Intellectual Climate Change: Can we Survive the Rising Sea of Data in the 21st Century?

Happy New Year!  It’s a whole new decade – time for some summing up, and some looking forward.

If I had to pick a defining image of the last ten years, it would be a tidal wave – a wave as big as the wall of water that drowned New Orleans, as big as the Christmas Day tsunami of 2004 – a flood not of water but of information that has broken over our collective shores.  Google search “information overload” and Wikipedia (result number 1 of 3,060,000) defines it as a condition resulting from the near instantaneous access to too much information, “without knowing the validity of the content or the risk of misinformation.”

The fact that our ability to produce and disseminate information has entirely outstripped our ability to analyze or fact-check is a reality of modern life.  To be sure, genetics is no exception – what with aCGH and the HGP and GWAS and other technology-driven acronyms spewing out data on the one hand, and the Internet on the other, where PLoS shares server time with the Discovery Institute, generator of creationism repackaged to resemble scientific research.

We might be forgiven for thinking, some days, that genetics is the ground zero of information overload.  But it’s not.  It’s happening everywhere.  Genetic counselors are often appalled at the giving out of genetic information willy-nilly – witness the response on the genetics community to such unwelcome friends in the sandbox as 23andme or DeCodeme – and the knee-jerk reaction is to say that genetic information is special, uniquely powerful, and must be given out by those with specific education and counseling skills (Hey!  That would be us!).

This type of thinking runs along the lines of genetic exceptionalism – the notion that genetics is fundamentally different than other sort of information and must be treated differently as a result – and while in some ways it may be right, it is also increasingly unrealistic. Yesterday’s PhD thesis work is tomorrow’s home-brew chemistry experiment, and microarrays are changing the economics of testing so that panels that once checked for 8 or 9 conditions now check for 300, while full-genome sequencing lurks around the corner, the paperback version of the HGP, available soon on Amazon.com.

What can we do, not to be the ones with our finger in the dike as the information tsunami rises around us like ocean water lapping at the Maldives?  We can’t cut off the flow of information.  We often call for commercial companies to give out information through genetic counselors, but is that really a solution?  The idea of commercial entities that do it “right” rather than “wrong” is comforting, but self-regulation poses inevitable conflicts of interest.

We may have jobs, perhaps good jobs, from companies that need genetic counselors to explain their products to consumers, but that doesn’t mean that, for genetic counselors as a whole, jobs within industry are a solution to the information overload dilemma.  Drug companies hire doctors to promote their pharmaceuticals, and while there is nothing wrong with working for a drug company, employing physicians is not the functional equivalent of a regulatory framework.

Across all fields from journalism to philanthropy, people are discovering ways to act as the mediator between the flood of information and the end users. The next-generation winners in information management are those who will be able to sift through and shape the available data flow into a manageable and trusted form – information brands.  We need to be consumer reports; we need to be wikipedia; we need to be CNN – we need to be a trusted filter that distinguishes true and false as well as necessary and unnecessary for the consumer of genetic information.  Jobs within industry will flow from that branding – what else do we bring, that a pamphlet or a webpage could not just as effectively communicate? – but they will not create the brand.  What will?  That is the million dollar question.

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Learning from the Naturopathic Model

I recently sat down with Jill Davies, a genetic counselor who is doing some really interesting work with genomics and preventive medicine in the primary care setting.  I won’t get into the details here, as I am hoping Jill will describe her role in her own words on DNA Exchange in the next little while. But our meeting has my wheels turning and has given me some new found inspiration about future career possibilities.

Coincidentally, the evening before my meeting with Jill, I attended my first naturopathic medicine appointment. My new family doctor has a patient share with an in-house Naturopathic Doctor (ND), in which my electronically stored medical records can easily be shared between the two. I’ve always been a little curious about naturopathy, and the pure ease of this system provided the added boost to follow through and try it.

During my hour and a half appointment with the ND we discussed in detail my medical history, family history, health concerns and general health goals. My main reasons for seeking naturopathic services are:

  1. the prevention of disease
  2. optimizing my health

As I discussed these goals with the ND it struck me that these very same objectives could drive me to seek personal genome services. I’ve always thought about personal genomics from an academic perspective, and to my surprise, never really put myself in role of the consumer. I’ve certainly thought about the consumers, but always as some abstract group of people most commonly referred to “early adopters.” So for the first time I could envision these services not just as a DTC internet purchase or as a function of specialty medicine, but as part of the primary care setting.

