Virtual and in-person interpretation: a qualitative study from the perspective of professional medical interpreters

Abstract

Purpose

Professional medical interpreters aim to provide high-quality interpretation for non-English language preference (NELP) patients; however, the impact of various interpreter modalities (virtual versus in-person) is unclear. This project explored the impact of interpreter modality on the in-person care experience through focus groups with medical interpreters to identify strengths, limitations, and clinical situations where in-person or virtual interpretation modalities are most beneficial.

Methods

We conducted a qualitative study using focus groups with professional medical interpreters. Sessions were recorded, transcribed, and anonymized. Transcripts were then coded and analyzed using thematic analysis.

Results

We conducted five focus groups with 24 professional medical interpreters and identified four themes: relationship development; understanding and accuracy; accessibility, flexibility, and flow; and care quality. Interpreters found many functions are best served through in-person interpreters. However, there are certain circumstances in which virtual interpreters can be effectively utilized to increase access and allow flexibility.

Conclusions

Interpreters primarily promote in-person interpreters for increased understanding, equity, and human connection to best serve patients. They provided salient examples and a deep understanding to inform the utility of different modalities in various clinical situations. There are opportunities for health systems, clinicians, and families to improve access to interpretation and ensure interpreters can use their full skill set to improve patient care and equity.

Key messages.

• The professional medical interpreter's skill set expands when present in person.

• In-person interpretation is preferred to increase understanding, equity and connection.

• Virtual is generally appropriate for short visits, follow-up, results or medication review.

• In-person Interpreters can be prioritized for complex patient visits.

• In-person interpreters increase safety and patient input in unpredictable situations.

Introduction

Over 68 million US households speak a non-English language, with 29 million of these having limited English proficiency [1]. Significant health outcome disparities exist for non-English language preference (NELP) patients, or those who prefer a non-English language with respect to their care [2]. NELP patients access fewer preventative services [3], experience poorer chronic disease management [4, 5], have higher hospital readmission rates [6], and encounter more safety events [7–9] than patients with English language preference.

As the USA grows increasingly multilingual, access to professional medical interpretation is necessary to ensure quality medical care for all patients. Language assistance is required by federal law [10]. We know that, across multiple settings, bilingual clinicians or use of trained medical interpreters improve patient outcomes [11, 12], increase patient safety, and prevent adverse events [13–16].

Access to medical services through virtual care, via telephone and video, including medical interpretation, expanded in the wake of the COVID-19 pandemic [17, 18]. These changes improved patient access to medical interpreters [19–22], but there is mixed evidence regarding how interpreter modality (in-person vs virtual) impacts patient experience [15] and care quality [23]. Some studies show high levels of patient satisfaction with virtual interpreters, including in the clinic, hospital, and emergency room [18, 24–27]. Others suggest that patients and clinicians prefer in-person interpreters [28–32].

Interpreter modality affects the flow and efficiency of healthcare visits. Access to virtual interpreters increases frequency of interpreter use, decreases patient and clinician wait time [20, 33, 34], and increases on-time case rates in surgical settings [35]. In contrast, outpatient studies show that in-person interpreters reduce visit times, and decrease no-show and late arrival rates [30]. In the emergency room, patient length of stay was longer and mortality rates higher with virtual interpreters [36].

There is limited qualitative research comparing healthcare visit experience with in-person versus virtual interpreters, including from interpreters themselves [37, 38]. Patients indicate improved relationship development and trust building with in-person interpreters [29, 32, 39, 40], and suggest a loss of body language and cultural cues with virtual interpreters [32, 41]. In-person interpreters may be particularly valuable in situations with high medical complexity [15, 40], multiple educational components [40, 42], complex psychosocial aspects [15, 29], or hearing impairment [41]. In-person interpreters foster a safe environment for diverse NELP patients, improving patient compliance and clinical outcomes and reducing disparities [11, 42, 43].

Our study aims to contextualize in-person and virtual interpretation modalities from the viewpoint of professional medical interpreters to understand variations in experience and identify clinical situations where each modality is most beneficial.

Materials and methods

This study was deemed Not Human Research by the University of Minnesota Institutional Review Board.

Participants

For this qualitative study, we conducted five focus groups with 24 professional medical interpreters. Participants were recruited via electronic recruitment flyer. We utilized professional interpreter organizations, interpreter training programs, employment agencies, and health systems, as well as personal networks and snowball sampling for recruitment via emailed and posted flyers. Interested participants were directed via QR code to an electronic screening tool.

