Medical Interpreters’ Construction of a Mediator Role
Elaine Hsieh
Patients with limited-English-profi ciency (LEP) often experience inequality in health services and poor health outcomes. Researchers have noted that when language barriers exist in provider-patient communication (i.e., when com- pared to English-speaking patients), a patient is likely to receive more diagnos- tic testing (Hampers, Cha, Gutglass, Binns, & Krug, 1999; Waxman & Levitt, 2000); is less likely to receive preventive care (Woloshin, Schwartz, Katz, &
Welch, 1997) and follow-up appointments after an emergency department visit (Sarver & Baker, 2000); is less likely to understand health care providers’
instructions (Doty, 2003; Gerrish, 2001); and is less satisfi ed with the quality of care (David & Rhee, 1998). Their fi ndings suggest the urgent need to develop effective interventions to improve the quality of health care services received by patients with LEP, one of which is to provide interpreters in health care set- tings (Allen, 2000; Jones & Gill, 1998).
Interpreters often are viewed as the standard solution to language barriers between physicians and patients (Department of Health and Human Services, 2001; Flores, 2005; Flores et al., 2002; Woloshin et al., 1997). Interpreters tra- ditionally have been conceptualized as conduits, invisible non-thinking lan- guage modems that allow providers and patients who do not share a common language to communicate with each other. Interpreters-as-conduits remains the prevalent ideology of translation models and training programs in many dif- ferent areas. For example, the Cross-Cultural Health Care Program (1999), one of the leading programs in medical interpreter training, views the conduit role as the default role for interpreters. In an analysis of code of ethics docu- ments from more than 20 institutions, Kaufert and Putsch (1997) concluded that many of the codes emphasize a mode of interpretation that calls for an objective and neutral role for medical interpreters. The National Standards of Practice for Interpreters in Health Care recognizes the various responsibilities of interpreters (e.g., advocacy and cultural awareness) but still emphasizes the importance of accuracy and impartiality in interpreters’ practice (National Council on Interpreting in Health Care [NCIHC], 2005). Recently, NCIHC has proposed a national code of ethics for interpreters (for a complete discus- sion on the code of ethics, see NCIHC, 2004), which are based on three core
values: benefi cence, fi delity, and respect for the importance of culture and cul- tural differences. In regards to fi delity, NCIHC (2004, p. 13) noted,
The ethical responsibility of the interpreter, therefore, is to convert mes- sages rendered in one language into another without losing the essence of the meaning that is being conveyed and including all aspects of the message without making judgments as to what is relevant, important, or acceptable. […] The principle of fi delity requires that interpreters have the ability to detach themselves from the content of information.
The conduit model has been a prominent feature of the transmission mod- els of communication, viewing communication as the transfer of information from a sender to a receiver (for a discussion of Shannon & Weaver’s [1963/1949]
conduit and noise models, see Dysart-Gale, 2005). The model adopts a mono- logical and linear view of communication, assuming that meanings are cre- ated by the speakers (as opposed to co-created by all participants, including the interpreter, involved in the conversation; e.g., Bakhtin, 1981). The model also presupposes linear communication, in which the interactions between the speakers are only possible via the accurate, faithful, and neutral relay of the interpreter.
There are several reasons that a conduit model remains popular. First, interpreters traditionally have been expected to claim an invisible role (i.e., minimizing their presence and infl uence in the communicative process) so that they can claim authority and credibility for their services (Hsieh, 2002).
