health care interpreting, interpreter services, Interpreter Training, medical interpreting, new interpreters, standards of practice for interpreters

The Tenth Standard of Practice: Don’t Be Alone With the Patient

An empty waiting room and…

Just kidding. There is no tenth standard of practice, and there is no standard that explicitly states, “Don’t be alone with the patient.” But the way interpreters and interpreter trainers talk, you’d think there was. I am guilty of participating in the creating and reinforcing of this belief.

“Just DON’T do it,” I remember telling interpreter trainees back in 2009, when I was cutting my teeth as an interpreter trainer. “Don’t EVER be alone with the patient.”

Anyone (including my former trainer self) who imagines that interpreting is this mechanical, this robotic, and that the environment is this much under the interpreter’s control is either not a working interpreter, or used to be an interpreter and has conveniently forgotten all about the realities of interpreting, for their own convenience as a trainer: It’s easier to demand that trainees meet unreachable standards and scare them to death of being along with patients than it is to talk about WHY it’s not ideal to be alone with a patient, and what to do when it happens.

The important thing is to not set unreasonable standards. What happens when we insist interpreters never be alone with a patient, and then they find themselves alone with the patient? They inevitably will cross way over the line, since there’s just two possible scenarios we’ve established: Being alone with the patient (good) and not being alone with the patient (bad).  But what happens when we explain what the issues are, and what they can do when they do find themselves alone with the patient? This changes the conversation into something useful.

Let’s tackle this first: What really is the problem with being alone with the patient? Because it’s problematic, but we have to know how to talk about it. There’s no standard of practice that says Don’t Be Alone With the Patient. But there are few ethical principles that can be applied here.

First: Confidentiality. The easiest way to not be exposed to confidential information when there’s nobody there to interpret it to, is to not be alone with the patient telling you all about his medical history. Worse, the patient tells you a “secret”, and then tells you not to tell the doctor.

That leads us to role boundaries. The interpreter’s role is to interpret, and that role is blurred in everyone’s eyes when the interpreter is hanging out chatting with the patient. That’s when we get providers thanking us for our “help”, as if we were the patient’s friend doing them a favor by interpreting. Naturally, if the interpreter is seen as a friend or family of the patient, we’re going to be asked to do things that go beyond our role. And what happens when you’re alone with the patient and she just told you all about the reason she’s here, and then the doctor comes in and asks her, “Why are you here?” You got it. The patient is going to turn to you, the interpreter, and say, “I just told you.” Then you’re stuck explaining to the patient that even though she just told you all about it, she still has to tell the doctor herself, while you interpret. Then you’re stuck explaining to the doctor what you’re explaining to the patient. Not ideal.

This then brings us to impartiality. It becomes difficult to remain impartial when now all of a sudden you’re spending all this time alone with the patient, not interpreting. Imagine also the perception of medical staff when the interpreter is there hanging out with the patient chatting during the whole visit. It contributes to the misunderstanding of the interpreter’s role, the interpreter as professional.

Being alone with the patient is a real thing that happens. If it’s unavoidable that I’m alone with the patient in a waiting room, or an open bay and we’re chatting, I always make it a point to tell the provider when he or she approaches us, something like, “Oh, she was just asking me where I learned Spanish and I was telling her I lived abroad in college.” Now this brings the provider into the loop, rather than isolating the patient from the provider and vice versa. I can’t tell you how many times this little trick has actually started a conversation between the provider and patient, while I fade into the background and interpret.

These challenges can be overcome if we explain these things to interpreters. Why not talk more about how you introduce yourself to the patient, so the role is clear? Why not talk about self-awareness, and just being aware of how your own impartiality might be affected, and make sure that doesn’t influence your interpretation?

While you can be certain that at times you will not be able to avoid being alone with the patient, I want to propose some hard-and-fast rules for when it happens. While there might be a time you’ll have to navigate small talk, and redirect the patient to remind them to save their healthcare-related comments for the medical staff, there is no reason EVER I can think of that an interpreter should give advice, or overshare personal information, which includes sitting with the patient and sharing photos, and having such a boisterous conversation that nobody present can ignore it.

When training interpreters who’ve been interpreting without training, I get a lot of push back on this point. They complain that leaving the patient’s room with the medical staff or not sitting next to them in the waiting room feels rude. I get that. I used to do the same thing before I received training. But know what the great thing is? We can change. We can decide that from now on, we’re going to politely excuse ourselves when the doctor says he’s needs to go grab his stethoscope and will “be right back”. Because “be right back” always means “be back after five people have stopped me in the hallway to ask a question and I’ve responded to a bunch of pages”. When we decide to wait in the hallway, we can have some scripted response ready when the nurse says something like, “All the other interpreters wait in the room with the patients.”