Eligible participants included professional medical interpreters in Minnesota with greater than three years' experience, employed more than 20 h per week, and with experience interpreting using both in-person and virtual modalities. Recruitment was broad to capture participants from a variety of languages, cultural backgrounds, geographic locations, and clinical settings.

Seventy-five screening surveys were opened; 39 were deemed eligible and contacted. 24 participated in focus groups, with the majority of non-participants limited by time and scheduling constraints.

Data collection

Five virtual focus groups with three to six participants each were held between March and June 2023 and conducted using a semi-structured moderator guide. The guide (Supplement A) was not pilot tested but developed from clinical experiences, literature review, conversations with interpreters, and reviewed by experienced qualitative researchers. Moderator guide development [44] incorporated principles of trauma-informed research [45] and cultural humility [46], with aim to balance power dynamics [47] and support peer-to-peer conversation. Questions focused on participants' views of the interpreter role, benefits and challenges of working in-person and virtually, and experience during the COVID-19 pandemic.

Focus groups were 90–120 min and hosted virtually via Zoom [48], utilizing audio, video and chat components, with consent confirmed verbally and via chat. Sessions were moderated by two authors (C.B., K.F.) and assisted by three authors (F.A., L.M., M.M.). Moderators included active MDs (K.F., L.M.), MPHs (C.B., L.M.), medical students (F.A., M.M.), and former interpreters (F.A., M.M.), all female. Participants were aware of the researchers' professions, background, and frequent work with NELP patients and interpreters. Some participants and moderators had on occasion worked together, but none were actively employed within the same organization. Participants completed a demographic survey and received a $50 gift card for their participation.

Analysis

Sessions were recorded and transcribed via Zoom and transcripts were reconciled with audio and video files. All moderators kept field notes, which were consolidated and discussed post-session. Transcripts were coded for thematic analysis using an inductive approach [48]. The initial coding structure was developed during interim analyses after completion of the first three focus groups. Once codes were developed, a minimum of three separate authors coded each transcript using NVivo 14 [49]. Six total coders were utilized, including all five moderators. An iterative process of paired debriefing followed by large group discussion was used to refine codes from each transcript and themes were identified. Summaries were developed for each thematic category. Each coding summary was written by one author and reviewed by a second author to ensure encapsulation of key concepts. Focus groups were conducted until no unique themes were identified.

Results

Professional medical interpreters (n = 24) participated in five focus groups. Twelve languages were represented, with Spanish as the majority language. Participants interpreted in a variety of clinical settings, employment models, and community sizes. All interpreters worked using both in-person and virtual modalities, with two-thirds working 50% or more in the in-person setting. Key themes emerged centered on relationship building, accuracy, accessibility, quality and equity. See Table 1 for demographics and Table 2 for illustrative quotes.

Table 1.

Participant sample characteristics.

Characteristics	Count (%)
Age
18–20 years	7 (29.2)
21–40 years	9 (37.5)
41–60 years	7 (29.2)
Decline to share	1 (4.2)
Sex
Female	14 (58.3)
Male	9 (37.5)
Decline to share	1 (4.2)
Languages interpreted (select all that apply)
Spanish	12
Russian	3
Arabic	2
Chinese/Mandarin	2
American Sign Language	1
Bulgarian	1
Hmong—White	1
Japanese	1
Nepali	1
Portuguese	1
Taiwanese	1
Ukrainian	1
Type of employer (select all that apply)
Self-employed/independent contractor	15
Local interpreter organization	6
National interpreter organization	2
Single clinic/hospital	1
Healthcare system	11
County or state employed organization	0
Other	3
Community size (select all that apply)
Small town (<5000 people)	1
Large town (5000–25 000 people)	3
Suburban (25 000–100 000 people)	10
Urban (major city > 100 000 people)	18
In-person interpretation
All or nearly all of my patients	9
More than half of my patients	7
About half of my patients	4
Less than half, but still a significant number of patients	1
A small group of patients	2
Video interpretation
All or nearly all of my patients	0
More than half of my patients	0
About half of my patients	2
Less than half, but still a significant number of patients	7
A small group of patients	13
Telephone interpretation
All or nearly all of my patients	0
More than half of my patients	4
About half of my patients	1
Less than half, but still a significant number of patients	5
A small group of patients	12

Study participants (N = 24) include professional medical interpreters participating in virtual focus group sessions from Feb 2023 to June 2023.

Table 2.

Illustrative quotes.