A conduit model allows interpreters to deny any personal interference with their work. Second, a conduit model appears to be a straightforward way of interpretation and requires minimal training (i.e., an interpreter just needs to relay everything and not make any judgment). When talking about the complexity of interpreters’ functions and roles in health care settings, Sara, a participant in our study who is also a practicing interpreter and trainer for medical interpreters, explained that the industry-standard 40-hour training is insuffi cient to educate the interpreters to be profi cient in the variety of roles;
however, she concluded, “You had better say, ‘Everybody has to be robot.’ That way, you don’t have to deal with all the other issues. […] It’s easier.” Finally, a conduit model suggests that the speakers are the only persons who have control over the process and content of communication. In other words, the speakers (e.g., provider and patient) can confi dently assume that the inter- preter says exactly what they said and that they still have full control over the information exchanged
The ideology of interpreters-as-conduits has been challenged in the past few years. Language and social interaction researchers have argued that human communication exchanges are always dialogical and the meanings and contents of communication are co-constructed by all participants of the communicative activity (Georgakopoulou, 2002; Miller, Hengst, Alexander, &
Bilingual Health Communication 137 Sperry, 2000). Through both qualitative and quantitative analyses, research- ers recently have argued that interpreters are not neutral or impartial par- ticipants in medical encounters but actively participate the communicative process (Angelelli, 2002, 2004; Davidson, 2000, 2001; Hale, 1999; Hale &
Gibbons, 1999; Metzger, 1999; Rosenberg, 2001). Angelelli (2002, 2004) con- cluded that interpreters perceive their role as visible regardless of their work settings (e.g., conferences, courts, or hospitals), which also is evident in their role performances in the communicative process (i.e., actively intervening in the interpreter-mediated interactions). Interpreters often need to reconcile between the ideology and the practice of medical interpreting (Hsieh, 2001, 2006a, 2006b). In fact, interpreters may assume a variety of roles (e.g., conduit, co-diagnostician, institutional gatekeeper, patient advocate, and professional) to manage the complexity of bilingual provider-patient interactions (Hsieh, 2004a, 2006a, 2007). These studies successfully challenged the idea of inter- preter neutrality and inspired researchers to develop more complex theories of interpreter-mediated activities.
These studies, however, suggest a missing link in researchers’ efforts to deconstruct interpreters’ claim of neutrality (i.e., a conduit role): If the conduit model remains the dominant ideology in the training programs and code of ethics for medical interpreters (Dysart-Gale, 2005), how do interpreters legiti- mize their practice? Do they still claim a conduit role? If yes, why and how do they enact the role?
To answer this question, I undertook a study to examine the roles of medi- cal interpreters. Results reported here are part of a larger study, which included ethnographic shadowing of Mandarin Chinese interpreters’ daily assignments (i.e., participant observation) and in-depth interviews with interpreters from various cultures. I recruited medical interpreters from two interpreting agen- cies in the midwestern area in the United States. Both agencies view medi- cal interpreting as their primary task and have contractual relationships with local hospitals. A total of 26 participants from 17 languages (i.e., Arabic, Armenian, Assyrian, Mandarin Chinese, Cantonese, French, German, Hindi, Kurdish, Polish, Russian, Spanish, Turkish, Ukrainian, Urdu, Vietnamese, and Yoruba), of whom 21 were practicing medical interpreters and 5 held manage- ment positions in interpreting offi ces. Interpreters included in this study are all considered professional interpreters and work as freelance interpreters in local hospitals. The majority of interpreters (n = 17) had participated in a 40-hour training course developed by the Cross Cultural Health Care Pro- gram (CCHCP), which has been viewed as an industry-recognized standard for training professional interpreters. Those who had not attended the course either had passed certifi cation programs offered by individual hospitals or had acted as trainers in education programs for medical interpreters.
I shadowed two Mandarin Chinese interpreters for the ethnographic study, following their daily routines, audio-recording the interpreter-mediated medi- cal encounters, and taking fi eldnotes to include nonverbal and contextual
information. Three months after the beginning of the ethnographic study, I conducted 14 individual and 6 dyadic interviews (each lasted 1 to 1½ hours).
All dyadic interviews consisted of two interpreters from different languages (except one that included two Spanish interpreters). In these interviews, I relied on my experience as a medical interpreter and my prior data collected through the participant observation to navigate through the design, preparation, and interview process. Two research assistants and I used grounded theory for the data analysis for both the ethnographic and interview data (Strauss & Corbin, 1998). The focus of the research questions was to explore interpreters’ under- standing of their roles and to generate rich and diverse views, opinions, and experiences from participants of various cultures. The transcription includes two primary types of notation. The texts are CAPITALIZED when they were the speakers’ emphasis and italicized when they were my emphasis. Each inter- preter is assigned a pseudonym. In the transcript, health care providers are denoted as H, interpreters as I, and patients as P. I also have assigned pseud- onyms for all participants so that readers have a better understanding of the interactions and relationships between providers, interpreters, and patients.
