How to Raise a Good Examination Room Interpreter

Takayuki Oshimi, MD (Primary Care Physician & Occupational Health Physician)
Keiyukai Yoshida Hospital

20 October 2004

Dr Oshimi presented a guide to how to train an ideal clinical interpreter, who can work effectively in Japanese communities in countries outside of Japan.

  1. What is a clinical medicine interpreter?

  2. What skills should they have?

  3. How should they be trained?

Dr Oshimi's Profile:

Dr Oshimi has kindly provided the handout and full text of his presentation.

How to Raise a Good Health Care Interpreter


Thank you Mr. Chairman. Good evening, ladies and gentlemen.
Itfs my pleasure to present my views on "How to Raise a Good Health Care Interpreter."

Currently, I work as a physician in Asahikawa, Hokkaido.
Personally, I am interested in promoting health care interpreting, as a means to support equal access to the health care in English-speaking countries for individuals with limited English proficiency.

Recently, with the increase of the Japanese who settle in English-speaking countries, the need for language assistance in health care settings is growing.
I have had the pleasure of visiting Vancouver, and Auckland, both of which have large Japanese populations, and both have health care interpreting services.
Ifm also a member of the National Council on Interpreting in Health Care in the United States. By studying health care interpreting models already established in foreign countries, a workable standardized training plan can be instituted here in Japan.
The purpose of todayfs presentation is to introduce you to the health care interpreting services that exist outside of Japan, and to promote a national certification system in Japan.
Now, letfs get started.


First of all, what is a health care interpreter? Wefll take a look at a definition. And then wefll look over the existing models of health care interpreting. Next, wefll cover the roles of health care interpreters, and existing training programs.
In the following section, wefll go over health care interpreting skills, which include basic language skills, a code of ethics, familiarity with cultural issues, health care terminology, integrated interpreting skills, and the paperwork health care interpreters need to be able to translate.
And finally, wefll conclude with a summary of the key points with follow-up questions about a certification system in Japan.

1. Whatfs a Health Care Interpreter?
1 – a. Definition
Health Care Interpreting is defined by "The National Council on Interpreting in Health Care" as;
That which "takes place in health care settings of any sort, including doctorfs offices, clinics, hospitals, home health visits, mental health clinics, and public health presentations. Typically the setting is an interview between a health care provider and a patient. "
Health Care Interpreter is defined by "The California Standards for Healthcare Interpreters Association" as one who:
1) Has been trained in health care interpreting
2) Adheres to the professional code of ethics and protocols of health care interpreters
3) Is knowledgeable about medical terminology
4) Can accurately and completely render communication from one language to another

Next, letfs take a look atc
1 – b. The Models of Health Care Interpreting
There are several models of health care interpreting. The models that currently exist usually fall into the following categories. Ifll describe each model here.

The First Model isc
No Interpreter
Providing no interpreter is an unacceptable approach, but frighteningly common. Trying to provide health care across a language and cultural barrier with no assistance, practically guarantees poor quality care, which could, in the worst-case scenario, end up as a malpractice suit.

The Second Model is thec
Chance Interpreter Model
Chance Interpreter is also called an "ad hoc interpreter", which is an untrained person who is called upon to interpret, such as a family member interpreting for his or her parents, a bilingual staff member pulled away from other duties to interpret, or a self-declared bilingual in a hospital waiting room who volunteers to interpret.
These chance interpreters invariably have zero training as interpreters and are unlikely to be able to provide accurate or even useful interpretation.
Though family members have an important role to play in supporting the patient, their personal relationship is in direct conflict with the role of an interpreter. Family members routinely edit, add, change the message, and end up taking control of the interaction between patient and provider instead of facilitating it.

The Third Model is thec
Bilingual Support Staff Model
An untrained bilingual support staff member is not much better. These staff members also tend to edit, add and change the message. Unless their language proficiency is tested, it may be discovered that they donft have the language skills necessary to interpret well.
Even if they have enough proficiency, they may feel frustrated when they are taken away from their regular jobs to interpret often. Some of these problems can be solved by screening their language skills and by setting up a more formal system for using bilingual staff services.

Next we have thec
Remote Interpreting Model
This is interpreting provided by an interpreter who is not in the presence of the speakers, for example, interpreting by telephone, or videoconferencing.
Remote interpreting is carried out with an interpreter connected electronically to the principal parties. In health care settings, a doctor and a patient are normally in the same room, but the interpreter can be used to serve individuals who are also connected to each other electronically.
Advantages of remote interpreting include on-demand access in a wide array of languages.
These services are especially useful for emergencies, for uncommon languages. However, the expense of installing such a system may be a concern. And professional interpreters who are proficient in this model will also expect higher remuneration than most on-site interpreters.