The more we’re able to apply ethical principles to our interpreting practice, the better we can be at guiding our newer colleagues, and explaining to providers why we do what we do. Because our ethics and standards are a mystery to most people. But they shouldn’t be a mystery to interpreters.

What do you think? Have you had difficulty with this topic? Are you an ASL interpreter who wants to share how this is different for you? Let us know all about it in the comments!

18 thoughts on “The Tenth Standard of Practice: Don’t Be Alone With the Patient”

  1. Excellent article. Wish scripted responses/suggestions were included in the article for such uncomfortable scenarios for novice (myself included) interpreters. Even if I understand the ethical approach and presented with an ethical scenario on the spot, I find it difficult to convey in an appropriate wording. Scripted suggestions do help a lot.

    1. I didn’t include suggestions for scripted responses because I was trying to keep it under 1,000 words, but since you asked…
      When I introduce myself to a patient and we’re in a waiting room: “Hi, I’m Liz, the interpreter. I’ll be waiting right over here, and when they call you back to be seen, I’ll go with you.” Then I go sit somewhere else. It doesn’t keep anyone from following you and starting a conversation, but I’ve found that people generally understand that we’ll interact after we go back to the room.If someone does start a conversation and brings up their medical information: “You know what? I’d be happy to interpret that information to the doctor when they call you back.” Then change the subject to something like the weather. When the medical provider leaves the room, and I leave behind them: “Excuse me. I’ll be back with the doctor/nurse/medical assistant.”
      When a nurse or doctor remarks that it’s weird that I wait in the hallway: “I don’t really need to be in there unless someone needs to speak to the patient.” Or, “I’ll give the patient his privacy while he waits for the doctor.” It’s not really necessary to mention that I do things differently from what they’re used to, since that’s already obvious. And I’m not going to address other interpreters’ behavior, just mine. The key of course is to say it all with a smile. Sometimes you might actually be in the way, so if you get that impression, you can always follow up your response with, “Is there a nurses station, or somewhere else I could wait so I’m out of the way?”

  2. Great Article! As a trainer myself I cannot emphasize this enough to all my trainees. I also point out to them that although not “word-by-word” specified in the code of ethics, under the IMIA Guide on Medical Interpreter Code of Ethics states very clearly (pg.6) “leave the room when the provider leaves the room” as the very first strategy for maintain impartiality. 🙂 The main issue with this important detail is the fact lots of interpreters do not really understand the meaning of every and each of our code of ethics and believe if the “words” are not there, won’t apply to them. Very well written article. There should be more like this!

    1. Alex it’s great to hear from a fellow trainer! Yeah, the goal is definitely to help them understand that they’re not going to find every scenario written out in our codes of ethics…I mean, sure it’s written out that you leave the room with the provider, but where does it tell me what to do when I’m stuck in the waiting room? I think this kind of practical application of standards and ethical principles is just impossible to teach in the usual 40-hour training…Though that’s a topic for a different post 🙂 Thanks for reading and commenting!

  3. Good article! I’ll hang on to it to show my students in the future. I’ve had providers ask me why I leave the room, and I usually say something like, “To avoid awkward conversations.” Or sometimes, “So they won’t ask me questions I’m not qualified to answer.” Providers usually understand that. If patients ask why, I may say “to give you a little privacy” or just “It’s our custom.” If it looks like we’ll be waiting a while for the provider to return, I often find myself a chair and sit down in the hall, just outside the exam room door. Staff frequently tease me, “were you sent to the hall because you were bad?”, to which I usually reply, smiling, “No, I’m the hall monitor.” If patients insist on following me outside and chatting, so be it, but I try to keep it brief and relatively impersonal. My pet peeve is patients who start asking prying questions about my private life; polite chitchat is one thing (Do you have kids?) and then there’s prying (WHY do you ONLY have ONE CHILD?). Again, I find keeping my answer polite, but brief, usually helps.

  4. As an ASL interpreter, I don’t find that I handle it much different than you do. I do visit in the waiting room to learn the clients signing speed, style and language level. Talk about benign subjects like the weather, etc. Once we’re called back, I am just another medical professional doing a job – leaving when the Dr or nurse leaves.

  5. I think it’s best to leave the room when possible. However, if I do find myself alone with the patient I don’t panic because I know how to maintain a professional boundary. If I find a patient making inappropriate remarks or asking uncomfortable questions I just decline to respond or change the subject just like I would with anyone else. These are skills interpreters will have to develop, just like any other professional. I’m careful not to discuss religion, politics or other hot-button topics. If the patient tells me some piece of medical history I have them tell it in their own words to the provider. If it’s life-threatening I tell the provider if the patient forgets to. If they’re annoyed because they just explained it to me, I tell them the provider is asking for the patient to speak for themselves. If a patient and I start to form a friendship and it becomes difficult to be impartial, I excuse myself from their encounters. There are really simple solutions to all of the possible dilemmas you’ve mentioned in your article. And in some situations where I’ve been in a procedure with the patient and incidentally alone with them for a few minutes it’s been mostly a positive outcome. I’m glad you can shed some light on these innocuous situations. An interpreter should spend most of their time interpreting and intermittently managing these types of situations.

