interpreting __________
In the next lesson, we’ll take a look at the social movement and resulting
legislation that led to guaranteeing the rights of everyone in this country,
regardless of ‘legal’ status, to have professionally trained medical interpreters.

Lesson 4: Title VI of the Civil Rights Act of 1964
Goal:
• To describe the role of Title VI of the Civil Rights Act of 1964 in fostering
linguistic access for LEP persons in the US
Title VI of the Civil Rights Act of 1964
“No person in the United States shall, on the grounds of race, color, or national
origin, be excluded from participation in, be denied the benefits of, or be subjected
to discrimination under any program or activity receiving Federal financial
assistance.”
The name, “Title VI,” may confuse some. The Civil Rights Act has a total of eleven
parts or “titles” as they were called. This lesson focuses exclusively on Title VI (U.S.
Department of Justice, 2014). The other titles deal with equal access to jobs, the
prohibition of discrimination in public accommodations, the desegregation of
public schools, and the right to vote.
You may well wonder what this particular legislation in 1964 has to do with the
profession of medical interpreting, but its importance cannot be emphasized
enough. Virtually all legislation and executive proclamations since 1964 that
strengthen the right of every person in this country to access the services on an
equal basis, regardless of the language that they speak or understand, is based on
this 1964 legislation.
While the main thrust of the civil rights movement was to eliminate any legal basis
for discrimination against African Americans, everyone in this country benefited.
As far as language access is concerned, all subsequent court decisions have held
that while language is not mentioned explicitly, the part on “national origin”
covers language. And, the protection is for everyone in the US, regardless of
immigration status. The majority of
LEP patients
The majority of LEP patients that need interpreting don’t realize that they have that need
interpreting
this right. Many, when asked if they need an interpreter, will answer, “no, thank don't realize
you.” They assume that the fee for having an interpreter will show up as an that they have
this right.
additional item in an already expensive hospital bill.

Or, that they would have to pay the interpreter out-of-pocket and on the spot. To
counter this lack of understanding of their rights, some hospitals encourage staff
to explain to patients that their interpreting services are free of charge.
Title VI and Language Access
Although Title VI makes no mention of language, a 1974 ruling (Lau v. Nichols)

The US Supreme
Court from the US Supreme Court determined language to be related by proxy with
determined national origin (Supreme Court of the United States, 1974).
language to be
related by proxy
with national 1974: The integration of a primarily English-speaking California school district with
origin
Chinese students makes educational competitiveness among minorities difficult
due to them being denied instruction of the English language as one of the
solutions they were requesting.
US Supreme Court Chief Justice William O. Douglas wrote the following:
“There is no equality of treatment merely by providing Chinese-speaking students

with the same facilities, textbooks, teachers, and curriculum, for students who do
not understand English are effectively foreclosed from any meaningful education.”
The Majority decision:

The school system should find ways to instruct Chinese students effectively,
disregarding the language barrier. Not providing them instruction in English is in
violation of the 14th Amendment.

Chapter 2
BASIC INTERPRETING
SKILLS

Lesson 5: Consecutive Interpreting and the Conduit Role
Goals:
• To better understand consecutive interpreting and the conduit role of the
medical interpreter.
• To practice the consecutive mode and the conduit role.
The Conduit role
The role of conduit relies on the consecutive mode of interpreting to render the
meaning of the entire message as accurately as possible, avoiding omissions,
additions or substitutions, without polishing the message.
An example of polishing the message would be filtering

profanities or expressing a “nicer” or more socially
acceptable form of the message. The interpreter must be
accurate for messages carrying high register, low
register, profanities, aggressive language, and body
language (also known as paralinguistic communication).
Some interpreters may omit the interpretation of facial

expressions, sighs, looks, grins, or onomatopoeic sounds.
A closer look demonstrates that paralinguistic elements
such as non-verbal sounds are essential resources in
face-to-face interpreting. Figure 4. Body language carries
meaning
In the case of body language, the interpreter must convey the meaning of that
form of communication without being perceived as mimicking or mocking the
speaker.
For some, the name “conduit” doesn’t bring to mind any clear meaning. The
California Healthcare Interpreting Association (CHIA) uses the term “message
converter,” which we think is clearer and has included throughout this textbook,
even though the profession’s standard term continues to be “conduit.”

The conduit uses the first person when interpreting for patient and The conduit uses
provider. This decreases the potential for error, encourages direct the first person
communication between the patient and the provider, and allows when
interpreting for
the interpreter to remain in the background. patient and
provider.
What is another way of explaining this concept?
In a conversation:
The first person is the person who is speaking.
The second person is the person or persons to whom the first person is speaking.
The third person is the person, or persons or things about which you are speaking.
And yet another way to understand this concept:
Table 1. First, second, and third person in English
Singular Plural
First person I We
Second person You You, Y'all
Third person He, She, It They
Speaking in the
Interpreting in the first person
"first person" is Speaking in the ‘first person’ is the standard in the interpreting profession.
the standard in
the interpreting
profession.
What does this mean?
Example #1:
If the patient says (in his language): My head hurts!

The Interpreter says (in English): My head hurts!
Example #2:
Patient (adult female): I felt bloated, and my ovaries hurt a lot during my last
period. (In her language.)

Interpreter (male): I felt bloated, and my ovaries hurt a lot during my last period.
(In English.)
Or, contrasting this use of the ‘first person’ speech to what many untrained
interpreters might use, with the same example:
Patient (adult female): I felt bloated, and my ovaries hurt a lot during my last
period. (In her language.)
Interpreter (male): She said that she felt bloated and that her ovaries hurt a lot
during her last period. (In English.)
Aside from this not being acceptable in the medical interpreting profession, what
else do you notice?
• It requires you to change what is said.

• It takes longer to make the changes than to say simply what the patient said.
• This switches the attention to you as the person reporting what another
person is saying, rather than simply repeating what was said.
This incorrect form of interpreting is called ‘reported speech.’ You ‘report’ what
was said instead of repeating exactly the meaning of what was said.
Interpreting the meaning
As a conduit, the interpreter strives to render an accurate version of the original The interpreter
message, rather than a literal one. strives to render
an accurate
version of the
Example #1: original
message, rather
Nurse: Your baby is beautiful and is so “silly.” than a literal
Interpreter: Your baby is beautiful and is so “dumb”? (In the patient’s language) one.
In this case, “silly” is referring to cute rather than dumb.
Example #2: Interpretation of the meaning, not the literal words
Doctor: That is very funny, Mr. Lopez. You’re pulling my leg, right?
Interpreter: That is very funny, Mr. Lopez. You’re kidding, right? (In the patient’s
language)

In the example from the previous page, the interpreter knows the meaning of the
idiomatic saying in English and interprets the meaning of what the doctor was
saying.
Note: In Spanish, the expression pulling my leg has a linguistic equivalent, pulling
my hair. That equivalent can also replace the original idiomatic expression used
by the doctor. It would be as follows:
Doctor: That is very funny, Mr. Lopez. You’re pulling my leg, right?
Interpreter: Eso es muy chistoso Señor López. Me está tomando el pelo, ¿verdad?
Using idiomatic equivalents in the other language is the preferable form of

interpreting.
Interpreting in Interpreting in the conduit role, the interpreter conveys the same register, style,
the conduit role, body language, and tone of the speaker per NCIHC standards of practice, and then
the interpreter
conveys the
checks for understanding. If the interpreter senses that either the patient or the
same register, provider is not understanding the meaning of what the other person said, the
style, body interpreter needs to switch to the Clarifier role.
language, and
tone of the
speaker Consecutive interpreting involves pauses and is considered the standard and
most used mode of interpreting in healthcare settings.
PRACTICE: Role-plays
Throughout the basic interpreting skills portion of this textbook, we will give
students a chance to practice what we have just introduced. We do this in the
form of acting out roles or role-plays. We will start on a simple level and gradually
increase the difficulty of the role-plays as we learn new skills.
Below are three scenarios. Three students are needed for each role-play to act as
a provider, patient, and interpreter. For this first set of scenarios, all three
students in each group can have their textbooks open and read from the text in
English. If you prefer, the patient can speak their part in their target language. If
not, just read them in English.
You will note that the role of the interpreter in each scenario is to interpret what
the provider or patient has just said.

What the provider says will be interpreted into the interpreter’s target language.
What the patient says will be interpreted (or read from the book) for the provider
in English. The interpreter can either interpret what is said orally or interpret the
text directly from the textbook.
For the second scenario, each student will rotate to a new role. The goal is to offer
each student a chance to play the role of interpreter.
Scenario 1 (for three people)
PROVIDER: Good Morning, Sir. I have some questions that I need to ask you today.
INTERPRETER: Interprets in target language.
PROVIDER: Do you have any food, seasonal, or medication allergies?
PATIENT: Yes, when I eat dairy products, I get a rash on the palms of my hands.
INTERPRETER: Interprets in English.
PATIENT: But I do not have any allergies to medications that I know.
PROVIDER: Have you been out of the country recently?
PROVIDER: Have you been exposed to any infectious diseases that you are aware?
PATIENT: No, I haven’t traveled anywhere recently, but my daughter did have chickenpox about
six months ago!

PATIENT: I did not get it from her as I remember having it myself when I was about 10 years old.
PATIENT: I also got a vaccination when I was younger for tuberculosis and measles.

Now, be sure to rotate roles for the next scenario:
__________
PROVIDER: Good Morning, Mrs. Gonzalez. What brings you into the clinic today?
PATIENT: Oh, hello, doctor. I don’t feel very well at all. I have a fever, and I can’t stop shaking.
PROVIDER: Can you tell me more about it, Mrs. Gonzalez?
PATIENT: I have no appetite, and my bones ache all over. Every time I stand up, I get a very bad
headache, and my nose is so congested.
PATIENT: I am coughing and coughing. Oh! I am so scared that I have this new flu!! The Swine
Flu??
PROVIDER: Mrs. Gonzalez, is anyone else in your homesick?

PROVIDER: How long have you felt this way?
PATIENT: It started yesterday, and nobody else is sick. But will they become sick? Oh no!…
PATIENT: What should I do not to get them sick? Oh, I am so scared!
PROVIDER: Mrs. Gonzalez, I will be drawing some blood and would like to listen to your heart
and lungs.
PROVIDER: If it is, in fact, the H1N1 virus, we will tell you what to do to protect your family, and
give you some medication to help the symptoms.
PROVIDER: Please do not be worried. We will take good care of you.
Now, be sure to rotate roles for the final scenario:
PROVIDER: Good afternoon, ma’am. My name is Jane, and I have a few questions to ask before
the doctor comes in.

PROVIDER: Are you currently taking any prescription or over-the-counter medications?
PATIENT: No, I only will take medicine if I am really sick and need to. I have a problem swallowing
pills.
PROVIDER: Do you smoke, drink alcohol, or take any recreational drugs?
PATIENT: I stopped smoking four years ago when I stopped drinking, as I didn’t like the way it
made me feel. I live a clean lifestyle now!
PROVIDER: Thank you. I would like to check your pulse, weight, blood pressure, and temperature,
and then the doctor will be in to see you.
The next lesson, on the interpreter’s role as a message clarifier, will explain how an interpreter
can ask for a repeat of what they didn’t hear or understand from either the provider or the
patient.

Lesson 6: The Message Clarifier role
Goals:
• To describe the message clarifier role of the medical interpreter
• To understand how to transition to this role from the conduit role
• To practice interpreting in this role
The Message Clarifier role
The message clarifier role addresses linguistic nuances or barriers that can cause
confusion as to the meaning of the message:
1. Lack of linguistic equivalency: EMT, MRI, ambulance
2. High register: idiopathic
3. Regional linguistic variations: milk bottle, bowel movement, a cold
4. Slang, idiomatic sayings: do me a solid, joint, play it by ear, hard one to
call
5. Symbolic meaning: There is a heatwave, goosebumps
6. Ambiguous messages: the nodding of the head
This is the role that is also used to simply ask the speaker to repeat what they just
said because you weren’t able to hear, or because you need them to speak in
shorter phrases and with more frequent pauses. The interpreter cannot interpret
what they can’t hear or remember.
How to make the transition from speaking with the voice of the patient or
provider to your own voice
When we interpreters speak in our own voice and not the patient’s or provider’s,
we make this clear by intervening in the conversation by switching from first (1st)
to third (3rd) person by saying:
“The interpreter would like to clarify …” Or

“The interpreter requests that the provider repeats what was just said, but in
shorter phrases.” Or
“The interpreter requests that the provider lowers the register.” Or
“The interpreter requests that the provider speaks in simpler terms.”
This action is taken to make it very clear that it is now not the patient nor the
provider speaking, but rather the interpreter.

Example of the use of high register or medicalese:
(Note: the patient has already indicated that he has difficulty understanding
Western medical terminology in his language a few minutes ago.)
DOCTOR: Depending on the results of the biopsy, we’ll determine if our course of
action is prophylactic or therapeutic.
INTERPRETER: (To the doctor, in English) The interpreter requests that the doctor
lower the register.
DOCTOR: When we get the test results back, we’ll decide what to do next, if we
use just preventive measures or medical treatment.
Transparency in communication
In switching from the conduit or message converter role to the clarifier role, the
message clarifier maintains transparency. Transparency is when the interpreter
Transparency is
when the informs both parties about the situation and the intent to clarify. Both parties then
interpreter know what is going on and why the interpreter is speaking their own words.
informs both
parties about
the situation Example:
and his or her
intent to clarify.
DOCTOR: And if you or your family ever feel that you are having symptoms of a
heart attack, please call 911 and request an ambulance.
INTERPRETER: (noting a puzzled look and “uneasy” body language from the
patient after she interprets what the doctor has just said.) Señora Garcia, I’m
speaking now as your interpreter. You appear to be puzzled. Did the doctor say
something that you didn’t understand? (In the patient’s language)
INTERPRETER: (in English and to the doctor): The interpreter just asked the patient
if you said something that confused her.
PATIENT: (in her language) I don’t know what “am bu lance” is that I should call.
INTERPRETER: (Has two options: She can either interpret what the patient has just
said to the doctor, or she can say to the doctor that she will paint a ‘word picture’
for the patient, describing what an “ambulance” is in many words.)

As soon as the meaning of this word “ambulance” is clarified for the patient, the
interpreter switches back to the conduit role and continues in that role until there
is a need to stop the conversation and clarify something else.
The interpreter, in the message clarifier role, does not engage in ‘side
conversations’ with either party. Below is an example of a ‘side’ conversation:
PATIENT: (leaning over to the interpreter and speaking in a quiet voice) Do you
think I should have this operation that the doctor is suggesting?
INTERPRETER: (Speaking directly to the patient in her own voice) I don’t know. I
heard of a woman that had the same operation and then lost her left foot. Maybe
you should get a second opinion. (None of this was interpreted to the doctor).
What do you think the doctor thinks as she hears this back and forth conversation
that she can’t understand? The interpreter is there for both the patient and the
provider, but in the example above, the provider has been left out, ignored.
If we interpret the professional way, we make certain that both the provider and
patient know what is going on and don’t feel left out. Again, this is called
‘transparent’ communication.
The previous example should have been more like the following:
PATIENT: (leaning over to the interpreter and speaking in a quiet voice) Do you
think I should have this operation that the doctor is suggesting?
INTERPRETER: (to the patient) As your interpreter, I can’t give you my opinion, but
I will interpret your question to the doctor.
INTERPRETER: (then, to the doctor) The patient just asked me, as her interpreter,
if I thought she should have the operation that you suggested.
This approach lets the doctor know that the patient clearly has questions about
what was suggested and needs more of an explanation. The interpreter switches
back to the conduit role and interprets what each says.

In the message In the message clarifier role, the interpreter checks for understanding and then
clarifier role, the returns to the conduit role as soon as possible, to make the intervention less
interpreter
invasive. Being ‘invasive’ in just another way of saying ‘interrupting’ the
checks for
understanding conversation that you are facilitating between the patient and provider and
and then returns speaking your words in your own voice.
to the conduit
role as soon as
possible
Register
High register involves complex terminology, including technical jargon. Many
patients and at times, even the interpreter, will not comprehend the more
technical or complicated medical terms the provider might use.
At the other extreme, some patients or their family members may use regional
variations of the main language, or slang, that the interpreter doesn’t fully
understand.
What can the interpreter do?

First, in the case of ‘high register’ sometimes jokingly called ‘medicalese,’ the
interpreter can interpret at the same register level and then check for the patient’s
understanding (frowns, body language that indicates that the patient is
uncomfortable, or not understanding).
Then the interpreter can raise her hand and intervene in her own name, asking
the provider to ‘lower the register’ or ‘speak in simpler terms’ after she checks
with the patient to see if he can follow what the doctor is saying. It looks
something like this:
INTERPRETER: (to the doctor) The interpreter senses that the patient does not
understand what is being said, so I’m going to ask him.
(to the patient, in the patient’s language) Mr. Nguyen, are you able to understand
what the doctor is saying?
PATIENT: (in the target language) No, I don’t understand all of this complicated
talk.
INTERPRETER: (to the doctor) The interpreter requests that the doctor lower the
register as the patient has just confirmed that he does not understand what you
are saying.

Lowering the register means expressing the same concepts in simpler terms.
Lowering the
register means
expressing the
It is best practice is to:
same concepts
• Interpret at the same register as the speaker, and then in simpler terms
• Check for signs of lack of understanding (nodding of the head, eyes darting,
frowning, etc.), and
• Intervene transparently and ask the speaker to lower the register.
We now have several scenarios for you to practice this new clarifier role.
Role-plays
Since you now have some experience with role-plays, for this round, we
recommend that the interpreter have the textbook closed. That way, if the
provider or patient speaks too long for you to remember what they said and
interpret accurately, intervene in the third person and ask them to repeat, but in
shorter phrases. This is the best way to get some practice using the clarifier role.
Or if the provider uses complicated explanations, and you know from your
understanding of the patient’s unfamiliarity with Western medical terminology,
you can ask the provider to lower the register, or you can paint a word picture.
This may also be necessary when linguistic equivalents in the target language are
not available.
Scenario #1 (for three people):
(We’re now dropping in on the middle of an interpreted medical encounter)
PROVIDER: The drugs used in chemotherapy treatments cause the WBCs to

decrease after each treatment. As the WBC’s decrease, and especially when it is
at its lowest point, you may develop an infection. That is why we constantly check
the ANC so we can provide the necessary recommendations.
PATIENT: Wow, so...what does that mean? It sounds scary!

__________
PROVIDER: A cardiac catheterization is an examination that is done to look for signs of heart
disease and evaluates the condition of your heart.
During the test, we will be taking x-ray movies and recordings of the pressure in your arteries and
the chambers of the heart. This information will help your doctor decide which form of
treatment, if any, is best for you.
PATIENT: X-Ray movies? I didn’t think that this was going to be that complicated.
__________
PROVIDER: Good Morning. My name is Stephanie. How may I help you?
PATIENT: Yes, good morning. I have an appointment with um…, doctor… what was his name? I
don’t remember. Well, you know, he is a tall man with a mustache. At least that’s how I remember
him from the last time I was here, which must have been three months ago. Wait, no. I think it
was before that because I remember my mother had not returned from Puerto Rico yet, so it must
have been around March and not April. She went back to the island to visit her sister. She’s very
sick, and she wanted to see her before she passed away. Thank God she was able to make it right
on time. She got to see her sister for a couple of days before the inevitable.
PROVIDER: Do you have your appointment card with you? I can check the computer. Let’s see….
Here you are…. You will be seeing Dr. Gambino today. He is running a little behind, but he should

be with you soon. Tell me, are you still living at the same address? Is your phone number the
same as the last time you were here? Are you still working at the restaurant?”
PATIENT: No, I was laid off about three weeks ago. Now I am looking for work, but I can’t find
any.
PROVIDER: I’m sorry to hear that. Well, have a seat, and Dr. Gambino’s nurse will call you shortly.
______________
Note: This scenario is an example of a low register. But it can also allow the interpreter to practice
using a hand signal to stop the conversation and request that the patient or provider repeat what
was said but in shorter phrases.
You will have noticed, from these scenarios, that providers and patients don’t often make it easy
for the interpreter to interpret everything that is said. We gave you an explanation of the clarifier
role to help you, but that isn’t enough. Practice and good memory skills are required, as well as
clear rules of engagement.
Lesson 7 will give you some more tools to help lay the ground rules from the beginning of the
session to help minimize the problems that you noticed with these scenarios.

Lesson 7: The Rules of Engagement
Goals:
• To understand what a “pre-session” is and why it is crucial for a successfully
interpreted session.
• To understand the importance of where the interpreter should sit or stand in
an interpreted encounter.
• To understand how to conclude an interpreted session with a “post-
session.”
Rules of Engagement
The medical interpreter is exposed to a wide variety of medical scenarios and

settings.
How can we standardize the protocol of interpreting?

The best way to start a medical interpretation is by outlining the rules of
engagement or how you want the provider and patient to deal with each other
and with you, the interpreter.
Introducing yourself to the patient/family members

In many cultures, a handshake is how an introduction or greeting begins. As Setting
professional
interpreters, it is important to set some professional boundaries from the very
boundaries
beginning. Physical contact is one of them. A greeting does not have to include a A greeting does
handshake to make it respectful or professional. not have to
include a
handshake
Also, it is important to consider that the patient or interpreter can impact the (physical
health of the other party with this physical contact. However, if the patient contact) to
make it
extends his/her hand for a handshake, the interpreter should reciprocate if respectful or
cultural and religious beliefs allow. professional.
PRE-SESSION: What are the main rules of engagement?

The interpreter proactively outlines the rules of engagement to manage the flow The interpreter
of the medical encounter by conducting a pre-session where he/she informs the proactively
outlines the
patient and the provider of the role of the interpreter, including the following rules of
elements: engagement to
manage the flow
of the medical
encounter by
conducting a
pre-session

For the patient, in your target language:
• Your name
• Your language
• Who you work for (the hospital, clinic, agency, etc.)
• Please speak directly to the nurse or doctor, not to me
• I will interpret everything that is said
• Please speak in short sentences and with frequent pauses
• A hand signal will indicate a pause is necessary to interpret accurately or to clarify something.
• Everything will remain confidential
• Feel free to ask the doctor any questions that you have.
• Do you have any questions?
For the doctor or nurse in English:
• Your name
• Your language
• Who you work for (the hospital, clinic, agency, etc.)
• Please speak to the patient, not to me
• I will interpret everything that is said in this encounter
• Please speak in short sentences and with frequent pauses
• A hand signal will indicate a pause is necessary to interpret accurately or to clarify something.
• Is there anything special I should know before we start?
If you have worked with the provider before, it is still better to continue using a pre-session
with the provider unless otherwise indicated. Don’t forget to ask, “Is there anything special
that I should know before we start?” Of course, this needs to be asked when the patient is
not present, as many patients may understand what is said, even though they don’t feel
comfortable expressing themselves in English.
Note: Some hospitals require a pre-session before every medical encounter.
Because of the pressure to see as many patients as possible, doctors, in particular, are often
rushed, and will not want to “waste” time with a pre-session.
The professionally-trained medical interpreter both understands this time pressure and keeps
their pre-session, particularly with the doctor, to a minimum, including: “speak directly to
(patient/provider), I will interpret everything, everything will be confidential (patient only).”

This is easiest if you and the doctor know each other and have experience working together. The
doctor will appreciate your cutting the pre-session with them to “Is there anything special that I
should know before we start?”
POSITIONING: Where the interpreter should sit or stand
One way that the interpreter can help direct the conversation between the
provider and the patient is by thinking clearly about where to sit or stand if sitting
is an option.
Remember that we want to encourage the conversation to take place between Encourage the
the provider and the patient, and not have it directed to the interpreter. We do conversation to
not want to be the center of attraction in an interpreted encounter. take place
between the
provider and the
What is the best position for the interpreter in an ideal doctor’s office encounter? patient, and not
have it directed
Next to the provider? to the
interpreter.
Figure 5. Interpreter positioned next to the provider
Next to the patient?
Figure 6. Interpreter positioned next to the patient

Equal distance from the two, as in one of the points in an equilateral triangle?
Figure 7. Interpreter positioned at equal distance, forming a triangle
Next to but slightly behind the patient?
Figure 8. Interpreter positioned next to but slightly behind the patient
In most other countries, for example, the triangular positioning is the standard, but in the United
States, we take into consideration the power imbalance in a hospital situation.
In an interpreted session in a hospital, who is perceived as having the most authority or power?
Some may recognize that the patient has the power to make the final decision, but most patients
that we will interpret for don’t realize this. They often don’t want to be perceived as “imposing”
on the doctor or the facility and will agree to whatever is suggested by the provider, especially if
they view the provider, and the interpreter as the two most powerful participants present, and
the interpreter stands next to the provider.
“Washing one’s hands of the conflict between the powerful and the powerless means to side
with the powerful, not to be neutral.”
- Paulo Freire, the Brazilian educator and author of “Pedagogy of the Oppressed.”

In an ideal
To help even out this power imbalance, in an ideal situation, the interpreter
situation, the should stand next to the patient in a diagonal position at a 45° angle, to be able to
interpreter see both the provider and patient and encourage direct communication between
should stand patient and provider.
next to the
patient, in a
diagonal
position (at a
45° angle)
Figure 9. Interpreter positioned next to the patient at a 45-degree angle
As most interpreters recognize, there are many exceptions to this “ideal

situation.” For example, if the interpreting takes place in the ER, likely with a
family member being the person that you are interpreting for, you will want to be
near the family member, but able to both hear what is being said and also staying
out of the way of the array of providers.
In that same situation, if the patient is asked to respond to a question with a body
movement when they are not able to speak, you will need to be facing the patient
to be able to see that body movement as they lie on the operating table and
speaking clearly so that the patient has the likelihood of understanding you.
If you are interpreting for several family members, you need to position yourself
in such a way that you can hear what the provider is saying and, at the same time,
be able to have your voice understood by the family members.
If you are interpreting in a mental health situation, you should sit by the door.
Keeping in mind the goal of facilitating the communication between the

provider(s) and the patient and family members, you need to use your judgment
as to what will work best given the exigencies of the situation. Much of this will
work itself out logically if you keep that goal in mind.

POST-SESSION
This ‘wrap-up’ step has not been included in most basic training, and it may not be accepted in
some situations.
In an upcoming lesson, we will cover the importance of being aware as an interpreter of your
relationship to the hospital or clinic in which you are working and the rules as laid out in a contract
with the language agency you will likely be working for.
Having said that, both the International Medical Interpreters Association (IMIA) and the
California Healthcare Interpreting Association (CHIA) make reference to what could fall under the
heading of a ‘post-session.'
The IMIA lists it in its Standards of Practice adopted in 1998, which was endorsed by the National
Council on Interpreting in Health Care (NCIHC). It is under the heading of “A-15 Assist the provider
with interview closure activities.”
The California Healthcare Interpreting Association (CHIA) has it in its “California Standards for
Healthcare Interpreters” © 2002 as Protocol 3 Post-Encounter, Post-Session or Post-Interview, as
follows (California Healthcare Interpreting Association, 2002):
“Interpreters provide closure to the interpreted session by taking measures to:
a. Inquire about any questions or concerns the parties may have for each other, and to ensure
that the encounter has indeed ended.
b. Provide directions or to accompany the patient to subsequent appointments that day.
c. Facilitate the scheduling of follow-up appointments and to remind the patient or the
receptionist to request an interpreter.
d. Document the provision of interpreting services, as required by each organization’s policies.
e. Debrief providers or the interpreter’s supervisor, when appropriate, about concerns of
interpreters or providers arising from the session.”
As an agency interpreter, you will need to comply with the license agreement that the agency
has with the hospital or clinic.
It is possible that none of the above will be allowed by the hospital, clinic, or the language agency.

