An encounter with a patient who has limited or no proficiency in the English language (often referred to as LEP – for Limited English Proficiency)Leon presents a major challenge to both the medical staff and the interpreter. At Siloam we have a large percentage of our patients who do not communicate effectively in English. Our patient population is truly diverse, with 86% of our patients being foreign born, representing 85 countries, and speaking 77 languages. The two most common languages spoken by our LEP patients are Arabic and Spanish. We are truly blessed to have several staff providers who speak Spanish well enough that they can deal directly with their Latino patients.

However, in the overwhelming majority of the encounters with LEP patients, the linguistic and cultural gap between the patient and the provider must be successfully bridged in order to achieve a positive outcome for the patient. It is the interpreter (either physically present or telephonically available) who bears a major portion of the responsibility for ensuring that accurate communication takes place between the patient and the provider.

One of the biggest challenges that interpreters have to contend with is the use of idioms by the provider or the patient. Idioms are combinations of words that have a figurative meaning that is separate from their literal meaning. They are common expressions that cannot be properly understood by simply analyzing the meaning of the individual words. Idioms exist in all languages and we all use idioms in our daily speaking. They are important tools in communicating with others, and often add flavor and enhanced meaning to our communication. However, they can present the interpreter with cultural and linguistic challenges.

Here are just four examples in English that I have come across recently at Siloam:

–         “Hit the nail on the head.”

–         “The squeaky wheel gets the grease.”

–         “Between a rock and a hard place.”

–         “It’s a piece of cake.”


No one can be fully familiar with all the idioms in his or her native language, much less in any additional languages that they may speak. Consider for a moment that there are 21 countries where Spanish is spoken, 25 nations that speak Arabic, and 60 countries where English is spoken as the national or official language.

So, how should the interpreter react when faced with idioms?

–         Ideally, the interpreter will be familiar with the idiom that is used by the patient or the provider, and fully understands its meaning in the original language. He or she will also know if there is a direct equivalent in the other or target language. Allow me to use the four examples from above, from English to Spanish to highlight this.




Hit the nail on the head.” To be exactly right about something. Poner el dedo en la llaga.

(Put one’s finger on the sore spot.)

“The squeaky wheel gets the grease.”


The person who complains the loudest gets attention or service. Niño que no llora, no mama.

(The child who doesn’t cry, doesn’t suckle.)

“Between a rock and a hard place.”


You are in a difficult position where you have to choose between unpleasant alternatives. Entre la espada y la pared. (Between the sword and the wall.)
“It’s a piece of cake.”


Something that is very easy. Es pan comido.

 (It’s eaten bread.)

Now, let’s examine the two remaining possibilities:

–         There is no direct equivalent idiom in the target language. However, the interpreter understands the idiom in the original language and can accurately explain it in the target language.

–         The worst case scenario is when the interpreter does not know what the idiom means in the original language; does not know of an equivalent expression, and thus has no idea how to accurately interpret it into the target language.

What should the interpreter do in this last scenario? He/she cannot simply omit the phrase because it could be important for the other party, and the interpreter is responsible for rendering everything that is said in one language accurately into the other. The interpreter should immediately tell the other party that the person who just spoke used an idiom that the interpreter is unfamiliar with and the interpreter will now ask that person to explain what the idiom means. The interpreter will then tell the person who used the idiom that he/she didn’t understand it and request a clarification.   This is done to ensure “transparency” so that all parties know exactly what is going on.


What can providers and patients do to facilitate their interactions? One possibility would be to refrain from using idioms as much as possible. However, if they do use them, then they should verify that the interpreter has fully understood them and not be surprised if the interpreter requests a clarification.

The interpreter can mention the use of idioms during the pre-session briefing with the patient and provider.


Here are some useful Internet references for English idioms: This site enables you to find out the meaning of the most common English idioms.  This site offers an extensive dictionary of 3,739 English idiomatic expressions with their corresponding definitions. It also has a discussion forum and a section of recently added expressions. While the other two mentioned sites list their idioms alphabetically, this site goes a step beyond that. It also lists idioms by categories, such as Body Idioms and Medical and Health Idioms.

Siloam interpreters might wish to familiarize themselves with these sites when they are not busy with patients.

Dennis F. Caffrey
Certified Medical Interpreter – Spanish

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  1. Mark McCaw says:

    Thanks for this insightful blog. Watching idioms becomes even more critical as we as individuals pursue more distinct personal interests, yet, find ourselves mingling in a growing multi-cultural community. Do you find that idioms are more prevalent in the speech of Southern speakers (of the USA)?

  2. Karina Maza says:

    This is very interesting, Dennis! Thank you for sharing. I don’t think I’ve had the pleasure to meet you at Siloam. I think it’s important to sometimes remind providers that it’s better to refrain from using idioms, especially if they are working with interpreters whose first language is not English, since we are not so familiar with these expressions.

    P.S: It is important to note that “poner el dedo en la llaga” is not really the equivalent for “hit the nail on the head”. We actually use the same expression for this: “dar en el clavo”. “Poner el dedo en la llaga” means to say something uncomfortable or make someone feel bad about something that is already a painful experience. I guess in English, the equivalent would be “to rub salt in the wound”.


  3. Dennis Caffrey says:

    Karina: Thanks for your input. I fully agree with you that “dar en el clavo” is the closest, most direct Spanish idiom for “hit the nail on the head.” However, it is not the only one: others include “dar en el blanco/en la tecla, dar en el chiste”. or “poner el dedo en la llaga.” You correctly point out that “poner el dedo en la llaga” also has other meanings. I think this confirms the main point that I was hoping to make with my article – that idioms can be complicated in medical encounters and that, when possible, should be minimized.

    One area that has had my attention at Siloam for some time now is the lack of interaction among the volunteer interpreters, as well as between the interpreters and the medical staff in the context of improving our interactions with the patients. I am sure that situations arise on an individual encounter basis that could and should be shared with others (obviously without violating confidenciality). Up until now we have not had a means to share those situations with each other. As interpreters we rarely even see each other. For example, there is no overlap between shifts. I would be very interested in discussing any ideas you might have in this regard.

  4. Elizabeth Spencer says:

    Dennis, what a relevant topic…idoms in the face of medical interpreting. Thanks so much for your input. Idioms seem to roll off of my tongue without any thought. I totally agree about refraining from using them. Even though idioms can “lighten” a serious topic, which we come across in medical encounters, it is best to avoid confusion at all costs.

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