The clinical interaction
6.5 The interpreted consultation
listening was what set the stage for the all-important disclosure. In his time- less treatise Rhetoric, Aristotle wrote that one of the key skills of argumentation (which he, like many ancient Greeks, viewed as a highly scholarly activity) is the imaginative and intuitive decision of where to begin.67Had Dr Patel begun his evidence-based decision making at the obvious place (with asthma or hy- pertension), he would have short-changed his patient. Because he placed high priority on the quality of the interactional narrative, and was sensitive to the new story that was tentatively emerging, he discovered the starting point at which his patient – probably unconsciously – sought to begin their dialogue.
This is an example of the use of clinical intuition which I discuss in more detail in Section 5.3.
As illness in general becomes more complex, more multifaceted and more long-term (see Section 10.1), a ‘literary’ approach to clinical interaction (Charon’s ‘narrative competence’) is likely to become increasingly important in clinical practice. A working definition of such an approach might be that:
rNarrative competence views the illness, and the patient’s efforts to deal with it, as an unfolding story within his or her wider lifeworld.
rIt acknowledges the patient as the narrator of the story and the subject (rather than the object) of the tale, and hence gives central importance to the patient’s own role in defining, managing and making sense of the illness.
rIt recognises that a single problem or experience will generate multiple in- terpretations and that the key version to be addressed is the one framed and developed by the patient.
rIt embraces both trust (the patient makes herself vulnerable and stakes confi- dence in the clinician in the act of telling her story) and obligation (the clinician incurs ethical duties in the act of hearing it).
rIt views the spoken (and enacted) dialogue between health professional and patient as an integral part of the clinical management.
But as I hope I have shown in this section, narrative competence does not absolve the clinician of the duty to base his or her recommendations on the best available scientific evidence. Indeed, I believe passionately that the narrative- competent clinician will be better able to draw appropriately and judiciously on the tools and techniques of evidence-based medicine, to apply sensitivity and common sense to the application of evidence to this particular case and to communicate the ‘evidence’ to the patient in a way that is personally relevant and culturally congruent.
unless more than one such lens (and perhaps multiple lenses) are used. Table 6.2 shows a number of different approaches that have been taken to the academic study of the healthcare interpreting. You will see that some have taken a level of analysis above that of the individual consultation (e.g. the organisation, the professional group or the healthcare system) and are beyond the scope of this chapter on clinical interaction. I will consider below those traditions that have addressed healthcare interpreting at the level of the interpersonal interaction.
The most obvious (and, some would argue, the least well-theorised) ap- proach to studying interpreted consultations is to assume that the problem is purely one of translation. The interpreter is seen (in the words of one interpreter interviewed in my own research – see below) as a ‘bilingual parrot’. What is said individually by doctor and patient is assumed to be what each of them wanted to say, and the big research question is whether the interpreter has cor- rectly bridged the communication gap between them. Such research, which assumes a narrowly biomedical framework (the patient generally enters the consulting room with a ‘disease’ that needs to be diagnosed and treated, and must be given instructions about how to take the medication, etc. – see Section 2.1), is best undertaken by collecting audiotaped (or videotaped) consultations and getting an independent translator to ‘mark’ the quality of translation in each direction. Such studies have generally demonstrated that translation er- rors are common in some professionally interpreted consultations73and even more common when the interpreter is untrained (e.g. family member interpret- ing or using bilingual staff).70−72Most such studies conclude that the solution to this problem is to ensure that professional interpreters are more highly trained, that lay interpreting is discouraged (or even outlawed) and that standards for translation quality are developed and implemented.
As ever with the biomedical model, this approach to the interpreted con- sultation is very worthy, within the constraints of its world view. But research from the interaction analysis tradition (see Section 6.1) throws additional light on the interpreted consultation. Not only are such consultations often charac- terised by inaccurate translation, but they are also different in other ways from language-concordant consultations. In particular, as Ludwein Meeuwesen and her colleagues have shown, consultations across a language barrier with im- migrant patients are more likely to be shorter and to contain fewer words of welcome, less empathy and less orientation (e.g. telling the patient what to expect); and immigrant patients show less assertiveness (and less emotion in general) than indigenous ones.74,75These findings add another dimension of quality in interpreted consultations to the metaphor of the bilingual parrot!
