Why are pre-sessions necessary?
Doctor: “Tell him to hop up on the exam table… Now, has he had these symptoms for a while? Ask him if he’s taken anything for it…” (Wait, why is the doctor talking to me and not the patient? What do I do now?)
Patient: “Oh dear, that doctor looks too young to be practicing medicine… Wait, did you just interpret this? Why would you do this?” (Oh no! Now the patient won’t trust me!)
If you are a professional medical interpreter, chances are that you have encountered similar situations. If you are only just starting out in the profession, somebody might have warned you about these things happening. Yes, on an ideal interpreting assignment, the doctor and patient speak in utterances of reasonable length and at a reasonable pace, not saying anything they wouldn’t want to be interpreted, all the while making eye contact and speaking directly to each other. In real life, things may not go so perfectly – and not because people involved don’t want us to do our jobs, but rather because they might not have worked with interpreters before and therefore might not know the best way to fully utilize the help of a professional interpreter. They might also have concerns about having another person present at a doctor’s appointment – one that is not wearing scrubs or a white coat and at first glance does not look like part of a healthcare team. As a result, patients might be reluctant to divulge sensitive information in the presence of an interpreter. The list goes on.
As interpreters going into a healthcare encounter, we can either hope that none of the above happens, or we can help ensure that conditions are created that enable us to interpret to the best of our abilities and allow us to do our job – that is, enable people to communicate as if they were speaking the same language. One way to make this happen is by having a pre-session.
What is a pre-session?
According to this glossary prepared by The National Council on Interpreting in Health Care (2008), a pre-session is
A short discussion, held prior to the interpreted session, between the interpreter and the service provider or between the interpreter and the limited-English-proficient patient.
The definition goes on to explain the dual purpose of a pre-session:
With a patient, the pre-session serves to introduce the interpreter, establish rapport, inform the patient as to how the interpreter will work, and allow the interpreter to assure that (s)he can understand the patient’s speech. With a provider, the pre-session serves to introduce the interpreter, establish a collegial relationship, inform the provider as to how the interpreter will work, and provide the opportunity for the provider to share any information about the upcoming session that might be helpful to the interpreter.
The Medical Interpreting Standards of Practice explain the need for a pre-session when describing the main duty of an interpreter:
Setting the stage. The role of the professional interpreter is still new and largely unknown in the medical setting. For this reason, it is important for interpreters to set clear expectations of their role at the very start of the triadic (provider-patient-interpreter) encounter, stressing in particular the elements of accuracy, completeness, and confidentiality. It is also important in the early moments of the triadic encounter for the interpreter to attend to other concerns, such as arranging the spatial configuration of the parties in the encounter, addressing any discomfort a patient or provider may have about the presence of an interpreter, or assessing the linguistic style of the patient, keeping in mind at all times the goal of establishing a direct relationship between the two main parties.
What should interpreters include in a pre-sesssion?
Before we get into rules and regulations and all the reasons for why certain elements of a pre-session need to be included, I wanted to give you an idea of what a pre-session might look like.
Hello, my name is _________ and I am your ___________(Russian) interpreter. Please know that everything that happens during this encounter will remain confidential. I will interpret in the first person and I will say everything exactly as you say it. I must interpret everything that you say. Please speak directly to the (patient/provider). I would ask you to pause frequently to allow the interpreter to interpret accurately and completely. In addition, I may need to ask for clarification.
This is not a template or a perfect example of a pre-session. You might need to add some elements that are unique to the setting you work in or take out things you deem extraneous. For example, I sometimes say that I am not a healthcare provider and therefore am unable to answer any medical questions but will be happy to interpret the patient’s questions to an appropriate member of the healthcare team. I would like to encourage you to develop your own text for a pre-session, refine the content until you are sure it has everything you need and then practice your delivery – your goal is to deliver your pre-session smoothly and under 30 seconds, unless a situation requires a deeper discussion or more clarification.
So what IS a perfect template for a pre-session? I suggest turning to the industry standards for guidance.
In the Standardized Interpreting Protocols outlined in California Standards for
Healthcare Interpreters, Protocol 1 specifies that before an encounter, interpreters are to establish the ground rules by doing the following:
a. Provide their name, the language of interpreting, and, if needed, their
b. State that they will maintain the confidentiality of the encounter
regarding both provider and patient, and to explain to the patient what
‘confidentiality’ means in the healthcare setting when indicated.
c. Inform the parties of the elements necessary for a smooth interpreted
1. The requirement for interpreters to interpret everything spoken by
2. The importance of the patient and provider addressing each other
3. The need for the parties to pause frequently to allow for interpreting.
4. The possibility that interpreters may need to intervene for clarification.
d. Ask if the provider needs to brief the interpreter about anything in
advance of the upcoming interaction, and to share any concerns the
interpreter might have.
