Conduit or co-participant: A discussion of interpreting models.
While much has been written on models of interpreting, perspectives on this subject have evolved with the growth of the profession. In health care settings, as elsewhere, research and practice have redefined traditional interpreting roles in the interests of producing more effective communication.
Perhaps the best-known recent discussion of a sign language interpreter’s role in medical interpreting is found in Metzger’s Sign Language Interpreting: Deconstructing the Myth of Neutrality (1999). Metzger introduced her research with this statement: “In discussions of the issue of interpreter neutrality, the anecdotes that interpreters and lay people share suggest that the traditional perception of the interpreter’s role as a neutral conduit of language is at odds with people’s real-life experiences” (p. 1). Her study analyzed two types of medical discourse mediated by interpreters. One set of data was from role-plays of medical interviews facilitated by student interpreters, and the other was from actual medical interviews facilitated by a professional interpreter. In addition to translating statements made by the health care provider and the patient, both groups of interpreters were found to initiate statements on their own. These included “source attributions,” i.e., indicating who was talking, repetitions, requests for clarification, dealing with interference, and calling for the attention of one of the parties (pp. 114-122). Her findings were similar to those in Roy’s (1989 & 1993, as cited in Metzger, 1999) analysis of interpreted dialogue: Interpreters participate in the discourse by regulating turns, and by altering discourse to accomplish participants’ goals.
Studies on spoken language interpreting have found similar results. Wadensjo (1992) studied medical interviews interpreted by spoken language interpreters and categorized their performances as “relaying,” i.e., conveying what the parties intended to say, and “coordinating” (pp. 18-19). Coordinating functions include asking for clarification, prompting a response or turn from one of the parties, explaining what one party means, or explaining that one party doesn’t understand the other. Angelelli (2003) proposed the term “visible co-participant” to describe the interpreter’s role, in contrast with the invisible, completely neutral role traditionally ascribed to interpreters and still commonly promoted in professional organizations of interpreters and in interpreter education (pp. 3-26).
In her book, Medical Interpreting and Cross-Cultural Communication, Angelelli (2004) noted that, due to the lack of a “theoretical underpinning to account for the special type of interaction that occurs in a medical setting,” standards of practice for interpreters are often based on those for court or conference interpreting, valuing accuracy over goal, intent and context, and seeing the interpreter as a conduit (pp. 2, 7). She observed and interviewed spoken language interpreters in a California hospital who had a great deal of experience in medical interpreting, but little formal training. Angelelli found that the interpreters both saw and conducted themselves as “co-constructors to the interaction,” rather than as invisible interpreters (p. 7). The interpreters actively managed issues of power and solidarity, and the asymmetrical relations between speakers of dominant and less dominant languages. She described the interpreter’s role as “opaque co-participant” rather than “transparent language modem” (p. 11). She pointed out that interpreters accomplish this by means of “text ownership,” i.e., saying something not originated by one of the parties to the encounter, in response to social factors such as the patient’s ethnicity, level of education, or socio-economic status (p. 76). She proposed a continuum of interpreter visibility that ranges from low to high, with a corresponding impact on the medical or personal information involved. Interpreters in this study used a variety of metaphors to describe their roles as they saw them: bridge, detective, diamond connoisseur, and miner, the last three referring to their perception of the need to locate relevant information amid an extended response to a health care provider’s question (pp. 130-131). Wadensjo’s (1992), Metzger’s (1999), Roy’s and Angelelli’s research all showed that an interpreted conversation is necessarily “triadic,” i.e., the interpreter is an active participant in a three-party conversation (p. 4).
Dysart-Gale (2007) pointed out that the view of interpreters as conduits is based on the “transmission model of communication” (p. 240). The medical discipline has traditionally followed this model as well: The doctor talks and the patient listens (p. 241). The author suggested that a more appropriate model for both parties involved is the “semiotic model,” which envisions meaning evolving through the collaboration of the participants. Writing about spoken language interpreters, Dysart-Gale proposed additional roles: clarifier, cultural broker, and patient advocate (p. 239). As clarifier, the interpreter might add information when a cultural difference renders the message unclear. An interpreter acting as cultural broker would provide a cultural framework that allows the receiver to understand the message, and an interpreter in an advocate role might act on behalf of the patient outside of the medical interview, with the goal of promoting quality of care as well as quality of communication. Dysart-Gale added that “role expansion” is controversial, and that some fear it is tantamount to “practicing medicine without a license” (p. 240).
Araujo-Lane and Phillips mentioned that interpreters run the risk of blurring the boundaries between interpreting and medical practice (p. 171). They suggested that interpreters need to explore the concepts of impartiality and transparency and find a “professional center,” which allows them to be accurate and ethical while being transparent and aware of “a complex dynamic that involves understanding themselves, the patient’s culture and the U.S. health care system” (pp. 167-173). According to Solomon (1997), to achieve transparency interpreters must explain to health care providers the difficulties they encounter in translating a concept, and negotiate ways in which it might be adapted to make it understandable (p. 91).