How might each of these five parts work out in practice?
a) Inquire about any questions or concerns the parties may have for each other, and to
ensure that the encounter has indeed ended.
INTERPRETER: (to the patient) Mr. Nguyen, do you have any unanswered questions that you
would like to ask Dr. Garcia before you leave?
INTERPRETER: (to the doctor) I just asked Mr. Nguyen if he has any unanswered questions
for you before he leaves. Do you have any final questions or comments for Mr. Nguyen?
b) Provide directions or to accompany the patient to subsequent appointments that day.
This may cause the most problems if the interpreter is not an employee of the clinic or
hospital.
Of course, if the provider requests that the interpreter accompany the patient or help the
patient with directions, regardless of whether you are a freelance interpreter or staff
employee, this would be something that would be very beneficial to the LEP patient, and
acceptable for an agency interpreter to do.
c) Facilitate the scheduling of follow-up appointments and to remind the patient or the
receptionist to request an interpreter.
Some patients may “get by” with the English language at the front desk at a clinic. However,
it is not uncommon for patients to have problems scheduling new appointments and
remembering the follow-up and procedure instructions.
The aid an interpreter can provide at this point of contact can ensure proper scheduling and
reinforce any additional instructions or procedures.
d) Document the provision of interpreting services, as required by each organization’s

policies.
This is true for staff interpreters, but the agency or freelance interpreters must follow the
procedures agreed upon by the entity that sent them to the appointment.
Usually, this would entail checking in and out of the appointment via vouchers, telephone
calls, text messaging, or online management systems, indicating the start and finish time of
the interpreted session.

e) Debrief providers or the interpreter’s supervisor, when appropriate, about concerns of
interpreters or providers arising from the session.”
This process is usually linked to staff interpreters since it goes beyond the normal parameters
of a medical interpreting encounter. Many programs around the country accomplish these
functions through other professionals such as Community Health Workers (CHWs), Patient
Advocates, or Care Coordinators.
Group discussion
Considering two contractual situations (freelance and staff interpreter):
1. Analyze the pros and cons of a pre-session

2. Analyze the pros and cons of a post-session
Role-play
Form groups of 3-4 students in each group, and encourage the students to write a short script
where they can apply the concepts learned in this and previous lessons, particularly the use of
the pre- and post-session, and positioning. Each group should have one interpreter and at least
one patient and one provider.
Suggested topics for the script are interpreting scenarios in the following locations:
- Primary care physician’s office
- Emergency department
- Labor and delivery unit
- Rehabilitative therapy (PT, OT, ST, behavioral, etc.)

Lesson 8: Simultaneous Interpreting
Goals:
• To understand under which circumstances it is best to use the simultaneous
mode of interpreting
• To practice simultaneous interpreting scenarios
Simultaneous Interpreting
When most people think of simultaneous interpreting, they have images of the
United Nations (UN) interpreters, transmitting the message of speakers from
throughout the world, in many world languages as the ambassadors to the UN
speak. No pauses, no intervention by the interpreters who are sitting behind large,
sound-proof booths, out of sight of the speakers, yet these interpreters are crucial
to the majority being able to understand what is being said.
Simultaneous interpreting involves hearing one language and, after a few seconds Simultaneous
to process and reformulate what is being said, interpreting the meaning of the interpreting
involves hearing
message into another language.
one language
and, after a few
While consecutive interpreting is the standard mode in the medical interpreting seconds to
process and
profession, there are times when the interpreter needs to switch to the reformulate
simultaneous mode. what is being
said,
interpreting the
For example, when emotions are running high in an emergency scenario, it may meaning of the
not be appropriate or feasible for the interpreter to ask the speaker(s) to slow message into
another
down and speak with pauses. Under those circumstances, it is better to switch to language.
the simultaneous mode of interpreting.
This is also common when interpreting in mental health encounters. And, for
similar reasons, in mental health interpreting, the patient with mental health
issues is less likely or, at times, less able to speak with pauses. Even asking a
patient to speak differently may cause problems for the psychologist who needs
to hear the patient speak without interruptions.
Simultaneous is the appropriate mode in the scenarios indicated above.

Simultaneous interpreting is used in a small minority of situations, but it is used.
And the discrepancy has a lot to do with the type of encounter that the interpreter
is assigned to more frequently.
In the case of the two nationally accredited certifying bodies for healthcare
interpreters, both test for consecutive and sight translation, but only one tests
briefly for simultaneous.
Consecutive and
Consecutive and simultaneous interpreting are entirely different skills. One
simultaneous person may be an excellent consecutive interpreter and, at the same time, a
interpreting are substandard simultaneous interpreter. Another person may be an excellent
entirely
different skills simultaneous interpreter and a not-so-good consecutive interpreter. Some
interpreters learn to do both well.
Both modes of interpreting require being able to concentrate and focus without
being distracted, and both require highly developed skills in both languages.
Consecutive and simultaneous involve the following aspects:
Stress levels
While interpreting in simultaneous, there are some demanding and threatening
situations, mostly due to uncertainty about the interpreter's ability to cope or
keep up. Although, similar concepts can be expressed by the pressure of the
interpreter to recall the speech in the consecutive mode. Simultaneous
interpreters process between 100 to 189 words per minute, depending on the
speaker’s speed.
Processing time
Décalage is the lag time between when you hear the speaker and when you start
interpreting in the other language. Contrary to the belief that longer décalage may
result in more accurate renditions, there is research evidence that indicates
otherwise. Experienced interpreters in the simultaneous mode are as accurate or
more accurate than those experienced in the consecutive mode.
Self-monitoring
Self-monitoring is the interpreter’s ability to compare the source message with
the final interpretation. It is an important skill that allows the interpreter to
monitor the quality of interpreting. Also, self-monitoring allows you to recognize
your limits, as the quality of your work will decrease with fatigue or stress.

Self-correction
This process follows self-monitoring. The interpreter must recognize and correct
errors quickly to be able to maintain the pace of the speaker's speed.
__________
Tips for practicing simultaneous interpreting
Scaffolding: Start by repeating audio or video in the same language it is recorded. For example,
if the audio/video is in English, repeat it in English. This exercise will help you get in the habit of
repeating information while listening to somebody else speaking.
Record yourself: Use a cell phone app (sound recorder, voice memo, or another similar app), or
a computer microphone to record your rendition in the same language and when interpreting.
Transcripts: Try to use audio/video sources that provide a transcript of the audio/video. Use the
transcript to quantify your performance by verifying your accuracy.
Resources to practice simultaneous interpreting
NICHC eLearning workshops: https://elearning.nichc.org
Recorded conferences or presentations: http://interpreting.info/questions/507/recorded-

conferences-or-presentations-for-practising-simultaneous-interpretation

Lesson 9: Sight Translation and Summarization
Goals:
• To define sight translation.
• To identify appropriate and inappropriate sight translation requests and be
able to decline inappropriate requests professionally
• To practice accurate sight translation
• To understand that summarization is not a standard interpreting technique
• To learn when summarization is considered appropriate
Sight Translation
Sight translation is the act of reading a written text in one language and giving an Sight
oral rendition in the other language. This is very common in healthcare translation is
the act of
interpreting and can cause a variety of problems for medical interpreters who do
reading a
not understand basic guidelines. Sight translation may be appropriate or not. written text and
Generally, we can apply a three-factor analysis: giving an oral
rendition in the
other language.
• Length of the document (short vs. long documents)
• Content of the document (non-vital vs. vital documents)
• Provider’s presence (present vs. absent)
Factor 1: Length of the document (short vs. long)
As a general guideline, we define a short document as one that is half a page long
(single-spaced), or one-page long (double-spaced).
In general, the only documents that should be accepted for sight translation are
short documents. This is appropriate with or without the presence of a provider.
If it is a long document, it could take a long time for the interpreter to complete
the sight translation, and it may lead to complaints about the interpreter
exceeding the allotted time for the appointment.
Examples of “short documents” that don’t require the presence of a provider

include intake or registration forms, appointment reminders, accident report
forms (when, where, and how an accident occurred), short surveys, work absence
notes, and financial income disclosure forms.

These types of documents just ask for or state facts about a situation. No medical
diagnosis or expertise is required. Besides, the patient usually completes this
document with no assistance, even for English speakers.
Vital documents contain important medical information that patients may have
questions about and will need to have them answered by providers.
A short document that contains “vital” medical information should only be sight
translated in the presence of a provider. Examples: Instructions on how to take
medications, discharge instructions, or Do Not Resuscitate (DNR) instructions.
Long documents
“Long documents” would include anything more than a page or two long. This
would include pre-operative instructions, basic educational brochures about
chronic illnesses, common surgeries, etc.
Most of these documents are already translated by an ATA-certified translator and

are available in PDF format (free of charge) in many different languages from the
National Institute of Health’s MedlinePlus and HealthReach websites:
www.nlm.nih.gov/medlineplus/languages/languages.html
http://healthreach.nlm.nih.gov/
Again, long documents are not appropriate for sight translation, both because of
the time required to do an accurate sight translation, and because they contain
important medical information (vital).
Factors 2 & 3: Content of the document (non-vital vs. vital) & provider’s
presence
If the document is short but is ‘vital,’ the interpreter cannot do a sight translation
without the presence of a provider to be able to answer any medical questions
that the patient may have. So, what should an interpreter do when a provider is
requesting sight translation of a document?
Ask yourself two questions: How long is the document? And, does the document
contain vital or non-vital information?
The following table contains general guidelines to help interpreters determine

what to do when asked to do sight translation:

Short document – Non-vital Short document – Vital
OK to do sight translation with no provider Provider must be present to answer
present. questions.
1. Appointment reminders 1. Instructions on how to take medications

2. Patient registration forms 2. Instructions on how to operate devices
3. Financial aid applications that deliver medications, measure, or
4. Workmen’s comp accident reports control vital signs.
5. Surveys
6. Referrals
7. Work absence notes
Long document – Non-vital Long document – Vital

Ask provider to summarize key points, and Provider must be present to answer
you interpret. Provider must be present to questions.
answer questions.
1. Informed consent for a voluntary research 1. Educational brochures

study. 2. Advanced directives
2. Assignment of benefits, financial 3. Consent forms
agreements. 4. Privacy/patient rights
5. Discharge instructions
6. Power of attorney
Factors to consider before doing a sight translation without provider present

Determine whether the request is appropriate (vital or non-vital). If it is non-vital
and short, proceed to do a sight translation as follows:
• Read the entire document to yourself

• Detect any words or expressions you may not understand
• Ask for clarification, if appropriate, and if a provider is available.
• Sight translate at a steady, moderate pace, exactly as written (don’t add, edit
or omit any information).
• Your sight translation should only be spoken (oral). Do not write anything
down unless you are a certified translator.
If it is an inappropriate request to do without the presence of a provider or if it is too long:

You can politely turn down this inappropriate request by saying something like the following:

“My profession’s Standards of Practice don’t allow me to sight translate vital
documents without a medical professional being present to answer questions. If
you would like to summarize the key points, I would be more than happy to
interpret for the patient.”
Something to think about

We have learned that the professionally-trained medical interpreter should not
remain with the patient after the provider leaves. This is the accepted practice for
medical interpreters. But there is an important and often overlooked
contradiction here. Aren’t we asking the interpreter not to follow this standard of
practice by staying alone with the patient to do a sight translation without the
presence of a provider?
__________
Practicing sight translation

Start by answering: Is this an appropriate document that you could sight
translate? In the presence of a provider or by yourself?
SHORT PROCEDURE UNIT: PATIENT DISCHARGE INSTRUCTION SHEET

If you have excessive bleeding, excessive pain, or are unable to keep liquids down
____________ due to nausea or vomiting, or if you experience any other unusual problem that
you believe is related to your procedure, call your physician. If you are unable to
____________
contact your physician, call the hospital at (555) 123-4567, and ask for the Short
____________ Procedure Unit (6:30 A.M. - 6:30 P.M.), Monday through Friday, or come to the
Emergency Department.
____________
• Remain quietly at home through the night following the procedure.
____________ • Do not drink alcoholic beverages for 24 hours.
____________ • If you are slightly nauseated, take only small amounts of clear liquids every 15-30
minutes until nausea goes away. If you are not nauseated, eat a light dinner.
____________
• You may experience a sore throat post-operatively. This is common after general
____________ anesthesia and will clear in a few days. You may use throat lozenges.
• If you received a general anesthetic, do not drive a car or operate machinery until
____________
the day after the procedure.
• Do not take stimulants or other medications for 24 hours after the procedure
unless prescribed by your doctor.
• The SPU nurse will call you within 24 hours after your procedure.
Is this an appropriate document that you could sight translate? In the presence of a provider or
by yourself?

Summarization
Summarization is not an accepted interpretation technique, and for that reason,

Summarization
we don’t devote a separate chapter to this “mode” of interpreting. is not and
accepted
interpretation
Summarization can lead to common types of mistakes (changes and additions), technique, and
and it may lead to critical omissions. it can lead to
common types
of mistakes
Summarization typically takes place in a teaching hospital when several providers (changes and
present in the room are speaking to each other in a very high register using the additions), and
it may lead to
patient’s illness and treatment as a way to teach medical students. critical
omissions.
The doctor is not really attempting to speak to the patient, and you, as the
interpreter, may not even be able to hear all that is being said, since the professor
of medicine is often speaking to a small group of medical students. You
summarize or explain what is happening to the patient, more as a courtesy to let
them know what is going on. This is not interpreting or translating, and that is why
it is not a mode of interpreting frequently used in the profession.
Another situation may be in an emotion-packed room with several of the patient’s

family or friends present, especially after hearing a shocking diagnosis or
comment from a provider. It may become extremely difficult for the interpreter
to have the speakers pause to interpret, so rapid-fire summarization of as many
of the key points as the interpreter can hear and understand, would be
appropriate. The purpose is to give the provider a basic feel for what the different
people present are saying.
As soon as the provider starts speaking, the interpreter should be able to switch
back to the conduit role and consecutive mode.

Lesson 10: Short written translation
Goals:
• Students will be able to translate short written materials such as
instructions or directions accurately.
• Students will be able to identify appropriate vs. inappropriate translation
requests and will be able to decline inappropriate ones professionally.
Short Written Translation
We can easily say that the name for the second most common mode of
interpreting, sight translation, is a misnomer. It would be more accurate to call it
‘sight interpretation’ or something similar. We read from a written text in one
language and give an oral rendition of this in the other language. This is clearly an
interpretation of the written message, not a written version.
We clarified from the very beginning the difference between interpreting and
translation, and yet in discussing the different tasks that many interpreters are
asked to complete, we see the words “translation” twice: "sight translation" and
"short written translation."
Most basic medical interpreter training courses have discouraged healthcare

interpreters from writing anything down unless they are translators certified by
the American Translators Association (ATA). Founded in 1959, it now has more
than 10,000 members who are either translators or interpreters, by far the largest
professional organization of our broader profession.
And while there is nothing in the standards of practice of any major organization
of the medical interpreting profession that explains whether or not it is acceptable
to do short written translations as a medical interpreter, the profession is clearly
changing, if not formally, at least in practice.
As remote interpreting becomes more widespread, there is the general

acceptance of the need for medical interpreters to be able to do short, written
translations. Some call this part of the blending of the two separate professions
and point to a move towards 911 systems being changed to allow the acceptance
of “texted” 911 messages (www.fcc.gov/text-to-911).

If the person calling in the emergency information is not able to speak, such as in
a home invasion or spousal abuse situation, some emergency systems are now
capable of receiving the notifications of emergencies via texting. The interpreter
must be able to understand what is being texted as well as be able to text back a
written response in the caller’s language.
It is also true that some job listings for medical interpreter positions describe job
duties that include interpreting as well as translating. If that is the case, and you
have been hired under those descriptions, then you will need to explain any
limitations you may have to your new organization and decide whether or not you
can pass the ATA certification exam for your languages. You will also need to
consider purchasing Errors and Omissions insurance, also known as professional
liability insurance.
It may help to mention that a May 2012 US Supreme Court decision clearly decided
that there is a difference between a translator and an interpreter. The justices said
that translators write, and interpreters speak:
www.supremecourt.gov/opinions/11pdf/10-1472.pdf
Are you qualified to translate?
Translating Translating documents entails the use of specific linguistic, writing, and technical
documents skills. These are some of those skills:
entails the use
- Native or near-native proficiency in both languages
of specific
linguistic, - Analytical capabilities
writing, and
- Cultural competence
technical skills.
- Educational attainment (usually at the college level as a minimum)
- Expertise in the terminology of the subject matter
- Capable of doing terminology research? “Localization”?
Appropriate vs. inappropriate items to translate
As the title of this lesson indicates, the appropriate guideline is “short.” Using the
“vital” vs. “non-vital” designation from the sight translation lesson will also help
you understand the difference between appropriate vs. inappropriate.

In general, if you would need a provider to be present to answer a patient’s
questions, it is best to have the provider summarize the key points with the
interpreter present to interpret.
Most educational brochures about the common cold, chronic illnesses, and basic
operations and procedures are all available, free of charge, through the National
Institutes of Health’s MedlinePlus and Health Reach websites:
www.nlm.nih.gov/medlineplus/languages/languages.html
http://healthreach.nlm.nih.gov/
They are available in many different languages, translated by professional

translators. Knowing and explaining this to the responsible person at your hospital
can help all concerned. If the hospital takes advantage of the professionally
translated materials available, it will save the hospital time and money, as well as
cutting down on liability risks.
Simple, short translations that might be acceptable would be appointment

reminders, menu items, and instructions on how to take their prescribed
medications. Nearly all the rest either are too long or are already available in PDF
format for free. For remote interpreting, the obvious category that qualifies is the
short text message appealing for help from 911 texts.
Guidelines for short written translations
The interpreter will translate the short message as accurately to the meaning as
The interpreter
possible, making certain that the patient can understand what is written. This can will translate
be determined by asking the patient to read the written message or explain to you the short
message as
the meaning of the message written in the patient’s language. accurately to
the meaning as
Note: Remember that not all patients will be able to read in their language, so an possible, making
certain that the
oral explanation from the patient may be key. patient can
understand
what is written.
How to professionally decline inappropriate written translation requests
When the interpreter receives a request to translate a written document deemed

inappropriate, such as discharge instructions, research study consent forms, or
educational brochures, the interpreter can decline the request as follows:

• "My national standards of practice do not allow me to perform a written translation of
documents that should be translated by a certified translator."
• "As a contractor, my functions are almost exclusively limited to rendering communication

orally. Written translation can be performed but only for non-vital short documents."
• "Many informational resources are already professionally translated and available free of
charge in multiple languages from the National Institutes of Health (NIH)."

Lesson 11: Memory and Note-taking
Goals:
• To understand that there are different categories of memory and that you
can improve your memory skills.
• To understand the basic purpose of note-taking and to decide how to best
go about taking useful notes.
• To understand the importance of being able to concentrate and retain
information long enough to be able to interpret it accurately
Memory and Memory Development
Short-term memory is the primary or active memory that may last for seconds.
On average, the short-term memory capacity is 7+2 units of information (a string
of digits, letters, words, etc.) (Lisman & Idiart, 1995).
Long-term memory: Deals with long-term storage of data like the meaning of
words, concepts, facts, past experiences, etc.
Although there are additional subdivisions for types of memory, medical

interpreters use short and long term memory to render an interpreted message.
We want to show you that you can improve your memory skills through exercises
later in this lesson. The figure below depicts the subdivision of memory types:
Figure 10. Types of human memory (Human-Memory.net, 2010)

Storing information
There are
Memory has to do with storing information for future use. There are different
different "tools" "tools" that we can use to help us remember things better. Reviewing these tools
that we can use can help an interpreter make better use of these tools and improve the quality
to help us
remember and accuracy of a message we interpret. Here are some of those tools:
things better.
Chunking: Is the process of rapidly recognizing similar traits of items in a message
and categorizing or dividing them into groups (focusing on meaningful units and
underlying message). This technique may be useful when interpreters need to rely
on memory to arrange the syntax of the message in the target language when the
grammar structure differs from the English language.
Counting: Many interpreters, when a patient or provider starts to name a list of

things, will mentally assign numbers to each item on the list, helping the
interpreter to remember a series of things. For example, interpreters commonly
use finger counting to aid in the recollection of the items on a list.
Visualization or threading: this technique may be useful for visual learners. The
interpreter forms a thread of mental images based on the narrative that can be
useful to recall when reformulating the interpreted message.
Mnemonic phrasing: This tool helps some interpreters build anagrams with the
first letter of the words from a list. For example, the list of accuracy, advocacy,
confidentiality, cultural competence, impartiality, professionalism, and respect
can become A2C2IPR, or AACCIPR, or PRACCIA. How would you apply the
mnemonic technique to a list of patient signs: temperature, respiratory rate,
blood pressure, heart rate, weight, and height?
Repetition: The act of repeating a string of letters or numbers several times in a

short period may help to commit those strings to short term memory.
Not all tools work equally for everyone. There are different learning preferences,
and some people may prefer visualization over chunking, or mnemonic phrasing
over repetition. Whatever the case, you will find which tools work for you and use
them to your advantage as you gain experience in the medical interpreting
profession. You may find that one of these tools works best for you most of the
time or that you naturally use two or three of these tools. There is no one size fits
all tool.

Retrieving information
You are more likely to remember:
• What you want to remember

• Something similar to what you already know
• Information that you use often
• The items at the beginning and the end of a list than the ones in the middle
Stress
• Too much stress can and will reduce your ability to remember
• Moderate stress (as in intense focus) can increase your ability to remember
• You can become distracted by signals from the environment that can interfere
with your ability to store and recall information
PRACTICE: Writing a story
The following image has pictures of more than 40 different items. Memorize all
the things and write a story, including all of them. You’ll have 20 minutes. Share
your stories with the class. Refer to the images provided in the presentation.
Figure 11. Objects to create a storyline

Note-taking
Note-taking is Note-taking is possible in consecutive interpreting but is not possible in

possible in simultaneous interpreting.
consecutive
interpreting but
is not possible in It is important to let the patient know why you are taking notes and that you will
simultaneous either give them your notes when the appointment is over or will destroy them
interpreting.
while the patient is present (for example, using the “Confidential” bins for
disposal). This has to do with maintaining confidentiality as well as the patient’s
trust. Some patients will be very uneasy, seeing you, a person who they might
have just met, taking notes about their health situation. Reassuring them that the
notes will just be to help you interpret exactly what is being said and that they will
not remain in your possession.
Remember that if you are going to take notes in a face-to-face session, you will
need to be prepared with your note-taking tools, including working pens. Once an
encounter has started, you cannot interrupt it to go and collect your note-taking
tools.
It is highly recommended that you use what is known as a stenographer’s

notebook. They have the spiral binding at the top, are about 5 inches by 8 inches,
and have a vertical line down the middle of the page (see image).
Figure 12. Stenographer’s notebook
It’s more cumbersome to have anything larger, and it can be very distracting if you
are making noise by constantly flipping pages to get to the next available note-
taking page.

Using paper that is divided in the middle, like the image shown above, will help
you save space and separate paragraphs better than a non-marked paper.
For accurate interpreting, the interpreter must be rested, focused, and able to
concentrate. It is not recommended that you try to learn the new skill of note- It is not
taking as you are interpreting. If you have not already developed your own note- recommended
that you try to
taking system and are not used to doing it, you can take classes or courses from learn the new
your local professional organization or community college. Some interpreters opt skill of note-
taking as you
not to take notes as it distracts their rendition of the spoken message. If that is
are interpreting.
your case, you need to concentrate more on your memory skills development.
Taking notes can relieve the memory effort, but it has to be done properly. And it
takes practice.
The notes should ideally be taken in the target language (so that translation is
done while taking the notes), although some terms may be more effectively
recorded in the source language or shorthand. The main reason to take notes in
the source language is to minimize fatigue.
The notes should indicate which parts of the message are the main points and
which ones are supporting points. Probably, the benefits of note-taking,
organizing, focus, and memory development reinforce each other.
Note-taking strategies
Focus on ideas, not words. Develop your own personal note-taking system based
on what works for you. And do this ahead of time. Spacing, abbreviations, and
symbols are elements that can be used in building a note-taking system. Spacing
is commonly used to tell the main ideas apart from the supporting ideas (titles and
subtitles).
Notes should be taken on only one surface of the notepad, and they should be
easy to read and unambiguous. The abbreviations should have a single lexical
meaning, and symbols should not be invented on the spot.
In summary, to maximize our memory capabilities, an interpreter must be rested

and focused. Experience can give the interpreter the confidence that their
memory can and will improve with practice.

Note-taking is a
Note-taking is a skill that has to be developed over time. It takes advanced
skill that has to preparation, including being organized with the tools that you need well before
be developed the interpreted encounter starts. Symbols that you will use to shorten your writing
over time. It
takes advanced time need to be worked out ahead of time and committed to memory. Inventing
preparation, symbols on the spot may mean that you have no idea what they mean as you try
including being
to use them to help you remember what was said.
organized with
the tools you
need well Exercise 1
before the
interpreted In groups of two, tell your partner your favorite story and then have them do the
encounter same for you. Limit the story-telling to under 5 minutes each. Then be prepared
starts.
to tell your partner’s story to the rest of the class.
Exercise 2
In groups of two, read some of the practice scripts used in class while the other
student is taking notes. Read at a steady, moderate pace.
Rotate with the other student so that both of you can practice note-taking.

Lesson 12: Remote Interpreting
Goals:
• To understand the nature of remote interpreting
• To understand the differences between in-person and remote interpreting
for all involved parties
• To understand why this way of interpreting is a permanent part of medical
interpreting
Remote Interpreting
What is remote interpreting?
The term “remote interpreting” refers to any interpreting between two people "Remote
who do not speak the same language that uses an interpreter who is not in the interpreting"
refers to any
same room with them. This may be telephonic or video remote interpreting (VRI) interpreting
and may happen within a hospital, from a call center not affiliated with any between two
particular hospital, or clinic, or from the privacy of one’s home. people who do
not speak the
same language
that uses an
A brief history of remote interpreting interpreter who
is not in the
same room with
While many may imagine that telephonic interpreting was first used in the United them.
States, it actually was first introduced into Australia in 1973 (TIS National, n.d.), as
a response to a large influx of immigrants that didn’t speak or understand English.
Over the phone (OPI) or telephonic interpreting was introduced in the US in

1981. Over the next decades, its use spread to many fields, such as healthcare.
While most medical interpreters entering the profession assume they will be
doing face-to-face or in-person interpreting, the fact is that most hospitals or
clinics post job descriptions specifying that they require a minimum of three years
of experience interpreting in healthcare settings.
A growing number of interpreters entering the field with no “official” verifiable

work experience, start out working for one or more language agencies as freelance
interpreters, not as employees, but as independent contractors with no benefits
nor guarantee of hours or pay.