It is not my intention here to debate the efficacy of nutrigenomic products (such as Carolyn’s The DNA Diet, for example) or even the use of genomics in naturopathic medicine, but instead present the current model of naturopathic medicine as a potential model for personal genome services.

Consider this:

People seek naturopathic medicine services for a number of personal reasons. They meet with a professional with specific training in naturopathic medicine, and discuss their concerns. The naturopathic doctor then uses whatever “tools” they feel are most useful to address those concerns. Sometimes the knowledge gained from this service will be used to compliment the patient’s primary medical care, and sometimes not. In settings with a patient-share system with a family doctor, any test results can be easily shared between the two providers to enhance patient care. Generally, the patient can claim at least part of the cost of naturopathic medicine services from their private health insurance plan.

If you read the paragraph above again and substitute “personal genome” for “naturopathic medicine” and “genetic counselor/geneticist” for “naturopathic doctor,” does this seem incredibly plausible to you? It sure does to me.

_____________________

(initially posted on herNaturehisNurture)

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Happy New Year from DNA Exchange!

When we started this blog a little over 7 months ago, we had no idea what sort of response we would get.  The morning that DNA Exchange went live and we sent the initial note out to the listserv, I was really nervous about how it would be received. My fears were clearly unfounded; I’ve been excited and encouraged by the overwhelmingly positive response from our community, with an average of over 4000 visits to the site each month.  Thank you to all of you who come back every week to read about and weigh in on the issues that we choose to highlight here.

In 2010 the goal of DNA Exchange remains the same: the promotion of public discussion about genetics and genetic counseling related issues. We hope that this discussion will continue to grow within the GC community and that we’ll see a host of new guest bloggers in the new year. We also aim to have some other stakeholders provide guest posts in the upcoming months, in order to further broaden the conversation.

We are planning a few small changes for the new year:

  • We have a new domain name: www.theDNAexchange.com. However, our old domain (www.dnaexchange.wordpress.com) will still redirect you here.
  • We are planning a new monthly feature called “GC Alerts” in which we will highlight what is being said about genetic counselors and genetic counseling on the web.
  • Finally, we are sending out an open call for a new header photo for the site. If you have an image that you think would work well for our blog header, please pass it along.

Happy and healthy new year to all. Thanks again for supporting what we do here. If you have any suggestions about how we can make things better, we are all ears.

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Practicing What We Preach: Genetic Counselors, Disability, and Advocacy

Disclaimer:  I do not consider my deafness a disability, however, society defines it as a disability.   Therefore, I utilize quote marks and refer to it as “disability.”

As genetic counselors we are trained to respect and advocate for patients.  We are also trained to not to make pre-assumptions about their strengths, skills, and weaknesses.  Our training doesn’t always seem to apply outside of the counselor-patient setting.

As a deaf person, I knew it would be a difficult journey when I first applied to genetic counseling programs.  Little did I know how difficult it would be as a deaf person to find my place in this profession.  Genetic counselors learn about many different genetic conditions and work with many people who have various genetic conditions.  Oftentimes these genetic conditions fall under the category that society labels “disabilities.”  Even though I do not consider myself to have a “disability,” other genetic counselors sometimes took a different view.

Here are just a few of the barriers I have faced in this field because of my deafness:

  • I have been rejected from genetic counseling programs solely because I was deaf.
  • When I was invited for interviews for genetic counseling programs, I didn’t always have an interpreter available for the whole interview.
  • I was told by rotation supervisors that deaf people should not be genetic counselors.

The list goes on and on but my personal struggles are not the main focus of this post.  I just used some of my personal experiences to serve as examples.

Fortunately, these attitudes are not universal among all genetic counselors.  I have had some positive experiences during my brief career.  For example, I have never had people advocate for me as much as some groups within this field have.   It wasn’t until I started graduate school that, for the first time in my life, I truly felt like there were people out there who did want to see me succeed and were willing to go out of their way to advocate for me.

The barriers I have faced within this profession has made me question how genetic counselors truly view people with “disabilities.”  It has made me question if genetic counselors feel equal or above their patients who have “disabilities.”  Do genetic counselors serve as advocates because of some sort of deep need to help “poor unfortunates” or do they like being in the helper role and not because they truly want to see their patients be successful?  This is a very difficult question to ask of the profession and of ourselves.