Metzger (1999) recommended that a similar strategy be used toward Deaf patients. Arguing that one issue is the differing schema between health care providers and Deaf patients, she suggested that interpreters should provide information about the interpreted interview to both parties so that all have a similar schema (p. 197). Interpreters need to recognize that, although they cannot include their own opinions and ideas in their interpretations, they cannot as humans be entirely impartial either. In the field of sign language interpreting, a well-known article by Charlotte Baker-Shenk (1991) entitled “The Interpreter: Machine, Advocate or Ally?” reminds interpreters that they cannot be completely neutral. They must be aware of the impact of the choices they make, and make responsible decisions (p. 120ff).
Although there is little research on the actual behavior of sign language interpreters in medical settings other than Metzger’s work, there is research on spoken language medical interpreters’ behavior. Kaufert and Putsch (1997, as cited in Angelelli, 2003, p. 6) found that interpreters expanded and adapted health care providers’ communication, provided cultural explanations and advocated on behalf of patients. Hsieh (2006) studied 26 professional spoken language interpreters who had completed 40 hours of training developed by the Cross Cultural Health Care Program (p. 5). The author found that the interpreters saw themselves as part of the health care team, and tailored their communication strategies to the goal of diagnostic efficacy, for example, by “editorializing” information to emphasize key medical points, seeking information on their own without a prompt from the health care provider, and volunteering medical information to patients. “Editorializing” took the form of deciding whether or not information provided by the patient had medical value before passing it on to the provider, or editing the provider’s statements to more efficiently elicit information from patients (p. 7). Interpreters also substituted medical concepts for patients’ culture-specific comments about their illnesses (p. 28). When the provider left the room, they often summarized, explained, or repeated previous information for the patient. Occasionally they even went so far as to volunteer information on their own, such as suggesting an alternate treatment or discussing their own experience with a disease. The researcher concluded that the interpreters were acting on their own preconceived notions of doctors as authority figures, rather than on an actual assessment of the current interaction, causing them to over-emphasize the information-gathering aspect of the encounter at the expense of the doctor’s goal of establishing a relationship with the patient (p. 23). The behaviors of the interpreters in Hsieh’s study contrast sharply with the model most sign language interpreters follow. For example, Neumann-Solow (1981) advised interpreters to leave explanations of terms to the medical professionals (p. 6).
Often, the difficulties interpreters are responding to when they deviate from the neutral role have to do with conflicting expectations or with cultural differences between provider and patient. A common example, familiar to ASL-English medical interpreters, is the cultural difference between a provider who expects a brief answer to a question about the current illness and a patient whose culture requires that an explanation of the present circumstances be rooted in past events. Spanish speakers, like ASL users, often respond with narratives rather than one-word answers (Sanheim, 2003, p. 35). Mediating culture and world-view are challenges both spoken and sign language interpreters face.
Interpreters and cultural differences.
According to Shuy (1976), problems that arise in medical interviews can be attributed to differences in linguistic and cultural backgrounds and to different goals and understandings of the interaction by patients and health care providers (p. 365). Harmer (1999) characterized “health care culture” as emphasizing rapid diagnosis and treatment, efficient use of services, and a minimum of interaction (p. 86). Lee (2002) suggested that differences between patients’ and doctors’ cultural beliefs and values “hinder the establishment of the cooperative partnership” important in a doctor-patient relationship (as cited in Angelelli , p. 19). Cambridge (1999) wrote that dangers are inherent in the interpreted medical encounter due to the participants’ “lack of a common ground within the transaction” (p. 201).
Mindess’ 1999 book, Reading Between the Signs: Intercultural Communication for Sign Language Interpreters, highlights some of the cultural differences between the culture of the U.S. non-deaf majority and U.S. culturally Deaf citizens as they influence the interpreting process. For example, non-deaf mainstream Americans living in a relatively low-context culture value self-reliance and independence (p. 70). In contrast, Deaf Americans live in a more high-context culture, and place more value on the group than on the individual (p. 113). In a telecourse presentation comparing Deaf and non-deaf cultures, Marie Philip (1993) explained that it is customary for a Deaf person to consult others in the group before making an important decision, a practice that would be seen as overly dependent by many U.S. non-deaf majority members. Harmer suggested that some “grassroots” Deaf people may seek out better-educated peers for medical advice (p. 90).
This kind of cultural difference is not unique to the Deaf community. Dysart-Gale (2007) explained that group members might develop their beliefs and attitudes toward disease not from information given by health care providers, but through communicating with their social group (p. 241). Commenting on a study by Kaufert and Putsch (1997) that showed spoken language interpreters making cultural adjustments in their interpretations, Solomon (1997) pointed out that the emphasis in medical encounters is on patient autonomy. However, not all cultures value autonomy. In some cultures, the preferred norm is to allow a spouse, family members or friends to participate with the patient in important medical decisions (p. 89ff).
