Are you an NHS clinician? You might be tempted to allow a patient to bring a family member, community member or friend with them to interpret. It feels convenient and you might think it saves taxpayers' money, but what are the hidden long term costs? Read on to find out what problems you can expect if you use friends and family to interpret instead of professionals.
Do
Bear in mind that your patient might want their family around them for emotional support, or care planning, or if they lack capacity. Be sensitive to the possibility that in other cultures, families may be even more involved in the patient’s care than is normal in your culture.
Don’t
Don’t ask the family member to interpret. Just because they are present, and have better English than the patient, that doesn’t mean you can ask them to interpret. As we’ll see, interpreting is for professionals only.
Be culturally sensitive. Some patients who are likely to adopt a ‘whole family approach’ to care could include those from Chinese, Indian and Pakistani families. However, being involved in care and being responsible for interpretation are two quite different things.
Who suffers if doctors use family and friends to interpret?
The patient. Use of family and friends has been related to inferior clinical care. (read more here.)
You. The use of professional interpreters can improve treatment adherence (read more here)
Your colleagues. The clinicians who treat your patient tomorrow will rely on the accuracy of what you learn about that patient today.
The NHS budget. Patients with Limited English Proficiency stay longer in hospital when professional interpretation is not offered (more here)
The family member. You will learn more about the emotional repercussions for them later in this article.
Please note: At English Unlocked we have expertise around spoken word interpreters working in public services. Deaf patients who rely upon BSL interpreters also require professional interpreters. Learn more about the problems they encounter here.
Red flags
It is never advisable to rely on family and friends to interpret for your patient, and there are certain occasions when you should be especially wary of doing so. One of them is when the 'interpreter' is a child. You’ll find out what the others are at the end of this article.
What can go wrong?
You are much less likely to get a full picture or get your full point across if you conduct an appointment with a family member or friend interpreting. Inaccuracy can creep in for two reasons-
Unintentional mistakes due to lack of training.
Deliberate omission
First let’s look at unintentional mistakes. Why are they more likely?
Unintentional mistakes
Untrained bilingual people can’t be expected to have the specialist vocabulary (in two languages!) which is required to have a medical conversation.
Medical vocabulary is not everyday vocabulary. Even words which we might consider to be common knowledge (like blood pressure, kidneys, syringe) may not be available to your ‘interpreter’ in both of the languages they speak.
If they cannot accurately convey the information in both directions this can result in misdiagnosis or inappropriate prescribing.
Deliberate omission
Why do people leave things out?
Both the patient and the ‘interpreter’ might feel compelled to leave things out, and when you read our list of reasons you will understand why.
1. Five reasons why friends and family members leave things out
Unlike a professional interpreter, they have a relationship with your patient, plus their cultural expectations around healthcare and propriety may be different from what you are used to. Here are some examples-
Bad news or worrying facts. Family members may want to protect their loved one from the upsetting truth. This might include the side effects of treatments, the attendant risks of procedures, or the severity of a diagnosis. If you give information on these or other sensitive topics to your patient it is unrealistic (and unfair) to assume that it will be accurately interpreted by a friend or family member.
Intimate details. Words like faeces, urine, and vagina are medical, but all such words have vulgar equivalents. What if the person who is interpreting for you only has the ‘vulgar’ words in their repertoire and lacks the medical ones? Will they feel able to say them out loud to a respected family member? Even if they do have all the medical words they need in the target language, talking about such intimate facts with their family member may feel like a trespass of their dignity.
Cultural differences. Here is just one example. Respite care, palliative care, or going to stay at a rehabilitation unit are western solutions which may not exist in the native culture of your patient.
If this is the case, sending a family member out of the home to receive care at the hands of strangers might be seen as a dereliction of duty. The family member might feel unable to interpret your suggestion to their loved one for fear of seeming uncaring.
Shame/ stigma/ taboos. For example, your questions regarding mental health might not get through to the patient because the family member fears offending them. Equally, the patient may feel too ashamed to disclose mental health issues (or other taboo topics) with you while their friend or family member is there.
Coercive control and domestic abuse. Not only husbands and not only male relatives can be party to this.
2. Four reasons why patients leave things out.
Please note that this is not an exhaustive list-
If the ‘interpreter’ is a member of their community who is doing a favour, the patient may fear becoming the focus of gossip.
If the ‘interpreter’ is the offspring of the patient, they may feel the urge to protect them by holding back certain information. Even if their child is an adult, they may wish to protect them from full knowledge of how grave their problem is.
The patient may feel mortified by the idea of explaining private matters. Even seemingly innocuous topics like skin complaints can unexpectedly move in an intimate direction which could not have been predicted.
Autonomy and control can be an issue. If your patient is experiencing domestic abuse, they may be desperately hoping that you, the doctor, will insist on getting a professional interpreter but be unable to indicate this preference to you in any way.
Emotional repercussions
Please also consider the emotional wellbeing of your patient and their ‘interpreter.’ Both can experience upsetting feelings, during and after the appointment.
If you're asking a family member to interpret bad news of any kind, this can sour the relationship between those two people. The person breaking the news can feel responsible for the pain caused/ regret their choice of words/ replay the painful conversation endlessly in their mind.
A son or daughter can find it upsetting to learn about their parent’s frailties. Especially if they're a child but even for adults.
Gender differences and generational differences can make this even worse. For example a daughter interpreting for a mum is different from a son doing it, and a husband for a wife might feel more intrusive than a sister.
It leaves both parties with an unpleasant feeling if private matters have been discussed which would never usually be spoken of. If you're from a different culture than the patient, these boundaries and sense of propriety might be different or more extreme, so don't assume that just because you wouldn't mind then the same thing applies to them.
Conclusion
It is never a good idea to use a family member or friend to interpret. NHS England recommends that you only use spoken word interpreters who are qualified to level 6 (the name of the qualification is a DPSI Health.) You can read the full guidelines here.
There are some circumstances where it is especially important to insist upon using a qualified interpreter-
Six golden rules.
Never use a friend/ family member to interpret if-
You are giving bad news
You are gathering consent
You are asking questions to reach a diagnosis
The patient might talk about private, sensitive matters (E.g. bowel and bladder/ reproductive health/ mental health)
The family member is a child
The patient may be experiencing coercive control/ domestic abuse.
Training is available
Here at English Unlocked we provide training for people who work with (spoken word) public service interpreters. Training can help you to manage difficult situations and get the best out of interpreting services. A discount is currently available for our next ticketed training. Use offer code INTERPS22 for £10 off (usual price £60 per person.) To book a bespoke course for your whole team, get in touch.
Acknowledgements
These guidelines have been created in collaboration with the Health and Race Equality Forum. Thanks also to interpreters Hiba Bayyat and Philippe Muriel for their input.