I am playing the role of the devil’s advocate here.  This is not intended to be an attack against the genetic counseling profession.  Rather this post is intended to hopefully encourage genetic counselors to question why they may advocate for a person if they’re a patient but not if they’re not a patient.  What does it tell us about ourselves? Why does it appear that the role of serving as advocates have boundaries?  Where are those boundaries?  Should there even be boundaries?

Does it mean society’s attitude towards people with “disabilities” is so powerful and ingrained in us that we have to be specifically trained how to advocate and be on neutral grounds when counseling patients?   Does it mean our training is not good enough for it to cross over in all other aspects of our profession?

Is it that “disability” seems to go hand in hand with being a patient and it’s hard to separate those two?  Is it time to change our perspectives of people with “disabilities” to more than just patients?

I know it is possible for genetic counselors to pull together and advocate for other people.  My question is why doesn’t this happen on a more consistent basis?

Do genetic counselors need to analyze their perspectives on “disabilities” more thoroughly?  How can this be done?  I would love to see this profession become more welcoming to those with “disabilities” instead of constantly questioning their ability.  Oftentimes what one may see as a “disability” is that person’s strength.

I have seen this profession make attempts to make this field more diverse.  Usually diversity is thought to include people from different socioeconomic, ethnic, and religion background.  Why can’t diversity include people with “disabilities?”

I have learned so much from people within this field who have pulled together to advocate for me when the profession tried to work against me.  I want to make this field more accessible to people with “disabilities.” I want to pay forward what I have been given.

I genuinely want to hear your opinion regarding this topic.  It’s the only way I can start to understand why there are so many barriers within this profession and why we only seem to apply our training in certain settings (e.g. patients vs. professionals).

Changes won’t happen until we understand.  To understand something, we need to explore and question things.

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A Ghost From Christmas Past (Gate B4)

 

Not uncommonly we run into our patients outside of the workplace – in supermarkets, restaurants, and the like. When this happens, patients are usually friendly and chatter pleasantly while we frantically try to recall their names and what had brought them to our clinics. It can even be amusing, like the time my (then) 4 year old daughter and I were in the dressing room of the community swimming pool, buck naked, when the guy next to me stared at me for a bit, then exclaimed “Hey – I recognize you. You’re Bob Resta. You called us with some great news the other day. I can’t wait to tell my wife I saw you.”

Sometimes, though, these chance encounters are awkward and complicated.

It was just before Christmas in the late 1990s. We were at the airport to pick up my daughter who was returning home after having finished her first semester at college . Watching your child become a young adult and start life’s journey evokes many conflicting emotions, but after four months apart mostly you are excited to see your kid again.

In the eyes of our offspring, parents are capable of the most acutely appalling acts that are a constant threat to a teen’s cool quotient. Once we recognize this, it becomes parents’  – well, mostly fathers’ –  life mission to engage in embarrassing public behaviors, in loving payback for their children’s you-are-so-geeky-old and you-are-not-related-to-me attitudes toward their hopelessly unhip elders. Lest my daughter forget what she had escaped from four months earlier,  we decided to greet her at the airport wearing low-budget reindeer antlers resplendent with miniature holiday decorations.

This was a more naive time when you could still greet passengers at the gate and you weren’t confined to waiting behind the luggage carousels far from where loved ones have exited their planes. Our excitement grew when the PA announced her flight’s arrival at Gate B4, antlers perched on our heads in full kitschy splendor, grins locked on our faces in anticipation of her eye-rolling horror.

The first passengers emerged at the gate, wearing a slightly confused look as their eyes and brains adjusted from the cruelly close horizon of the seatbacks in front of them to the hustle and bustle of a busy airport. I was scanning for my daughter among the exiting passengers when the foremost one approached me. “You’re Bob Resta” she said in a flat, low tone tinged with grief at its edges. “Last Christmas you called me with the most devastating news of my life. I will never forget your voice or what you said to me.” At a loss for words, I looked at her, unable to remember anything about her. She paused for a moment, looked a little longer into my eyes,  and then continued on her way.

Amid the background airport din, I could barely make out Joni Mitchell’s melancholy voice, “I wish I had a river /I could skate away on.” Shell-shock replaced my smile. One of my reindeer antlers drooped and its miniature candy cane decoration dangled helplessly. My gaze returned to the departing passengers but I lost track of why I was waiting there.