Main theme	Illustrative quotes
Developing relationships	“But that fact that they have somebody, someone, that is, of course, interpreting, but that in a way, in my corner, this is somebody in my corner. They are here with me. And it's not, you know, you don't have that anxiety of not being able to be understood. So in a way it, quells much of that anxiety, and then it helps them to open up and receive the help that they really need.”
	“And I think that as an interpreter professionally and working with collective cultures, right, individuals that come from a collective background. It's not just interpreting for the patient, it's also interpreting for their family, members, and I think that that was a challenge, and that made it very helpless where their loved one was the main person that was, quarantined or isolated in this area, and then they didn't have that natural support system.”
Improving accuracy and understanding	“Behavior is so important. How people talk, the gestures, the things that they express without words. That is something that so far, technology hasn't been able to provide us in the same way.”
	“We have a lot of Spanish-speaking countries, and we use different words… a lot of words that don't even convey the same message depending on the country you're coming from. A lot of the comprehension that I'm depending on is on the visual contact that I have with the patient. I don't always know how much of it they're understanding or how much it's not getting through.”
	“I have noticed [a difference between telephone and video], for instance, for physical or occupational therapy. And I have noticed it because I can see. And if the person is not doing, you know, lifting the arm as they're indicated over the phone, there's just no way. And sometimes the visual cues really help.”
Accessibility and flexibility	I used to spend 4 hours for one patient in the emergency department. Now, I can serve 4 patients in 1 h over the video or the phone. So yes, there is a significant difference now, that is only if everybody is ready, because even on video and phone, there is a huge time waster.”
	“… [Virtual] it's super great for quick questions, like if the nurse needs to check in with you like, “Have you pooped today?”. It's a quick yes or no question. So little things like that where in person interpreter it takes much more time for you to even put in the request than it might take to ask a question. So like very simple, quick questions, I think remote interpreting is super useful, for.”
Health equity and quality	“You never know when it's going to be better to have an in-person interpreter. I remember walking out of a primary care appointment which you'd say basic. But during that appointment, the provider teased out nuances of meaning from the patient on things that were pretty important and pretty vital and that they needed to be followed up on.”
	“…It's not the same level of care. It's not the same level of service when we're working remotely… compared to when we're working in person because of the limitations that we have when we're working remotely to really understand, and if needed, advocate for patients if they're really not understanding. If we notice something, we can step out of the room with the provider and mention something that we might have picked up on, that they might want to explore more that we wouldn't be able to do—we wouldn't be able to see it if we're not on video. And even when we're on video, it's the quality and technology, it's just not 100% yet, not in my experience.”

Additional informative quotes from focus group sessions that illustrate each of the four themes surrounding virtual and in-person medical interpretation (March—June 2023).

Theme 1: developing relationships

Interpreters find relationships are more easily built in person, leading to increased comfort, safety, and trust. Patients appear more engaged and open with in-person interpreters.

When the patient is in distress and you have a live person in front of you helping…it makes him or her to feel calmer, to relax, and to speak more thoughtfully.—Participant 31, Session 5

Strong in-person relationships between patients, families, and staff provide common ground for communication, allowing interpreters to better support patients and advocate when needed. In-person interpreters have more positive interactions and are more fully included in the healthcare team, building mutual professional respect.

In-person interpreting is always a great benefit especially, in yes, those complex, more critical life-changing kind of medical service. And I think that it's beneficial in the sense that, again, you are there. There's that support, there's that team collaboration. There could be briefing, debriefing after the session, whatever the encounter/appointment is.—Participant 14, Session 3

Interpreters observe that intimate human relationships may take an emotional toll on patients, clinicians and interpreters with stronger impacts working in person. Virtual interpreters can provide distance and increase patient anonymity and privacy.

[Virtual interpreting] provides privacy for some patients that maybe don’t want to be seen by a third party.—Participant 43, Session 1

Patients may prefer to have fewer people present during sensitive scenarios. Virtual interpretation allows for interpreters from outside the local community. Remotely, interpreters note less vicarious trauma during challenging encounters.

Theme 2: improving understanding and accuracy

In-person interpreters can provide additional context; identify the speaker and observe actions, integrate nonverbal communication while reading emotions, pick up on hesitations, and see subtleties that influence meaning within conversation.

Behavior is so important. How people talk, the gestures, the things they express without words.—Participant 62, Session 4

Some languages have regional variability, and require specific dialect use or pronouns, which can be challenging virtually and require more frequent checks for understanding. In-person interpreters support conversation flow, read cues, and pick up on side conversations, enhancing the interpreter's ability to correctly convey meaning and assess patient understanding.