The AMDA International Medical Information Center is a major organization in Japan, which provides multilingual remote interpreting services.

And then we have thec
Bilingual Provider Model
The ideal model for providing language service is to assign a bilingual and bicultural provider. However, it is difficult to find providers in all the different languages a medical center might need. This model also doesnft serve the language needs of the patient outside the medical interview: for example, at the pharmacy, at radiology, or at the reception desk.

Finally there is thec
Professional On-Site Interpreter Model
A more reliable and reasonable approach is to use professional on-site interpreters. Some institutions hire full-time staff interpreters, while others have contracts with interpreters who are paid only for the time they interpret. Other institutions, such as travel insurance companies, have contracts with language agencies. Travelers who require health care interpreting can get it as part of their travel insurance.
In Japan, demand for the on-site interpreters who have competent professional skills, has been on the rise.

1 – c. The Roles of Health Care Interpreters
The fundamental purpose of health care interpreting is to facilitate communication between two parties who do not speak the same language and do not share the same culture. Various obstacles to cross-cultural communication include language complexity, differences in cultural norms, as well as organizational or systemic barriers facing the foreign patient.
In this section, wefll take a look at the roles of health care interpreters.

Message Converter
In this role, interpreters are supposed to convert the meaning of all the messages from one language to another, without additions, deletions, or changes in meaning.
To do this role, interpreters must manage the flow of communication between all the parties present. Interpreters need to intervene when parties speak too fast or fail to allow the interpreter time to interpret. They also manage turn-taking, indicating to individuals speaking at the same time that they will be heard in sequential order or that a party must be allowed to finish speaking.

Message Clarifier
In the message clarifier role, interpreters should identify possible words or concepts that might lead to misunderstandings. When the interpreters notice them, they need to interrupt the communication, alert the parties that there are signs of confusion. They also need to ask the speaker to describe the words or concepts in a simpler way. If needed, interpreters need to explore ways to assist speakers to describe concepts using analogies.

Culture Clarifier
The culture clarifier role goes beyond word clarification. When there is evidence that any of the parties may be confused by cultural differences, interpreters need to interrupt the communication process, identify cultural concerns that could be impeding mutual understanding, and assist each party in explaining the cultural concept. When requested, interpreters need to explain cultural customs and patientfs common beliefs with respect to health. They must also educate the patient on the biomedical concept of the host country.

Patient Advocate
Patients with limited language proficiency find it difficult to advocate for their own right to the same level of care as the native speakers. In this situation, interpreters are often the only individuals in a position to recognize a problem and advocate on behalf of the patient. Health care interpreters have duty-of-care function.
However, this active supporting role must remain an optional role for each health care interpreter.

1 – d. Health Care Interpreter Training Programs
Training models that currently exist beyond the level of short orientations or periodic on-the-job training, usually fall into one of the following categories.

Academic Training Programs
Academic training programs can be quite varied. They can offer certificate programs, including a Bachelor or Master of Arts degree program. However, only a small percentage of colleges and universities offer interpreter training of any sort, especially for health care interpreting.

Bilingual Health Care Employee Training Programs
The health care institutions, such as a medical center, or an HMO, give training programs for its bilingual employees, such as receptionists, nurses, or lab technicians. These employees are familiar with the specific health care settings, but this model has the same disadvantages as "the role of the bilingual support staff model".

Community Training Programs
Community organizations train the bilinguals living in the community. The length of the training varies according to the facility and ranges from one day (8 hours) to one week (40 hours). The providers of these programs maintain close ties to the medical facilities and have a better understanding of the health care system, but relevant topics of the field may be omitted, and teaching ability and experience of the trainer vary widely.

Intensive Training of at least 40 hours
Most of these courses serve as a basic introduction or an intermediate training course designed for both new and experienced interpreters.

Agency Training Programs
Some agencies provide training for their interpreters, and the programs vary greatly in their approaches to testing and training.

2. Health Care Interpreter Skills
To play all the roles of health care interpreting effectively, the interpreters should have special skills. The following six components are essential in determining whether or not a candidate is qualified to be a health care interpreter.