A total of 11 health care providers, four patients, one patients’ family mem- ber, and two mandarin Chinese interpreters were included in the participant observation data. All providers’ pseudonyms begin with H (e.g., Helen and Henry) and the four patients’ pseudonyms begin with P (e.g., Pam and Paula), and the Chinese interpreters are Christie and Claire.
The Construction of an Invisible Role
Conduit was, by far, the role that is identifi ed most explicitly and frequently by the interpreters in this study (i.e., 21 of 26 participants claimed various forms of a conduit role). By examining interpreters’ narratives and the metaphors with which they explicitly identifi ed, I will demonstrate that interpreters’ con- ceptualization of the conduit role extends beyond an information or linguistic transferring role. Contrary to an earlier study (Angelelli, 2002), which con- cluded that interpreters perceived their role as visible across various settings, the interpreters of this study strived to be invisible (i.e., to minimize their presence) in provider-patient interactions. For example, Selena, an interpreter with 32-years experience, stated, “I am sort of in the background, I am the voice, I try to be faceless. That way, I don’t interfere with their communication or their rapport between the patient and the provider.” Colin described his role, “I try not to exist in a sense. I just sort of let the patient and the provider talk, and I just interpret.” Sara explained, “The goal [of medical interpreting]
would be to perform such a job that it seems that you were never there.”
Interpreters who identify with a conduit role often claimed that all that they do is “just interpret everything” and they are “just interpreters.” The con- stant use of “just” in their narratives refl ect their effort to claim a limited role (i.e., they are nothing more than a conduit). Claire explained,
Bilingual Health Communication 139 Because when I went through the training, we have to interpret every- thing exactly as what the doctor said, even have to interpret exactly the same tone, and same expression, and the same use of words. So, I just did the same. I would always try to follow what I learned in the class. So, I did the same thing. I just interpreted in Chinese, just equivalent what he said in English.
The pursuit for neutrality challenges interpreters to justify their perfor- mances. Their physical presence in the medical encounters and their func- tions in eliminating language and cultural barriers between providers and patients make it diffi cult for interpreters to claim that they are truly faceless or nonexistent. Some interpreters claim a non-thinking status to justify their inter- preting strategy. In other words, if their performances do not require them to think in the communicative process, they cannot interfere with the process or the content of provider-patient communication. Peter explained, “No matter what my judgment or my opinion, or my feelings [are], in a health care provider setting, I interpreted everything.” Roger shared a similar attitude, “You cannot adjust [information] the way you like it or how you think. You are here to work, not to think. Remember.”
Metaphors for the Conduit Role
In addition to the claims about a non-thinking role, interpreters developed many metaphors that are indicative of a conduit role. For example, interpreters often claimed that they are just the voice. The voice metaphor often is associ- ated with the interpreters’ desire to establish direct communication between the providers and the patients. Scott explained, “We are like the voice, we are not a person. […] We become the voice of the professional, but we also become the voice of the patient. We are not a person in terms of being addressed to us directly.” Interpreters in this study talked about how they actively incorporate this concept in their practice. For example, Silvia said, “I am only the voice and I keep reminding the doctor and the patient to talk to each other.” Sophia said that at the beginning of a medical encounter, she would explain to her clients, “I am just a voice of you. Whatever you said is what I am going to say without adding or removing or anything. I’d rather if you talk directly to [each other].”
Robot (or machine) is another metaphor that interpreters used to describe their roles. The mechanical nature (i.e., non-thinking, non-feeling, and yet highly-skilled characteristics) of a robot corresponds to the values of a con- duit model. A few interpreters talked about their roles as robots or machines.
For example, Steve explained, “I mean I’d rather be considered more like a machine. They know that I am there, and then, I am doing my job, but I’d rather not be there as another person controlling the situation at all.” Sara even argued, “If you want to keep your job, you want to become, really, a kind
of robot in order to keep your job.” A mechanical view of interpreting is valued because human beings make mistakes and machines are thought to be more reliable, performing with great consistency. Shirley, a manager of interpreter services, recognized the human nature of interpreters, which may become unreliable as pressure mounts:
We are human, and we have feelings, it’s just like everybody else. However, in that moment, you are the person that the staff is depending on to pro- vide that communication, to convey the same spirit that it is being given.