Why the move to remote interpreting?
The estimate of the number of languages in the world today varies greatly.
According to the website Ethnologue (Ethnologue.com, 2015), there are more
than 7,100 living languages. But even if there were only 10% of those languages,
no hospital in the world can afford to have a full-time, professionally trained
medical interpreter on staff three shifts per day, seven days per week for each of
710 languages. It simply is not feasible in any sense of the word.
Hospitals moved quickly to telephonic interpreting by the first years of the new
Some patients millennia, and it keeps expanding. Some patients find that the use of telephonic
find that the use interpreting gives them more privacy when they want just that. Others find it
of telephonic
interpreting
impersonal and hard to understand.
gives them more
privacy when There is no reason to believe that this growth in the use of remote interpreting
they want just
that. Others find will change as more and more people find their way to the US and speak a growing
it impersonal number of languages, some vaguely familiar, some previously unknown.
and hard to
understand.
The evolution of remote interpreting
As technology has improved, and with the deaf and hard of hearing community
refusing the use of “choppy” video projections of remote interpreters, by 2011,
we saw the advent of completely smooth projections of remote ASL interpreters,
even on large screens.
Language agencies specializing in remote interpreting for the deaf and hard of
hearing realized that they had something that applied to spoken language
interpreting and quickly started marketing systems and devices to hospitals,
mounted on movable carts that allowed video remote interpreting to become
much more accessible.
By 2012, various companies had incorporated technology that allowed the

interpreting to take place on portable “smart” phones and tablets, through HIPAA-
compliant systems to ensure patient privacy. The old, costly “wired” video remote
systems will soon become a thing of the past as will the use of landline
“telephones.” Many people have the ability to see the person that they are
speaking with on their smartphones, even for daily phone conversations.

How remote interpreting impacts the interpreted encounter
There are many factors that can negatively impact a remotely-interpreted session. There are many
factors that can
negatively
First, it would be the quality of the equipment being used and the remote impact a
connection. remotely-
interpreted
session.
Second, it might be the skill of the provider in knowing how to work with a remote
interpreter. This could include the provider’s understanding of the need for a pre-
session to lay the ground rules for the smooth functioning of the encounter.
Third, at least in OPI, is the inability of the interpreter to see the patient and the
doctor. This is less of an issue with VRI, but as both provider and patient move
around, without repositioning the video camera, it can also be a problem. For a
more thorough presentation of Over the Phone Interpreting (OPI), read the 6-page
Guide by Nataly Kelly called “A Medical Interpreter’s Guide to Telephone
Interpreting from August of 2008”: www.imiaweb.org/uploads/pages/307_2.pdf
New problems and challenges facing remote interpreters
As commercial call centers replace on-site interpreting centers, and all types of
interpreting are mixed in, from real estate to banking, health care, and education,
the same types of issues arise that one finds in any job. There are reports of not
allowing breaks, of low pay, of lack of medical coverage, and of using interpreters
who have no training in any aspect of interpreting.
The issues of working conditions and a livable pay scale will need to be dealt with
on a national scale as interpreters join together to continue consolidating the
professional standards.
The challenge of finding a balance
With tight budgets, interpreter service coordinators are constantly faced with the
challenge of deciding which modality to use for their LEP patients. OPI? VRI? Face-
to-face (if the staff has the ability to interpret the language)?

Many hospitals, especially with experienced interpreters in charge of managing
interpreter services, have come up with guidelines as to which modality to use in
different situations.
For example, for simple appointment reminders, telephonic interpreting is

adequate. VRI can be used for answering questions about how to re-bandage a
wound safely or to observe a movement question that the patient has.
However, when medical encounters require a review of body systems, an initial

visit to a physician (where a new patient history is created), meetings with
multiple providers, technical explanations, or life-altering decisions, the use of a
face-to-face interpreter is highly recommended. This is particularly true when it
comes to end-of-life situations, or giving a patient or their families bad news. Of
course, this depends on the availability of an interpreter for the language in
question, either staff or through an agency.
What is different in remote interpreting?
• Facing a lack of, or fewer visual cues, remote interpreters need to rely more on
note-taking.
• A pre-session is also standard in remote interpreting, although how much you do
is determined largely by the company that you sign an agreement with or that
employs you.
• Remote interpreters usually provide their interpreter number for the record.
• Remote interpreters can have digital and print glossaries in front of them at all
times.
• Remote interpreters get paid by the minute (when working from home), or hourly
(at a call center)
• Most remote interpreters cover different types of interpreting: medical, legal,
commercial, etc.
• Other language interpreting agencies that focus on remote interpreting have
exclusive agreements with hospitals and clinics to provide health care interpreting
and offer the profession’s basic training to all of their interpreters. This exclusive
healthcare focus helps the interpreters be able to concentrate on medical
terminology and not be as concerned with becoming experts in vocabulary related
to real estate or banking.

Chapter 3
THE IMPACT OF
CULTURE ON
COMMUNICATION
AND HEALTH

Lesson 13: Introduction to Culture
Goals:
• To define culture from a broad-based perspective
• To acknowledge your own culture.
• To understand the origins of stereotypes.
• To identify common stereotypes from different cultures.
• To define cultural competence in healthcare
What is Culture?
“Culture should be regarded as the set of distinctive spiritual, material, intellectual

and emotional features of society or a social group, and that it encompasses, in
addition to art and literature, lifestyles, ways of living together, value systems,
traditions, and beliefs.” (UNESCO, 2001)
Culture: “The thoughts, communications, actions, customs, beliefs, values, and

institutions of racial, ethnic, religious, or social groups.” (Bazron, Dennis, & Isaacs,
1989)
So, what is culture for you?

Can you define culture?
Culture and Interpreting
A professional medical interpreter must be extremely aware of the impact of A professional

culture on a medical encounter. This is especially important in the US, as it is one medical
of the most diverse countries in the world. interpreter must
be extremely
aware of the
Cultural diversity fosters innovation, collaboration, creativity, great scientific impact of
culture on a
achievements, academia, music, art, food, etc.; but it can also lead to medical
misunderstandings that may affect the health outcome of limited-English encounter.
proficient patients. One big problem medical interpreters work to avoid is medical
errors. Another is to help avoid potential conflicts based on cultural differences in
medical encounters.

Elements of culture
• Symbols: things that carry emotional meaning
• Language: including slang
• Values: guidelines for social interactions
• Beliefs: regarded as true by a group
• Norms: mores (formal norms), folkways
Figure 13. Mixing of elements
(informal norms)
The human brain: The hardware of culture
Nature or Nurture?
That question shows up in past and current
discussions regarding human behavior, human
health, and other scientific and social issues.
Figure 14. Brain, the hardware of culture

Our brain is a magnificent complex organ that
requires years of physical, emotional, and social stimuli to develop its structure
and functioning.
How much does culture influence the brain?
How much does the brain influence an individual’s culture?
Are we culturally pre-wired?
One piece of information that most of us are lacking is about the area of the
human brain that responds before any other, and that is the frontal lobe. In less
than a second, this part of the brain decides “friend or foe” or “flee or fight.” This
is actually the basis for modern-day stereotypes. But how can that be so? Is it, in
fact, something that we are born with? Can anything be done about this split-
second reaction?
Looking back in the early development of humans, they lived in smaller groups,
usually limited by what nature could provide them with and quite isolated by wide
and wild rivers, or high mountains, or dense forests or jungles. Humans got used
to living and interacting with people who had learned to survive by using the same
learned ways of surviving predators -- animal or human -- or weather.

When one day a person would see someone or several people crossing the
mountain or floating on something in the river, they had to make a very quick
decision to flee or to stay and fight. It was a survival response.
If they misjudged the unknown, they wouldn’t survive to tell anyone about it.
This is a primary reaction of the brain, and it is reinforced by visual cues such as
aggressive signs, or something unfamiliar to us, that are perceived as being
dangerous.
This same genetically-programmed response is still a part of our brains today. The
question is, in today’s world of hundreds of millions of people living in relative
proximity from all corners of the world, is this response helpful? Or has it now
become a cultural obstacle?
With this information, what can we now say about stereotypes?
Returning to the question posed earlier as to whether or not anything can be done
about the pre-programmed response to the unfamiliar or the ‘different’ that leads
to stereotyping -- the answer is ‘yes.’ All interpreters must try to learn as much as Interpreters
possible about different cultures’ attitudes towards health, illness and how to deal must try to learn
as much as
with them. This is part of becoming culturally competent in the healthcare
possible about
profession, a concept that we will explain more fully later in this lesson. different
cultures'
attitudes
Part of the effort of interpreters constantly striving to be aware of different towards health,
cultures and stereotypes includes anticipating how patients will perceive the illness and how
to deal with
interpreter. The interpreter needs to build a relationship of trust quickly so the
them.
patient feels more comfortable, but without confusing this with an attempt to
establish a friendship relationship, seamlessly showing that we respect the
patient, their family, their customs and that we are there for them.
Many cultural interactions in the US are plagued with situations that alter the
perception and communication between people. Some of these interactions rely
on preconceived ideas about certain groups of people or stereotypes. Although
stereotypes are not entirely unfounded, most of them are based on subjective
observations, instead of overall facts or any knowledge about the individual
human beings in question.

Can you say that every person that is from Colombia is Catholic, likes to drink
strong coffee, and speaks Spanish? Many Colombians have other religions (Jews,
evangelicals, etc.), drink tea, and 6% of the population does not speak Spanish.
Instead, they speak indigenous languages.
Stereotypes may also alter the communication

between the patient and the provider. The presence of
a medical interpreter can be useful to identify and
clarify any doubt or misunderstanding based on
preconceived ideas.
In the physician’s office, the clothes that each person

wears, the general physical appearance (height,
weight, hair and skin color), the regional variations of
the spoken language (both English and target
Figure 15. Stereotype in
healthcare? language), eye contact or lack thereof, promptness,
and many more factors, affect how the appointment
will proceed. The role of the interpreter is both to be aware of his or her own
presence and stereotypes and to help assure the successful communication
between the patient and provider.
Cultural
Cultural interactions that are not understood, or are biased by stereotypes, are
interactions that harmful to successful communication. In the case of patients, many factors
are not involved in medical encounters and the complexity of the US health system are
understood, or
are biased by unfamiliar, and therefore frightening. This may cause patients to respond with the
stereotypes, are “flee” response, or not to adhere to the treatment plan, or necessary follow-up
harmful to
appointments.
successful
communication.
Activities
• Gather with members of your language or country and produce a list of
stereotypes and prejudices that “others” have of you, your country or culture of
origin. If you are the only representative of your country or language, please do
this activity individually.
Questions to answer: “How can this affect me as a person? How can this interfere
in my work as a medical interpreter?”
Share with the class.

• On your own, write down what you would honestly consider being your
prejudices or stereotypes. Recognizing them, if you haven’t done this before,
this exercise can help you change or at least keep them under control, to be
able to play the positive role that you are needed to play in the interpreted
encounter. You will not be asked to share what you write down unless you
choose to do so.
Online activity: Stereotyping (QUIA): http://goo.gl/VvXO5h
How can we define personal culture?
You can also see ‘culture’ as the sum total of every single experience, sensation,
interaction that an individual human being has gone through in their lifetime that
forges that particular individual. This is possibly easier to understand if you ask
yourself if there is any other person in the world who is exactly like yourself.
The answer, from that perspective, is likely ‘no,’ there isn’t another person in the There isn't
world exactly like any of us. We can share many different likes or dislikes, habits, another person
in the world
and so forth, but no two human beings are exactly alike or share identical factors
exactly like any
that have influenced the person that they are now. of us.
Even twins, as an example of people who have the same biological parents, are
surrounded by the same environment, and raised with the same values, end up
being different. These differences are expressed in their culture as preferences of
communication styles, music, interaction with people, etc.
Cultural Competence
What is Cultural Competence in healthcare?
Cultural competence in health care is the ability to respect a person and his or her Cultural
culture and beliefs as being a part of the broad spectrum of human beliefs, competence in
health care is
customs, norms, without necessarily indicating agreement with the same. It also
the ability to
involves being aware of your culture, biases, and prejudices as well as respect a person
understanding that ethnic or cultural stereotypes may also identify the patient's and his/her
culture and
view of you. beliefs

Cultural competence entails knowing your limitations in addressing issues across
cultures, and understanding your style, recognizing when it may not be working
with a given patient.
Being culturally competent entails more than just "knowing" what not to say or
do when interpreting for members of certain cultures to not offend the patient. It
is also understanding and embracing the differences in cultures and beliefs as
assets and not as barriers.
Cultural competence continuum (at the organizational level)

Cultural Cultural competence in health care describes the ability of systems to provide care
competence in to patients with diverse values, beliefs, and behaviors, including tailoring delivery
health care
to meet patients’ social, cultural, and linguistic needs (Betancourt, Green, &
describes the
ability of Carrillo, 2002).
systems to
provide care to
patients with
diverse values,
beliefs and
behaviors,
including
tailoring delivery
to meet
patients' social,
cultural, and
linguistic needs.
Figure 16. Cultural competence continuum at the organizational level (National Center for Cultural
Competence, n.d.)

Lesson 14: A brief history of the US Healthcare System
Goal:
• To review the history of the US healthcare system
A brief history of the development of the US Healthcare System

Before the 1800s
The indigenous people that were here in what is now known as North America had The indigenous
their healers and approaches to health and wellness for thousands of years before people that
were here in
the arrival of the first European settlers. They used what would be known in what is now
today’s world as traditional medicine, based on the medicinal characteristics of known as North
America had
plants available in their areas and approaches that had been tested for countless
their healers
generations. Some tribes that have survived continue some of these practices and approaches
today. to health and
wellness for
thousands of
For the European settlers, health care was provided based on cultural tradition years before the
arrival of the
and knowledge of plants that they learned to use from the original inhabitants. first European
The better-off settlers had access to Western-trained doctors and others settlers.
influenced by western medicine but with little or no formal training or titles.
The first medical school in what became the United States was founded in 1765,
under the name "College, Academy, and Charity School of Philadelphia," which is
now known as the University of Pennsylvania.
Figure 17. US population density in 1800 (Source: The Social Explorer)

During the 1800s
The delivery of care changed over time from experiences serving people wounded
in wars, to providing care by solo practitioners.
The new country was rural in its vast majority for its first 150 years, and most
healers were women who had learned from previous generations. They were
bonesetters and midwives who exchanged goods as a form of payment for their
services from other community members.
Towards the end of the 1800s, hundreds of thousands fled civil wars resulting
from the attempt to form modern nation-states in Europe. Others were fleeing
famine caused by crop failures from food sources that had been introduced from
the “New World.” The medical schools in the new United States, a few founded in
the second half of the 18th century, even before the country was founded, only
accepted white males and the doctors that they produced were not available for
the most part outside of the major population centers
The new
The new European immigrants included medical doctors, and their approach to
European solving medical problems became the norm by 1900.
immigrants
included
medical doctors The new immigrants brought their preference for allopathic or Western Medicine,
and their
with formally trained doctors and nurses.
approach to
solving medical
problems
became the
norm by 1900.

The 1900s
New revolutions and wars in Europe, from the 1905 Russian Revolution to the
beginnings of World War I, brought another major influx of hundreds of thousands
of European refugees and immigrants. For the most part, they were familiar with
Western Medicine and wanted their children to be treated by “a real doctor.”
Hospitals were in the main population centers, with the larger hospitals with more Hospitals were
specializations located in the largest cities. As the cost of medical treatment rose, in the regions'
the first “cooperatives” were formed in the late 1920s, where employees would main population
centers, with
pay a very small fee (as little as $.50 per month) to guarantee up to three weeks the larger
of hospital care per year. This “pooling” of resources and cooperatives eventually hospitals with
more
led to what is today known as Blue Cross/Blue Shield.
specializations
located in the
These initial efforts to make health care more accessible were actively opposed by largest cities.
the main national professional organization of physicians, the American Medical

Association (AMA). It was founded in 1847 and remained the main national
professional organization of physicians in the US.
A big part of the complexity of the US health system has been shaped by lobbying
efforts and court actions supported by the AMA, such as restricting the number of
accredited medical schools and opposing a universal healthcare system.
A major change: Medicaid and Medicare
The Social Security Act was passed in 1935 (it didn’t include medical care), and it
was amended in 1965 to add what is now Medicaid (Centers for Medicare & Medicaid is
Medicaid Services, 2015). The Health Insurance Association of America describes described as "a
government
it as a “government insurance program for persons of all ages whose income and insurance
resources are insufficient to pay for health care.” program for
persons of all
ages whose
Medicaid is jointly funded by state and federal governments and managed by each income and
state, so the quality and effectiveness vary from state to state. Medicaid recipients resources are
insufficient to
must be US citizens or legal permanent residents, and low-income alone is not pay for health
enough to qualify for assistance. care."
In 1966, the US federal government launched the national social insurance

program known as Medicare (Centers for Medicare & Medicaid Services, 2015).

It provides a certain level of health insurance for people aged 65 and older who
have worked and paid taxes into the Medicare system. Before 1966, there was no
coverage for the elderly, but this program only covers about one-half of all medical
expenses and it is administered through roughly 30 private insurance companies
throughout the US. Individuals must pay for additional insurance to attempt to
cover the other 50% or pay out of pocket.
The 2000s
The opening of
The opening of the new millennium brought growing discussion in the US about
the new out of control costs of medical care and the low ranking among industrialized
millennium nations based on major health indicators.
brought growing
discussion in the
US about out of
control costs of
medical care
and the low
ranking among
industrialized
nations based
on major health
indicators.
Figure 19. National health expenditures per capita (The Henry J. Kaiser Family Foundation, 2014; Centers
for Medicare & Medicaid Services, 2019)
The Centers for Medicare & Medicaid Services reported that the US health
expenditure per capita added up to $10,739 in 2017 and $11,172 in 2018.
In order to have a better frame of reference and adjusting for price differences, in
2017, the US spent $10,739 per capita.

Whereas in the UK, the country with the best overall health system among industrialized nations
spent $4,246 (OECD, 2018). One would think that spending more money per capita would
produce better health outcomes, but in the case of the US, it is quite the opposite. Two studies
(2014 & 2017) ranked the US last when comparing the health systems of eleven industrialized
countries (See the figure 20 below).
Figure 20. The overall ranking of health systems from eleven industrialized countries. Adapted from 2014
and 2017 Mirror, Mirror on the Wall (The Commonwealth Fund, 2014; The Commonwealth Fund, 2017)
For FY2019, approximately 60 million people (51 million older adults and 9 million younger adults
with disabilities) rely on Medicare (KFF, 2018). As of November 2018, nearly 66 million people
were enrolled in Medicaid (Medicaid.gov, 2019). As of February 2019, 36 states and Washington
D.C. have adopted Medicaid expansion, and 14 states have not adopted the expansion (KFF,
2019).
Executive Order 13166 of August 11, 2000

Requires all federal agencies and all recipients of federal funding to provide meaningful access
to their services to persons with limited-English proficiency (LEP). From the LEP website
(www.lep.gov):
On August 11, 2000, the President signed Executive Order 13166, "Improving Access to Services
for Persons with Limited English Proficiency."
The Executive Order requires Federal agencies to examine the services they provide, identify any
need for services to those with limited English proficiency (LEP), and develop and implement a
system to provide those services so LEP persons can have meaningful access to them.

It is expected that agency plans will provide for such meaningful access consistent with, and
without unduly burdening, the fundamental mission of the agency.
The Executive Order also requires that the Federal agencies work to ensure that recipients of
Federal financial assistance provide meaningful access to their LEP applicants and beneficiaries.
To assist Federal agencies in carrying out these responsibilities, the U.S. Department of Justice
has issued a Policy Guidance Document, "Enforcement of Title VI of the Civil Rights Act of 1964 -
National Origin Discrimination Against Persons With Limited English Proficiency"
(https://goo.gl/X43kS2).
This LEP Guidance sets forth the compliance standards that recipients of Federal financial
assistance must follow to ensure that their programs and activities normally provided in English
are accessible to LEP persons and thus do not discriminate based on national origin in violation
of Title VI's prohibition against national origin discrimination.

Universal healthcare
In 1978, the International Conference on Primary Care in Alma Ata (USSR at that time) produced
a declaration, the Alma-Ata Declaration with ten points to consider “for urgent action by all
governments, all health and development workers, and the world community to protect and
promote the health of all people of the world...” (World Health Organization, 1978)
This declaration defined health as “a state of complete physical, mental, and social well-being,
and not merely the absence of disease or infirmity, is a fundamental human right and that the
attainment of the highest possible level of health is a most important world-wide social goal...”
The declaration also defined primary care goals and the people’s right to participate in the
planning and implementation of their health care. An important part of this declaration is the
association of political, social, and economic factors to health and health care.
Although this declaration did not achieve all its goals, it brought attention to primary care
(preventive) medicine and what is known today as the social determinants of health and their
influence on health outcomes.
Universal healthcare is still an evasive reality to many countries, such as the United States, that
relies on a combination of public (Medicare, Medicaid, CHIP), and private insurance options
(HMO=health maintenance organizations, PPO=preferred provider organization, etc.)
The Patient Protection and Affordable Care Act (PPACA) was approved by Congress, signed into
law on March 23, 2010. Different provisions were scheduled to be gradually implemented since
2010. The individual mandate tax was implemented in 2014 (health marketplace). Since then,
additional modifications were introduced by the federal government in 2016 that was not part
of the original conception of the PPACA.
Although this is an attempt to repair a disjointed and wasteful US health system, a lot of
opposition and confusion remains in a health system that is shifting its payment model from fee-
for-service to quality-based patient outcomes.
And, although this might not be perceived as pertinent to medical interpreters, when the focus
shifts to quality-based outcomes, the use of medical interpreters and other non-clinical
professionals should become more mainstream and requested, with possible standardization of

national training and professional standards, incorporating medical interpreters in the list of
professions whose services are eligible for insurance reimbursement.
Figure 22. Universal healthcare around the world (Chartsbin.com, 2010)
The Patient Protection and Affordable Care Act (PPACA) aka "ACA" or “Obamacare”
The PPACA has several sections that deal with language requirements in health plans and
insurance-related topics (U.S. Department of Health & Human Services, 2015). Although not all
of those topics are directly related to the work of medical interpreters, it is important to mention
two sections, sections 1557 and 5307:
Nondiscrimination - PPACA Section 1557:
• Extends Title VI’s prohibition of discrimination based on race, color, or national origin
• Extends protections to “contracts of insurance.”
• Allows the same enforcement mechanisms available under Title VI
• Has requirements for Notices, PPACA Section 1001 (PHSA 2719)
• Requires group health plans to implement the appeals process
• Requires that plans provide notices to all enrollees in a “culturally and linguistically
appropriate manner.”
• Created consumer assistance by ombudsman office - ACA 1002
• Requires small plans (100 or less) to translate notices when 25% of enrollees or more are
literate only in a non-English language.
• In May 2019, the Department of Health and Human Services proposed a regulatory reform to
eliminate non-discrimination based on language, arguing that it would save U.S. taxpayers

$3.6 billion over five years. This figure is apparently arbitrary. This proposed reform sparked
the protest of most professional organizations related to language access services throughout
the United States.
ACA 5307
Cultural Competency Curriculum:
• Demonstration programs are to include:
o Language services
o Pay for language services by including funding allowances in budgets
o Collect and report data on participants’ language needs and use of language services
o Stratify results by LEP/non-LEP or language subgroups (when sufficient numbers exist) to
identify any discrepancies in outcomes based on language needs.
10 Essential Health Benefits of the PPACA:
The PPACA requires all major medical plans and qualified health plans to offer the following ten
essential health benefits:
• Laboratory services
• Emergency services
• Prescription drugs
• Mental health and substance use disorder services
• Maternity and newborn care
• Pediatric services, including oral and vision care
• Rehabilitative and habilitative services and devices
• Ambulatory patient services
• Preventive and wellness services and chronic disease management
• Hospitalization
Since 2016, the federal government has attempted to dismember the provisions and regulations
of the PPACA with partial success.
Although the PPACA is still the law of the land as of the third quarter of 2019, it is uncertain what
the next iteration of a health system in the United States will be.
The debate as to which changes should be incorporated has been widely politicized and remains
to be resolved. There is growing support for the adoption of a government single-payer (universal
health care) system, but long-term legislation addressing this matter is not yet a reality.

Schools of medicine in the U.S.
Osteopathic medicine was intended to be a reform in medicine, emphasizing preventive care,

and avoid the overuse of medicines. The Osteopathic school of medicine trains individuals with
the Osteopathic Manipulative Treatment (OMT) involving the use of hands to diagnose and treat
illness. Graduates from this school of thought are called Doctor of Osteopathy (D.O.)
Allopathic medicine does not include OMT, and their graduates are called Medical Doctors
(M.D.).
Currently, both D.O.’s and M.D.’s practice medicine in very similar ways.
Doctors in medicine
The healthcare professions are also reflecting the diversity of the U.S. population. People of
different racial backgrounds were more widely admitted to medical schools as a result of the Civil
Rights Movement. This was also true for the increase in the number of female physicians.
Similarly, there is also an increasing number of foreign-born physicians that work in the U.S.
Medical interpreters need to be aware of this diversity and their potential linguistic (accent),
register, and cultural implications.
Activity: Healthcare professionals in the US

An important aspect for a medical interpreter to learn is the diversity of healthcare occupations
and professions that are part of the professional workforce in the US health system. How many
times have you been to the hospital or a clinic and observed the profession’s names that do not
exist in your country?
Form groups of 3 or 4 students and select one of six scenarios to produce a list of all the
healthcare professionals that attend to a patient directly (contact with the patient), or indirectly
(no contact with the patient).
Scenario 1: Specialist’s office Scenario 4: Mental health hospital, or unit

Scenario 2: The emergency department Scenario 5: Community health clinic
Scenario 3: The labor & delivery unit Scenario 6: Rural hospital
Note: Several healthcare professions may not exist in all countries around the world. If that
happens in your country, or with your language, you still have to identify a proper linguistic
equivalent of the healthcare profession that conveys the meaning behind the profession’s name
and functions.

