As Dr. Deb McLeish prepared to inject Botox into the arms and legs of 10-year-old Jossi Cabello to relieve stiffness from cerebral palsy, McLeish had to make sure Jossi’s mother understood the risks.

Guadalupe Cabello speaks Spanish, so McLeish relied on an interpreter, Guadalupe Mangin.

McLeish told Cabello that Botox is related to the toxin that causes botulism, which can result in paralysis. Mangin repeated the words in Spanish.

But when Botox is injected into muscles, it stays in the nerves and doesn’t go into the bloodstream, McLeish said, pausing as Mangin relayed the message.

“That’s why we can use it as a therapy,” McLeish said, Mangin echoing her again.

Cabello consented to the treatment.

Mangin, who works for UW Health, isn’t just bilingual. She’s trained and certified as a health care interpreter, a job that is becoming more standardized as health care organizations treat an increasingly diverse spectrum of patients.

Years ago, hospitals and clinics relied on bilingual employees or patients’ family members to help if communication wasn’t clear. But medicine is technical, with liability on the line. Family members sometimes filter information, thinking they’re protecting loved ones when they could be jeopardizing their care.

Today, health systems employ interpreters, hire others on a freelance basis and use national phone or video services as back-up. In 2013, health systems in Dane County started requiring in-person interpreters to be certified. To help train people for the national exam, Madison Area Technical College expanded its health care interpreting classes in 2012.

For patients with limited English proficiency, trained interpreters are a vital part of the health care team, said Shiva Bidar-Sielaff, UW Health’s director of community partnerships and interpreter services.

“There is no way somebody can transmit information accurately without the knowledge of medical terminology and the ability to stay neutral in that setting,” said Bidar-Sielaff, who helped establish national standards for health care interpreters in 2005.

“We would never ask a daughter who is a nurse to get her mother’s IV started,” said Anne-Louise Plesh, interpreter services manager for Dean Clinic and St. Mary’s Hospital. “In very much the same way, we would not expect a daughter to interpret her mother’s test results to her.”

Rahda Sijapati, who speaks Nepali, is one of about 75 certified freelance interpreters in the Madison area who work at various health systems.

She and her husband came to Madison from Nepal more than 30 years ago. The demand for her language skills spiked about five years ago when Nepali-speaking refugees from Bhutan started moving to the area. About 260 are here now.

The influx prompted Sijapati to get certified as a health care interpreter. “What better way to serve people who have no voice because of linguistic barriers,” she said. “It is very rewarding.”

Training, certification required

Bidar-Sielaff, who speaks Spanish, French and Farsi, became UW Health’s first staff interpreter in 1997. UW Health now employs seven full-time Spanish interpreters and one full-time American Sign Language interpreter, using staff, freelance, phone or video interpreters for about 200 appointments a day in about two dozen languages each month, she said.

Dean Clinic hired its first interpreter, for Spanish, in 1996, said Plesh, of Dean and St. Mary’s, who speaks Spanish. The clinic and hospital, combined, now employ eight full-time and five part-time Spanish interpreters and one full-time interpreter for sign language. After Spanish, demand is highest for sign language, Hmong and Nepali.

Meriter-UnityPoint Health employs two full-time Spanish interpreters. Group Health Cooperative of South Central Wisconsin has four interpreters, three in Spanish and one in Hmong. Access Community Health Centers has seven Spanish interpreters, and Public Health Madison and Dane County has three.

The organizations also use freelancers, for languages such as Arabic, Farsi, Mandarin and Vietnamese.

Health care providers who receive federal money have been required to provide free interpreting services for patients with limited English proficiency since the Civil Rights Act of 1964. But it wasn’t until 2000 that a federal executive order specified details of the requirement.

The National Council on Interpreting in Health Care, formed in 1998, published a code of ethics in 2004. Standards of practice came the next year, an effort for which Bidar-Sielaff was co-chairwoman.

The Joint Commission, which accredits hospitals, became more stringent with its interpreter criteria in 2011. The Dane County Medical Interpreter Coalition decided the next year to require certification, which involves at least 40 hours of training and passing the national exam. Combined, training and the exam cost $200 to $500 or more.

The certification requirement took a toll. Nearly 50 people who had been working as interpreters in the Madison area decided not to become certified or didn’t pass the exam, Bidar-Sielaff said.

But knowing the rules — interpret everything said, protect confidentiality, stay current with medical terms, ask for clarification if needed and keep emotional and personal distance from the patient, for example — is key to ensuring that doctors can make accurate diagnoses and patients can receive appropriate medical information, said Rebekka Gallardo, a Spanish interpreter at Dean-St. Mary’s.

“An interpreter’s job is to transmit the meaning without adding, subtracting, without personal involvement,” Gallardo told students in an introduction to health care interpreting class she taught at MATC in May.

Being a health care interpreter is a big responsibility, Gallardo told the students. “You’re the only one in the room who knows what’s going on completely,” she said.

Jose Flor, 30, who lives in Madison and grew up in Colombia, took Gallardo’s class and hopes to work as a health care interpreter in Spanish.

When his mother visited Madison a few years ago, she ended up in UW Hospital for a month with a complex medical condition. As Flor watched a staff interpreter convey symptoms and relay test results, he was struck by the importance of the role.

“Helping people with a similar heritage express their discomfort, their concerns, just makes sense to me,” he said.

Navigating health care difficult without interpreter

Homnaka Akpandja came to Madison in 2006 from Togo, in West Africa. She speaks French but wasn’t connected with a health care interpreter until months after her daughter Eva, now 5 years old, was born.

Navigating clinic visits and the birth without understanding much English “was very difficult,” she said recently through interpreter Susan Knutson, a freelancer.

Now Akpandja is glad to have Knutson or another interpreter at medical appointments. Since having knee surgery in April, Akpandja has been undergoing physical therapy at Dean.

“Use your butt!” physical therapist Dan Reimer said recently as he guided her through squat exercises.

Knutson interpreted, ending with the French term “les fesses.”

“Les fesses; does that mean buns?” Reimer said, joking with both women.

“It means butt,” Knutson said. “They don’t say buns. That’s our slang.”

McLeish, the UW Health pediatric rehab doctor who gave Jossi Cabello the Botox injections, knows some Spanish and used it to win over her young patient.

“Que bonita, sus dedos,” she said, remarking on Jossi’s toes as she took off the girl’s socks before giving the shots.

But with technical details — explaining the procedure’s risks, discussing the sedation Jossi would get, answering questions about special chairs Cabello was considering buying for her daughter — Mangin’s skills were indispensable.

Cabello, who came to Madison 13 years ago from Mexico, said she knows enough English to call and make appointments.

“But for everything else, I need the help of interpreters,” she said through Mangin.

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David Wahlberg is the health and medicine reporter for the Wisconsin State Journal.