2 – a. Basic Language Skills
The most basic skill that an interpreter must have is competence in speaking and understanding the two languages to be interpreted. Every interpreter, even the most skilled, will need to expand his or her vocabulary through training and ongoing study. However, basic oral proficiency in both languages is a prerequisite for anyone wishing to serve as an interpreter. Demonstrating a will to improve oral proficiency is the first step for the candidates.
There are a number of English oral proficiency tests. However, most of them have literary and academic orientation, and are not very suitable for testing the oral skills of interpreters. I want to emphasize that interpreting is fundamentally an oral skill, and that even candidates who do not read and write well can be excellent interpreters and should not be initially screened out based solely upon inadequate written test results. Indeed, for some minor languages, there are few interpreter candidates who have had the opportunity to study the foreign language formally. For this reason, many health-care-interpreting institutions do not include formal testing of written language skills as a part of the minimum screening necessary for an initial assessment.

2 – b. Code of Ethics
Some Questions to Discuss
Would anyone care to volunteer to read the questions for us, please?

1. In the course of an assignment, should an interpreter interpret statements, which he/she knows to be untrue?
Next, please.
2. You arrive early for an interpreting assignment at a hospital. The client recognizes you as the interpreter and starts to tell you that he/she feels really depressed and is considering suicide. Would you advise the doctor of this conversation or would you keep it to yourself?
3. Should an interpreter interpret for friends and relatives?
4. You are sent by an agency to interpret for a client. The client brings a friend along to interpret and refuses your service. What would you do?

Letfs think about some possible answers. Anyone care to share your thoughts?
Letfs discuss together.

Health care interpreters should expect to face these types of difficult situations.
A code of ethics is a set of principles or values that governs the conduct of health care interpreters and provides guidelines for making judgments about what is acceptable and desirable behavior in a given context or in a particular relationship.

The following code of ethics offers a set of principles that are generally accepted by a number of health care interpreter associations in the United States.
As in all codes of ethics, it does not provide definitive answers to all of the dilemmas interpreters face. As a profession, health care interpreters need to come to a clearer understanding of the ethical dilemmas that are unique to the field. This code of ethics for health care interpreters is offered in the spirit of establishing a starting point towards creating a common understanding of ethical practice in the field of health care interpreting.

The interpreter shall treat as confidential all information learned in the performance of their professional duties. This means that interpreters will not disclose to anyone any information acquired on the job. Confidentiality is to be maintained in all situations except when the government mandates the disclosure of information in specific situations such as child abuse, elder abuse, or a person threatening harm to him/herself or others. Currently there are no specific legal guidelines for interpreter responsibilities regarding confidentiality. It is interpreterfs responsibility to understand the standard operating procedures of the individual institution in question.

Accuracy and Completeness
The interpreter shall render the message faithfully, conveying the content and spirit of the original message while taking into consideration its cultural context. This means that interpreters shall interpret everything the speaker says without changing the meaning, conveying what is said and how it is said without additions, deletions or alterations, but with due consideration of the cultural context of both the sender and the receiver of the message. The interpreter must convey the meaning of gestures, body language, and tone of voice. Additionally, interpreters must reveal and correct any errors they have made during the interpretation.

The interpreter shall maintain impartiality and shall not counsel, advise or project personal biases or beliefs. Interpreters remain impartial by suspending judgment and making no personal comment on the content of the communication. They avoid distorting the message in favor of one party or the other. Under no circumstances should interpreters give advice to patients.

Professional Boundaries
The interpreter shall maintain the boundaries of the professional role, refraining from personal involvement. Interpreters need to avoid getting personally involved with the people for whom they interpret. This does not mean that interpreters cannot be friendly and caring. The development of rapport with patients and providers during a pre-session is a part of the interpreterfs professional role and does not necessarily represent personal involvement.

Professional Development
The interpreters shall strive to continually further their knowledge and skills. Interpreters need to engage in ongoing professional development activities. They should improve upon their linguistic knowledge and maintain their interpreting skills by reading current literature and taking advantage of educational opportunities such as workshops, trainings, etc. They should also continue to expand their knowledge of the medical contexts in which they may be called to function and of the socio-cultural contexts including folk medicine and illnesses of the patient populations for whom they interpret.

Cultural Competence
The interpreter shall develop awareness of their own and other cultures in order to promote cross-cultural understanding. Interpreters should strive to bridge the cultural differences between all participating parties, by seeking to minimize, and if possible, to avoid potential misunderstanding based upon stereotyping or differing cultural practices, beliefs or expectations. Under certain conditions such as clashing cultural beliefs or practices, a lack of linguistic equivalency, or the inability of parties to articulate in their own words, the interpreter should assist by sharing cultural information or helping develop an explanation that can be understood by all.