Healthcare occupations
Table 2. Required academic training for the most common healthcare occupations
Occupation Education Acronym Equivalent in
target language
Audiologist HS (12 yrs) AuD
Bachelor’s (4 yrs)
Doctoral (4 yrs)
Chiropractor HS (12 yrs) N/A (US)
Doctoral (4-5 yrs)
Dental Assistant HS (12 yrs) RDA
Certificate (1 yr)
Dental Hygienist HS (12 yrs) RDH
Associate’s (2 yrs)
Dentist, Stomatologist HS (12 yrs) DDS, DDM
Doctoral (4-5 yrs)
Diagnostic Medical Technologist HS (12 yrs) Multiple
(Ultrasonographer, cardiovascular Associate’s (2 yrs)
and vascular technologists)
Dietitian and Nutritionist HS (12 yrs) RD
Emergency medical technician HS (12 yrs) EMT
(EMT), paramedic Certificate (1 yr)
Genetic counselors HS (12 yrs) CGC
Master's (2-3 yrs)
Licensed Practical Nurse (LPN) HS (12 yrs) LPN
LPN training (1-2 yrs)
Registered Nurse (RN) HS (12 yrs) RN
Certified Registered Nurse HS (12 yrs) CRNP
Practitioner or Nurse Anesthetist Bachelor’s (4 yrs) CRNA
Physician's Assistant (PA) Master's (1-3 yrs) PA
Medical Assistant (MA) HS (12 yrs) MA
Certificate (1 yr)

Lesson 15: The Culture of Western Medicine
Goal:
• To analyze the way healthcare information is collected and handled by
providers
The Culture of Western Medicine
The physician’s method

Healthcare providers usually follow a method to solve medical problems, usually in three
stages:
• Collection of information: patient history and testing

• Diagnosis: all pieces of information are analyzed
• Treatment plan: design and implementation
• Patient education: any healthcare intervention should involve some form of patient
education.
This process is not unidirectional. In many instances, patients need to go through additional
rounds of testing due to previously unknown findings and that may influence the health
status of the patient.
Figure 23. The physician's method
Collection of information: Healthcare providers need to collect several pieces of information to

determine the overall cause(s) of the problem.

Part of this work entails collecting patient information using a written source, such
as patient intake forms. However, the key to collecting patient information is an
oral interview with the patient.
Written forms are often made available to the patient in advance, either online or
through regular mail.
The purpose of collecting this information is to establish a baseline knowledge of

the patient’s family, medical, and social history. This is mostly true when patients
initiate care with a new family physician or clinic, or when visiting a health system
that is not interconnected with the system where the patient’s information is
stored.
Collecting information includes finding and verifying anatomical and physiological

signs and symptoms, and biochemical levels to determine the possible cause of
the chief complaint, or to establish a primary care history for routine care. The
chief complaint is the primary source of pain or discomfort, motivating the patient
The chief
complaint is the to seek medical care.
primary source
of pain or
discomfort The most common methods of collecting information include, but are not limited
motivating the to, patient intake forms, the medical interview, and blood and imaging testing.
patient to seek
medical care
Diagnosis: once information is collected from different sources, the healthcare
providers determine a diagnosis of the patient. At this point, it may be necessary
to conduct additional testing, depending on the initial results.
Treatment plan: after diagnosis, physicians devise a treatment plan to improve

the patient’s health outcome by addressing the cause(s) affecting the patient. A
treatment plan can be as simple as a round of antibiotics, or as complex as
extensive surgeries, procedures, and rehabilitation therapies.
Patient education: regardless of the length or complexity of the treatment plan,

the patient is an integral component in following the treatment plan. For that
reason, patients are educated on the guidelines and instructions to follow for a
proper, continuous, and safe implementation of the treatment plan.

LEP patients tend to suffer the consequences of ineffective communication. The
first source of confusion may well be the units of measurement used in the US
that are used in only two other countries in the world (See Figure 24). Without the
use of a culturally competent medical interpreter, the patient may have no idea
what the US measurements mean.
Figure 24. Use of the metric system around the world - Gray: use of the metric system; Red: use of the
imperial system (Duell, n.d.)
With innumerable cultural differences and beliefs in play, having a professionally With
trained medical interpreter is key to the patient being able to understand their innumerable
treatment plan and how to implement it. cultural
differences and
beliefs in play, a
The medical interview professionally
trained medical
The medical interview is by far the most important tool a physician has to collect interpreter is
useful information from the patient’s medical, family, and social history. key to the
patient being
able to
For LEP patients, the medical interview tends to be a major barrier to properly understand
communicating their chief complaint and other aspects related to their health.
Lack of effective communication that goes beyond the language barrier usually
happens when there is a significant difference in the register used by either
patient or provider.
For example, a typical question during a medical interview is: “please describe the
type of pain you’re feeling.” The physician is expecting an answer based on a list
of common pain descriptors, such as sharp, pressing, acute, shooting, etc. (Refer
to pain descriptors table at the end of this lesson).

However, the patient typically identifies the question with the intensity of the
pain: mild, medium, or strong. The difference is based on the fact that patients
are not used to using explicit pain descriptors.
This is how a Western-trained medical doctor approaches solving a patient’s

health problem.
Medical interview scenario

Let’s see what this might look like in a typical medical appointment. You will note
that we use the device of a ‘narrator’ in the example below to describe why the
doctor says what she says.
For purposes of brevity and illustrating the point here, we will leave out the role
of the interpreter but know that everything that the doctor or patient says must
be interpreted.
Señora Martinez, a 30-year old single mother of two young children, has come to
see her primary care physician (PCP), concerned about her headaches that have
lasted for days and seem to be getting worse.
Dr. Lee: Good morning, Mrs. Martinez. How are you today?
Mrs. Martinez: I’m fine, thanks, but I’ve had a headache that bothers me a lot,
and I need you to check it.
Narrator: (Mrs. Martinez has had Dr. Lee as her PCP since the birth of her first
child.)
Dr. Lee: How long have you had these headaches?
Narrator: (Dr. Lee is trying to find out if the headaches are related to her menstrual
cycle, seasonal allergies, or other environmental factors.)
Mrs. Martinez: They have been going on now for about a month.
Narrator: (Dr. Lee needs to make sure these headaches are unrelated to her
menstrual cycle.)

Dr. Lee: Have you noticed if the headaches are present at a particular time of the
month? For example, during your menstrual period?
Mrs. Martinez: No, I don’t think so. They have been happening pretty much all
month long.
Narrator: (Dr. Lee now needs to determine the location of the headaches and if
they are related to musculoskeletal issues)
Dr. Lee: Please indicate the exact location of the headache and if it moves, and in
which direction.
Mrs. Martinez: Well, it starts here in the front of my head, in the center, and then
it moves a little bit to the sides.
Narrator: (Dr. Lee now needs to determine if the headaches are related to
migraines)
Dr. Lee: Mrs. Martinez, when you have the headaches, does the light bother you?
Do you feel dizzy or nauseous?
Mrs. Martinez: No, not really. But it bothers me a lot.
Narrator: (Dr. Lee rules out migraines and switches now to find out the likelihood
of allergies)
Dr. Lee: Mrs. Martinez, are you allergic to pollen, dust, or mold? Do you have any
seasonal allergies?
Mrs. Martinez: I don’t know. I didn’t think of that before.
Narrator: (Dr. Lee will perform a simple examination by pressing her sinuses to
trigger a pain response)
Dr. Lee: Mrs. Martinez, you have a headache now, so I would like to perform a
simple test by touching parts of your face. Please tell me if you feel pain.

Narrator: (After performing the examination, Dr. Lee determines that it is likely
that the patient has allergies due to pain triggered by touching the area of her
sinuses)
Dr. Lee: Mrs. Martinez, I would like to order an allergy test that can confirm
whether or not you have environmental allergies that may be causing your
headaches.
__________
A doctor Our goal in offering this example is to illustrate how a doctor trained in Western
trained in medicine switches his or her line of questioning to try to pinpoint the body system
Western that is causing the patient their problem. Knowing how this works will help the
medicine
switches the line interpreter anticipate seemingly rapid changes in questioning.
of questioning
to pinpoint the
body system A general set of guidelines for medical interviews follows the following general
causing the pattern: (List is partially based on Guide to taking a patient history, Thomas
patient's
Secrest)
problem.
Patient interview guide

Greeting
• Brief introduction
• Identifying one’s role and patient
• Visual assessment of the patient’s demeanor
Personal history (usually collected before the physician’s presence)
• Age
• Height/Weight
• Sexual identity (this is a new factor being implemented)
• Marital status
• Pregnancies/births/miscarriages/stillborn
Chief complaint
• What is the main reason making the patient seek medical care?
• Is there additional pain, aches, discomfort, or symptoms?
Present medical history
• Location and radiation of complaint
• Severity of complaint
• Setting, timing, and duration of onset
• Previous similar complaints

• Factors that exacerbate and relieve the chief complaint
• Associated symptoms
• The chief complaint explained by patient
Past medical history
• Review of body systems:
o Cardiovascular
o Respiratory
o Gastrointestinal
o Genitourinary
o Ob/Gyn
 Pregnancies/Births
 Menstrual period
 Pelvic exams
 Pap smears
o Neurological/Psychiatric: senses, mental health
o ENT: ears, nose, and throat
Childhood illnesses
Past surgeries/procedures
Immunizations
Allergies
Family history
o Disease history
o Parents’ health
o Children’s health
Drug history (medications)
o Current medications
 Prescribed
 OTC (over-the-counter)
o Past medications
o Allergies to medications
Lifestyle
o Alcohol use
o Smoking
o Recreational drug use
o Occupational status
o Sexual identity

Table 3. Pain descriptors commonly used in medical encounters
PAIN DESCRIPTOR MEANING EQUIVALENT IN TARGET LANGUAGE
Ache
Acute pain
Blinding pain
Burning pain
Chronic pain
Constant pain
Cramps
(musculoskeletal)
Cramps
(smooth muscle)
Crushing pain
Cutting pain
Dull pain
Fleeting pain
Gnawing pain
Intermittent,
comes and goes
Mild pain
Numbing pain
Overall pain
Pain and stiffness
Piercing pain
Pins and needles
Sharp pain
Shifting pain

PAIN DESCRIPTOR MEANING EQUIVALENT IN TARGET LANGUAGE
Shooting pain
Sickening pain
Soreness
Spasm
Stabbing pain
Stinging pain
Sudden pain
Tenderness
Throbbing pain
Tingling
_______________
_______________
_______________
_______________
_______________
_______________
_______________

Lesson 16: The Cultural Clarifier role
Goals:
• To describe the role of the cultural clarifier
• To practice the role of the cultural clarifier
Cultural Clarifier Role
The cultural clarifier (mediator) role addresses cultural beliefs that may cause
confusion between the provider and the patient and how the interpreter helps
overcome this type of barrier.
Cultural barriers to communication

Many have divided cultural barriers into two different categories:
What is said: Words or expressions can have different meanings in a different

cultural context. For instance, the word “bottle” can refer to a baby’s bottle in one
context or a strong alcoholic beverage in another. These barriers are, generally,
cognitive in nature.
How something is said: Certain hand gestures, tone, eye contact, touch, and
physical proximity, for example, can be interpreted as threatening or otherwise
offensive in certain cultures. These barriers are mostly non-cognitive and can have
a substantial negative impact on communication.
A cultural hurdle (an unanticipated cultural difference)
A cultural hurdle is a factor you were not anticipating as a potential source of A cultural
confusion or surprise. hurdle is a
factor you were
not anticipating
A cultural hurdle can force you to stop if you have not anticipated it and are as a potential
confused as to how to respond. Cultural hurdles can cause you problems as an source of
confusion or
interpreter if you are not prepared for them. This could be as minor as a patient surprise.
who doesn’t respond with an outstretched hand when you reach out with yours
to shake hands, or something as profoundly confusing as another patient who will
answer ‘yes’ to everything, to not appear to be rude.

If the interpreter is not aware of the multitude of
different approaches to the world, even from
people who speak the same basic language, the
‘unexpected’ response from the patient can cause
confusion or surprise, and the unplanned body
language response of uneasiness on the part of
the interpreter can further complicate the
Figure 25. Negotiating a hurdle
communication in the encounter.
Cultural hurdles are quite common when individuals from one culture anticipate
a response from the patient that would be the same response that they would
have to the same situation. When the patient reacts quite differently if you are
not prepared and culturally aware of different possible responses, you can
become confused, and the patient will sense this.
Steps to cultural clarification: Providing a cultural framework
Detect a potential cultural misunderstanding: Look for verbal or nonverbal cues

that a cultural misunderstanding may be occurring.
Be Transparent: Inform both parties that you intend to clarify a cultural

miscommunication.
Don’t be judgmental: Explain the nature of the cultural belief you think to be
involved in the misunderstanding and make sure both parties have a clear
understanding of what is happening (cultural, transparency, clarification). Do not
make assumptions or express any opinions you may have about it.
Get out of the way: Let the parties decide what they want to do with the
information provided as a cultural framework. Go back to your conduit role as
soon as you can and allow communication to be as fluid and direct as possible
between the patient and the provider.
Respect: Be respectful of both parties. Avoid stereotyping. Don’t “side” with either
of the parties.

Culture hurdles - Examples: What should the interpreter do?
Scenario 1
A nurse educator is visiting a hospital patient that has congestive heart failure.
NURSE: "Mr. Perez, what kind of diet are you currently following?"
INTERPRETER: interprets in the target language
PATIENT: "Oh, the normal one."
Comments: ____________________________________________________________________
______________________________________________________________________________
Scenario 2
A mother with a newborn baby approaches a front desk receptionist in a pediatric outpatient
clinic.
PATIENT: (source language) "Hello, I have an appointment. My name is Rosa Sanchez."

INTERPRETER: interprets in English
RECEPTIONIST: "I don't see an appointment for baby Sanchez. Maybe you have the wrong date."
Comments: ____________________________________________________________________
______________________________________________________________________________
Scenario 3
A pregnant Asian woman constantly refuses to have ice chips during labor.
Comments: ____________________________________________________________________
______________________________________________________________________________
Scenario 4
The family of a terminally ill patient refuses to speak about hospice services.
Comments: ____________________________________________________________________
______________________________________________________________________________
Scenario 5
The parents of an Asian child are being investigated for child abuse after
discovering numerous bruises on the child's back.
Comments: ____________________________________________________________________
______________________________________________________________________________

Navigating cultural hurdles
The professionally trained medical interpreter strives to be able to identify a

variety of cultural beliefs and traditions and attempts to provide a cultural
framework to both patient and provider to avoid miscommunication. For the
newer medical interpreter who is not certain what the cultural belief is about, but
senses that the words have a different meaning for the patient than what would
commonly be interpreted, simply raising the possibility of a different meaning can
lead the provider to ask more in-depth questions to try to understand what the
patient is trying to say.
Exercise:
Now that we’ve covered most of the skills that you will need as a new interpreter,
we will divide you into groups of 3 or 4, depending on the class size. Your task is
to take 20 to 30 minutes to come up with an original role-play scenario that will
allow you to put into practice all of your skills:
- Pre-sessions, post-session, positioning;

- Conduit, clarifier, cultural clarifier roles;
- Interpreting in the first person or third person, as appropriate
- Dealing with a cultural hurdle that will most likely become the basis for your
original scenario.
Time allowing, the best option is to come up with three different scenarios around
three different potential cultural hurdles that will allow each of you to play each
of the three main roles.
There is no need to write out the script. Setting the stage for what the health
problem is centered on and having the group discussion should be enough for you
to play your roles more naturally than you would if you had the time to write out
everything.
If your group has no target languages in common, you will need to be more
creative in how you interpret what the patient is saying. We will have you present
these role-plays in front of the entire class and then solicit constructive comments
after each role-play. Remember, performing in front of your fellow students can
be intimidating and make you nervous. A real interpreted session may be less
stressful, but we can all consider this in our constructive comments.

Lesson 17: The Advocate/Systemic Clarifier Role
Goals:
- To understand the health care interpreter’s role of the advocate/systemic
clarifier and why it is essential to the patient’s health
- To understand why this is the least-used role of the healthcare interpreter,
due to its controversial nature
- To understand why it takes experience to understand when and how to use
this role
Advocate/Systemic Clarifier Role
The role of advocate, as it is most commonly known in the healthcare interpreting

profession, is the role agreed upon by most of our professional organizations, that
gives guidelines for the medical interpreter on how to help the patient and the
patient’s family get the care that they need and deserve. Without this help, many
newcomers to the US healthcare system feel lost, as do many of their US-born
counterparts.
The advocate/systemic clarifier speaks not as the interpreter but on behalf of the The advocate,
patient, with the patient’s agreement, usually to guide the patient to the person systemic
clarifier speaks
or persons that can help them in the next stage of their care. However, this role is
not as the
the most invasive and controversial role of the medical interpreter and merits a interpreter but
closer look as to why it is controversial. on behalf of the
patient, with the
patient's
Advocacy addresses systemic barriers that create healthcare disparities and other agreement,
usually to guide
issues related to health literacy, discrimination, and social determinants of health
the patient to
(low income, sub-standard living conditions, and high-risk behaviors, among the person that
others). can help in the
next stage of
their care.
Most of the time, however, advocacy consists of tasks related to basic care
coordination. This is a process through which trained individuals help patients
eliminate or overcome barriers to their care. It involves flexible problem-solving
to address specific barriers through local and non-local resources.
The healthcare system in the United States could not be more complicated,
including those born here who speak English as their only language.

What is Health Literacy?
“Health literacy is the degree to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make appropriate health
decisions.” (Institute of Medicine, 2004)
Estimates are that upwards of 46% of US-born English speakers have low health literacy (National
Center for Education Statistics, n.d.). This 46%, nearly one-half of native English speakers, have a
very hard time finding their way through a very complicated, confusing system that is not uniform
for all. The system often assumes the patient’s ability to understand medications, pre-operation
or discharge instructions, and then hits the patient with very large, hard-to-understand bills for
the care given. For those who do not speak English, language becomes an additional barrier to
an already confusing situation.
Use of the Advocate/Systemic Clarifier Role
The role of advocate/systemic clarifier depends on your experience and knowing your
relationship to the hospital or clinic where you are doing the interpreting. The controversy on the
use of advocacy starts on several fronts.
First of all, most new interpreters who will have the opportunity to do in-person interpreting will
do so based on a contractual agreement with a language agency that in turn, will have a signed
agreement with a hospital. These agreements will often specify a very restricted use, if not a
prohibition, of the interpreter doing anything other than interpreting in the medical encounter
using the first three roles of the interpreter (conduit, message and cultural clarifier).
It is crucial for a new medical interpreter to understand his or her relationship to the hospital or
clinic as being different from the relationship that a full-time staff interpreter has with the same
entity.
Second, hospital administrators often adopt policies to avoid the additional cost of having the
interpreter on-site for a longer time. Changing this thinking will help them understand how this
additional time with an interpreter who speaks the patient’s language helps improve the
patient’s health outcome as it saves the hospital money in reducing the use of unnecessary tests
as well as reducing the number of quick returns to the emergency room.
Third, knowing how and when to intervene on behalf of the patient comes with experience that
few new interpreters have. It is one of the most frequent complaints that language agencies
receive from healthcare organizations.

Advocating
It helps to equalize the imbalance of power between patients and the system. Advocating
Examples of advocacy at the interpreting/care coordination level include: helps to
equalize the
imbalance of
Helping to schedule a follow-up appointment, giving directions to the pharmacy, power between
interpreting for patients to have their prescriptions filled, obtaining language- patients and the
system.
appropriate directions from the pharmacy.
Guidelines for appropriate advocacy
The guidelines for effective and appropriate advocacy are clearly defined by the
IMIA and NCIHC Standards of Practice:
Advocates act to protect an individual from harm or to correct mistreatment or

abuse.
It is appropriate to advocate when:

 The patient perceives there is a problem based on the quality of care, and
the problem is not due to a misunderstanding.
 When the patient refuses to comply with the provider’s orders or continued
care.
 When the patient needs a referral to a different facility or services provided
elsewhere.
 When advocacy does not compromise confidentiality.
 When advocacy is performed for the benefit of the patient and not the
interpreter, or a third party.
Advocacy takes place outside the interpreter’s roles and, often, outside the Advocacy takes
normal interview with the doctor. As an interpreter, it is up to you to decide place outside
whether to initiate the role of an advocate if the patient has not requested it. the interpreter's
roles and, often,
outside the
But, if the patient does not want to pursue the issue, then the interpreter stops. normal
interview with
However, if a patient insists on filing a complaint or taking action, you MUST the doctor.
interpret what they say, regardless of your personal opinion.

Steps to conduct appropriate advocacy
• Identify the person in charge to speak with to address the issue.

• Introduce the patient and yourself to the person that can best assist you.
• Ask the help of the person (do not blame or attack).
• Use an assertive communication style.
Being assertive:
“Say what you mean, mean what you say, but don’t say it mean.”
• Ask for their input instead of telling them what to do.

• Thank them for their efforts and help.
• If the answers do not solve the issue directly, suggest an alternative solution:
Is there someone else I could speak with?
• Maintain a cordial and friendly tone during the entire conversation.
• Be aware of your non-verbal interactions (body language) going on
throughout the encounter: be warm and friendly, encourage eye-to-eye
contact, listen actively, and smile.
The range and

The range and scope of your advocacy will be contingent upon the type of contract
scope of your and relationship you have with the facility. It is not the same for a phone
advocacy will be interpreter as it is for a full-time staff interpreter.
contingent upon
the type of
contract and The advocacy role is most appropriate for staff interpreters. Although limited,
relationship you
have with the
contractors can advocate minimally, usually pointing the patient in the right
facility. direction, or to the right person.

Chapter 4
THE CODES OF ETHICS

©.. All Rights Reserved. 114
Lesson 18: Codes of Ethics
Goals:
- Incorporate the importance of having a code of ethics in our decision-making
process
- Analyze the principles of the codes of ethics from three professional medical
interpreters' organizations
- Discuss the basic principles underlying these main medical interpreters’ codes
of ethics
- Practice applying the codes of ethics in challenging ethical scenarios
Ethics
What is “Ethics”? Where do they come from? Why is it important to have a code
of ethics?
A code of ethics isn’t the product of a single person’s ideas about how to function.
It is normally based on the decisions of people who practice the same profession.
After much debate and discussion, they adopt guidelines that can more accurately
reflect the goals and accepted behavior of those practicing that profession.
A code of ethics is an agreed-upon set of guidelines to help members of a

profession standardize their behavior. It is not a set of laws, even though one or
more of the parts of a code of ethics may reflect laws that happen to govern
portions of the profession.
The codes of ethics for medical interpreters
We’ll examine three codes of ethics for medical or healthcare interpreters that are
printed below.
• First is from the National Council on Interpreting in Health Care (NCIHC). The
digital version can be found at www.ncihc.org
• The second is from the International Medical Interpreters Association (IMIA),
and the digital version can be found at www.imiaweb.org
• The third and final one is from the California Healthcare Interpreting
Association (CHIA). The digital version can be found at www.chiaonline.org

NCIHC
Code of Ethics for Interpreters in Health Care
Adopted July 2004
1. The interpreter treats as confidential, within the treating team, all information learned in the
performance of their professional duties, while observing relevant requirements regarding
disclosure.
2. The interpreter strives to render the message accurately, conveying the content and spirit of
the original message, taking into consideration its cultural context.
3. The interpreter strives to maintain impartiality and refrains from counseling, advising, or
projecting personal biases or beliefs.
4. The interpreter maintains the boundaries of the professional role, refraining from personal
involvement.
5. The interpreter continuously strives to develop an awareness of his/her own and others
(including biomedical) cultures encountered in the performance of their professional duties.
6. The interpreter treats all parties with respect.
7. When the patient’s health, well-being, or dignity is at risk, the interpreter may be justified in
acting as an advocate. Advocacy is understood as an action taken on behalf of an individual
that goes beyond facilitating communication, with the intention of supporting good health
outcomes. Advocacy must only be undertaken after careful and thoughtful analysis of the
situation and if other less intrusive actions have not resolved the problem.
8. The interpreter strives to further continually his/her knowledge and skills.
9. The interpreter must, at all times, act in a professional and ethical manner.

IMIA
Code of Ethics
Adopted in 1987 and revised in 2006
1. Interpreters will maintain the confidentiality of all assignment-related information.
2. Interpreters will select the language and mode of interpretation that most accurately conveys
the content and spirit of the messages of their clients.
3. Interpreters will refrain from accepting assignments beyond their professional skills, language
fluency, or level of training.
4. Interpreters will refrain from accepting an assignment when family or close personal
relationships affect impartiality.
5. Interpreters will not interject personal opinions or counsel patients.
6. Interpreters will not engage in interpretations that relate to issues outside the provision of
health care services unless qualified to do so.
7. Interpreters will engage in patient advocacy and in the intercultural mediation role of
explaining cultural differences/practices to health care providers and patients only when
appropriate and necessary for communication purposes, using professional judgment.
8. Interpreters will use skillful unobtrusive interventions so as not to interfere with the flow of
communication in a triadic medical setting.
9. Interpreters will keep abreast of their evolving languages and medical terminology.
10. Interpreters will participate in continuing education programs as available.
11. Interpreters will seek to maintain ties with relevant professional organizations in order to be
up-to-date with the latest professional standards and protocols.
12. Interpreters will refrain from using their position to gain favors from clients.

CHIA
Code of Ethical Principles
1. Confidentiality
Interpreters treat all information learned during the interpreting as confidential.
2. Impartiality
Interpreters are aware of the need to identify any potential or actual conflicts of interest, as
well as any personal judgments, values, beliefs, or opinions that may lead to preferential
behavior or bias affecting the quality and accuracy of the interpreting performance.
3. Respect for individuals and their communities

Interpreters strive to support mutually respectful relationships between all three parties in
the interaction (patient, provider, and interpreter) while supporting the health and well-being
of the patient as the highest priority of all healthcare professionals.
4. Professionalism and integrity

Interpreters conduct themselves in a manner consistent with the professional standards and
ethical principles of the healthcare interpreting profession.
5. Accuracy and completeness

Interpreters transmit the content, spirit and cultural context of the original message into the
target language, making it possible for patient and provider to communicate effectively.
6. Cultural responsiveness
Interpreters seek to understand how diversity and cultural similarities and differences have a
fundamental impact on the healthcare encounter. Interpreters play a critical role in
identifying cultural issues and considering how and when to move to a cultural clarifier role.
Developing cultural sensitivity and cultural responsiveness is a life-long process that begins
with an introspective look at oneself.

Ethics: Common core values
After reading each of the codes of ethics above, there are some differences in the language used.
However, all three main codes of ethics adhere to the same core values (in alphabetical order,
not in order of importance):
1. Accuracy
2. Advocacy
3. Confidentiality
4. Cultural Competence
5. Impartiality
6. Professional Conduct
7. Respect
Take a moment to discuss the differences as you see them.
Common core values
ACCURACY
• Interpreters must render the message as accurately as possible, maintaining the meaning,
spirit, and the context of the message regardless of the mode or role of interpreting.
• Interpreters must correct their misinterpretations as soon as they realize that they have made
a mistake.
• Interpreters make no additions, corrections, or deletions.
• Interpreters maintain the tone and the message of the speaker even when it includes
rudeness and obscenities.
• Interpreters clarify the meaning of nonverbal expressions and gestures that have a specific or
unique meaning within the speaker’s culture.
ADVOCACY
• Interpreters should act as advocates when the patient’s health, safety, or dignity is at risk.
• This must be done keeping in mind the relationship that the interpreter has with the facility
where the interpreting is taking place.
• Advocate only if the patient agrees that he or she wants this to happen.
• Even if the interpreter disagrees with the patient, if the patient wants to proceed, the
interpreter follows their wishes.

