![]()
1
INTERPRETER-MEDIATED MEDICAL ENCOUNTERS AS A FIELD OF RESEARCH
Interpreter-mediated medical encounters represent an interdisciplinary area of research as it highlights the intersection of languages, cultures, and medicine, all of which entail distinct values and norms. Since 2000, there has been a significant increase in related research (Brisset, Leanza, & Laforest, 2013), with the United States being the country with the most publications in this area. In countries that are considered multi-ethnic societies (e.g., Australia and Canada) or that represent a destination of intensive immigration (e.g., Denmark, Germany, The Netherlands, Spain, Switzerland, the United States, and the United Kingdom), there have been strong collaborations between the government, the healthcare industry, and the research community to ensure quality care for patients who experience language barriers in healthcare settings. In this book, I use the term language-discordant patients rather than patients with limited English proficiency (LEP) or hearing impairment to include the broader category of patients who do not share the same language with their providers, including all signed and spoken languages.
The recent increase in research publications signals an important confluence and paradigm shift in the conceptualization of interpreter-mediated medical encounters. In particular, researchers from a wide variety of traditions and disciplines, including translation and interpreting studies, linguistics, communication, and medicine have provided unique perspectives to the conceptualization and investigation of this area. Rather than situating healthcare interpreting in a particular disciplinary tradition, my goal is to put the phenomenon of interpreter-mediated medical encounters front and center. In particular, in this chapter, I will:
ā¢situate interpreter-mediated medical encounters in multiple disciplines
ā¢explore the theoretical contributions of interpreter visibility and roles
ā¢investigate institutional control over interpreter performances
ā¢examine the assumptions of and preferences for professional healthcare interpreters.
A.What Is an Interpreter-Mediated Medical Encounter?
Depending on the disciplinary tradition, interpreter-mediated medical encounters have been called and/or conceptualized differently. Compared to the long traditions of translation studies, which are rooted in comparative literature and religious studies (Kelly, 1979), interpreting studies1 is a fledgling discipline that first gained its professional identity through simultaneous interpreters (now often called conference interpreters) during the Nuremberg Trials after World War II (Gaiba, 1998; Pƶchhacker & Shlesinger, 2002). Interpreter-mediated medical encounters did not become a topic of interest in interpreting studies until the 1990s, when healthcare interpreters begin to demand a professional identity through accreditation and training (Harris, 1997). Within the field of interpreting studies, itās often called medical interpreting or healthcare interpreting, referring to interpreting activities (i.e., relaying information from one language to another) that take place in healthcare settings. A search of the literature suggests that the first use of the term medical interpreting appears in The Multilingual Manual for Medical Interpreting, a reference tool that allows providers to communicate through phonetic transliteration to diagnose and examine patients who do not speak English (Guercio, 1960). The first use of the term healthcare interpreting appears much later (i.e., in the late 1990s) in journal articles (Morgan, 1998; Pƶchhacker & Kadric, 1999). In recent years, there have been proponents for each term. Some argue that healthcare interpreting encompasses a broader definition of health-related interpreting activities than medical interpreting, much like legal interpreting is a richer category than court interpreting. Others argue that medical interpreting lends more weight to the importance of interpretersā work (A. Clifford, personal communication, August 14, 2013).
In this book, I choose the term healthcare interpreting/interpreter (rather than medical interpreting/interpreter) to avoid confusion with health professionals who often need to interpret medical records for diagnostic and treatment purposes. Healthcare interpreters include any individual who provides interpreting services to patients who do not share the same language as their providers. Healthcare interpreters therefore include both signed and spoken language interpreters, working in different modalities with varying degrees of professionalism (see Chapter 4).