 

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Communication in the Genomic Era

Last month the Genomics Law Report, a blog about the “intersection of genomics, personalized medicine and the law,” launched a series called “What ELSI is New?” They invited guest commentaries from various disciplines to provide a short post on what they felt was the most important ELSI issue facing the fields of genomics and personalized medicine. If you haven’t had a chance to peruse the series of commentaries, I’d definitely recommend it. I love the idea of looking at an issue from 360 degrees.

In full disclosure, I was very excited to be invited to contribute to this series. And you can find contributions from familiar players such as the NSGC Board of directors and Sharon Terry of the Genetic Alliance here and here. In considering the series in it’s entirety, I was struck by how many submissions centered on communication: between scientists, physicians, patients, the public. Below are a couple of excerpts I found particularly relevant to the field of genetic counseling.

From Chris Gunter of the HudsonAlpha Institute for Biotechnology:

I am struck by the absolute hunger of the public to understand genomics and personalized medicine… I propose our field engage in our own form of personalization: using education and media in all forms to convert the energy of the public into an army for science…

From Mathew Harper of Forbes:

…if genomics is really going to impact medicine, we’re going to have to start bridging the gap between the companies and scientists doing this early work and the traditional medical establishment…23andMe’s big contribution has been to start this conversation, but we’re still a long way from figuring out how genomics will fit into medical culture, no less into the regulatory framework.

From Zoe Mitchell and Dr. Gavin Harper of Oxford Nanopore Technologies:

As we enter an era of personalized, genomic medicine, the understanding and communication of probabilities is likely to be a stumbling block, not only for the public but for clinicians too…How to provide context, interpretation and counselling around these complex sets of probabilities is a new challenge in statistics, ethics and psychology.

I realize that the importance of communication isn’t news to anyone in the genetic counseling world. However, I like that it seems to be a focal point for the early thought leaders in the genomic era. This, in turn, will hopefully make our job of ensuring that our voice is heard in this discussion, just a little bit easier.

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Professional Certification Debate

I wrote on this blog earlier regarding anxiety surrounding the new ABGC certification exam. To my personal relief, I found out this week that I am amongst those who passed. However, I cannot help but wonder how the passing score was determined and what this new exam means for our profession. What does a passing score on this paricular exam really tell employers, doctors, and patients? Question-Marks

I have spoken to a number of counselors who felt the exam was not focused enough on the genetics that we have worked so hard to become beyond competent in. While I have many thoughts and concerns about the meaning of this exam and its impact on future of the profession, I am going to await further explanation from the ABGC before I write on this more.

If you want an excellent summary of the ongoing discussion amongst genetic counselors about the validity of the exam and results, please check out the blog authored by SLC graduates Sarah Savage and Catherine Clinton:

http://gcqc.wordpress.com/

I am particulary interested in how the previously certified counselors feel about the use of this new exam. Please leave your comments here or at the above named blog.

ANOTHER THOUGHT:  Maybe we should consider moving foward with a general genetic counseling exam and then have subspecialty GC exams i.e prenatal, cancer, metabolic, pediatrics, etc..so we can show where we have special genetics knowledge? Similar to the way in which the ABMG grants their certifcation to biochemical geneticists or cytogeneticists. THOUGHTS?

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It Was Bound To Happen Amway or Another

amwayglobalearthquakes

Remember Edward R. Murrow?  No?  Me neither.  How about Walter Cronkite?  I met him once in an elevator in 1980 (if by “met” you mean that I mistook him for the elevator man and ordered the most famous news anchor of the day to take me to the fifth floor.  I recognized him by the familiar resonance of his voice as he replied, “Well, alright, young lady,” and we continued on together for the rest of the ride in an amiable silence, him smiling benignly, me wishing there was somewhere to hide in an elevator).

But I digress.  Here’s the point: for those of us ancient enough to remember, there was a time when everyone turned to a Walter Cronkite for the news.  The news guys didn’t always get it right, but truth was what they were aiming for.  Then somebody got the idea to give the news a slant — let’s not descend into name-calling here but SOMEBODY (rhymes with pox) got the idea to make news a little more exciting for their audience.  The old news was boring – while the new news was provocative and inflammatory, a veritable cocktail of rhetoric and innuendo with the occasional fact thrown in like a garnish.  Fact: the olive in the martini glass of new news.