CONFIDENTIALITY
• Interpreters should maintain the confidentiality of all patients’ health protected information
under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) while
observing the rules of mandatory disclosure that may apply.
• This is the point that is governed by federal law
• What is said in the interpreted encounter stays there
• There are four exceptions to this, also governed by differing state laws: the cases that must
be reported to government bodies are:
o Child abuse
o Elderly abuse
o Spousal abuse
o A threat to harm self or others
CULTURAL COMPETENCE
• Interpreters must strive to continually develop knowledge about their culture and other
cultures involved in healthcare communication. Interpreters must clarify cultural differences
as needed to ensure effective communication.
• There are no cultural “experts” that know everything about every culture.
• Every interpreter needs to strive to become aware of as many different cultural nuances as
possible to be in a position to help convey the real meaning of what the patient is saying, or
trying to understand from the provider.
IMPARTIALITY
• Interpreters must refrain from including their personal biases, beliefs, or personal opinions.
Interpreters must not advise their patients.
• Even when a patient asks what the interpreter thinks that he or she should do, the interpreter
must not give an opinion or advice.
• If the interpreter feels so strongly about a particular issue that they don’t believe they can
remain impartial, including with their body language, the interpreter should withdraw from
the assignment.
PROFESSIONAL CONDUCT
• Interpreters must know their professional limits regarding knowledge of medical vocabulary
in either language. Interpreters show professionalism also by following the dress code of the
hospital where they are interpreting. They must avoid conflicts of interest, and should try to
keep abreast of the latest discussions and developments in the profession by joining local and
national professional organizations.

• It takes a life-long approach to learning new vocabulary, from slang to medical terminology
and everything in between, to be able to do the best possible interpreting job.
• If the interpreter knows that they don’t understand their language as it is spoken in a certain
country or area of a country, the interpreter should withdraw from the assignment.
• Interpreters avoid invitations to patients’ family events as part of keeping the relationship on
a professional basis, rather than a personal one.
RESPECT
• Interpreters must treat all parties with courtesy, and respect the patient’s right to make their
own decisions about their health.
• Interpreters are there for the provider as well as the patient and their family members and
must show respect for everyone at all times.
• Respect is shown in the target language by using the formal form of the language, rather than
the familiar.
• Respect is also shown by following hospital dress codes as well as the customs of the patient
and their family members.
_______________
For practice, we now offer 16 different scenarios in which an ethical dilemma is posed.
Read each scenario carefully and discuss the following questions in the context of each case
study:
1. What ethical principle or principles apply in this case?
2. What would be the “right” thing to do?

SCENARIO 1
The interpreter had some financial difficulties last month. In order to make some extra money,
he decides to offer rides to the patients coming to scheduled appointments at the community
clinic. He specifies he is already being paid for his services as an interpreter, so he is only charging
them for the ride.
• What ethical principle or principles apply in this case?

• What would be the “right” thing to do?
Notes:
Twist 1
How about if the interpreter is a taxi driver, or independent driver using an app such as Uber
or Lyft?
How does that change Scenario 1?
Twist 2
Your patient is an elderly woman. After the appointment is finished, you part ways with the
patient. A few minutes later, on your way out of the hospital you see her at the main entrance.
You know from the appointment that she lives just a few minutes away from the hospital. It is a
snowy day and the elderly woman needs a ride…
What would you do?

SCENARIO 2
The interpreter feels badly about a patient who recently suffered a miscarriage and is severely
depressed as a result. The interpreter makes an announcement at the local church asking her
friends to support the patient.
Later, the patient complains to the Patient Advocate that she never gave her permission for the
interpreter to do this.

Notes:

SCENARIO 3
The interpreter is a young person who enjoys the latest fashion trends. Several complaints are
filed against the interpreter’s style of dressing in the emergency room.
The interpreter is extremely upset and threatens to resign and pursue legal action.

Notes:
Twist
How about having tattoos on your body?
Will the patient’s perception of the interpreter change because of a tattoo?
How does the interpreter comply with the agency/hospital/clinic dress code and tattoos
policies?

SCENARIO 4
A patient complains to the financial counseling department that she can’t afford her “Medicaid
bills.”
When asked to elaborate, the patient says she has been giving money to an interpreter who told
her she needed to make monthly payments to Medicaid after she delivered her baby at the local
hospital.

Notes:

SCENARIO 5
The interpreter contacts all the pregnant patients she knows in the community and informs them
that she has resigned her position at the local hospital, and patients are now supposed to deliver
their babies at the county hospital one hour away, where the interpreter will be available to
interpret for them.

Notes:

SCENARIO 6
The interpreter is offered a $100 bill from a patient who wants to express his/her
gratitude. The patient insists that he/she will be extremely offended if the interpreter refuses to
take the gift.

Notes:

SCENARIO 7
A patient invites the interpreter to his wedding party to be his best man. The patient is very
grateful for the interpreter’s services carried out over his long months in the hospital and
considers him to be a good friend.

Notes:
Twist
Instead of inviting you to a wedding, what if the patient’s family invites you to the patient’s
funeral?

SCENARIO 8
The interpreter thinks the patient she is interpreting for is “very cute.”
After the appointment is finished, she gives the patient her personal phone number and
encourages him to call her at any time, should he need anything.

Notes:
Twist
The doctor thinks the interpreter assigned to the appointment is “very cute.” After the
appointment is finished, the doctor asks the interpreter for his/her personal phone number and
says it would be great to go out on a date.


SCENARIO 9
The medical assistant walks the patient and the interpreter to an exam room and asks the
interpreter to help the patient in filling the new patient questionnaire on an electronic device.
The medical assistant closes the door after leaving the exam room.

Notes:

SCENARIO 10
Two elderly daughters of an elderly Chinese man accompany their father to his visit to the
hospital. The 85-year-old man has stage 4 cancer. The daughters are fluently bilingual but agree
to have the hospital’s interpreter do the interpreting. During the pre-session, they explain in
English to the interpreter that the “c” word must never be uttered in Mandarin.
They further explain that the 3 of them are leaving for China in two days to allow their father to
live out the remaining time that he has in familiar surroundings, able to converse with everyone
and with family and friends.
As the doctor starts the session, the word “cancer” comes up, and the two daughters immediately
look to the conflicted look on the interpreter’s face. The daughters’ looks make it clear. No “c”
word.
The interpreter, who works for an agency, takes time to culturally clarify this family request to
the doctor who immediately explains that he is following the hospital’s very explicit policy of
informing all hospital patients of what he or she has. The daughters hear this in English and
convey their disagreement to the interpreter with their unmistakable body language.
The interpreter, from the same culture, makes a judgment on the spot. She uses the phrase
“serious illness” not “cancer” and proceeds.
The daughters thank her profusely after the session is over as the four of them leave the doctor’s
office.

Notes:

SCENARIO 11
The agency interpreter is sent to a home visit for physical therapy for a 50-year-old Mexican man
who was injured at his place of work. The physical therapist arrives just as the interpreter is
getting out of his car. He takes advantage of the time to do a pre-session with her. She says that
she can understand some Spanish but is sure that she misses a lot as she knows that she is not
fluent.
The wife of the patient answers the door and invites both of you to come in. She then offers
both of you some coffee. The physical therapist graciously says, “thank you, but I just drank a big
cup of coffee 15 minutes ago.” You love coffee and don’t want to appear ungracious, and you
haven’t had anything to drink as you had just completed a 2-hour session at a nearby clinic and
rushed to make it to this appointment. Then the gracious host comes in from the kitchen with a
plate of sweet bread and coffee and offers both again.

Notes:
Twists
As it is close to dinner time, the gracious host offers both a plate of food?
How about using the bathroom?

SCENARIO 12
You’ve worked as the main interpreter for an 85-year-old woman from a mountainous region of
a country where your language of service is spoken. She was hospitalized for five weeks and is
now well and has been released from the hospital.
A month later, this elderly woman returns to the hospital and is able to find you at work. She
warmly presents you with a hand-made garment that she has personally made, just for you. She
thanks you profusely for the wonderful job that you performed in interpreting for her. Also, you
think that the garment is truly a beautiful piece of art that you would love to wear. You ask
yourself, “How did she know these were my favorite colors?”

Notes:

SCENARIO 13
As you introduce yourself as the interpreter for a 40-year-old male patient, he introduces his
teenage son to you and explains that his son will be his interpreter.
The doctor arrives as this is happening.

Notes:

SCENARIO 14
After doing your pre-session with the patient’s mother, you go to the other side of the waiting
area.
A few minutes later, the mother walks towards you and tells you that she has to take her 2-year
old son (the patient) to the bathroom.
She is pushing a stroller and carrying a big diaper bag. She kindly asks you to check on her baby
daughter quietly sitting in the car seat.

Notes:

SCENARIO 15
You are sent to interpret at a local children’s hospital for a family from southern Mexico. The
patient is a 3-year old boy with a badly misshapen leg and a fitted prosthesis. The mother and
father and three slightly older siblings are all in the exam room with the doctor, an elderly Anglo
male doctor, who seems delighted to have everyone there.
Even though you have done pre-sessions with both the family of the little boy and the doctor,
the doctor starts by launching into some of the most mangled Spanglish you have ever heard.
Addressing the mother and father directly, the parents immediately look towards you, the
interpreter, somewhat astonished, with puzzled looks on their faces. They clearly do not
understand what is being said to them.

Notes:
Suggested reading:
The danger of knowing “just enough” Spanish (The New York Times, 2015)
https://well.blogs.nytimes.com/2015/11/12/the-danger-of-knowing-just-enough-spanish/

SCENARIO 16
You are a telephonic interpreter, and you are interpreting for a new mother who is being
discharged from the hospital. The discharge nurse tells the mother to be sure and bathe the baby
as soon as she gets home.
As an experienced interpreter, you’ve been through this same scenario more than a 100 times,
and you know that newborn babies are only supposed to be given sponge baths until the
umbilical cord shrivels up and falls off. What are your options as a telephonic medical
interpreter?

Notes:

Chapter 5
GUIDELINES AND
REGULATIONS

Lesson 19: The CLAS standards and their significance
Goals:
- To become familiar with the CLAS Standards
- To understand the basic themes of CLAS standards
- To know which CLAS standards apply to language access
Culturally and Linguistically-Appropriate Service (CLAS) standards
National standards for culturally and linguistically appropriate care provided by

the US Health and Human Services Office of Minority Health (OMH) were first
published in 2001 and revised in 2013 (U.S. Office of Minority Health, 2013). The
stated goals of the CLAS standards are to advance health equity, improve quality,
and help eliminate care disparities.
The strategy to accomplish these goals is to provide a blueprint for individuals and
corporate healthcare providers to render culturally and linguistically appropriate
services.
The 15 CLAS standards are divided into four themes:
• Principal Standard
• Governance, Leadership, and Workforce
• Communication and Language Assistance
• Engagement, Continuous Improvement, and Accountability
Principal Standard
1
“Provide effective, equitable, understandable, and respectful quality care and
services that are responsive to diverse cultural health beliefs and practices,
preferred languages, health literacy, and other communication needs.”
Governance, Leadership, and Workforce

2
Advance and sustain organizational governance and leadership that promotes
CLAS and health equity through policy, practices, and allocated resources.

3
Recruit, promote, and support a culturally and linguistically diverse governance,
leadership, and a workforce that are responsive to the population in the service
area.
4
Educate and train governance, leadership, and workforce in culturally and
linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance

5
Offer language assistance to individuals who have limited English proficiency and
other communication needs, at no cost to them, to facilitate timely access to all
health care and services.
6
Inform all individuals of the availability of language assistance services clearly and
in their preferred language, verbally, and in writing.
7
Ensure the competence of individuals providing language assistance, recognizing
that the use of untrained individuals and/or minors as interpreters should be
avoided.
8
Provide easy-to-understand print and multimedia materials and signage in the
languages commonly used by the populations in the service area.
Engagement, Continuous Improvement, and Accountability
9
Establish culturally and linguistically appropriate goals, policies, and management
accountability, and infuse them throughout the organization’s planning and
operations.

10
Conduct ongoing assessments of the organization’s CLAS-related activities and
integrate CLAS-related measures into measurement and continuous quality
improvement activities.
11
Collect and maintain accurate and reliable demographic data to monitor and
evaluate the impact of CLAS on health equity and outcomes and to inform service
delivery.
12
Conduct regular assessments of community health assets and needs and use the
results to plan and implement services that respond to the cultural and linguistic
diversity of populations in the service area.
13
Partner with the community to design, implement, and evaluate policies,
practices, and services to ensure cultural and linguistic appropriateness.
14
Create conflict and grievance resolution processes that are culturally and
linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
15
Communicate the organization’s progress in implementing and sustaining CLAS to
all stakeholders, constituents, and the general public.
DISCUSSION
How do the CLAS standards contribute to increased equality and eliminating

disparities in health care?
Would the implementation of CLAS standards contribute to the work of

healthcare interpreters?

Lesson 20: The Joint Commission and standards on
Language Access
Goals:
- To know what the Joint Commission is
- To understand basic concepts from the Joint Commission recommendations
on Language Access
The Joint Commission
The Joint Commission is a non-profit organization that was founded in 1934 with
headquarters just outside of Chicago, in Oakbrook Terrace, Illinois. It provides
accreditation for more than 20,000 health care programs in the US to be able to
participate in the Federal Medicare and Medicaid reimbursement program for
Medicare and Medicaid patients. Most state governments require Joint
Commission accreditation for Medicaid reimbursement. While there are now
newer, lesser-known accrediting organizations, the Joint Commission is by far the
best known and most used.
When an accreditation team from the Joint Commission arrives at a hospital,

unless it is one that has been implementing the Commission’s policy
recommendations, there can be near panic amongst hospital administrators.
To lose accreditation to participate in the Federal Government’s Medicare and

Medicaid reimbursement program would mean the loss of millions of dollars of
revenue as well as a public trust.
The Joint Commission on Language Access
R3 Report: Requirement, Rationale, Reference (February 2011), for accredited

organizations and health care professionals:
Patient-centered communication standards for hospitals

Requirements:
PC.02.01.21: The hospital effectively communicates with patients when providing

care, treatment, and services.

• EP1: The hospital identifies the patient's oral and written communication
needs, including the patient's preferred language for discussing health.
• EP2: The hospital communicates with the patient during the provision of care,
treatment, and services in a manner that meets the patient's oral and written
communication needs.
RC.02.01.21: The medical record contains information that reflects the
patient's care, treatment, and services.
• EP28: The medical record contains the patient's race and ethnicity.
RI.01.01.01: The hospital respects, protects, and promotes patient rights.
• EP28: The hospital allows a family member, friend, or other individual to be
present with the patient for emotional support during the course of stay.
• EP29: The hospital prohibits discrimination based on age, race, ethnicity,
religion, culture, language, physical or mental disability, socioeconomic status,
sex, sexual orientation, and gender identity or expression.
Rationale:
- These standards are designed to improve the safety and quality of care for all
patients and to inspire hospitals to adopt practices promoting better
communication and patient engagement.
- Research findings document that a variety of patient populations experience
a less safe or lower quality of care or poorer health outcomes associated with
their race, ethnicity, language, disability, or sexual orientation.
- Among other factors, these studies document that these disparities in health
care can be caused by cultural or language barriers that impair
communication with caregivers, impeded access to care, or fear of
discrimination.
The Joint Commission Standards on Language Access:

Develop a system to provide language services
"…Hospitals must develop a system to provide language
services to address the communication needs of patients
whose preferred language is not English, including patients
who communicate through sign language. Offer a mixture of
language services (for example, in-person, telephone, or video
remote interpreting) based on the needs of the patient
population so that services are available 24 hours a day, seven
Figure 26. The Joint
days a week." Commission on effective
communication (The Joint
Commission, 2014)

Non-Discrimination in Care (RI.01.01.01 EP29)
• Research has shown that perceived discrimination was negatively correlated

with health status for African Americans and whites, and individuals who
reported discrimination were less likely to receive preventive services.
• Studies of lesbian and bisexual women indicated that disclosing sexual
orientation to their physicians would negatively affect their health care, and
women who received care from providers who were knowledgeable and
sensitive to lesbian issues were significantly more likely to have received a Pap
test.
• There are several federal laws and regulations that protect patients from
various forms of discrimination.
• Title VI of the Civil Rights Act of 1964 prohibits discrimination based on
national origin and the Americans with Disabilities Act of 1990, and Section
504 of the Rehabilitation Act of 1973 prohibit discrimination based on physical
disability.
• Although these laws and regulations include some anti-discrimination
protections, state laws vary, and not all potential forms of discrimination are
covered.
• The requirement in RI.01.01.01, EP 29, underscores the importance of
providing equitable care to all patients and applies to hospitals nationwide.
Reference:
Effective Communication (PC.02.01.21 EPs 1 and 2)
• Identifying the patient’s oral and written communication needs is an essential

step in determining how to facilitate the exchange of information with the
patient during the care process.
• Patients may have hearing or visual needs, speak or read in a primary language
other than English, experience difficulty understanding health information, or
may be unable to speak fully or well due to their medical condition or
treatment.
• Additionally, some communication needs may change during the course of
care.
• Once the patient’s communication needs are identified, the hospital can
determine the best way to promote two-way communications between the
patient and his or her providers in a manner that meet the patient’s needs.

• Research shows that patients with communication problems are at an
increased risk of experiencing a preventable adverse event and that patients
with limited-English proficiency are more likely to experience adverse events
than English speaking patients.
• Title VI of the Civil Rights Act of 1964 prohibits discrimination based on
"national origin," which includes language.
• Federal policies state that "reasonable steps" need to be taken to ensure that
limited-English proficient patients have "meaningful access" to any program
or activity provided by hospitals that receive federal funding.
• The Americans with Disabilities Act of 1990 and Section 504 of the
Rehabilitation Act of 1973 prohibit discrimination based on disability and
require hospitals to provide auxiliary aids and services to effectively
communicate with patients who are deaf or hard of hearing.
Collecting Race and Ethnicity Data (RC.02.01.01 EP28)
• The collection of patient-level demographic data on race and ethnicity

provides hospitals with information on the potential cultural needs of each
patient, as well as an opportunity to monitor and analyze health disparities at
the population level.
• Although the Joint Commission standards do not specify how to categorize
data when collecting race and ethnicity data, many state reporting entities and
payers do specify these requirements.
• Numerous research studies and reports have shown that racial and ethnic
minorities are in poorer health, experience more significant problems
accessing care, are more likely to be uninsured, and often receive lower-
quality health care than other Americans.
• Collecting race and ethnicity information for each patient also provides the
hospital an opportunity to better plan for needed services; identify members
of a target population to whom elements of an intervention would apply;
understand potential patterns in access and outcomes for different segments
of the patient population, and increase patient and provider understanding.
Access to a Support Individual (RI.01.01.01 EP28)
• Access to a family member, friend, or other trusted individual provides a

patient with emotional support, comfort, and alleviates fear during the course
of the hospital stay.

Some hospitals have implemented unrestricted or flexible visitation hours as part of patient
and family-centered care initiatives.
• Results indicate that increased visitation hours provide a better understanding of the patient
and the patient's problems, better communication, and increased patient satisfaction.
• An increased family presence may provide some sensory organization to an environment that
may be overwhelming to patients.
• Unrestricted visiting hours can enhance the family’s role as a patient support system and
allow them to assist with care planning, clarify information, and reinforce patient education.
• While the concept of access to a support individual highlighted in RI.01.01.01, EP 28 is not
intended to dictate hospital visitation policy. It is intended to raise awareness of the need for
visitation policies that are inclusive of those who the patient identifies as important.
• The Joint Commission has expanded its definition of family to include individuals who may
not be legally related to the patient, which could incorporate someone who serves as the
patient’s support person.

Lesson 21: Overview of National Certification and Professional
Development
Goals:
- To become familiar with the two accredited national certification bodies
- To know the basic requirements and costs for attaining national certification
- To Identify the steps to take to further the medical interpreting profession
National Certification
The national certification for medical or healthcare interpreters is a process that was
implemented in 2009 by two certifying organizations. Both certifying bodies have a similar
process:
• Application
• Written examination online (language-neutral, in English)
• Oral examination (only available in 7 languages)
The total cost of each certification process is $485.00.
The National Board of Certification for Medical Interpreters

https://nbcmi.memberclicks.net
Application: Pre-requisites
1. Age: you must be 18 years of age or older
2. General education: high school diploma or GED (minimum)
3. Medical interpreter education: successful completion of a medical interpreter education
program (minimum of 40 hours)
4. Oral proficiency in English
5. Oral proficiency in the target language
Written examination: 51 questions. Passing score: 75%

• The roles of the medical interpreter (8%)
• Medical interpreter ethics (15%)
• Cultural competence (8%)
• Medical terminology in working languages (38%)
• Medical specialties in working languages (23%)
• Interpreter standards of practice (5%)

• Legislation and regulations (3%)
Oral examination: 45-60 minutes. Passing score: 75%?

• Mastery of linguistic knowledge of English (15%)
• Mastery of linguistic knowledge of another language (15%)
• Interpreting knowledge and skills (25%)
• Cultural competence (10%)
• Medical terminology in working languages (25%)
• Medical specialties in working languages (10%)
The Certification Commission for Healthcare Interpreters

www.cchicertification.org
Application: Pre-requisites
1. Age you must be 18 years of age or older
2. General education: U.S. high school diploma or GED (minimum), or equivalent from another
country
3. Medical interpreter education: at least 40 hours of medical interpreter education program
(academic or non-academic)
4. Oral proficiency in English
5. Oral proficiency in the target language
CoreCHI™: 100 questions. Passing score: 450/600 (75%) – Updated: August 2018
This is a written examination in English (language-neutral). This examination is the only
accredited examination for languages without an existing oral examination available whether
it is with CCHI or the NBCMI.
These are the domains of the CoreCHI™ examination:
• Professional responsibility and interpreter ethics (22%)
• Manage the interpreter encounter (22%)
• Healthcare terminology (22%)
• U.S. Healthcare System (15%)
• Cultural responsiveness (19%)
CHI™: 45-60 minutes. Passing score: 75%

This is an examination that tests oral proficiency in the target language (Spanish, Arabic, or
Mandarin) in consecutive and simultaneous interpreting, sight translation, and short written
translation.

• Interpret consecutively (75%)
• Interpret simultaneously (14%)
• Sight translate a written message (9%)
• Translate a written message (2%)
Table 4. Comparison between NBCMI and CCHI certification processes

WRITTEN EXAM ORAL EXAM LANGUAGES COST
NBCMI # CMI Spanish, Russian, Mandarin, Registration $35
Cantonese, Korean, Vietnamese Written exam $175
Oral exam $275
CCHI CoreCHI™ CHI™ Spanish, Arabic, Mandarin Registration $35
Written exam $175*
Oral exam $275
# When the oral examination is not available in the target language and the candidate has other proof of
linguistic proficiency.
* The Application and CoreCHI™ fees totaling $210 are paid at the same time.
Questions related to improving the profession
1. How are certified medical interpreters working to improve the profession?

The biggest gain for our relatively new profession is the development of national certification.
Where do we stand after ten years? What is the total number of certified medical or
healthcare interpreters for both CCHI & NBCMI?
As of January 2020, there were more than 5,500 certified interpreters combining all seven
languages.
Spanish Mandarin Arabic Cantonese Russian Vietnamese Korean TOTAL

NBCMI
2,089 59 --- 74 99 17 66 2,404
(CMI)
CCHI
2,838 159 122 --- --- --- --- 3,119
(CHI™)
TOTAL 4,927 218 122 74 99 17 66 5,523
CCHI Russian (126), Vietnamese (89), Cantonese (88), Korean (77), Somali
(CoreCHI™) (69), Portuguese (67), ASL (64), Nepali (60), Hmong (51), Japanese
(47), French (38), Farsi (23), Burmese (21), Polish (20), Haitian Creole
(17), Amharic (8), Cambodian/Khmer (7), Tagalog (7), Punjabi (6), 980
Hindi (5), Urdu (5), Romainian (3), Ukrainian (3), Turkish (3),
Kinyarwanda (2), Gujarati (1), Pashto (1), Croatian (1), Greek (1),
Wolof (1), Others (69).

The CCHI leadership, recognizing the problem of only having seven languages (as of 2016),
that are available from either the NBCMI or CCHI, decided to trademark its written exam,
calling it CoreCHI™. Leaders of the CCHI explain that granting this to individuals who interpret
for languages that may never be available for national certification (with written and oral
exams), recognize that these individuals at least know the basic standards of practice of the
profession. As of January of 2020, the CCHI reported that CoreCHI™ had been granted to 980
healthcare interpreters based on a passing score of 450 (600 is the highest). No proof of
linguistic proficiency is required for this CoreCHI™ designation.
The NBCMI does not agree with this approach. As of January of 2020, the NBCMI does not
offer any credential to those who pass its written examination and submit proof of linguistic
proficiency taken from third party companies approved by NBCMI.
Certification trends
As the figures on page 155 indicate, the majority of interpreters getting certified are still the
Spanish language interpreters. The number of interpreters in other languages is growing
slowly. The certification process is still accumulating a mass of professionals according to the
needs of the US healthcare system, and the development of nationally-normed
psychometrically-valued examinations.
At this point, due to both the cost of developing new tests for each language and the low
number of interpreters that have taken and passed the oral exams in the six newest
languages (other than Spanish), it is unlikely that oral examination in a two-language format
(English and Target) will increase soon. Instead, CCHI is developing an alternative oral
examination called English to English (EtoE). This oral examination does not intend to replace
the lack of oral examination for all other languages not included in the list of seven languages
available for the oral examination (Spanish, Arabic, Cantonese, Mandarin, Russian,
Vietnamese and Korean).
2. What are some of the benefits of national certification?

The first benefit is to raise the professional status of individuals offering to interpret for LEP
patients, by setting an objective standard that those in charge of interpreting can use to judge
medical interpreters.
The main goal of a professional medical interpreter should be to be the best message
conveyor possible. This is what LEP patients need and deserve. National certification
motivates experienced interpreters to improve their skill levels by requiring proof of
continuing education units and helping to raise the standards for the entire profession.