Respect for All Parties
The interpreter shall strive to support mutually respectful interactions among all parties. Interpreters can help build mutual respect within the triadic relationship by responding in a supportive manner within the interpreter role, using rapport-building skills, respecting the experience or expertise of all parties, allowing physical privacy to the patient, refraining from influencing patient decisions, and treating all participating parties equally and with dignity.

Professional Integrity
The interpreter shall demonstrate professionalism and personal integrity. The following are some aspects of professionalism:

If the interpreter believes at any time that they may have interpreted inaccurately or incompletely, they will make this known and, if possible, provide a corrected interpretation.

An interpreter shall not accept an assignment, or shall withdraw from an assignment, in which they
1) Are not competent to interpret accurately and completely
2) Perceive a conflict of interest between their role as interpreter and their personal involvement with one of the parties in the interpretation
3) Is so impacted by the content to be interpreted that they become unable to interpret accurately and completely.

The fee agreed to between the interpreter and the contracting/employing agency shall be the only compensation the interpreter will accept. The interpreter will not accept additional compensation or considerations from any party in the interpreted session.

Ethical Decision Making Process
An ethical dilemma occurs when there is confusion about an appropriate course of action.
To assist interpreters in determining a course of action in ethical dilemmas, the following steps are useful.
1. Ask questions to determine whether there is a problem.
2. Identify and clearly state the problem, considering the ethical principles that may apply and ranking them appropriately.
3. Clarify personal values as they relate to the problem.
4. Consider alternative actions, including benefits and risks.
5. Choose the action and carry it out.
6. Evaluate the outcome and consider what might be done differently next time.@

2 – c. Familiarity with Cultural Issues
This skill is an ability to anticipate and recognize misunderstandings that arise from the differing cultural assumptions and expectations of providers and patients and to respond to such issues appropriately. Here are the specific skills:
EInsight in cultural nuances in the communities
EUnderstanding the similarities and differences between the biomedical culture and the foreignerfs own culture
EBroader perspective in the different health care service areas
EFamiliarity with the health care systems in both the host country and the country of origin

The Differences in Health Culture
Herefs a case study that addresses the differences in health care culture and the problems that can arise from them.

Would someone like to volunteer to read the case study for us, please?

A young Japanese man living in Vancouver suffered a head injury playing soccer. He went to a GP (General Practitioner) with a Japanese health care interpreter.
After a thorough and extensive examination (History taking & Physical examination), the young man was diagnosed as having a minor concussion, and the GP concluded that a CT scan wasnft necessary.
The young man was worried about the possibility of a serious head injury, and he was doubtful that the doctor could make such a diagnosis without a CT scan. He requested one to the doctor, but the proposal was denied.
After the session, the interpreter present, who had worked in the Japanese system for a number of years as a nurse, sympathized and agreed with the young man. He experienced a number of similar cases, in which Japanese doctors ordered a CT scan regardless of the physical result. So, he told the man that he was right and that the Canadian doctor should have ordered the CT scan.
As a result, the man felt that not only wasnft he properly cared for, but also that whole Canadian system was sub-standard or perhaps even racist. He wished that he could see a Japanese doctor for "proper care".

A conflict arose because of procedural differences /between the health care cultures. Whereas in North America, emphasis is placed on the patientfs history and the physical examination, Japanese diagnostic procedure emphasizes extensive test results.
So the per capital number of scans alone is a clear indication of procedural differences. In the year 2000, there were only 13.2 scans in the U.S.A., compared to 84.4 in Japan. Americans use health care systems only in serious situations, and visit doctors about 6 times a year. But Japanese tend to go much more often. They go as often as 16 times a year.

The interpreter present made the mistake of sympathizing with the man and agreeing with him. Working as a nurse for a number of years, he had a bias for the Japanese system. This is a pitfall that must be avoided at all costs. It is the interpreterfs duty and responsibility not only to be linguistically and culturally proficient but also to understand the procedural differences so as to properly facilitate communication between the doctor and the patient. An appropriate course of action would have been for the interpreter to explain to the young man that doctors in Canada are trained to make a proper diagnosis through thorough and extensive observation (History taking & Physical examination). The man could have taken comfort in knowing that he was being cared for in a competent and professional manner that differs from the care that he was used to at home.
This terrible misunderstanding is a direct result of an incompetent interpreter. It is essential that the interpreter recognize the power he or she has to influence how a patient feels about the health care he/she receives. After all, a patientfs assessment of care provided is based on the patientfs interpretation of that care.