So, the last thing that the team needs is for that instrument to crumble.
Alternatively, interpreters used the robot metaphor to describe their struggles to adhere to a conduit role. A robot metaphor often was used to contrast inter- preters’ emotional reaction in medical encounters. As a result, robot becomes a metaphor that is situated against interpreters’ awareness of the challenge (i.e., their human nature) to live up to a conduit role (also see Hsieh, 2006a).
Although a robot metaphor often highlights the interpreters’ sense of confl ict, it, nevertheless, refl ects interpreters’ understanding of the expected roles that others have placed on them. Rachel talked about such internal confl icts:
We learned that we don’t have to talk to patients. We learned that. We are not allowed, right? I don’t like that. I can tell you, ‘It’s not right.’ We are not robots. We have training; I know why we are here. But I say that because it’s not true, I am not a robot.
Bridge is another metaphor that often is adopted by interpreters to describe their functions. A bridge, in a sense, is much like a conduit, providing a neu- tral channel for communication without adding personal interpretation or opinions. Steve explained, “I would just say that I’m there to provide some of the language bridge, to be a conduit.” Rachel echoed, “My role is just to be a bridge, a bridge between the doctor and the patient.” Although the bridge metaphor seems to be similar to a conduit in the sense that it provides a neutral channel for successful communication, interpreters’ comment often refl ected their awareness of the educational, socioeconomic, and cultural gaps between providers and patients. Rachel explained,
[The goal of medical interpreting is] to help other people to bridge the gap, that’s pretty much the theme of all the [training] classes. To help other people from our own country who do not speak English, who don’t know the system and who don’t know the culture, just to help them, guide them along, and help them as much as you can, to get through it.
Interpreters talk about how they adjust speakers’ register, interject their own explanations, describe terms that have no linguistic equivalent, check for
Bilingual Health Communication 141 understanding when necessary, or provide a necessary cultural framework for understanding. It is important to note that although these behaviors do not belong to the conduit role proposed by Cross Cultural Health Care Pro- gram (CCHCP, 1999), a major training program for medical interpreters in the United States, interpreters talked about these behaviors without seeming to be aware that these behaviors require them to become an active participant in the communication, evaluating the communicative process and interfering as necessary, which in fact makes them more than a conduit. In other words, although interpreters use bridge as a metaphor to describe the conduit role, the metaphor actually encompasses communicative behaviors that do not belong to a conduit role.
It is important to note that the interpreters who used a bridge metaphor still saw themselves as conduits. They also talked about their non-thinking status and neutrality. For example, after identifying his role as a bridge, Peter explained his interpreting strategy, “No matter how I feel, what is my private opinion, I interpreted everything that was said in the room.” Colin talked about how interpreters are bridges between two languages, providing cultural frameworks to other conversational partners; however, when one of his patients was asked to leave the clinic because of the lack of funds, Colin decided to not get involved because “It’s not my battle. Being an interpreter, that’s not our battle.” In other words, although interpreters were aware of their functions in bridging the gaps between the provider and the patient in various aspects (e.g., linguistic, cultural, educational, and socioeconomic aspects), they still strived to be and saw themselves as conduits. Nevertheless, the interpreters’ use of the bridge metaphor highlighted the fact that their understanding of the “conduit”
role has extended beyond the conduit model envisioned in their training pro- grams and the ideology of translation and interpretation.
The Communicative Goals of an Invisible Role
Conduit roles require interpreters to refrain from evaluating the process and the content of communication and interpret all information during the medi- cal encounter. Interpreters talk about conduit roles as a way to accomplish two major communicative goals: (a) transferring complete information, and (b) reinforcing the provider-patient relationship.
Transferring Complete Information
The fi rst goal is consistent with the ideology of conduit as it focuses on the neutral and faithful transfer of information. In Extract 001, the interpreter (Claire) performed a straightforward conduit role, helping the provider (Hil- lary) to investigate the patient’s (Paul) treatment history for his diabetes.