We haven’t yet reached a point where national certification is required to be able to work in
a medical setting, but it is a trend among major hospitals with staff interpreters.
Some hospitals now require national certification, if available. For example, Dane County,
Wisconsin, now requires it, and different states are considering requiring it.
Oregon has the highest standards of any state. Medical interpreters are required to be
nationally certified by either CCHI or NBCMI, have a minimum of 60 hours of basic training
(both accredited certifying bodies require 40), and 40 hours of interpreting experience in a
medical setting. After these requirements are met, the State of Oregon will certify the
healthcare interpreter. The State of Oregon also financed the elaboration of the tests for five
of the six languages that the NBCMI certifies.
Some hospitals pay or at least help pay the costs of certification. Others offer a pay
differential for those who are nationally certified. However, we are still in the process of being
recognized as a profession with national certification available.
The effect of pay rates on professional medical interpreters

What is happening to many experienced, talented medical interpreters? Some are
transitioning to legal interpreting. Some face-to-face interpreting services are being replaced
by remote interpreting (telephonic or video). The trend in remote interpreting is to pay
interpreters hourly when working in call centers, and by the minute when working from
home. The highest negotiated rate, $0.62 per minute for telephonic and $3.00 per minute for
the first ten minutes and $0.60 per minute after the first ten, when providing services via
video remote, won by Interpreters United Local 1671 in Washington State for
Medicaid/Medicare interpreters, is higher than what most agencies pay for remote
interpreting as of July 2019.
Many leave the profession simply because the pay rates may not be enough to pay the bills,
at least in certain areas of the country.
The key to improving the profession and helping to ensure that interpreters with years of
experience can continue in the profession is to join together with other interpreters both
within new or established professional organizations to work for better standards that lead
to higher pay scales, and the consolidation of the profession, as solutions that can benefit all.
Staff interpreters may already have some form of organization at their clinic or hospital level.
Informal weekly meetings of interpreters as a department or as feasible can foster the

agreement on interpretations to use and to work on solutions to common problems. Some
even develop their vocabulary lists so that the nomenclature of hospital programs are
interpreted the same way by all who interpret in that language.
All medical interpreters are urged to join local, regional, and national organizations: There
are state or regional professional organizations in virtually every part of the US. Nationally,
you have the National Council on Interpreting in Health Care (NCIHC) and the International
Medical Interpreters Association (IMIA). And, as the professional organization with the
greatest number of healthcare interpreter members, the American Translators Association
(ATA) is increasing its efforts to involve medical interpreters and make its organization serve
the needs of medical interpreters.
Picking an issue to work on

The key thing is to pick an issue that you feel needs to be resolved and then work on that with
others who have the same goals.
Federal reimbursement for professional medical interpreters

The majority of states do not yet participate in the Federal government’s Medicaid and
Medicare interpreting reimbursement program. This program is available with federal funds
to help states pay for medical interpreters for Medicaid and Medicare patients. This program
has to go through a state application and approval by the Centers for Medicare & Medicaid
Services.
Currently, only the following fifteen states take advantage of this program (IMIA, 2012):
1. Hawaii 6. Minnesota 11. Vermont

2. Idaho 7. Montana 12. Virginia
3. Iowa 8. New Hampshire 13. Washington
4. Kansas 9. New York 14. Washington DC
5. Maine 10. Utah 15. Wyoming
Who is making the decisions about how interpreting is organized?
• Who is making the decisions about organizing services for LEP patients, and on what
basis? Or, making the switch from in-person to OPI or VRI?
• We can look at this from the perspective of interpreters and what we need. LEP patients
and hospitals benefit when decisions are based on the health and well-being of the
patients. Whether we’re staff or freelance interpreters, adequate pay is key.

• Compare ASL or Court-certified with medical. What’s the difference based on? Standards
are different, with ASL certification being the highest, followed by national certification
for medical interpreters, and followed by court interpreters.
Help raise the bar
a) Pursuing an education in medical interpreting (basic and advanced) is the first step. Can
you help raise the bar by yourself?
The key is getting together with other professionals in established organizations: NCIHC,
IMIA, ATA, or CHIA.
A list of state and national professional organizations can be found on the International
Medical Interpreters’ Association website: http://goo.gl/GdIiEp (IMIA, 2019)
b) How can you help hospitals make the right decisions in whatever form?
Professionalism, consistency.
c) How many of you have worked to get the non-English media (visual or print) to get out
the word to different communities about their rights under Title VI?
It’s easy and free, and editors and newscasters are often eager to share news relevant to
their audiences.
d) Have you worked with others to publicize what it is that we do as interpreters?

International Translators (and Interpreters) Day is September 30th.
3. What does the PPACA (Obamacare) have to say about medical interpreters and language
access?
The PPACA states in Section 1557 that LEP patients have the right to communicate through
an interpreter at no charge, based on Title VI of the Civil Rights Act. It also mentions that the
language of translations and notices must be kept in plain English (U.S. Department of Health
& Human Services, 2010; IMIA, 2019).
4. What are some of the latest developments in the profession nationally?
o Testing from home anytime from NBCMI.
o More emphasis on interpreters being able to do short written translations (CCHI tests this
briefly).
o More states considering legislation or regulations regarding national certification. Oregon
remains the state with the highest state certification standards.

o The minimal national standard for medical interpreter training may be going up to 60 or
more hours.
o Some areas in the country are considering a defined academic pathway for language
interpreters, such as Philadelphia.
The medical interpreter profession is relatively new and changing rapidly. It will change in the
direction that medical interpreters want it to change, only if we are involved in the process.
What do I do after finishing my medical interpreter training?
• Continue educating yourself in medical terminology and your second language (online
resources, supermarket, magazines, etc.)
• Prepare a professional résumé.
• Join LinkedIn, update your profile, and start networking.
• Join local, regional, and national professional interpreters' organizations.
• Obtain proof of your immunizations: annual TB (PPD), seasonal Flu shots, MMR, Hep B,
Chickenpox, DTaP.
• Obtain proof of your background check: criminal background, child abuse clearance, FBI
fingerprinting.
• Obtain proof of your linguistic proficiency in English and your target language(s).
• Apply to work through local interpreting agencies.
• Think twice before accepting work from an agency that doesn't check your credentials.
• Research the agency's reputation and how they treat their interpreters.
What working environments are there available for medical interpreters?
• Full-time hospital/clinical staff

• Freelance
• Telephonic (home vs. call center)
• Video remote (hospital vs. call center)

Lesson 22: Self-care
Goals:
- Identify stress factors and learn how to cope with them
- Identify self-care techniques
Stress
For new interpreters, this topic may seem unwarranted. For those with experience
as interpreters, it is clear why we include it.
What does stress mean to you? The term ‘stress’ was defined in 1936 by Dr. Hans
Selye as “the non-specific response of the body to a demand for change.”
This definition has evolved over time, and it now includes a more comprehensive
definition: “A state of mental or emotional strain or tension resulting from adverse
or very demanding circumstances.” (Oxford Dictionaries)
How do you experience stress while doing medical interpreting?

Doing your best to keep up with both the patient and the provider, using the same
register, dealing with regional variations in vocabulary from the patient, working
with those who have never worked with an interpreter before, and many other
details can be very stressful.
Channeling another person’s health problems, especially when the patient is just
told that they have an incurable disease, or when a child dies in front of you, can
be very stressful. Very few medical interpreters can simply act as if nothing has
affected them, during and after the interpreted session.
As you accumulate experience, you should be able to anticipate potentially As you

stressful encounters. It is the level of experience of going through difficult accumulate
experience, you
situations that can prepare you to handle them without being overwhelmed by should be able
stress. to anticipate
potentially
stressful
Of course, there are interpreted sessions that make you smile and relieve tension encounters.
as well when a cancer patient is told that they are now cancer-free or when
interpreting for parents taking their first child to his or her first routine check-up.

However, if an interpreter is not aware of the potential for stress and its impact
on his or her ability to interpret, that can become a major problem.
Figure 27. Karasek's Demand-Control model of job stress
The American sociologist Robert Karasek, explains occupational stress as a

function of the demands of a particular job versus the control (or latitude)
afforded to the worker to cope with the demands.
Depending on the working agreement that you have, your job as a medical
interpreter will be somewhere between the “active” and the “high strain”
positions on the graph.
This means very high demands with very little control or latitude to manage them.
Therefore, it is very important that you have resources that you can use to cope
with stress.
Self-care
There are three times that we will face stress and three somewhat different ways
of dealing with stress during those times: before, during, and after a medical
encounter.

Before the medical encounter
The most important part of self-care is to get plenty of sleep every night, but The most
particularly the night before interpreting. Getting enough rest allows you to important part
of self-care is to
concentrate and focus on what is being said in the session, and it allows you to get plenty of
maintain a good level of performance. Recent studies also have shown that it helps sleep.
many of your body systems, including your immune system.
The second most important part of self-care is to prepare for the coming day. If
you know that you have an early morning appointment, don’t wait until the
morning of the appointment to plan what you’re going to wear or take with you
for taking notes or healthy snacking. A good way to be prepared is to lay out your
clothing for the next day and keep one set of “ready-to-work” clothing in your car
at all times in case you get the last minute call while you’re not near your home.
Figure out what works best for you to hydrate and have this ready to go. You may
only be able to drink before and after an assignment. The same applies to your
favorite healthy snack.
Personal hygiene is also very important. Bathing, brushing your teeth, wearing
clean, comfortable clothing, making sure your hair is as you would like it to be, are
all part of minimizing the stress that you feel as well as acting professionally. Plan
your time accordingly to achieve all these tasks before going to work.
Another matter you should consider is traffic, especially for contractors. Your
planned route could be partially or entirely blocked.
Being rested and prepared will allow you to cope with all sorts of stressful
situations.
Leading up to the interpreting session
Examples of stressful situations that interpreters can encounter, even before the
interpreting starts:
- Last-minute assignments (8:30 am call for a 9:45 am appointment when you
thought you didn’t have one until 1:00 pm)
- Traffic jams and possibly arriving late for an assignment.

- Reaching the clinic (for staff interpreters) by phone to let them know you
might be late to an assignment (without getting a traffic ticket for driving
distracted).
- Not reaching the dispatcher because you neglected to charge your cell phone
- Forgetting your cell phone at home.
- Reaching your agency (for contract interpreters) to let them know you might
be late for an assignment.
- Finding a place to park that won’t charge you more that you’re going to get
paid for the assignment.
- Finding the site of the assignment in a large hospital when it is your first time
there.
- Deciding how long you can wait for a possible no-show to show up, so you will
be able to interpret for the patient without being late for your next
appointment in another clinic.
There are more stressful scenarios, but this is a start.
What, other than being rested, can you do to prepare for the pre-appointment
stress?
• Listen to traffic reports, if available, as soon as you get up, to get advanced
warning of major traffic problems. Using GPS and traffic apps may also be
helpful (for example, Waze)
• Have your work tools ready in one spot (bilingual medical glossary, dictionary
handy to study while waiting for the patient to arrive). Many of these tools are
now available as free apps that can be downloaded to your smartphone.
• Make sure you’ve charged your cell phone. Have a car-compatible charger, just
in case.
• Study the hospital layout and know where you’re supposed to park and how
to get to the right building in a large hospital. Most hospitals publish their
campus maps on the guest or visitors section of their websites.
• Dress business professional but comfortable, following the clinic or hospital’s
dress code. In general, dress codes indicate no jeans or shorts, no tennis shoes
or sneakers, no open-toe shoes, no sleeveless shirts or blouses.
• Foot care: wear comfortable shoes as you may be standing for long periods.
Consider using gel pads or other orthotic inserts.
• Travel light: minimize your garments and work tools.

During the medical encounter
As you interpret
During the encounter, including as it starts with meeting the patient and doing
your pre-session, be prepared for things not always going smoothly.
• The patient may not be happy that you are assigned as the
interpreter. They may want a relative or some other untrained person to
interpret for them (friend, neighbor). Follow the hospital guidelines. They
usually include your professional presence as a specific requirement, or if
the patient still declines to use a professional medical interpreter, the
patient may have to sign a waiver or interpreter decline form. In general,
you need to have the provider dismiss your services to be able to leave the
appointment. Follow the check-in & check-out protocol with your agency
and the hospital or facility where you were summoned to interpret.
• There may be unreasonable expectations by the patient or provider. For
example, inappropriate sight translations, a patient request to translate
bills or letters, etc.
• You may experience disrespectful behavior or rejection by the patient or
provider.
• You may be subjected to discrimination and stereotypes.
• Providers may not pause for you to interpret what they say due to lack of
experience, bad mood or simply because they have difficult personalities.
• An important tool for the interpreter is doing a pre-session to explain the
rules of engagement clearly.
• Encounters that involve decision-making for end of life situations. If the
prognosis is hard for you to handle emotionally, try to remind yourself that
without you, this communication cannot take place. However, if you
cannot handle the difficult situation, it is professionally acceptable to
withdraw instead of staying and compromising the communication
between patient and provider.
Remember to be professional and respect all parties involved, despite what you
would like to say.
This is not about you; it is about the patient’s health.

After the interpreted encounter
After you finish interpreting, it is not at all abnormal to feel somewhat relieved
but also stressed. This is part of you having done a thorough, professional job and
living the pain and anguish of the patient and her family vicariously. It is not a
shortcoming on your part. Recognizing this, not ignoring stress, is the first step to
finding the best way for you, as a unique individual, to relax and de-stress.
This can take about as many different forms as there are medical
interpreters! There is no one right answer. If you are extremely stressed out,
contact the appropriate person at your language agency or hospital to help you
work this out. Ignoring a traumatic situation will not make it go away.
If you are sharing a situation as part of a stress-relief mechanism, you must

remember confidentiality. Say nothing specific about a stressful session that
would allow anyone to identify the patient. This rule is especially important for
social media users that tend to share personal comments. Be aware that what
goes on the Internet can never be taken out completely, and you may be
“unconsciously” revealing someone’s identity with geotags or specific comments.
Some people relax by going for a walk with their family or favorite pet. Others jog,
listen to music, play different sports, garden, dance to their favorite music, go out
to eat with friends or family, paint, etc. Hobbies and relaxation techniques vary,
but the need to de-stress from your work is important and an ongoing task to keep
you healthy and ready for the next assignment.
Professional ways to cope with stressful situations

• Always establish a tone of professional courtesy and respect.
• Clearly state the limitations of your role to both parties in your pre-sessions.
• Show empathy to the patient without compromising your emotional integrity
(vicarious trauma).
• Withdraw from an assignment if you believe that your personal opinions, beliefs,
and emotions may compromise your performance.
• Know your limits: Decline assignments above your expertise, or enlist the help of
a more senior/experienced person.
• For very long assignments, try to negotiate a schedule with a 15-minute break
every 2-3 hours, and a 30-60 minute lunch break.

Lesson 23: Infection control and occupational safety for
medical interpreters
Goals:
- To discuss the importance of infection control for medical interpreters
- To learn how infections are spread
- To recognize common signs and symptoms of infections
- To learn how to use universal and standard precautions to prevent infections
- To learn about recommended immunizations for medical interpreters
- To learn the basic principles of hand hygiene
Infections, occupational safety, and infection control
The goals of occupational safety and health are to foster a safe and healthy work
environment and to protect coworkers, patients, and family members.
The risk of infection for medical interpreters is relatively low. However, the
The risk of
potential consequences of a hospital-acquired infection can be devastating. infection for
Interpreters need to be aware of the potential risks involved in healthcare medical
occupations in order to keep their patients and themselves safe. interpreters is
relatively low
Occupational hazards in healthcare are regulated by various federal, state, and
local agencies. Every hospital or healthcare institution has an infection control and
environmental safety department that is in charge of implementing and
overseeing compliance with these regulations.
Some of the areas regulated by law include:
• Mandatory immunizations and Tuberculosis testing

• Restrictions on food and drink consumption in patient areas
• Hand hygiene
• Adherence to standard and special precautions
• Screening visitors and staff before entering vulnerable patient areas
• Accident prevention and reporting of inappropriate behavior
Infections
An infection is the growth of harmful germs in the body. Germs are microscopic
organisms such as viruses, bacteria, and fungi. Germs causing diseases are called
pathogens.

Not all germs cause infections. Only germs that are pathogens and can spread
from person to person, or from the environment to a person are infectious.
Common infectious diseases include the flu (or influenza), hepatitis A, B and C,
and HIV/AIDS. There are also some very dangerous infections that are acquired in
hospitals, such as Clostridium difficile (C. diff), or Methicillin-resistant
Staphylococcus aureus (MRSA). These are known as “nosocomial infections.”
Recommended immunizations for medical interpreters are:
• Influenza (yearly)
• Tetanus diphtheria (Every 10 years or if injured)
• Pneumonia (1 dose)
• Measles, Mumps, Rubella, Varicella
• Hepatitis B (3 shots)
In order to control infections effectively, it is important to understand how germs

spread. Germs need to grow in a “host” first. A host can be a person, an animal, a
plant, water, or food.
Germs grow more rapidly in environments that are damp, warm (between 40 –
140oF), have oxygen, and are dark.
Once they grow, germs that have a way to get out of their host can become
infectious. Sometimes germs use a “vector,” which can be a mechanical vector
such as a needle, or a biological vector, such as an animal or a person that comes
in contact with the germ, and helps transport it to someone else.
Germs typically spread through body fluids, such as blood, mucus, feces, wound
discharge, or urine. You can come in contact with germs in four ways:
• Direct Contact: By touching blood or body fluids of an infected person

• Indirect contact: By coming in contact with something an infected person has
touched, such as clothing and bedding items, glasses, silverware, etc.
• Airborne contact: By germs traveling through the air
• Droplet spread: By coming in contact with very small drops of moisture coming
from infected secretions (cough or sneeze)
Signs and Symptoms of Infections
Infections can be localized or systemic. Localized infections are contained in one

area of the body, such as a hand or an arm, whereas systemic infections are spread
throughout the body.

Symptoms of a localized infection include swelling or oozing of a wound or a
wound that is red, warm and painful.
Signs and symptoms of a systemic infection include fever, chills, weakness,

increased heart rate, and breathing, sweating, general malaise, nausea, dizziness,
tiredness, a generalized rash, or confusion.
Standard Precautions
Practicing standard precautions is the single most effective way to protect you and
your patient from passing infections around and becoming infected. Standard
precautions are also called universal precautions. Standard precautions consist of
treating everybody as if they had an infection. They include:
• Hand Hygiene
• Use of Personal Protective Equipment (PPE) such as gloves, when needed
• Minimizing the potential for contact
• Immunizations
It is important to know that people can have an infectious disease and not know
it. They might be an asymptomatic carrier if they came in contact with a pathogen
that has an incubation period (the time the pathogen needs to reproduce before
making the person sick), or they may have immunity against the disease. In both
cases, the person is a vector. They can pass the pathogen along to others.
Hand Hygiene
Practicing appropriate hand hygiene is the single most important thing an

interpreter can do to prevent the spread of infection. There are two ways to take
care of your hand hygiene:
• Gel in and out of patient encounters: Every time you go into a doctor’s
office or hospital room, use the antiseptic gel provided to clean your
hands, even if you don’t touch anything in the room. Remember, germs
can also spread through the air. Let’s review the steps for appropriate gel
hand hygiene as recommended by the CDC:
o Nail areas are most likely to hide germs. Maintain short fingernails.
Avoid nail extensions
o Place one teaspoon of gel into the palm of the left hand.
o Bring 4 fingertips and thumb of the right hand together, dip into
the gel, and expose all nail areas to gel.
o Transfer gel to right palm.

o Bring 4 fingertips and thumb of left hand together, dip into the gel, and
expose all nail areas to gel.
• Spread gel all over the surfaces of both hands. Get between the
fingers. Completely cover the thumbs.
• Do not rub hard; just expose all skin and nails to gel.
• Wash your hands: If they become soiled after using the toilet or before and after
eating. Also, wash your hands before and after entering a patient’s room where
enteric precautions have been posted. Let’s review the CDC’s recommendations
for handwashing:
o Wet hands thoroughly
o Apply soap and rub for at least 20 seconds
o Focus on nails and cuticles where most organisms reside
o Wash nails by scratching the opposite palm
o Rinse both hands thoroughly without touching each other
o Dry with a paper towel
o Turn off faucet with a paper towel
For more information on hand hygiene, go to

www.cdc.gov/handhygiene/index.html
Special Precautions: When patients are known or suspected to be infected with

dangerous pathogens, you will see a set of special precautions posted on the door.
If you have difficulty understanding or following these precautions, talk to the
nurse in charge and ask for directions.
It is extremely important to follow these directions correctly to be able to protect

yourself from very serious, potentially life-threatening diseases.
Special precautions include:
• Airborne Precautions: Special precautions against germs known to travel

by air. Most of the time, they will include using a respirator or goggles or a
face shield.
• Droplet Precautions: Droplets can transmit diseases such as pneumonia,
meningitis, pertussis, rubella, and bubonic plague. You will be required to
wear a gown, goggles and respiratory protection.
• Contact Precautions: Germs such as MRSA are spread through direct
contact with the patients or their body fluids. You will be required to wear
a gown or gloves. It is recommended that you leave any personal items
(such as cell phones, purses, etc.) at the nurses’ station before you enter
the room. Contact precautions also include Enteric Precautions, which
means the germs come from the patient’s fecal matter. Germs such as
hepatitis B and C. diff spread this way.

Personal Protective Equipment (PPE)
Personal protective equipment is specially designed equipment you may need to
wear to protect you and your patient from infection. The most common personal
protective equipment (PPE) used by interpreters includes:
• Gloves: There are two types, nitrile, and vinyl. They help avoid dangerous
germs from coming in contact with your hands.
• Masks and respirators: Used when there’s a risk of exposure to airborne
or droplet spread pathogens.
• Goggles or face shields: Use to prevent germs from coming in contact with
your eyes.
• Gowns and aprons: Used when there could be splattering of blood or body
fluids, such as during certain procedures
If you are called to interpret in a sterile procedure area (such as the operating
room or cath lab), you may be required to change into a surgical scrub or jumpsuit.
Follow the regulations of the facility.
Minimizing Exposure
Interpreters who are pregnant or immunocompromised are at a higher risk of

becoming infected by pathogens. Pregnant or immuno-compromised interpreters
should refuse assignments involving children or adults with active infections.
Also, if you are ill, you are at a higher risk of bringing dangerous germs to your
patient. Stay at home if you have fever, chills, runny nose, cough, rash, open sores,
or diarrhea. Remember, patient safety and dignity are paramount. Patients in
isolation due to an infectious disease must be afforded the same dignity and
respect we offer everyone else. While you should be careful always to observe
universal and any posted special precautions, you should never exclude or
discriminate against patients as a result of their diagnosis.

Chapter 6
BASIC ANATOMY,
PHYSIOLOGY, AND
TERMINOLOGY

Lesson 24: Introduction to Medical Terminology
Goals:
- To become familiar with the structure of medical terms, by building and
deconstructing terms
- To become familiar with the basic word elements of medical terms and be able
to decode meaning using word elements
- To practice medical terminology in the target language(s)
Medical Terminology
Medical terminology was developed as a universal classification system to allow Medical

doctors at different medical schools in different parts of the world to use a single terminology was
developed as a
word to name things like organs, body parts, or medical conditions. universal
classification
Most medical terms come from Latin or Greek, and most of them are part of system
Western or Indo-European languages.
Word elements
There are three main word elements that combine to form medical terms:
• Roots (Combining forms)

• Prefixes
• Suffixes
Roots, suffixes, and prefixes are commonly used in Standard English to create
words. For example, the word “nostalgia” comes from the Greek root “nostos”=
homecoming, reunion, and the suffix “algia”= pain - painful longing for one’s
home or homeland.
Some medical terms may have more than one root, prefix, or suffix. For example,
endocrinopathy (roots = end/o, crin/o; suffix = pathy) is a disease of the endocrine
(internal hormone secretion) system.
Roots
Roots are word elements used to make medical terms. Most of them are Greek.
Roots represent the primary meaning of medical terms and often indicate a body
part around which the term forms.

Examples:
o Laparo- = abdomen
o Dermato- = skin
o Hepato- = liver
Prefixes
Prefixes are always at the beginning of the word, adding meaning to it.
Examples:
o Peri- = around
o Tachy- = fast
o Epi- = over/above
o Ecto- = outside
Categories of Prefixes
There are four main categories of prefixes:
• Prefixes of time or speed
• Prefixes of direction
• Prefixes of position
• Prefixes of size or number
Prefixes of Time or Speed

These prefixes denote time or speed of events.
Examples:
o Ante/pre = before (antepartum - before birth)
o Brady = slow (bradycardia - slow heart rate)
o Neo = new (neoplasm - new growth)
o Tachy = fast (tachycardia - fast heart)
o Post = after (postpartum - after birth)
Prefixes of Direction
These prefixes signify the direction of events.
Examples:
o Ab = away from, outside, beyond (abnormal - away from or outside the
norm)
o Ad = toward, near (adjacent - beside)

o Con, sym, syn = with (congenital - “with birth”, symbiotic - “with life”, Synarthrosis -
“with joint”)
o Contra = against (contraindication - against direction)
o Dia = across, through (diabetes - to “pass through”)
Prefixes of Position
These prefixes denote the position of body parts, lesions or injuries relative to other body parts
Examples:
o Ec/ecto/exo = outside (ectopic)
o En = inside (encephaloscopy - To look inside the brain)
o Endo = within (endoscopy - to look inside)
o Extra = beyond (extrasystole - outside the contraction of the heart - abnormal heartbeat)
Prefixes of Size and Number

These prefixes signify the size or number of events, injuries, lesions, body organs or systems
Examples:
o Di/bi = two (biannual - twice a year, diplopia - double vision)
o Hemi/semi = half (hemiplegic - paralysis of half of the body)
o Macro = big (macrocyte - big cell)
o Poly = many (polydactyly - many fingers)
Suffixes
These are additions that always come at the end of the word and add meaning to it. Suffixes are
used in medical terminology to convert roots or combining forms into nouns, to modify nouns to
mean something different or to convert a noun into an adjective.
Examples:
o Algia = pain
o Itis = inflammation
There are four main categories of suffixes:

• Suffixes that signify medical conditions
• Suffixes that signify diagnoses, test information, or surgical procedures
• Suffixes associated with a medical specialty
• Suffixes that convert a noun into an adjective

Suffixes that signify medical conditions
o -algia = pain (arthralgia - pain of the joints)
o -cele = protrusion/hernia (meningocele - protrusion of the meninges)
o -malacia = softening (osteomalacia - softening of the bones)
o -osis = abnormal condition (osteoporosis - abnormal condition of the bones -
loss of bone density)
Suffixes that signify diagnoses, test information, or surgical procedures:

o -centesis = surgical puncture (thoracentesis - surgical puncture of the thorax)
o -ectomy = surgical removal (hysterectomy - surgical removal of the uterus)
o -plasty = surgical repair (rhinoplasty - surgical repair of the nose)
o -tomy = incision (laparotomy - incision of the abdomen)
Suffixes associated with a medical specialty

o -iatro- = physician (pediatrician - physician for children)
o -an/ist- = specialist (optician - specialist in vision / orthopedist - from orthos:
straight/correct and paedos: rearing of children)
o -ics/-iatry = medical specialty (pediatrics - specialty of children / psychiatry -
specialty of the mind)
o -logi = study of (gynecology - study of women)
Suffixes that convert a noun into an adjective

o -ic = converts root into an adjective (orthopedic - pertaining to the
orthopedist)
o -iatric = converts root into an adjective (pediatric - pertaining to children)
o -ular = converts root into an adjective (vascular - pertaining to blood vessels)
o -aneous = converts root into an adjective (cutaneous - pertaining to the skin)
Combining forms
A combining form is a vowel that is used to combine a root, and a prefix, a suffix, or all 3. The
vowel is used as a link between two words. It is usually an ‘o’.
Prefixes and suffixes are interchangeable. The same elements can be placed at the beginning or
at the end of a given root to change its meaning.
Examples:
Path/o/logy Lapar/o/scopy
disease/ /the study of abdomen/ /visual examination

Decoding terminology in three steps:
• First: divide the word into its elements: Root(s), suffix(es) and prefix
• Second: decode the meaning of each element
• Third: Decipher starting with the suffix(es), then the prefix, and finally the root(s)
Example:
Prefix Root Suffix Meaning
Inflammation of
Osteoarthritis osteo = bone arthr- = joint -itis = inflammation
the bone joint
Practice:
Using the table below, decipher the following terms following the three steps (Not all terms have
the three-word elements)
Table 5. Practicing the deconstruction of medical terms

Root/
Term Prefix Suffix Meaning
Combining form
Gastroscopy
Hyperthyroidism
Perinatal
Amniocentesis
Psychopathy
Appendectomy
Anorexia

Remember the three steps
• Divide the word into its elements: Root, suffix, and prefix
• Decode the meaning of each element
• Decipher starting with the suffix, then the prefix, and finally the root
Pronouncing medical terms

• Pronouncing medical terms correctly is very important for effective communication
• Medical terms are cognates in almost every western language. However, sometimes there
are false cognates. An example of a very dangerous false cognate is the word 'intoxicado.'
Saying what you mean: Pronunciation practice

• Anemia [uh-NEE-mee-uh]
• Angioplasty [AN-jee-uh-plas-tee]
• Bursitis [ber-SAHY-tis]
• Disease [dih-ZEEZ]
• Hemoglobin [HEE-muh-GLOH-bin]
• Lymphoma [lim-FOH-muh]
• Neuritis [nu-RAHY-tis]
• Osteoporosis [OS-tee-oh-puh-ROH-sis]
• Paraplegia [par-uh-PLEE-jee-uh]
• Pulse [puhls]
• Radiation [rey-dee-EY-shuhn]
• Reflex [REE-fleks]
• Retina [RET-nuh]
• Rheumatism [ROO-muh-tiz-uhm]
• Sciatica [sahy-AT-i-kuh]
• Septum [SEP-tuhm]
• Sinus [SAHY-nuhs]
• Therapy [THER-uh-pee]
• Typhoid [TAHY-foid]
• Vaccine [vak-SEEN]
Singular and plural

Medical terms are usually identifiable by the ending. There are three sets of grammatical rules
that are used in etymology: Greek, Latin, and English (or another host language)

General rules
• A endings: plural is AE: scapula / scapulae

• AX endings: plural is ACES: thorax / thoraces
• IS endings: plural is ES: neurosis / neuroses
• IX or IE endings: plural is ICES: cervix / cervices
• UM endings: plural is A: septum / septa
• US endings: plural is I: calculus / calculi
• Y Endings: plural is IES: biopsy / biopsies
Exceptions
• Virus / Viruses
• Can you think of another?
Review
• What are the three-word elements of medical terms?