A good way to remember all of the above is a tool called CIFE, developed by Zarita Araujo-Lane, owner of Cross Cultural Communication Systems. CIFE is an acronym which stands for Confidentiality, I use first person, Flow and Everything will be interpreted. (you can find a printable poster of CIFE here).
Now let’s break down the components of CIFE.
C – Confidentiality. The very first item in the Code of Ethics for Interpreters in Health Care states that
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.
This may seem obvious, but seemingly innocent actions may lead to breaches in confidentiality, such as talking to a patient’s family members or not taking care to keep your interpreting notes/records out of sight.
National Standards of Practice for Interpreters in Health Care further clarify on this point:
7. The interpreter maintains confidentiality and does not disclose information outside the treating team, except with the patient’s consent or if required by law. For example, an interpreter does not discuss a patient’s case with family or community members without the patient’s consent.
8. The interpreter protects written patient information in his or her
For example, an interpreter does not leave notes on an interpreting session
in public view.
I – I use first person. Interpreting in the first person means saying everything exactly as it is said by the speakers – if a doctor says “I need to examine you”, an interpreter says “I need to examine you” – in the target language, of course.
In the Standardized Interpreting Protocols outlined in California Standards for
Healthcare Interpreters, Protocol 2 specifies that interpreters should:
c. Use the first person (“I”) as the standard form of interpreting, to enhance direct patient/provider communication, and to exercise discretion in switching to the “third person” when the first person form causesconfusion or is culturally inappropriate for either or both parties.
F – Flow. This addresses the need for parties to pause to allow the interpreter to interpret accurately and completely and the possible need for an interpreter to intervene and ask either party for clarification.
The National Standards of Practice for Interpreters in Health Care state the following:
3) Managing the flow of communication. In the interest of accuracy and completeness, interpreters must be able to manage the flow of communication so that important information is not lost or miscommunicated. Interpreters may also have to attend to the dynamics of the interpersonal interaction between provider and patient, for example when tension or conflict arises.
Protocol 2 of the Standardized Interpreting Protocols in California Standards for Healthcare Interpreters state that interpreters facilitate communications by acting to:
e. Manage the smooth flow of communication by, for example, pacing the
amount of information presented, avoiding side conversations with either
party, and preventing parties from speaking simultaneously.
E – Everything will be interpreted. And yes, that includes that comment about the doctor being too young, or the patient having too many children and not knowing when to stop. The rationale behind this is that if you wouldn’t say something in front of a person who speaks the same language as you, you shouldn’t say it in front of a person who doesn’t.
The Code of Ethics for Interpreters in Health Care states
Interpreters strive to render the message accurately,conveying the content and spirit of the original message, taking into consideration the cultural context.
The National Standards of Practice for Interpreters in Health Care provide further guidance:
1. The interpreter renders all messages accurately and completely, without adding, omitting, or substituting.
For example, an interpreter repeats all that is said, even if it seems
redundant, irrelevant, or rude.
If you’d like more tips and examples on introducing yourself, here is a wonderful blog post by a Mandarine Chinese interpreter Shenny.
As you can see, a pre-session can help interpreters address the problematic situations described at the beginning of this article – and many more!
Unfortunately, it’s true that a pre-session does not grantee that everything will go perfectly. Patients and doctors might still address all their questions to the interpreter or make comments to the interpreter and not intended for each other’s ears. However, not having a pre-session can guarantee that these thing will happen. By having a pre-session, you let the parties know how to make the best use of your skills in order to successfully achieve their communication goals and you also present yourself as a professional interpreter.
California Healthcare Interpreter Association (CHIA). California Standards for Healthcare Interpreters. Retrieved from http://www.chiaonline.org/CHIA-Standards
CIFE: An Interpreter’s Tool (n.d.). Retrieved from https://multco.us/global/cife-interpreters-tool
International Medical Interpreter Association (IMIA). Medical Interpreting Standards of Practice. Retrieved from http://imiaweb.org/uploads/pages/102.pdf
The National Council on Interpreting in Health Care (NCIHC). A National Code of Ethics for Interpreters in Health Care. Retrieved from http://www.rwjf.org/content/dam/farm/toolkits/toolkits/2004/rwjf26946
The National Council on Interpreting in Health Care (NCIHC). National Standards of Practice for Interpreters in Health Care. Retrieved from http://www.cchicertification.org/images/pdfs/NationalStandardsofPractice.pdf
National Council on Interpreting in Health Care (NCIHC). The Terminology of Healthcare Interpreting. A glossary of Terms. Retrieved from http://www.ncihc.org/assets/documents/NCIHC%20Terms%20Final080408.pdf