2 – d. Health Care Terminology
Health care interpreters should be familiar with health care terminology. Here are some terminology categories that are presented for easier study.
EProcedures / Tests
ESpecialists / Departments
E Medications

Learning tips
Laymanfs terms not jargon
In learning this terminology, the learners should keep in mind that they should learn the terms orally, and they should be familiar with the everyday-usage, not jargon. Health care providers donft use jargon to explain the tests or treatments. Patients also use everyday expressions for describing their symptoms. So, interpreters should be familiar with everyday expressions.

Learning the context of the terminology
If the interpreter doesnft know the context of the terminology, he/she canft find the appropriate word for it in another language. Here are a few examples.
For example, "closed", as in "this shop is closed". What is the appropriate Japanese word for it?
Whatf the appropriate word for Acute Mountain Sickness?
Can anyone translate this word for us, please?
"Acute Mountain Sickness" is not ‹}«‚ŽR•a. It should be translated into ŽRŒ‚¢.
"High Altitude Illness"

Medical interview protocol
To be a good examination room interpreter, the interpreter should know the H & P extensively. The H & P protocol is as follows:
1. Chief complaint
2. History of present illness
3. Review of systems
4. Past medical history
5. Past surgical history
6. Family history
7. Social history
8. Medications
9. Allergies
10. Physical examination

For examplec
1. I have a sharp pain in the abdomen.
2. When & how did it start? Questions about provoking & palliating factors.
3. Other symptoms they may have. Have you been eating normally? Have you had any nausea, vomiting, or diarrhea?
4. Have you ever had measles, or chicken pox?
5. Have you ever had an appendectomy?
6. Does any member of your family have diabetes, or heart disease?
7. This includes the categories, such as alcohol, tobacco, sex, travel, occupation, and drugs.
8. In some cases, medication side effects may be responsible for the patientfs symptoms.
9. So allergies may be.

Recommendation of materials for learning health care terminology

By role-playing medical interviews, the learners can acquire the basic knowledge of the protocol. If you are personally interested in learning the medical interview protocol, I recommend the following readings.
Medical Interview Protocol

In addition to that, watching "ER" is very beneficial. It contains a lot of terminology and you can learn various medical protocols.

The lists of basic terminology by MMIA
MMIA (the Massachusetts Medical Interpreters Association) has useful terminology lists on its website:

2 – e. Integrated Interpreting Skills
Integrated interpreting skills refer to the full complement of skills that a competent interpreter calls upon to ensure the accuracy and completeness of each message.
In addition to the central skill of oral language conversion, there are other skills that a competent interpreter should have.
These skills include asking for pauses and clarification, using a variety of devices to remember important information, and managing the flow of communication.
Here are the skills at each session stage.

Pre-Session Skills
Before the session begins, interpreters establish the basic guidelines.
EState that they will maintain the confidentiality of the session
EInform the parties of the elements necessary for a smoothly interpreted session, including
1. The requirement for interpreters to interpret everything
2. The importance of direct communication
3. The need to pause for interpreting
4. The need to intervene for clarification

In-Session Skills
During the session, interpreters facilitate communication to support the patient/provider relationship by acting to:
EPosition the parties to encourage direct communication
ERemind the parties to communicate directly to each other
EUse the first person ("I") as the standard form of interpreting to enhance direct communication
EManage the smooth flow of communication
EIntervene for clarification when interpreters do not fully understand the terminology or the message

Post-Session Skills
To provide closure to the session, interpreters take measures to:
EInquire about any questions or concerns the parties may have for each other
EFacilitate the scheduling of follow-up appointments
EDocument the provision of interpreting services, as required by each organizationfs policies
EDebrief providers or the interpreterfs supervisor, when appropriate, about concerns arising from the session

Health & Well-Being of the Interpreter
Following the interpreted session, it is important for interpreters to recognize and address their need to recover from an emotional and stressful session by following these steps:
EAcknowledging that healthcare interpreting is hard work
E Understanding patientfs responses in various situations
Health professionals are trained to deal with the five most common responses to "loss" situations, such as terminal diagnosis.
1. Denial: No, itfs not true! You must have mixed up the test result! It must be somebody else!
2. Anger: Why me? Itfs not fair! I have always lived such a healthy life! I am too young to die!
3. Bargaining: What if I give up smoking? What if I try this new wonder diet?
4. Depression: The patient may be withdrawn and refuse to speak.
5. Acceptance: The patient may accept that he or she is going to die, may only wish to speak to those closest to him or her.