• What does dermatitis mean?
• What organ does a cardiologist treat?
• What is a neuroma?

Lesson 25: Body organization, from cells to organisms
Goals:
- To identify the levels of organization in the human body
- To learn the anatomical position, planes, and directional terms for the human body.
Levels of organization
Observing physical features is a powerful way to determine the complexity of living organisms.
However, it would be like an incomplete jigsaw puzzle if we didn’t put all the pieces together.
The levels of organization of the body are:
• Molecular: Atoms bond together to form more complex structures known as molecules.
For example, hydrogen and oxygen bond together to form water. In the body, many atoms
bond together to form cells.
• Cellular: The body is made of millions of cells that continually work together to sustain life.
• Tissue: Cells specialize and bond together to form tissues (i.e., muscle tissue)
• Organs: Tissues with common functions come together to form organs.
• Systems: Organs working together are part of a system.
Figure 28. Levels of organization in the body

Anatomical position
The classic anatomical position looks at the body, standing up from the front. The legs are
extended with the feet parallel to each other and the palms of the hands are turned outward:
Figure 29. Anatomical position (Source: http://goo.gl/hLfcM5)
Directional terms
• Superior: From the waist, moving upward to the top of the head.
• Inferior: Below the waist, moving downward to the bottoms of the feet.
• Anterior / Ventral: The front of the body, or towards the front of the body.
• Posterior / Dorsal: The back of the body, or towards the back of the body.
• Medial: Towards or at the midline of the body.
• Lateral: Away from the midline.
• Proximal: Closer to the origin or point of attachment.
• Distal: Farther away from the origin or point of attachment.
• Supine: Lying face up.
• Prone: Lying horizontal, face down.
How do you say these words in your target language?

Practicing anatomical positions
o The nose is on the _________________ part of the face.

o The spine is on the _________________ side of the body.
o The neck is _________________ to the chest.
o The nose is _________________, and the ears are _________________.
o The stomach is _________________ to the chest.
o The elbow is _________________ to the wrist.
o The fingers are _________________ to the wrist.
Table 6. Practice of anatomical positioning in the target language

Root Meaning Equivalent in the target language
Anter/o anterior, front
Dors/o Back
Poster/o posterior, back
Super/o superior
Body planes
Body planes are imaginary, flat,

slices through areas of the body.
They are used to locate structures,
lesions, or injuries. The body is
always represented in the
Anatomical Position. There are three
main body planes each of which cuts
right through the middle of the body
from different directions:
• Frontal Plane: separates the

body into front and back.
• Sagittal Plane: separates the
body into left and right.
• Transverse Plane: separates
the body into upper and
lower
Figure 30. Body planes

Body cavities
Body cavities are hollow spaces that contain body organs.
There are seven main body cavities:
• Dorsal cavity: Includes the cranial and spinal

cavities.
o Cranial cavity: Brain, meninges, and all the

organs within the skull
o Spinal cavity: Contains the spinal cord,
meninges, and nerves emerging from the
spinal cord
Figure 31. Body cavities

(Source: http://goo.gl/zd7o5F)
• Ventral cavity: Includes the thoracic, abdominal and
pelvic cavities
o Thoracic cavity: Contains the heart, lungs. It is divided from the abdominal cavity by
a muscle called the diaphragm.
o Abdominal and pelvic cavities: Contain the internal organs for digestion and
reproduction, also called viscerae (stomach, intestines, and reproductive organs). The
abdominal and pelvic cavities make up the abdominopelvic cavity.
Abdominopelvic cavity
The abdominopelvic cavity is divided into 9 regions:

• Right and left hypochondriac regions: Hypo means “under” and “chondro” means
“cartilage.” These are the spaces located just under the cartilage of the ribs.
• Epigastric: Epi means “over” and “gastro” means “stomach.” This is the region just
above of the stomach.
• Umbilical region: Umbilicus means “belly button.” This is the central region that
contains the belly button.
• Hypogastric: The region below the belly button.
• Right and left lumbar regions: Located at the waist level below the hypochondriac
regions.

• Right and left inguinal regions: Flank the hypogastric region. Inguinal means “groin.”
This is also referred to as the “groin area.”
Figure 32. Abdominopelvic cavity and Spinal column with vertebrae
Divisions of the spine
The spine is composed of 7 cervical (neck), 12 thoracic (chest), 5 lumbar (below the waist), 5
sacral (lower back), and 3-4 coxal (coccyx or tailbone) vertebrae.
Review
1. What are the levels of body organization?
2. The frontal plane divides the body into _________ and _________.
3. Fill in the cavity names in the following diagrams:

Diagram 1:
Figure 33. Diagram of body cavities
Diagram 2:
Figure 34. Abdominopelvic cavity diagram

Lesson 26: Integumentary, muscular, and skeletal systems
Goals:
- To identify the terminology pertaining to the integumentary and skeletal systems, including
basic structures, word elements, common conditions, common procedures, and specialists
Integumentary system
The skin is the largest organ in the body. The integumentary system includes hair, nails,
sebaceous, and sweat (sudoriferous) glands.
Figure 35. Skin diagram
Specialists:
• Dermatologist
• Allergist

Word Elements
Table 7. Combining forms from the integumentary system
Root Meaning Linguistic equivalent in the target language
Albin/o white
Cirrh/o yellow
Jaund/o yellow
Cutane/o skin
Cyan/o blue
Cyt/o, -cyte cell
Derm/o, Dermat/o skin
Epi upon
Pallor pale, paleness
Common conditions of the integumentary system

• Skin lesions: areas of the skin that are abnormal.
• Acne: Pimple outbreak. They are greasy secretions (sebaceous glands) that clog the
openings of hair follicles.
• Dermatitis: Inflammation of the skin.
• Dermatosis: Any disease on the surface of the body (skin, hair, nails).
• Eczema: Disease characterized by rough, swollen patches of skin.
• Rash: Area of irritated or swollen skin. Many rashes are itchy, red, painful, and irritated.
• Psoriasis: Chronic disease characterized by inflamed patches with silvery white scabs.
• Basal cell carcinoma: Cancer of the basal layer of the skin.
• Squamous cell carcinoma: Cancer of the top layer of the skin.
• Melanoma: Cancer of melanocytes (cells with melanin), which provide skin color (tanning).
Common medical procedures of the integumentary system

• Cryotherapy: Treatment by cold (typically with liquid nitrogen).
• Incisional biopsy: Removal of part of a lesion to be studied for abnormal cells.
• Excisional biopsy: Total removal of a lesion to be studied for abnormal cells.
Skeletal system
The skeleton is a rigid and articulating structure made up of 206 bones and two main parts:
- Axial skeleton: Cranial, facial, thoracic, and spinal bones.
- Appendicular skeleton: Shoulder, pelvis, arms, and legs.

Other parts of the skeletal system include:
Joints: Where two or more bones meet. A joint can be articulated or fixed.
Ligaments: Straps of connective tissue connecting two bones together.
Tendons: Straps of connective tissue connecting the muscle to the bone.
Specialists: Rheumatologist, Orthopedist, Physical, and Occupational therapists, Chiropractor.
Figure 36. Types of bone fractures
Table 8. Combining forms from the skeletal system

Root/Comb. form Meaning Linguistic equivalent in the target language
Ankyl/o stiff
Arthr/o joint
Brachi/o arm
Carp/o wrist
Chondr/o cartilage
Cost/o rib
Crani/o skull
Dactyl/o finger
Kinesi/o movement
Kyph/o hump
Lord/o curvature
Orth/o correct, straighten
Pod/o foot
Spondyl/o vertebrae

Muscular system
The muscular system is made up of three different types of muscle:

- Skeletal: Voluntary movement (muscles attached to bones)
- Cardiac: Muscles of the heart
- Smooth: Involuntary movement (part of organs’ structure)
Word elements
Abduction = Away from the midline Pronation = Turning downward

Adduction = Toward the midline Supination = Turning upward
Eversion = Turning outward Dorsiflexion = Bending backward
Inversion = Turning inward Plantar flexion= Bending sole of the foot
Extension = Opening joint angle Rotation = Turning on its axis
Flexion = Closing joint angle
Specialists:
• Orthopedist
• Physical and Occupational therapists
• Neurologist
• Chiropractor
Common conditions of the muscular system
• Carpal Tunnel Syndrome (CTS): compressed nerve going through the carpal tunnel due to
repetitive motion. It causes swelling, weakness, pain, tingling, numbness.
• Rotator cuff injury: injury in one or more of the components of the rotator cuff, the rotating
joint of the shoulder.
• Epicondylitis: pain and irritation of the tissue connecting the forearm muscle to the elbow.
• Muscular dystrophy: progressive weakness and muscle mass loss due to abnormal genes.
• Myasthenia gravis: droopy eyelid and mouth due to breakdown of communication
between nerves and muscles.
• Fibromyalgia: chronic widespread muscle pain and tenderness, possibly due to the way in
which the pain signals from the nerves are processed.

Lesson 27: Cardiovascular and lymphatic systems
Goals:
- To learn the terminology pertaining to the cardiovascular and lymphatic systems, including
- To practice the terms in your target language(s)
Cardiovascular system
Structure of the heart
The heart is a muscular organ
comprised of three layers:
Endocardium: Inner layer

Myocardium: Muscle
Pericardium: Outer layer
The heart is divided into four chambers

or compartments:
Upper part: Two chambers called atria

(plural), or atrium (singular). Right and
left atrium.
Lower part: Two chambers called

ventricles (plural). Right and left
Figure 37. The human heart ventricle.
Valves
There are four (4) valves in the heart:
Tricuspid valve: Between right atrium and ventricle
Bicuspid or mitral: Between left atrium and ventricle
Aortic valve: Between the left ventricle and the aorta
Pulmonary valve: Between the right ventricle and the pulmonary artery
The heart has two sides: right and left. Each side has one atrium (or auricle) and one ventricle.

The right side of the heart is in
charge of the “pulmonary
circuit,” which takes blood from
the body to the lungs to be
oxygenated.
The left side is in charge of the

“systemic circuit,” which carries
oxygenated blood from the
lungs into the rest of the body.
The right atrium receives blood

from all body parts to the
atrium, and it pumps blood from
the ventricle to the lungs. The
left atrium receives blood from
the lungs.
The left ventricle receives blood

from the left atrium and pumps
it to the body.
Figure 38. Cardiovascular system
Electric System of the Heart

It is composed of three nodules or bundles
connected by the Purkinje fibers:
Sinoatrial node: The pacemaker of the heart.
Atrioventricular node: Transmits signals from atria

to ventricles.
Atrioventricular bundle: Transmits signals

throughout ventricles.
Figure 39. Electrical system of the heart

Blood vessels
There are 3 types of blood vessels:
Arteries: Take blood away from the heart

Veins: bring blood back to the heart
Capillaries: Connect the arterial and venous
systems
Figure 40. Blood vessels
Blood
The cardiovascular system transports oxygen, nutrients, and wastes throughout the body using
the blood as a fluid.
The liquid part of the blood called plasma (mostly water) contains dissolved nutrients (such as
oxygen, O2), and waste products (CO2).
The solid part of the blood includes red blood cells (erythrocytes) and white blood cells
(leukocytes).
The blood also contains platelets, which are tiny pieces of blood cells inside membranes. Platelets
cause blood cells to clot when a blood vessel is cut.
Figure 41. The blood parts Figure 42. Types of blood cells

Word elements
Angi/o = Blood vessel Hemo/a = Blood

Aort/o = Aorta My/o = Muscle
Arteri/o = Arterial Peri = Around
Ather/o = Fatty plaque Phleb/o = Blood vessel
Atri/o = Atrial Stenosis = Narrowing, closing
Brady- = Slow Valv/o = Valve
Cardi/o = Heart Varic/o = Dilated
Coron/o = Coronary arteries form a Vas/o = Blood vessel
“crown” around the heart. Ven/o = Vein
Ectasis = Dilation, stretching Ventricul/o = Ventricle
-emia = Blood
Common blood disorders
• Anemia: Lack of red blood cells.

• Leukemia: Is a type of blood cancer that begins in the bone marrow and leads to an
uncontrolled increase in the number of white blood cells.
• Hemophilia: Is a bleeding disorder in which the blood does not clot normally, is usually
inherited, and most commonly occurs in males.
• Thrombocytopenia: Decreased concentration of platelets.
Common procedures
• Electrocardiogram (EKG): A test that registers the electrical impulses in the heart.
• Echocardiogram (Echo): A sonogram of the heart.
• Cardiac catheterization (Cardiac cath): A procedure in which a catheter is inserted through
the femoral artery and coiled to the heart to determine if there are any coronary
obstructions.
• Angioplasty: A procedure in which a catheter is inserted through the femoral artery and
driven to the heart to break up plaque and resolve coronary obstructions.
• Coronary bypass (CABG): A type of heart surgery that consists of bypassing an obstructed
portion of a coronary artery using a graft from a vein.

• Transcatheter Aortic Valve Replacement (TAVR): A type of minimally-invasive surgery to
replace a heart valve through cardiac catheterization. It is also called Transcatheter Aortic
Valve Implantation (TAVI).
Common cardiovascular disorders
• Coronary Artery Disease (CAD): The coronary arteries, which provide nourishment to the
heart, become obstructed by the formation of fatty plaques.
• Acute Myocardial Infarction (AMI): Part of the heart tissue dies as a result of coronary
obstruction.
• Atrial Fibrillation (A-Fib): A type of abnormal rhythm of the heart consisting of the atria
contracting irregularly and inefficiently.
• Ventricular Fibrillation (V-Fib): A type of abnormal rhythm of the heart consisting of the
ventricles contracting irregularly and inefficiently.
• Arrhythmias: Abnormalities of the rhythm of the heart.
• Hypertension (HTN): High blood pressure.
• Congestive Heart Failure (CHF): The heart muscle doesn't pump blood as well as it should,
triggering fluid retention (edema), shortness of breath, and other problems.
Specialists
• Cardiologist: Physician specialized in the medical treatment of the heart & cardiovascular
system.
• Electrophysiologist: Specialist in the electrical system of the heart.
• Cardiothoracic surgeon: Surgeon specialized in operating on the heart & cardiovascular
system.
Specialized terms
Angioplasty: Surgical repair of the blood vessel.

ASD: Atrium Septum Defect.
Cardiomyopathy: Disease of the heart muscle.
VSD: Ventricular Septum Defect.
TOF: Tetralogy of Fallot.
Stent: Mesh-like scaffold used to expand and hold blood vessels open in the heart.

Lymphatic system
The lymphatic system is in charge of circulating

lymphatic fluid around our body. It helps our body fight
infection by creating immune cells. It also keeps our body
fluids in balance.
Parts of the lymphatic system
Lymph vessels, lymph nodes, and lymph organs (tonsils,

thymus gland, spleen, appendix, Peyer patches in
intestines).
Figure 43. Lymphatic and circulatory systems

Word elements
Immun/o = The body’s defense system Phag/o = (Greek) “Phagos”= to eat

Lymphaden/o = Related to lymph nodes Phylaxis = Protection against infection
Lymphangi/o = Related to lymph vessels Splen/o = Related to the spleen
Lymph/o = Related to the lymphatic Thym/o = Related to the thymus
fluid or the lymphatic system Tonsill/o = Related to the tonsils
Specialists
• Hematologist: Physician that specializes in blood disorders.

• Allergist: Physician that specializes in the abnormal responses by the immune system.
• Immunologist: Physician that specializes in the immune system.
Common disorders
• Lymphadenitis: Inflammation of the lymph nodes.

• Lymphedema: Abnormal accumulation of lymphatic fluid.
• Lymphadenopathy: Enlargement of the lymph nodes.
• HIV/AIDS: Human Immunodeficiency Virus / Acquired Immune Deficiency Syndrome.
• Splenomegaly: Abnormal enlargement of the spleen.
• Lymphoma: Cancer of the lymphocytes, which are white blood cells.
• Rheumatoid arthritis: Chronic inflammatory disease affecting the small joints in hands & feet.

Lesson 28: Respiratory system
Goals:
- To identify the terminology pertaining to the respiratory system, including basic structures,
word elements, common conditions, common procedures, and specialists
Respiratory system
The respiratory system fulfills the critical function of providing much-needed oxygen to all tissues,
organs, and systems in the body.
This oxygen is an essential gas that is used by the body’s cells to produce energy by breaking
down glucose in the presence of oxygen (cellular respiration).
The respiratory system was designed to capture oxygen for cellular respiration and to excrete the
by-product, carbon dioxide.
Parts of the respiratory system:
Figure 44. Diagram of the respiratory system

Air comes in through the nose or mouth
and crosses the sinuses where it is warmed
up by a fine network of blood vessels.
Then it passes over the epiglottis, through

the larynx; then it travels down the trachea
into the bronchi, which progressively
divide into small tubes called bronchioles,
eventually ending at small sacs called
alveoli where it moves through a thin layer
of cells into the blood.
Figure 45. Alveolus gas exchange
Word elements
Bronch/o = Pertaining to the bronchi divides the chest from the

Laryng/o = Pertaining to the larynx, the abdomen (the body cavity
tube that carries air from the below the chest and above
nose to the trachea the pelvis)
Nas/o = Pertaining to the nose Pleur/o = Pertaining to the pleura,
Rhin/o = Pertaining to the nose which is the membrane
Ox/o = Pertaining to oxygen covering the lungs
Pharing/o = Pertaining to the pharynx, Pneum/o = Pertaining to the lungs.
the tube that carries air from From the Greek “pneuma”=
the mouth to the esophagus, air.
or air from the mouth to the Pulm/o = Pertaining to the lungs.
trachea From the Latin “pulmo” =
Phoni/a = Pertaining to speech. From lung
the Greek “phonos”= sound Sin/o = Pertaining to the sinuses
Phren/o = Pertaining to the Thorac/o = Pertaining to the thorax
diaphragm, the muscle that Trache/o = Pertaining to the trachea
Common disorders
• Asthma: A chronic disease that produces swelling and narrowing of the bronchi and
bronchioles. It is characterized by a cough, wheezing, and tightness of the chest.
• Bronchitis: Inflammation of the bronchi due to an infection or chronic irritation.

• Emphysema: A disease that produces damage to the alveoli, causing the air to become
trapped. Along with chronic bronchitis, emphysema is a type of Chronic Obstructive
Pulmonary Disease or COPD.
• Laryngitis: Inflammation of the larynx.
• Lung cancer: Cancer of the lungs. There are multiple types and multiple causes. The most
common types are non-small cell lung cancers, such as squamous cell carcinoma or
adenocarcinoma. Smoking is the most important risk factor for these cancers.
• Pneumonia: An infectious disease of the lungs caused by a virus or bacteria.
• Sinusitis: Inflammation of the sinuses.
• Tuberculosis: An infectious disease caused by a bacterium called Mycobacterium tuberculosis
or Koch’s bacillus, commonly referred to as “TB.” In its late stages, tuberculosis becomes
systemic, affecting the liver, the bones, and the brain.
Common procedures
• Bronchoscopy: A procedure that involves inserting a fiber-optic tube into the mouth, the
trachea and finally into the bronchi to examine for potential lung diseases.
• Pulmonary function test (PFT): Also called spirometry. The patient is asked to blow air into a
machine in order to measure their respiratory capacity.
• Chest X-ray: An X-ray of the chest. It is the most common test for diagnosing conditions in
the lungs.
• Tonsillectomy: Surgical removal of the tonsils.
• Tracheostomy/tracheotomy: Emergency procedure consisting of opening a hole into the
trachea to allow the patient to breathe.
• Intubation: Placing a tube through the nose or mouth into the trachea to give assisted
ventilation to the patient.
• Arterial blood gasses (ABG): Measurement of gasses in arterial blood.
• Pulse oximeter: External, noninvasive measurement of oxygen in the blood.
Specialists
• Pulmonologist: Medical doctor who specializes in the respiratory system.

• Otorhinolaryngologist (ENT specialist): Medical doctor who specializes in the ear and the
upper respiratory system (ear, nose, and throat specialist).
• Respiratory therapist: A therapist who treats the respiratory system.

Lesson 29: Digestive and endocrine systems
Goals:
- To identify the terminology pertaining to the digestive and endocrine systems, including
Digestive system
Mouth: Oral cavity that contains the tongue, teeth, and salivary glands that produce saliva. Saliva
contains enzymes that help initiate the digestive process.
Pharynx: Part of the digestive and respiratory systems. Food enters the pharynx on its way to the
esophagus.
Esophagus: A flexible tube that lubricates the food with mucus on its way to the stomach.
Diaphragm: A semilunar-shaped muscle dividing the chest from the abdomen.
Stomach: Central organ of the digestive system. The food enters the stomach through an orifice
(cardias). Acids and enzymes are produced by the stomach to break down food. After this
process, a substance called chyme passes to the small intestine through the pyloric sphincter.
Small Intestine: The small intestine has three parts: the duodenum, jejunum, and ileum. It’s
about 20 feet long, and nutrients are absorbed along its length.
Colon: From the small intestine, the chyme passes the ileocecal sphincter to go into the colon or
large intestine. The colon has three portions: ascending, transverse, and descending. Fecal
matter forms in the colon and passes through the rectum to the anus.
Rectum: The last 6 inches of the large intestine.
Anus: The orifice through which fecal matter is excreted
Liver: An accessory gland of the digestive system, the second largest organ in the body and its
functions include:
• Storage of energy and glycogen

• Production of blood clotting factors
• Production of proteins
• Recycling of old red blood cells
• Storage of vitamins
Pancreas: Another accessory gland of the digestive system. Its main functions are to produce
insulin, a hormone that facilitates the absorption of sugar by body organs, and glucagon, a
hormone that promotes the conversion of glycogen into sugar.
Figure 46. Digestive system diagram
Word elements
Abdomino = abdomen Cholecysto = gallbladder
Bucco = cheek Colon = large intestine
Cheilo = lip Duodenum = first portion of the small
Chole = bile intestine
Cholangio = bile duct Emesis = vomit

Esophago = esophagus Pancreato = pancreas
Gastro = stomach Pepsia = digestion
Gingivo = gums Phago = eating, swallowing
Glosso = tongue Procto = anus, rectum
Hepato = liver Pyloro = pylorus
Ileum = third portion of the small Recto = rectum
intestine Scopy = visual examination
Jejunum = second portion of the small Sialo = salivary glands
intestine Sigmoid = sigmoid colon
Laparo = abdomen Stomato = mouth
Litho = stone
Common disorders
• Appendicitis: Acute inflammation of the appendix (small sac attached to ascending colon).
• Cancer: The most common cancer of the gastrointestinal (GI) system is colorectal cancer. It
can develop from a polyp, an abnormal growth of the lining of the intestine.
• Cholecystitis: Inflammation of the gallbladder.
• Cholelithiasis: Gallstones.
• Cirrhosis: When scar tissue replaces the healthy tissue in the liver.
• Crohn’s disease: Inflammation of the small intestine (lining). It may cause ulcers or total
obstruction.
• Diverticulitis / Diverticulosis: Abnormal pouches in the intestinal wall.
• Fatty liver: also known as Non-alcoholic fatty liver diseases (NAFLD), it involves the
accumulation and storage of fat in the liver. If fat storage continues over time, it can progress
to Non-alcoholic steatohepatitis (NASH) and subsequently to cirrhosis of the liver.
• Gallstones: Stones in the gallbladder.
• Gastritis: Inflammation of the lining of the stomach
• Gastroenteritis: An acute inflammatory disease of the stomach and intestines.
• Gum disease: Starts with gingivitis (inflammation of the gums), followed by periodontitis
caused by bacterial growth in the mouth that may end in tooth loss if left untreated.
• Heartburn - Gastroesophageal Reflux Disease: Also referred to as GERD.
• Hepatitis: Inflammation of the liver. Types A, B, C, D, and E. It is commonly caused by a virus,
drugs or alcohol abuse, and a fat-rich diet.
• Hiatal hernia: Bulging in the esophagus-stomach connection through the diaphragm muscle.
• Inflammatory Bowel Disease (IBD): Is a generic term used for diseases related to chronic
inflammation of part or all the digestive system (i.e., Crohn’s disease, ulcerative colitis, etc.)

• Stomatitis: Inflammation of the mouth due to Herpes Zoster virus infection, or vitamin C
deficiency.
• Ulcers: Perforation of the lining of the stomach (gastric) or intestines (peptic).
Common procedures
• Endoscopy: A procedure that involves inserting a fiber-optic tube with a camera into the
mouth, to check the organs of the upper portion of the digestive system.
• Colonoscopy: A procedure that involves inserting a fiber-optic tube with a camera into the
rectum to check the Colon.
• Upper GI Series (Barium Swallow): Radiologic test involving a series of X-ray images and
movies to check the structure and function of the organs in the upper portion of the digestive
system.
• Lower GI Series (Barium Enema): Radiologic test involving a series of X-ray images and
movies to check the structure and function of the organs in the lower portion of the digestive
system.
Specialist: Gastroenterologist
Endocrine system
The word endocrine comes from the Greek endo = within and crinos = separate/secrete.
The endocrine system consists of a series of glands (organs) that produce hormones.
Hormones are chemical messengers made out of molecules such as proteins (amino acids), lipids
(steroids), and carbohydrates.
The functions of hormones are to transport messages to start or stop metabolic processes,
increase or decrease the production of other substances, and regulate metabolic processes in
general.
Therefore, the endocrine system is in charge of regulating homeostasis, controlling the body’s
metabolism, and regulating the body’s functions.