Mindess (1999) suggested several techniques for cultural adjustment and provided concrete examples, some of which are specifically related to medical settings. She also provided a “mental checklist” that interpreters can use to decide whether an adjustment is needed (pp.189-190). In these examples, “Not only did the interpreters not take over, but by their skillful handling of the situations and elimination of cultural red herrings, they allowed the participants themselves to control their interactions” (p. 188). This is a definite contrast to the practice of interpreters profiled in Hsieh (2006, ), who took a much more directive approach to cultural mediation, resulting in a skewing of the intent of the encounter.
Dysart-Gale (2007) wrote, “Almost by definition, medical interpreting is a service most often provided to socially marginalized groups …” (p. 238). This can affect communication in many ways. For example, Lee pointed out that doctors should not assume that patients will ask questions when they are confused or unsure, and should realize that the absence of questions does not indicate that patients are uninterested in knowing (as cited in Angelelli, , p. 19). Ferguson and Candib (2002) noted that minority group patients, especially those who do not speak English well, are less likely to evoke physician empathy, establish rapport with health care providers, receive sufficient information, and be involved in medical decisions (as cited in Angelelli, , p. 21).
Davidson (1998, as cited in Angelelli, ) suggested that the doctor and the patient have different views of an interpreter in a medical encounter. The doctor sees the interpreter as “an instrument that keeps the patient on track,” and the patient considers the interpreter a “co-conversationalist”. The author concluded that spoken language interpreters align themselves with health care providers, serving as “gatekeepers” for the patients for whom they interpret.
Given the obvious complexity of the medical interpreting task, it is clear that interpreters need preparation before working in this setting. Preparation includes both formal training and education, and knowledge needed for a specific medical encounter. Resources for both types of preparation will be reviewed in a later section of this paper.
Professional ethics and standards.
In both sign and spoken language interpreting, professional standards provide a critical foundation for effective interpreter practice; this is especially true of interpreting in medical settings. Bancroft (2005), as part of a project for the National Council on Interpreting in Health Care (NCIHC), reviewed interpreting standards worldwide, comparing their content (p. vi). Most emphasized consumers’ health and well-being, promotion of the patient-provider bond, and respect for all parties (p. 25). Relying primarily on standards from the International Medical Interpreters Association (http://www.mmia.org/), the California Health Care Interpreters Association (cms.chiaonline.org), and the “Bridging the Gap” curriculum (www.xculture.org), the NCIHC developed a set of standards for medical interpreters (http://www.ncihc.org/). The goal of the standards is to facilitate communication, promote accurate interpreting, support the patient-provider relationship, establish procedures for mediation during the interpreted encounter, overcome barriers to understanding, and promote ethical behavior. Although RID has a Standard Practice Paper entitled “Interpreting in Health Care Settings,” its purpose is more for guidance of consumers than of interpreters (http://www.rid.org/). The organization provides no specific standards for medical interpreting.
Both RID and the NCIHC have ethical codes available on their websites to guide interpreters’ practice. The NAD-RID Code of Professional Conduct, instituted in 2005, includes seven tenets, with “guiding principles” and “illustrative behaviors” for each. The NAD-RID code is intended to cover all situations, including medical. The NCIHC code is specific to medical interpreting, and includes the following standards: accuracy, confidentiality, impartiality, respect, cultural awareness, role boundaries, professionalism, professional development, and advocacy. Unlike the NAD-RID code, NCIHC guidelines specifically mention “cultural context” as a part of the interpreter’s purview, and encourage the interpreter to increase his/her cultural awareness. NCIHC also specifically states that the interpreter “may be justified in acting as an advocate”. The NAD-RID code allows the interpreter to “judiciously provide information or referral regarding available interpreting or community resources without infringing upon consumers’ rights” (Professionalism; Illustrative Behavior, 2.6).
Professional ethics are customarily included as part of sign language interpreter education, and many resources are available to program students and instructors. Although several of these, for example, Stewart and Witter-Merithew (2006), Cartwright (1999), and Humphrey (1999), included medical interpreting among the scenarios in their texts, they offered no specific guidance about how to make ethical decisions in health care settings. However, Gish (1990) specifically addressed ethical decision-making and health care. This book provides exercises in values clarification, gives a historical perspective on health care ethics, discusses specific health care issues such as distribution of health care resources, looks at the impact of stress and illness on communicators, reviews legal issues in health care, and leads students through both decision-making and professional communication activities.
The NCIHC also provides a “Guide to Initial Assessment of Interpreter Qualifications,” published in April 2001, intended to lay out a strategy for assessment of medical interpreters. This guide can be used either in conjunction with other quality assurance measures such as state or national certification, or alone. It includes basic language skills, ethical case studies, cultural issues, health care terminology, integrated interpreting skills, and translation of simple instructions.
RID has a national testing and certification program which awards both a generalist certificate and a certificate for legal interpreters. To date, RID does not certify medical interpreters.
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