EUnderstanding the health care providerfs minds
EWorking as a team
EOffering workshops

2 – f. Simple Translating Skills
Basically, health care interpreting requires only oral skills. In the health care setting, however, information is not always presented in the spoken form.
Therefore, the interpreter may be asked to translate written messages into spoken messages, or to translate short passages of written text into written form in another language. The documents, which the interpreter may be asked to translate, include the following:
EMedical documents
ERegistration forms
EPatient education materials
EAppointment cards
EPrescription labels
EDischarge instructions
It is important to keep in mind, however, that an interpreter is not necessarily qualified as a translator and does not have the means, while interpreting, to perfect a written translation. Therefore, the interpreterfs responsibility for providing written text is strictly limited to brief instructions, and if needed, interpreters must recommend that a qualified translator come in to do the job.

3. Follow-Up Questions

What are the issues in the certification of Health Care Interpreters in Japan?
As some of you may already know, formal certification of health care interpreters currently exists only in a few English-speaking countries, including Australia, and Britain.
Washington State, in the U.S., where the Department of Social and Health Services certifies medical and social service interpreters, is the only state, which has formal certification of health care interpreting in the U.S.

In Japan, there has been a growing desire among communities to establish closer ties with others in the field of health care interpreting, with the goal of establishing national standards, training programs, and certification. Here are a few examples.

This is an article in the Asahi Shinbun, a major Japanese newspaper on July 15th. The author, Makiko Mizuno, an assistant professor at Senri-Kinran University and a nationally renowned interpreter, insists that it be necessary to establish a certification system to provide competent professional interpreters in the community.

This symposium was held on Sep. 26th, and the topics discussed included health care interpretation in some communities and language comprehension and working memory.

This symposium will be held on Nov. 6th in Osaka, and the topics to be discussed include breaking down the barriers to communication, and the demands for language services in health care settings.

These multiple regional efforts will provide valuable experience with different approaches to certification, which can later inform the development of a national process.

While there have been suggestions that a national certification might be in order, we have a lot of problems to be solved.
We actually know little about what works in the certification of health care interpreters to institute a national program.

What is the purpose of certification?
First question. What is the purpose of certification?

Certification has different merits to different people. Some see certification as a way to guarantee quality interpretation to health care providers and patients. Many institutions see it as a way to avoid legal liability.
Some interpreters see it as a way to create skilled elite, who can then compete for higher wages.
Others see it as a way to create some standards in an emerging profession.

So, we have to think about this question.

Is it better to certify or to accredit interpreters?
Certification links testing with employability, i.e. only certified interpreters can work.
This approach can backfire for those seeking to certify in order to guarantee high quality service to populations of limited-English-proficiency.
If not enough interpreters get certified in certain language groups, those communities, and the providers that serve them, will find themselves with no interpreters at all.

Certification Test
Talking about certification test;
What exactly do we test?
How to best test? Written? Oral? Demonstration? Real time?

Standardized written tests are cheapest to apply and correct, but do we really want to test literacy and test-taking skills?
Real-time testing may be more accurate, but it is also time consuming and expensive. How do we devise a process that is both accurate and cost-efficient?

What is a minimum standard?
What languages should be tested?
Do we test in only the most common languages, such as in English?
Which are those?
How many do we include? What happens to the interpreters in other languages?
Is there any equivalent process for them?
Same test for every language?
Can you use the same testing methods with every language group?

Who will pay for the test?
How much to charge?
Who will pay for developing and implementing a certification process?
Can we just pass the cost on to interpreters?
How much can community interpreters be expected to pay, when they may be earning only a minimal fee or interpreting only infrequently?

We face these problems in developing a certification system.

Suggested Roles of MITA
It could be argued that higher pay, language screening, basic training, and accessible continuing education would do more to guarantee good interpreting than certification.

An organization or association with the expertise in both the health care setting and in cross- cultural communication, would be the best one for organizing the national standard.

MITA, which has a number of experienced medical interpreters and translators, would be the best association to organize the national standard of English-Japanese interpretation.

I hope interest in health care interpreting grows and that Japan becomes well established in the field.

Thank you very much for your attention and it would be my pleasure to address any of you personally with any questions or comments about anything youfve heard today so please donft hesitate.

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