Figure 47. Endocrine system
The endocrine system is comprised of the following glands:
• Pituitary Gland: Produces growth hormones, thyroid-stimulating hormone (TSH),

adrenocorticotropic hormone (ACTH), follicle-stimulating hormone (FSH), luteinizing
hormone (LH), prolactin (PRL), melanocyte-stimulating hormone (MSH), antidiuretic
hormone (ADH), oxytocin.
• Thyroid: Produces T3 and T4.
• Parathyroid: Produces calcitonin, parathormone (PTH).
• Adrenal cortex: Produces cortisol, aldosterone, androgen.
• Adrenal medulla: Produces epinephrine.
• Pancreas: Produces insulin, glucagon.
• Ovaries: Produce estrogen, progesterone.
• Testes: Produces testosterone.

Word Elements
Acro = extremities Hypophysio = pituitary gland

Adeno = gland Hyper = too much
Calci = calcium Hypo = too little
Crino = separate, secrete Megaly = enlargement
Gluco/Glyco = sugar Tropin = nourishment, stimulation
Abbreviations
Abbreviation Meaning
ACTH Adrenocorticotropic hormone
ADH Antidiuretic Hormone
BS Blood Sugar
DM Diabetes Mellitus
FBS Fasting Blood Sugar
FSH Follicle Stimulating Hormone
GH Growth Hormone
HbA1c Hemoglobin A1C
IDDM Insulin Dependent Diabetes Mellitus
LH Luteinizing Hormone
MSH Melanocyte Stimulating Hormone
NIDDM Non-Insulin Dependent DM
PRL Prolactin
TSH Thyroid Stimulating Hormone

Common conditions
Table 9. Common conditions in the endocrine system

Gland Hormone Low or High Disorder
Pituitary Growth hormone Low Dwarfism
Growth hormone High Gigantism, acromegaly
Antidiuretic hormone (ADH) Low Diabetes insipidus
Thyroid T3, T4 Low Hypothyroidism, Hashimoto
T3, T4 High Hyperthyroidism, Graves
(Thyroid enlargement) -- Goiter, thyromegaly
Adrenal Cortisol Low Addison’s disease
Cortisol High Cushing’s disease
Epinephrine High Pheochromocytoma
Pancreas Insulin High Hypoglycemia
Insulin Low Hyperglycemia, Diabetes types 1 and 2
Gonads Estrogen High (males) Gynecomastia
Testosterone High Hirsutism

(females)
Diabetes mellitus
The name "diabetes mellitus" comes from the Greek:

Diabainein = go through and the Latin: diabetes = siphon and mellitus = sweet
Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar, or
hyperglycemia, for long periods.
The most common symptoms of diabetes are the “diabetic triad”:

Polydipsia = increased thirst
Polyuria = increased urination
Polyphagia = increased appetite

There are three types of diabetes: type1, type 2, and gestational.
Type 1: Also known as “insulin-dependent,” it consists of the pancreas’ failure to produce insulin.
This is a hereditary condition. The cause is unknown, although recent theories point to abnormal
behavior of the immune system destroying normal pancreatic cells.
Type 2: Also known as “non-insulin dependent,” is caused by a combination of genetic
predisposition, excessive body weight, and sedentarism.
Gestational: Diabetes associated with pregnancy.
In 2014, 8.5% of the adult population in the world had diabetes (World Health Organization,
2016). The most common is type 2, representing over 90% of the cases. It is suffered equally by
men and women, and approximately 41.5 million people die each year from complications of
diabetes. In 2015, 30.3 million people (9.4% of the U.S. population) had type 2 diabetes with a
similar upward trend as most countries worldwide (Centers for Disease Control and Prevention,
2018).
Specialists
• Endocrinologist
• Nutritionist
• Registered Dietitian

Lesson 30: Reproductive and Urinary systems
Goals
- To identify the terminology pertaining to reproductive and urinary systems, including basic
structures, word elements, common conditions, common procedures, and specialists.
Urinary system
The urinary system is comprised of the kidneys, the ureters, the bladder, and the urethra.
Figure 48. Urinary system
Word elements
Cysto = bladder Oligo = little, few

Glomerulo = glommerulus (the filtration Poly = much, many
unit of the kidneys) Pyo = pus
Iasis = condition, state Pyelo = pelvis
Litho = stone Uro, urino = urine
Nephro, reno = kidney Ureter = ureter
Nocto = night Urethro = urethra

Common disorders
• Urinary tract infection (UTI)

• Cystitis: Inflammation of the bladder
• Kidney stones: stones or calculi formed in the kidneys from the crystallization of urea and
other minerals
• Pyelonephritis: Inflammation of the renal pelvis, the broadened top part of the ureter into
which the urine drains
• Glomerulonephritis: Inflammation of the glomerulus, the filtration unit of the kidneys
• Renal Failure: critical loss of kidney function that can be acute or chronic. It requires dialysis.
Common procedures
• Cystoscopy: The visual examination of the bladder

• Renal biopsy: Sample of kidney tissue to be evaluated for structure and function
• Urine test: Urine sample to be examined for physical and chemical abnormalities
• Urine culture: Culture of the urine to detect infectious bacteria
• Dialysis: Process for removing waste and excess water from the blood. It is used to replace
kidney function in people with kidney failure
o Hemodialysis: Type of dialysis in which the patient’s blood is extracted and run through
a machine called a dialyzer.
o Peritoneal dialysis: Type of dialysis in which the peritoneal membrane around the
intestines is used as a filtration membrane, by running a sterile solution containing
glucose through it.
Specialists
• Urologist: Medical doctor who specializes in disorders of the urinary system

• Nephrologist: Medical doctor who specializes in disorders of the kidneys

Reproductive systems
Male reproductive system
The main functions of the male reproductive system are to produce sperm cells (male gametes)
and to deliver them to the female reproductive system to fertilize an egg.
The testes or testicles are sperm-producing organs. They are located in the scrotum, an external
skin sac. During the initial development phases, the testes are formed in the abdominal cavity
from where they later descend to the scrotum by the time of birth.
The normal body temperature of 37°C (98°F) is too high for sperm to complete development. The
scrotum has a temperature of 3°C lower.
Figure 49. Male reproductive system
As sperm cells move into the urethra, they mix with fluids secreted by three glands: the seminal
vesicles (fluid rich in sugar), and the prostate gland (alkaline fluids), and bulbourethral glands (not
shown in Figure 49). This mixture is called semen.
The urethra passes through the penis, the male organ that delivers sperm in the female
reproductive system during sexual intercourse.

Female reproductive system
The main functions of the female reproductive system are to prepare for and successfully carry
a pregnancy to its normal term. Each month, the system produces a mature cell egg.
The ovaries are the egg-producing organs of the female reproductive system, located in the
abdominal cavity.
Girls are born with all of the egg cells they will ever produce. At birth, the ovaries contain about
2 million immature egg cells. The number of egg cells decreases over time as the female
individuals mature, first through the onset of menstruation (menarche), then during the
reproductive years, until they reach menopause.
During the reproductive years, the ovaries are stimulated by the body’s female hormones
(estrogens, LH, FSH), and multiple immature egg cells grow until (usually) one egg is released
from an ovary about every 28 days to the fallopian tubes, which are passageways from the ovaries
towards the uterus. It is in the fallopian tubes where one sperm cell fertilizes the egg cell, forming
a zygote and continuing its journey to the uterus while growing from zygote to embryo.
It is in the uterus, which is a hollow, organ composed of muscle fibers (smooth muscle) where
the growing embryo implants and develops in the uterus as a normal pregnancy.
Figure 50. Female reproductive system

Word elements
Amnio- = amniotic Sac Masto/Mammo- = breast

Balano- = glans, penis Meno- = menses,
Cervico- = cervix menstruation
Circum- = around Nato- = birth
Colpo/Vagino- = vagina Oophoro- = egg
Gonado- = gonads, Orchi- = testes
sexual glands Prostato- = prostate
Gyneco- = woman, female Salpingo- = fallopian tube
Lacto- = milk Vulvo- = vulva
Specialists
• Gynecologist: Specialist in female health.

• Urologist: Specialist in the urinary system and male reproductive health.
Common disorders
• STDs/STIs: Sexually transmitted diseases or infections. They are typically caused by bacteria,
viruses, and protozoa, which are passed between partners during sexual intercourse or
contact/exchange of body fluids. They include:
o Syphilis
o Gonorrhea
o Chlamydia
o HIV/AIDS
• Mastitis: Inflammation of the breasts. Can be a result of infections or irritation during
lactation
• Oophoritis: Inflammation of the ovaries
• Salpingitis: Inflammation of the Fallopian Tubes
• Epididymitis: Inflammation of the epididymis, the organ above the testicles where the sperm
matures before ejaculation
• Balanitis: Inflammation of the tip of the penis
• Prostatitis: Inflammation of the prostate
• Prostate cancer: Malignant enlargement of the prostate
• Fibroids: Benign fibrous tumors inside the uterus
• Endometriosis: Abnormal presence of endometrial tissue outside of the uterus

Common procedures
For males:
• Vasectomy: Ligation of the vas deferens, as a means of permanent sterilization of males.

• Orchidectomy: Surgical removal of the testes.
• Prostate Biopsy: Study of a sample of prostate tissue under the microscope to confirm or rule
out cancer.
• Transurethral Prostate Resection: Surgical procedure consisting of removing the prostate
through the urethra, using a flexible visual and surgical instrument called a resectoscope,
which is introduced through the tip of the penis. It is mostly performed as a treatment for
benign enlargement of the prostate.
For females:
• Papanicolaou: A sample of cells from the uterine cervix is taken by a swab and analyzed under
the microscope, more commonly known as a Pap smear.
• Amniocentesis: A small sample of amniotic fluid is taken, inserting a long needle through the
belly into the amniotic sac to be analyzed for genetic abnormalities.
• Colposcopy: Visual examination of the vagina using a magnifying glass and a lamp.
• Dilation & Curettage (D&C): Procedure consisting of the dilation of the uterine cervix and the
insertion of a surgical instrument called a curette to remove uterine tissue. It is used to treat
abnormal bleeding or after a miscarriage.
• Cone Biopsy: Procedure in which a conical wedge of tissue is removed from the cervix and
examined under a microscope.
• Laparoscopy: Surgical procedure that uses a thin tube with a light source that is inserted
through an incision in the abdomen to look at the female pelvic organs.
• Oophorectomy: Surgical removal of the ovaries.
• Hysterectomy: Surgical removal of the uterus.
• Mastectomy: Surgical removal of one or both breasts.
• Tubal ligation: Ligation or cauterization of the fallopian tubes for permanent sterilization of
a female.

Lesson 31: Nervous system
Goals
- To identify the terminology pertaining to the central and peripheral nervous systems,
including basic structures, word elements, common conditions, common procedures, and
specialists.
Nervous system
The nervous system regulates and controls all our body systems. It has two parts:
• Central Nervous System (CNS): Formed by the brain and spinal cord, and controls all of the
body’s behavior.
• Peripheral Nervous System (PNS): Contains the nerves that connect the brain and branch out
to every organ and body part. A part of the PNS that is gaining a lot of attention is the ENS.
o Enteric Nervous System (ENS): It controls the digestive function independently and in
coordination with the CNS, but it also plays a part in neurological disorders as part of
the gut-brain axis.
From the peripheral nervous system:
The Eye
Figure 51. Diagram of the eye

The eye is a very sophisticated camera, made out of two chambers filled with a soft gel-like
substance (vitreous humor) and a clear fluid (aqueous humor).
Parts of the eye

• Sclera: The white part of the eyeball.
• Cornea: The transparent dome that sits in front of the colored part of your eye. The cornea
helps the eye focus.
• Iris: Located behind the cornea, colorful part of the eye. Controls how much light goes
through the pupil.
• Pupil: Black circle in the center of the iris that changes in size depending on the amount of
light that enters it.
• Lens: A clear structure that sits behind the pupil. Behind the lens is the jelly-like material
called vitreous humor that helps give the eye its shape. It fine-tunes your vision.
• Retina: Very back of the eyeball. With the help of the optic nerve, the retina focuses light and
sends a visual image to the brain so it can interpret what is being seen.
The Ear
The ear is essentially an apparatus that translates air pressure into sound.
How do you hear?

• Outer ear: Collects sounds and sends it to the middle ear.
• Middle ear: Takes sound waves and converts them to vibrations that are sent to inner ear
(three ossicles).
• Inner ear: Vibrations enter the cochlea that is the hearing organ of the ear. The cochlea is
filled with liquid that acts as a wave when it encounters vibrations. This helps to create nerve
signals that the brain understands as sound.
Figure 52. Ear anatomy

Word elements
Arachn/o = spider (Refers to the Neur/o = nerve, cell, nervous system

arachnoid, the vascular -paresis = weakness
membrane around the brain) -phasia = speech
Cephal/o = head -phobia = unreasonable fear
Cerebell/o = cerebellum -plegia = paralysis
Cortic/o = cortex Schiz/o = divided
Encephal/o = brain Psych/o = mind
Gangli/o = ganglia (Singular Ganglion) Spin/o = spinal cord
Glia = glue
Specialists
• Neurologist: Specialist that treats disorders of the nervous system with medication and
therapy.
• Neurosurgeon: Specialist that performs surgical interventions to correct problems of the
nervous system.
• Ophthalmologist: Specialist that performs surgery to correct eye problems.
• Optometrist: A professional who specializes in studying visual deficiencies and correcting
them with glasses or contact lenses.
• Otorhinolaryngologist - ENT: A specialist who treats problems of the ears, nose, and throat.
Common Problems:
Infectious diseases
• Meningitis: Is an infection affecting the meninges, the membranes that cover the brain. It
can be caused by several microorganisms and is commonly diagnosed by performing a
spinal tap and drawing a sample of cerebrospinal fluid (CSF) to be studied under the
microscope.
Brain Trauma
• Concussion: A sudden shaking of the brain that can be caused by a blow to the head. It can
cause loss of consciousness, dizziness, and headaches.

• Subdural hematoma: Bleeding under the dura mater, the outermost meninge. It can be acute
or chronic, depending on the speed of the bleeding. Chronic subdural hematomas are most
common in older people, and they result from blows to the front or the back of the head
during a fall.
• Epidural Hematoma: Bleeding between the dura mater and the skull that results from direct
blows to the head and skull fractures.
Vascular insults
• Cerebrovascular accident (CVA): Commonly known as a stroke, it can be caused by the
obstruction of a blood vessel or the rupture of a blood vessel.
o Ischemia: A cerebrovascular accident caused by the obstruction of a blood vessel.
o Hemorrhage: Cerebrovascular accident caused by the rupture of a blood vessel.
o Transient ischemic attack (TIA): A temporary obstruction of a blood vessel.
• Aneurysm: A bulging in an artery as a result of the weakness of the arterial wall. Aneurysms
don’t produce any symptoms, and they can rupture at any time.
Degenerative diseases
Chronic diseases that advance slowly over time, with progressive deterioration of mental and
body functions.
• Multiple Sclerosis: A degenerative condition caused by loss of myelin, the substance that
recovers brain cells. It causes progressive weakness of the legs, double vision, paralysis, and
numbness.
• Parkinson's disease: A chronic disease caused by a dopamine deficiency. Dopamine is a
neurotransmitter, a chemical mediator, whose main function is to inhibit the effects of
norepinephrine. It is characterized by weakness, tremors, loss of facial expression, and
muscle rigidity.
• Alzheimer’s: A chronic condition that is characterized by loss of gray matter in the cerebral
cortex. It is the most common form of dementia, accounting for about 70% of all cases. It is
characterized by progressive memory loss and eventually loss of intellectual function, and
ultimately death.
• Seizure disorders: Are characterized by an abnormal, uncontrolled surge of electrical activity
in a region of the brain. They can produce convulsions, which are involuntary movements of
the trunk, face, arms, and legs.
o Epilepsy: A chronic disease characterized by recurrent seizures. It can manifest itself as
“grand mal,” involving severe tonic-clonic convulsions and loss of consciousness, or as
“petit mal” lasting only a few seconds, with or without convulsions.

Common procedures
• Electroencephalogram - (EEG): Recording of the electrical activity of the brain.

• Lumbar puncture – (LP): Also known as “spinal tap,” it consists of drawing a sample of
cerebrospinal fluid (CSF) from the subarachnoid space at the spinal cord level, to analyze it
for infections and other anomalies.
• Magnetic Resonance Imaging (MRI): This is a test that uses a very strong magnetic field and
radio waves to produce very detailed images of soft tissue, including brain and spinal tissue.

Lesson 32: Mental health
Goal
- To learn the terminology pertaining to mental or behavioral health, including word elements,
common conditions, common procedures, and specialists
Mental Health
The field of mental or behavioral health

is highly specialized, and it presents a
series of unique challenges to the
medical interpreter.
Because mental health conditions don’t

have obvious physical manifestations,
most symptoms are conveyed only by
oral communication.
Oral communication is also the primary

treatment. Because of the intrinsic
complexities of mental health
disorders, many linguistic and cultural
references are lost during interpreted
Figure 53. Mental problems
encounters.
Traditional basic training for medical interpreters doesn’t include specific training for mental
health settings. We feel that this is an important item to include as part of our basic textbook for
two main reasons:
First, the clients we most frequently interpret for are recent immigrants and refugees, many of
whom have suffered from traumatic experiences.
Second, because, according to the CDC, the prevalence of mental illness, particularly depression
and anxiety, is growing among younger people. According to the CDC, in 2006, 1 out of every 20
Americans older than 12 years of age had depression.

The challenges that mental health settings present to medical interpreters are extensive and
complex. Some examples are:
- Therapeutic alliances: It can be particularly difficult to build trust and rapport with patients
suffering from mental health conditions.
- Technical terminology: Mental health has a terminology of its own. Being familiar with this
specific set of terms is critical for maintaining accuracy.
- Unusual behavior: Pre-session and post-session interactions can be challenging due to
patients’ inability to comply with directions. Also, patients may exhibit some threatening or
distracting behaviors.
- Vicarious trauma: This is the result of witnessing traumatic situations or empathizing with
victims of trauma. It is very common among mental health professionals.
- Extreme linguistic dysfunction: Patients’ inability to understand or articulate spoken
language presents a uniquely difficult barrier to the medical interpreter. Your ability to be an
effective clarifier and advocate can be critical to navigating situations like this.
Specialists
For mental health disorders, there is a variety of treatments that can be different depending on
factors such as the patient’s diagnosis, the discipline of the provider, and the provider’s clinical
orientation.
There are 4 main types of providers:

• Psychiatrist: A medical doctor who treats mental disorders mainly with medication and talk
therapy.
• Psychologist: A mental health professional who uses only talk therapy to treat patients.
• Social Worker: A mental health professional who offers therapy based on the patient’s social
environment. This is the largest group of mental health professionals currently serving
patients in the US.
• Counselor: A mental health professional that focuses on helping patients cope with changes.
Knowing these factors is very important for the interpreter. Interpreters also should be aware of
their patient’s values, traditions, beliefs, family and support systems, and communication styles.
The patient’s level of acculturation, especially if they are a recent immigrant or refugee, can make
a great difference. Also, marginalization, social exclusion, substance abuse, and homelessness
can significantly affect communication during a mental health encounter.
It is extremely important for interpreters in mental health encounters to be effective cultural

clarifiers. It is not unusual in mental health to have patients’ traditional healing beliefs or

practices labeled as “psychotic ideation.” The medical interpreter needs to have a clear
understanding of their patient’s cultural dimension in general.
In order to achieve this, the interpreter should show an attitude of respect for the patient at all
times. We also need to be keenly aware of our values and prejudices, as well as those of the
provider. We have to be able to detect cultural references during the interview and make sure
to convey the importance of culture as an element of communication.
Common Conditions
All mental health conditions are listed in the Diagnostic and Statistical
Manual of Mental Disorders (DSM) – American Psychiatric Association.
The current revision is the DSM V, released in May 2013. Because this version
is recent, many practitioners are still transitioning from DSM-IV
Figure 54. Latest DSM
publication (Source:
The DSM-V has three sections http://goo.gl/wmNkFf)
• Section 1: Describes the manual’s chapter organization

• Section 2: Describes all diagnostic criteria and codes (discarding the multi-axial system used
in DSM-IV)
• Section 3: Describes emerging measures and models, and alternative model for personality
disorders (previously Axis III in DSM-IV)
The DSM-V is a very extensive and complicated manual, and we can’t summarize it all here.
Instead, we are just going to name the main titles and mention some of the most common
conditions found under each title.
DSM V – Section 2
• Neurodevelopmental disorders
o Intellectual Disability (Formerly “Mental Retardation”)
o Communication Disorders
o Autism Spectrum
• Schizophrenia spectrum and other psychotic disorders

o Schizophrenia: Is a condition that causes abnormal social behavior, failure to recognize
what is real, false beliefs, disorganized thoughts, hallucinations (hearing voices), limited

social interactions, flat emotions, and lack of motivation. It is believed that many famous
people like Vincent Van Gogh have suffered from schizophrenia. Diagnosis is based on
what the provider observes, and the story told by the patient.
• Depression: Is a mental health condition characterized by abnormal and persistent feelings

of sadness, ruin, or doom, which interfere with people’s daily activities. About 7% of adults
in America (or around 16 million people) suffered one or more episodes of major depression
in the last year.
• Anxiety Disorders
Excessive anxiety is also a very common mental health disorder, which often accompanies
depression. About 18% of American adults experience anxiety disorders. Common types are:
o Panic Attack
o Panic disorder
o Phobias
• Obsessive-compulsive disorders (OCD) and related disorders

o Hoarding disorder
o Substance abuse-related OCD
• Trauma and stressor-related disorders

o Post-traumatic stress disorder (PTSD)
o Acute stress disorder
• Dissociative disorders
• Somatic Symptom and Related Disorders

o Somatic symptom disorder
o Conversion disorder
o Pseudocyesis (false pregnancy)
• Eating Disorders
o Bulimia and anorexia nervosa
o Feeding disorder of early childhood (avoidant, restrictive)
• Disruptive, impulse-control and conduct disorders

o Pyromania
o Kleptomania
• Substance abuse-related and addictive disorders
• Neurocognitive Disorders
o Dementia (Alzheimer’s and others)
o Memory Loss

Abbreviations and acronyms
Term Definition
ACA Affordable Care Act (aka "Obamacare")
ADA Americans with Disabilities Act
AHRQ Agency for Healthcare Research and Quality
AMA American Medical Association
ANC Absolute Neutrophil Count
ATA American Translators Association
AuD Audiologist Doctor
CDC Centers for Disease Control and Prevention
CHIA California Healthcare Interpreting Association
CHIP Children's Health Insurance Program
CHW Community Health Worker
CLAS Culturally and Linguistically Appropriate Services
CRNA Certified Registered Nurse Anesthetist
CRNP Certified Registered Nurse Practitioner
DDS Doctor of Dental Surgery
DNR Do Not Resuscitate
ED Emergency Department
ER Emergency Room
EMT Emergency Medical Technician
ENT Ears, Nose, and Throat
H1N1 Swine Flu
US Health and Human Services Department, a cabinet-level
HHS
department
Human Immunodeficiency Virus, Acquired Immunodeficiency
HIV, AIDS
Syndrome
HMO Health Maintenance Organization
IMIA International Medical Interpreters Association

Term Definition
LEP Limited-English Proficient
LPN Licensed Practical Nurse
MA Medical Assistant
MD Medical Doctor
MRI Magnetic Resonance Imaging
NATI Nebraska Association of Translators and Interpreters
NCIHC National Council on Interpreting in Health Care
NICHC National Institute for Coordinated Health Care
NICU Neonatal Intensive Care Unit
NIH National Institutes of Health
OCD Obsessive-Compulsive Disorder
OMH Office of Minority Health
OPI Over the Phone Interpreting
OTC Over-the-counter
PA Physician's Assistant
PCP Primary Care Physician
PHSA Public Health Services Act
PPACA Patient Protection and Affordable Care Act (aka "Obamacare")
PPD Purified Protein Derivative
PPO Preferred Provider Organization
RBC Red Blood Cells
RD Registered Dietician
RDA Registered Dental Assistant
RDH Registered Dental Hygienist
RN Registered Nurse
SPU Short Procedure Unit
VRI Video Remote Interpreting
WBC White Blood Cells

Image credits
Cover photos: Photos courtesy of Health Care Interpreter Network (www.hcin.org) and San
Joaquin General Hospital, and Language World Services, Inc. - Carmichael, CA
www.languageworldservices.com

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“This textbook has been written by and for medical interpreters.
Its goal is to help explain the basic components of this relatively new profession
using a variety of approaches, in a logical order, including some of the newest
developments in the field.“
The National Institute for Coordinated Health Care

1717 Swede Rd., Suite 103 Blue Bell, PA 19422
215.632.9000
www.nichc.org
Working to eliminate healthcare disparities

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CORE MEDICAL INTERPRETER TRAINING®

Authors: Barry Fatland, Juan Gutierrez Sanín and Gerardo Lázaro

"Communicating Without Barriers"

©2020 Phoenix Language Services, Inc. All Rights Reserved. 1

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We include several of the profession’s codes of ethics, recognizing the

With this new textbook, by offering information about professional

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We intend to make the development of this textbook a dynamic experience. If you

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The Language Barrier

When nurses and doctors, in the profession commonly referred to as “providers,”

According to Flores (2003), untrained, untested bilingual people working as

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Figure 1. The cerebral cortex

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A series of misunderstandings led the providers to miss important signs and

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A wrong Wrong Diagnosis

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Types of barriers to communication

Barriers to communication that can affect a patient's health outcome:

2. Register (technical) barriers: This is an additional linguistic barrier, but of a

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Register (technical) barriers

People perceive things differently depending on their life experiences. Some

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We just explained the four main barriers to communication in an appointment

Roles of the Medical Interpreter

Now, we will describe the basic aspects of each of

There will be separate lessons later in this

The way roles are represented to the right is an

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Figure 3. The conduit role of the interpreter

2. The Message Clarifier:

The interpreter addresses the register (technical) barrier by switching to the

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4. The Advocate/Systemic Clarifier:

The systemic barriers are addressed by the Advocate/Systemic Clarifier role.

Transitioning between roles

Interpreters often switch from one role of interpreting to another. This

Transparency entails informing all involved parties of the actions to be taken

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Modes are different ways of interpreting which professional interpreters use in

Consecutive interpreting is considered the standard and is the most-used mode in

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Simultaneous interpreting involves processing both languages at nearly the same

Short written Translation

We have included a short lesson on short written translation later.

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Title VI of the Civil Rights Act of 1964

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Title VI and Language Access

Although Title VI makes no mention of language, a 1974 ruling (Lau v. Nichols)

US Supreme Court Chief Justice William O. Douglas wrote the following:

“There is no equality of treatment merely by providing Chinese-speaking students

The Majority decision:

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©2020 Phoenix Language Services, Inc. All Rights Reserved. 27