Being faceless over the phone–which I also do….I can help. I can kind of manage. But it's really hard to see if the people are understanding what I said. The way I interpret it, was it right? Was it the right word? Did it really click, or didn't it? I don't know. They gasp, and it could be a good thing or a bad thing, I don't know. But if I see a face, that really makes a difference.—Participant 23, Session 1

Interpreters observe variations in conversation quality and depth based on modality. Patients ask fewer questions with virtual interpretation. Clinicians delve deeper into patient concerns with in-person interpreters. Physicians complete more physical exam maneuvers with improved patient coordination in person, as providing instructions and describing maneuvers can be challenging.

From my experience, I actually had patient [sic] with the pulmonology - breathing test.. How do I actually cue how to breathe in, how to blow out, or let's say audiology, how do I actually see they can perceive sounds. And then the video doesn't do anything.—Participant 38, Session 1

Theme 3: accessibility, flexibility, and flow

Virtual modalities increase interpretation access for patients in remote, rural, or out-state locations, for those with mobility or transportation barriers, and in inclement weather or natural disasters. Virtual Interpreters provide access to a larger interpreter pool, which is especially important for less common languages.

We have a limited number of Japanese interpreters in the Twin Cities. We don't have a lot of the clients either…less than one hand, really. So, technically, I go everywhere in the States, and then I help a lot of people.—Participant 38, Session 1

Yet connectivity issues and noisy environments with virtual interpretation can increase appointment length as information is repeated multiple times. Physical distance from interpreting devices, background noise, and multiple people talking simultaneously makes virtual interpretation challenging.

You have over-the-phone and the phone is on speaker. You are hearing the fetal heart. You're hearing all of these background noises, the blood pressure cuff going off, and your devices will pick up every single thing.—Participant 14, Session 3

There are logistical challenges with in-person interpretation as well. Coordinating timing for multiple appointments becomes problematic when a clinician is behind schedule or a patient misses an appointment. Interpreter transportation creates logistical barriers including time for clinic-to-clinic travel, cost of transportation, and parking. Sometimes clinics refuse in-person interpreters if they are late.

The most challenging part is running from clinic A to Clinic B in such a short time, especially when the last doctor takes a longer than expected time, then you cannot just drop and I say “I got to run for my next one”. So you wait until you will be running it very tight between the 2 appointments. That's nerve wracking, that's the most challenging.—Participant 52, Session 3

Both virtual interpreters and in-person interpreters assist with visit flow, increasing access and efficiency. Often virtual interpreters can be accessed more quickly in an emergency. Some healthcare systems have virtual interpreters available while waiting for an in-person interpreter to arrive. When patients need to move throughout a facility, in-person interpreters can accompany them to increase continuity, timeliness, and efficiency.

There are patients coming through the emergency department that need to get attention right away, and we are not always there.—Participant 72, Session 5

Theme 4: high quality and equitable care

As interpreters reflect on the difference between interpreting in person versus virtually, many commented on the unpredictability of clinical interactions; the challenge of anticipating visit complexity and individual patient needs.

In an ideal world we will have plenty of interpreters for all…because I can’t tell you instances where I looked at my schedule and I was like “this should be simple,” …And I arrive and I’m so glad I was there in person, because it was such a complicated environment that you cannot foresee by just looking at the notes on the appointment or the specialty. It's a really hard call to make…because you’re not always gonna [sic] be right.—Participant 59, Session 5

Participants view interpreter access in all languages and clinical situations as essential to high quality, equitable care. Participants highlighted the key role of just-in-time virtual interpretation yet saw limitations. They had concerns about qualifications and training with interpreter services outsourced from other states and countries. Virtual interpretation, with more limited input, requires increased concentration and focus; their ability to serve patients well decreases. Many described virtual interpretation as “better than nothing,” as they observe lower quality conversations and interactions.

Factors influencing interpreter modality

Participants highlighted multiple situations best suited for each modality, emphasizing that interpreter, clinician, and patient modality should match whenever possible. Virtual interpreters are generally appropriate for patients with chronic conditions who need follow-up or brief consultations, to review results or refill medications. Straight-forward visits (labs, imaging, immunizations) are easily interpreted virtually. For hearing impaired patients, in sensitive encounters, or for those processing past trauma, virtual visits can increase accessibility (Fig. 1).

Figure 1.

Key patient, medical, and logistical factors where virtual interpreters may provide the greatest benefit.

In-person interpreters can be prioritized for more complex visits; those with new diagnoses, lengthy written materials, frequent and complex physical exam maneuvers, and high risk of harm. In-person interpreters are important with multiple participants, including large healthcare teams and multilingual families requiring simultaneous interpretation. In-person interpreters increase safety and promote patient input in unpredictable situations, such as the emergency room, labor and delivery, intensive care unit, and mental health crises (Fig. 2).