In the field of interpreting studies, healthcare interpreting is also understood as part of the larger category of community interpreting (Hale, 2007). Community interpreting is at times used interchangeably with public service interpreting, ad hoc interpreting, cultural interpreting, escort interpreting, liaison interpreting, contact interpreting, three-cornered interpreting, or dialogue interpreting. Itās important to note that because interpreting studies is a young discipline, the specific terms for its subfields are still changing. Each term highlights a slightly different aspect of the interpreting activity. For example, community interpreting and public services interpreting involve interpreters who provide services to assist individuals to access resources (e.g., court services, social welfare, public services, and healthcare services) within a specific social system or community (Pƶchhacker, 1999). Ad hoc interpreting suggests that the interpreters are typically untrained and provide makeshift services (Roberts, 1997). Liaison interpreting, along with escort interpreting, contact interpreting, and three-cornered interpreting, highlights interpreting activities involving interpreters who interact directly with at least two parties (Gentile, Ozolins, & Vsilakakos, 1996). Dialogue interpreting highlights the interactive and dynamic nature of the communicative activity. All these terms are contrasted with simultaneous conference interpreting,2 in which interpreters are highly trained professionals who provide simultaneous interpreting (i.e., interpreting while the speaker is talking) in a remote booth (often located at the back of a conference room) while their clients use headphones to listen to the interpreting.
In the fields of medicine and public health, interpreter-mediated medical encounters are generally situated in the larger subfields of minority health and cross-cultural care, which often are concerned about (a) health disparities (i.e., differences in the access to care as well as the processes, quality, and outcomes of care) experienced by minority and marginalized populations (e.g., patients with limited English proficiency (LEP) or hearing impairment) and (b) the unique social determinants (e.g., sociocultural norms, illness ideologies, cultural beliefs, education, insurance status, among other social constructs) that shape these individualsā illness experiences (Hogue, Hargraves, Collins, & Fund, 2000). Within the field of minority health, interpreter-mediated medical encounters are often conceptualized under the umbrella topic of language barriers or language access to care. Researchers of this topic area are concerned about how language-discordant patients can have equal access to and the same quality of care as their language-concordant counterparts.
The literature has provided conclusive evidence that when patients do not share the same language as their providers, they experience significant health disparities. They often receive fewer preventive services, fewer public health services, fewer referrals/follow-ups, and poorer quality of pain treatment, but utilize more resources (e.g., more diagnostic tests and longer hospital stays) when they do visit healthcare institutions (David & Rhee, 1998; Flynn et al., 2013; Jimenez, Moreno, Leng, Buchwald, & Morales, 2012; Lindholm, Hargraves, Ferguson, & Reed, 2012; Woloshin, Schwartz, Katz, & Welch, 1997). At an interpersonal level, they and their family members also receive lower quality of care, including but not limited to reduced interpersonal support, less patient-centered communication, and less patient satisfaction even in areas unrelated to language (Baker & Hayes, 1997; Karliner, Hwang, Nickleach, & Kaplan, 2011; Thornton, Pham, Engelberg, Jackson, & Curtis, 2009).
Parentsā LEP status is also a major predictor of their childrenās health disparities. Children of parents with LEP (compared to those with English-proficient parents) have delayed illness care, reduced routine care, higher resource utilization for diagnostic testing, longer hospital stays after an adverse event, and longer visits in the emergency department (Flores, Abreu, & Tomany-Korman, 2005; Lion et al., 2013). Parents with LEP have a higher risk of problematic medication dosing (Flores et al., 2005). They are also associated with triple the odds of a child having fair/poor health status, double the odds of a child spending at least one day in bed for illness in the past year, and significantly greater odds of a child not being brought in for needed medical care for six of nine access barriers to care (Flores et al., 2005). Compared to child patients whose families do not have language barriers, those whose families have language barriers have a significantly increased risk for serious medical events during pediatric hospitalization (Cohen, Rivara, Marcuse, McPhillips, & Davis, 2005). Although researchers are uncertain about the exact processes and pathways in which language barriers create health disparities (Jacobs, Chen, Karliner, Agger-Gupta, & Mutha, 2006), interpreters have been viewed as the standard solution to improve language-discordant patientsā access to and quality of care.