And it worked.  The public liked the new news, or at least they liked it better than the old news, which was bad news for the purveyors of real news (although ironically it worked out very well for the champions of fake news).  Soon, everybody was busy finding an angle, so that now instead of that one boring half an hour in the classroom, we have twenty-four hours a day of happy hour, with everyone shouting to be heard over the noise in the bar.  Five o’clock somewhere; time for a drink!

But I digress.  What I meant to say was this: today I read in a press release that Amway Global has entered into a partnership with Interleukin Genetics to sell their trademarked Inherent Health line of genetic tests, including the new Weight Management Genetic Test and the soon-to-be released Bone Health Genetic Test, which measures liability for osteoporosis.  How excellent is that?

Of course, they’re not entirely sure that it actually measures liability for osteoporosis.  Sure, they stand by their claim that it will improve peoples’ health – but the test is not even due out for another month, so it is far too soon to have any idea if it works and besides, according to the press release, claims like this are not promises but “forward-looking statements.”  When an organization is trying so hard to be forward-looking, it is hardly fair to expect them to be right at the same time, since predicting the future is a dicey business (as people are likely to discover, using the Inherent Health line of genetic tests).  And the company tells you right up front (if by “up front” you mean buried in the small print at the end): “Because such statements include risks and uncertainties, actual results may differ materially from those expressed or implied by such forward-looking statements.”

Naturally, Amway “disclaims any obligation or intention to update these forward-looking statements.”  Of course not.  Because they might not launch the test at all, or the technology might become obsolete, or the whole thing might turn out to be complete and utter bulls**t.  But how boring is all that fact-checking stuff?  And don’t they already know what their customers want to hear?

Here’s a backwards-looking statement I would like to make: I think I’ve seen this movie before.  It’s called The Invention of Lying and it stars Bill O’Reilly and Lou Dobbs and Keith Olbermann.  The critics hated it, but it has a happy ending – eventually, everybody hears only what they want to hear, and if by mistake they stumble onto information that contradicts their preconceptions, they are free to disregard it entirely – because all statements include risks and uncertainties, and actual results may differ materially.

Scream and yell and howl at the moon, but Glen Beck is not going off the air until his ratings drop and Amway is going to sell genetic tests if people will buy 66waltercronkitethem.  Where does that leave genetic counselors?  Shall we agree to be the PBS news of genetic testing: a sober, sensible broadcast admired by many and watched by few?  There are worse things in life one could be than Jim Lehrer.  I think Walter Cronkite, were he still alive and assuming he had gotten over the incident in the elevator, would be proud.

Or, we could all go work for Amway… five o’clock somewhere; time for a drink!

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The Small Satori of Genetic Counseling

Let’s face it – lots of genetic counseling is repetitious. Most of us have subconsciously scripted our own version of a counseling session that we follow more rigidly than we like to admit, the inevitable outcome of seeing hundreds of fairly similar patients a year, year in and year out. On particularly busy days, you may even  lose track of where you were  in the session when a patient asks a tangential question or there is a knock on your door. It can be a slog, a Groundhog Day-like re-playing of the same film with only minor variations.

This repetition stems to some extent from the educational component of genetic counseling, the need to impart complicated biomedical information with the ultimate goal of helping patients making good decisions about their medical care and lives. We want to combine knowledge with emotional guidance so patients can gain wisdom and personal insight. Sometimes, though, as you watch dazed patients stumble out of your office, you start to wonder just how effective or helpful you have been.

On the other hand, there is a zen-like quality to constant repetition of the same act. By focusing strictly on the task at hand you master it through endless repetition. You eventually perform without thinking of the mechanics of performing, and achieve a state of mastery without thought .  Chop that wood, carry that water. Brush left, brush right, Karate Kid. This frees the mind, making it receptive to sudden, unanticipated moments of enlightenment – satori, in the language of Zen. With a free mind, you can subconsciously pick up cues from patients’ words, expressions, and postures, and suddenly, you see into the heart and soul of your patient – Wumen’s thunderclap out of a clear blue sky. Ah –  this cancer patient is angry because his mother walked out on the family when his father was diagnosed with terminal colon cancer, not because I kept them waiting 15 minutes for the appointment. Look – all the worry left her face when I said she really did not need to have an amniocentesis; she just needed someone in authority to tell her that it was a good decision.