    1. Hello Lisa,
      It sounds like you have good skills to deal with different scenarios when you may end up alone with the patient. It is also important to keep in mind the possibility to being accused of something inappropriate we said or did OR get assaulted by the patient (which by the way it has happened to interpreters). Personally, I am a strong believer in not getting into a difficult situation if I can avoid it and even if we engage into a long conversation about soccer teams I will be seen by medical staff and administrators as breaking impartiality; and if it something life threatening the patient should be telling that directly to the provider . That’s why code of ethics and standard of practice for interpreters were developed. Not only to standardized our profession but also to keep us safe. Al the best!

      1. Hello,
        Thank you for your feedback. I work at an organization that includes interpreters as part of the medical team. We’re encouraged to focus on our task of interpreting but aren’t chastised for talking briefly with a patient while waiting to schedule an appointment. I think it’s important to consider the interpreters’ organizational or agency values and policies and act accordingly. It’s important to adhere to the Code of Ethics but I’ve also learned why they were made and avoid the pitfalls they were created to prevent as I outlined in my previous response. Thank you and best of luck.

  6. My two cents may not be applicable because I’m not strictly a translator–I work as a case manager for a medical service call center. We help clients with welfare checks, appointments, medical consultations, provider searches, transportation, you name it.

    Because I’m multilingual, I communicate with the clients in different languages when I check in with them if English is not their first language. As such, they sometimes ask me to help them with translating if they don’t understand their medical condition, their labs, their insurance or have claims or sick leave matters.

    Translation is another service we offer our clients. Obviously, they’ve already talked in depth with me about what’s going on so when I conference the call to one of our doctors or to their treating doctors, or their insurance or healthcare provider, or other entity that the client needs to talk to, I briefly summarize what the client and I spoke about with client and confirm that’s what they want in the discussion with the other party and I will explain that to whoever we’ve called.

    I also play the part of an advocate because I am familiar with the client (or because our doctors make certain recommendations for their health and wellbeing) and know what can be done ahead of time before things become an issue (whether it’s a medical or administrative issue) but I’ll always discuss this with the client first to make sure we’re on the same page before bringing anything up with the other party.

    So far, knock on wood, I’ve never had any problems with either party during these calls. If anything, both parties have always been appreciative of the outcome–the client, because of the language disconnect; the healthcare provider, not only because of the language disconnect but also because they’re usually overworked and appreciate the nudge to keep their patient on track with their treatment plan, or remind or help access other options for their patient. Of course, part of this is finessing the common goal of caring for the patient while not stepping on anybody’s toes in the process.

  7. When asked or even demanded to stay in the room i politely explain that I am not an employee of the doctor/hospital/clinic which means I am not covered by any insurances of the facility so I cannot be alone with the patient for liability reasons. It gets the focus off of me because it’s not my decision, there’s an actual reason that people cannot manipulate.

  8. Great article. To be honest, when I first received my training in interpreting, I found this rule a bit odd, but then I learned why it’s so important. It’s hard -sometimes- to stick to it, but we have to do our best. Once we master the technique(s), we can manage it.

  9. I worked at a health center where the interpreter salso scheduled appointments, took phone messages, accompanied patients throughout all the ancillary services, provided case management, etc. Being alone with the patient was inevitable, something I could only willfully avoid between the triage and the consult by stepping out of the room. But conversation would usually happen on the way to check out, or to the pharmacy, etc. I learned to avoid conversations that even resembled medical advice, but I had my own rapport with them within the parameters of the many roles the institution forced me to wear.
    Now I do video remote interpreting and sometimes we are left facing the patient directly. I will never initiate conversation, but sometimes the patient does. If it starts being about their medical care, I politely tell them that they must wait for the provider to be present in the room to talk about anything medical. Even if they say, “no, I’m just telling you so you know.” I explain that it isn’t necessary for me to know, that the provider will get the information they need when he or she comes into the room. Sometimes they start talking about something else, and then I smile, listen, nod, but give little information back.

    Like your blog said, situations vary and I believe part of being a good interpreter being able to gauge each one and react accordingly.

    1. Hi Gabrielle, Thanks for sharing your experience working in VRI. I think it’s a common misconception that when you’re working remotely you don’t have to worry about things like being left alone with the patient! While onsite and remote interpreters do have different challenges, this is definitely one that they share.

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