Figure 2.

Key patient, medical, and logistical factors where in-person interpreters may provide greatest benefit.

Interpreters note the inherent unpredictability of visit complexity and individual patient needs. They value patient and clinician input to determine best fit.

It's not even fair. It's like we’re making decisions for patients that involve patients' lives, and the way they will receive care. -Participant 59, Session 5

Conclusions

Leveraging focus groups with professional medical interpreters, we found that interpreter modality impacts multiple aspects of the clinical experience, including relationship development, patient and clinician understanding and accuracy, interpreter access, flow and flexibility, and quality of care. Virtual interpretation can play a key role for routine, well-established medical needs and emergent services. In-person interpretation should be prioritized for high risk, complex visits—new patients, new diagnoses, undifferentiated complaints—as well as large groups and emotional situations.

Interpreters identify in-person as the gold-standard. Building on previous qualitative studies, which identified in-person benefits including enhanced relationship development [29, 32, 39], increased utilization of visual cues [32, 41], and improved encounter flow [31, 36], our focus group participants outlined additional benefits. In-person interpreters better integrate cultural cues, instruct testing and physical exam maneuvers, and support written questionnaires and paperwork, enhancing the experience and comprehension for all.

In-person interpreters identify opportunities to support comprehension, advocate for patient needs, and protect against bias and racism [32]. Interpreters see increased care quality with in-person interpreters, when interpreters can clarify, debrief, and educate care team members. This improves trust in the healthcare system and decreases unnecessary healthcare visits due to misunderstandings. Interpreters see this as a critical equity issue; access to an in-person interpreter levels the field for NELP patients.

Interpreters find it challenging to use their full skill set in the virtual setting, and yet they see the value of virtual interpreters. Previous studies emphasize that professional interpreters, regardless of modality, are key to quality NELP patient care [12, 32, 37, 40], and technology increases professional interpreter access and utilization [20]. This is particularly critical in acute situations, as a bridge to in-person care, and with situations of geographic or linguistic isolation. Interpreters highlight the need to improve clinician, staff, and interpreter training and virtual interpretation best practices.

We see opportunities for enhanced integration of interpreters within the healthcare team as an important theme and future direction. Interpreter input has value in improving care delivery, including care planning, coordination across specialties, development of clinical protocols and patient education. Previous work suggests opportunities to embed interpreters into care teams [42, 43], potentially expanding their role to support patient navigation and education similar to community health workers. This would require discussion of interpreter scope with significant input from interpreters themselves, with potential to improve care.

Our focus groups highlight the impressive skill set that interpreters bring to the medical encounter; as well as how their toolbox expands when present in person. Even as technology and systems improve, in-person interpreters enhance visit quality.

Strengths and limitations

This study is one of few to focus on the interpreter perspective and included a diverse group of interpreters in regards to language, location, practice, and employer, providing a wide range of viewpoints. Interpreters routinely observe patients and clinicians and are uniquely qualified to speak to the impact of each modality.

However, both number of participants and focus groups were small—one included only three participants—and favored those working in the urban Twin Cities, with better access to in-person interpreters. The majority of study participants worked primarily in person or via hybrid models. Similarly, our research team members all practice within large academic health centers with a physician-heavy perspective, with minimal community, private clinic, or rural experience, limiting generalizability of results. Multiple participants and physicians worked together previously, impacting the power differential and increasing risk for bias.

Future directions

Better understanding of interpreter roles and best practices, especially virtually, is needed to ensure appropriate, effective, and equitable interpreter utilization by the healthcare team. This includes education on requesting interpreters, communication flow, and scope of practice. Many interpreters feel excluded from aspects of the healthcare environment and worry these attitudes are felt by and impact patients.

NELP patient input on the impact of interpreter modalities on healthcare experience, level of understanding, trust in clinicians, willingness to seek care, and views on privacy is critical. Clinician input would also provide insight, including regarding visit flow, information sharing, and impacts on clinician wellbeing and comfort serving diverse patients.

Funding

This project was supported by funding from the Minnesota Academy of Family Physicians Research and Innovation Grant, the University of Minnesota School of Public Health: Health Equity Work Group Microgrant, the Minnesota Medical Association Reuter-Lien Well-being and Health Equity Fund and the Ohio University Heritage School of Osteopathic Medicine Rural Health Grant.

Data availability

Supplemental data are available on reasonable request to the corresponding author.

Ethical approval

The University of Minnesota IRB reviewed this study protocol, procedures, and surveys and was deemed not human research.