Following the traditions of medical sociology, applied linguistics, and communication, researchers have examined the content and processes of interpreter-mediated providerāpatient interactions to explore (a) individualsā discursive practices in performing and negotiating specific roles, functions, and identities, and (b) participantsā attitudes, expectations, and evaluations of effective and appropriate behaviors in interpreter-mediated interactions. In these fields, interpreter-mediated medical encounters often are categorized under providerāpatient communication, a subfield of health communication. The early breakthroughs and momentum in the theoretical developments in interpreter-mediated medical encounters are from researchers who adopted these approaches. In particular, researchers were influenced by Goffman (1959, 1979) and Bakhtin (1981), exploring interpretersā management of the discursive process (e.g., Wadensjƶ, 1998) and role performances (e.g., Kaufert & Koolage, 1984). They conceptualized interpreters as active participants in mediating other participantsā diverse goals and objectives in healthcare settings.
It is important to note that interpreter-mediated medical encounters were investigated in the fields of medicine and social sciences for decades before researchers in interpreting studies recognized their significance (Pƶchhacker & Shlesinger, 2005). In particular, early publications largely emerged in the field of mental health as healthcare practitioners pondered about the roles, functions, and professional boundaries of interpreters in mental health care, an area in which language (performance) is both the site of a patientās symptom and the tool of the providerās diagnosis and treatment (Alderete, 1967; Bloom, Hanson, Frires, & South, 1966). To these scholars, a successful interpreter-mediated medical encounter is not just about interpretersā linguistic performances in relaying information from one language to another. Rather, researchers and practitioners conceptualized interpretersā functions and performances as an element of the therapeutic processes of healthcare delivery.
It is from this perspective that I extend my support for a paradigm shift in conceptualizing interpreter-mediated medical encounters. Rather than simply scrutinizing interpretersā āaccurateā transfer of information from one language to another, we need to recognize that the success of healthcare interpreting cannot be evaluated through equivalences between the source texts and target texts alone. Healthcare interpreting is situated in a larger communicative event (i.e., providerāpatient interaction) that entails specific goals (e.g., improving patientsā health), which are accomplished through healthcare delivery. While these arguments may have been proposed by other researchers, few have proposed a theoretical model for the corresponding changes in conceptualizing interpreter-mediated medical encounters. What does it mean when such a paradigm shift is applied to bilingual health care?
Patientsā health outcomes, including the quality of care and quality of life, cannot be overlooked as one considers the quality and success of interpreter-mediated medical encounters. In addition, the communicative event is situated in organizational settings/contexts, which may impose obligations and limitations of individual behaviors (for providers, patients, and interpreters alike). Interpreters are not simply there to relay information. They are part of the healthcare delivery team, shouldering the shared responsibilities and objectives with other health professionals.
Interpreter-mediated medical encounters, thus, represent a unique form of interpreting activity. The interpreter, as part of the healthcare team, is obligated to honor the organizational objectives in providing quality care that enhances the patientsā health outcomes. These objectives can be operationalized and their success can be measured (e.g., patient-centered communication, resource utilization, biomedical markers, and patient satisfaction). The criteria for evaluating the success of providerāpatient interaction should be no different than those for assessing the quality of interpreter-mediated medical encounters. From this perspective, language-concordant providerāpatient interactions can serve as the control group for interpreter-mediated interactions, a unique condition for studies of interpreter-mediated interactions. In other words, the interpreter performances are optimal when patients in interpreter-mediated interactions experience the same or better quality of care than their language-concordant counterparts, resulting in their improved health outcomes.
It is important to note that I do not argue that interpreter-mediated encounters should have the same quality of care as their language-concordant counterparts. The literature suggests that low health literacy (e.g., not having adequate skills to seek, process, and utilize health information to make informed health decisions) is a common problem in the United States, with only 12 percent of the population having proficient health literacy (National Network of Libraries of Medicine, 2013). We can assume that most people, including English-speaking individuals, do not have adequate communicative competence in providerāpatient interactions. Low health literacy is linked to poorer health outcomes and knowledge, problematic health behaviors, and disparities in resource utilization (e.g., increased hospitalization and emergency care and decreased preventive care; Berkman et al., 2011). There may be situations in which an interpreter can enable a language-discordant patient to enjoy a quality of care that is better than that of his/her counterpart. In later chapters, I will explore how such possibilities may exist and how they can be accomplished. For ...