What we really want, though, is for our patients to also have these small satori,  those magical moments when their faces light up, their eyes open wide, and everything falls into place for them.  These are some of the most rewarding and exciting moments of genetic counseling. Yes, yes, of course – I must tell my sister about my BRCA results to make sure she does not get ovarian cancer. She’s my sister ; I love her even if we are always bickering. You know – I just realized I do not need to have an amniocentesis; for some crazy reason, I was going to do it for my friends.

Repetition is critical to our professional development. In quiet, not-quite-perceptible ways, it builds our confidence, enhances our ability to understand our patients on a deep level, and plows the soil for the seeds of personal growth. For the compassionate bodhisattvas among us – like Jon Weil, June Peters, Luba Djurdjinovic and a few others – thunderclaps are second nature. For the rest of us – well, it’s back to chopping wood and carrying water.

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How To Work With Interpreters

Jessica’s most recent post, Interpretation Declined, struck a chord with me.  She brings up a very good topic and it was refreshing for me to see it from a different perspective. I wanted to expand on this topic some more since I have utilized interpreters as both a genetic counselor and as a patient.

Jessica writes about her experience as a genetic counselor who works with interpreters.  I’m writing from the other side of the fence; the patient’s experience using interpreters.  I hope some of you find this helpful or this serves as a refresher if nothing else.

The top 5 things I wish health care providers knew when working with interpreters.

Note:  I’m deaf myself and have worked with numerous interpreters in various settings.

1)    Make the situation less stressful as possible for everyone. It’s always stressful going to the doctor’s office but it is even more stressful not knowing if a qualified interpreter will be available for an appointment or if a medical provider knows how to use an interpreter.

I, personally, worry more about if an interpreter will be present at my doctor appointments than the actual appointment or not.  I greatly appreciate it when the doctor’s office calls me prior to my appointment to let me know if an interpreter has been scheduled.  This reduces my stress level and shows that the doctor’s office cares about accessibility and I’m a lot more likely to focus on my health itself than communication barriers that may arise.

When possible, genetic counselors should try to contact their patient in advance notifying them that an interpreter will be available even if it’s only an hour prior to the appointment.

This makes a big difference because it shows you respect your patients and shows them you want your patients to have equal access to information.

2)    Remember the interpreter is not there just for the patient, he/she is there for you also. For the longest time I felt like I was a burden whenever I needed an interpreter which in turn made me want to avoid going to the doctor.  Health care providers tended to make me feel like it was my fault I needed an interpreter because I couldn’t understand spoken English.

I read something a couple of years ago that made me realize that an interpreter is there not just for me but for the health care provider also.  I do not speak the same language my health care provider speaks and my health care provider does not speak the same language I do.  Hence we both need an interpreter to understand each other.

A suggestion for genetic counselors would be to remember it is not only the patient who needs an interpreter, YOU need an interpreter too.  Do not make the patient feel like he/she is a burden by making them feel like you had to go out of your way to work with an interpreter.

3)    Preparation. As genetic counselors we know the importance of case preparation prior to an appointment.  Don’t forget to prepare interpreters also.

When possible take 5 minutes prior to an appointment to review the case with the interpreter.  Mention the patient’s name because it is possible the interpreter may already know the patient from outside a medicine setting which could lead to awkward situations for the patient and possibly a bias in the translation.

Give a brief review of the case-particularly genetic terminology.   This gives you the chance to bring up any sensitive issues that an interpreter may say he/she cannot interpret without a bias.  A review of uncommonly used terminology helps ensure information gets translated correctly.

4)    Medical interpreters. My best health care experiences have involved medical interpreters.  I know many of you use telephone interpreters, but try and check as if your scheduled interpreter has any medical training.

If you work with a specific interpreting agency on a daily basis contact the company and ask if you can send some information to them that can be reviewed with interpreters.  I have found as a genetic counselor that it makes a huge difference when I provide an interpreter with a list of commonly used genetic terms with brief definitions.

5)    Know your rights and how to work with an interpreter. If you do not feel comfortable using a specific interpreter, request a different one.   You are entitled to working with a qualified interpreter.  Become familiar with the type of interpreter services your hospital works with.  How are those interpreters hired?  Do they have any medicine background?  What kind of certifications do they have?  Have they been trained to be neutral?  What are their qualifications?

Have high standards for interpreters you work with and develop work relationships with them.  Keep the communication line between you and interpreters open.

Don’t forget, you are speaking to your patient and not the interpreter.  Maintain eye contact with your patient and avoid using phrases such as “tell her,” “what does he think,” etc.

Relax and be comfortable.  🙂

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