Note that these findings do not contradict research on accuracy of translation – the latter is indeed a critical issue – but they are based on a different con- ceptualisation of the problem and hence start to add richness to the overall picture.
Another conceptualisation of the interpreted consultation sees it primarily as a complex social situation and is centrally interested in the presentation of self and the power relationships (and linked trust relationships) between clinician,
Table6.2Differentresearchtraditionsthathavestudiedhealthcareinterpreting. Qualityinthisresearch MainfocusMainlevelMainresearchtraditiondefinedmainlyExamplesofstudiesin DisciplinaryrootsofresearchGoalofanalysismethodsintermsofthistradition EpidemiologyMappingthe languageneedofa population Toinformplanningand provisionofinterpreting services
PopulationEpidemiological surveysNeedsassessment (languageneedis mappedaccurately, includingrelevant dialects,andchanges withtimearecaptured promptly)
Baker&Eversley (London),68McPake (Scotland)69 BiomedicineAssessingaccuracy andcompletenessof translationina clinician–patient exchange
Toimproveaccuracyof diagnosisandefficacyof treatment Interpersonal interaction Cross-checking translationof audiotaped consultations Accuracyoftranslation (phrasesusedby interpretermatchthose chosenbyan independenttranslator; therearenoomissions orembellishments)
Cambridge(UK),70 P¨ochhacker(Austria),71 Elderkin-Thompson (USA),72Angellelli (USA)73 PsychologyMeasuringtypeof communicationthat occursininterpreted consultationsand comparingthiswith non-interpretedones
Toinformtrainingand practiceofcliniciansInterpersonal interactionInteractionanalysis (seeSection6.1)Proportionofthe consultationthatisspent on,e.g.,welcomingthe patient,orientingthe patient,checking understanding,giving information,etc.
Meeuwesen (Netherlands)74,75
166
Medicalsociology/ sociolinguisticsExploringclinician– patient-interpreter interactioninits socialcontext,with emphasisonidentity, socialrolesand powerrelationships Toilluminatethesocial complexityofthe interpretedconsultation
Interpersonal interactioninits widersocialcontext In-depthqualitative analysisof transcriptsor narratives
Opencommunicative action(bothclinicianand patientseekmutual understandingandwork towardsthis).Voiceof thelifeworldisheardand attendedto(seetext). Interpretermoves judiciouslyand appropriatelybetween translatorandadvocacy roles
Roberts(UK),76Robb (UK),77,78Green(UK),80 Leanza(France)79 EconomicsEstimatingcostsand benefitsofdifferent servicemodelsof providing interpreters
Toimprove cost-effectivenessof services HealthcaresystemEconomicmodelling andevaluation Accuracy,sensitivityand transferabilityof economicmodel
Jacobs(USA)81 (Continued)
167
Table6.2(Continued) Qualityinthisresearch MainfocusMainlevelMainresearchtraditiondefinedmainlyExamplesofstudiesin DisciplinaryrootsofresearchGoalofanalysismethodsintermsofthistradition Organisational sociologyStudyingthe organisational processesand routinesthat underpinthe provisionof interpretingservices Toimproveservice efficiencyOrganisationIdeally,ethnographyExtenttowhichan effectiveandefficient processexistsfor providinganinterpreter wheneverapatient needsone
Greenhalgh(UK)82 Healthcare organisationand management
Estimatingthe qualityofcare providedwithand withoutinterpreters whentheseare needed Tomaximisequalityof careandminimiseerrorMultiplelevelsinthe healthcaresystemVariousmeasuresof qualityofcareProcessofcare(e.g. necessarytests completed),biomedical outcomes(e.g.cure), satisfaction,medical errorsoradverseevents
Green(USA),81,83Flores (systematicreviewof mainlyUSliterature)84 Education/ professional development
Identifyingand addressingtraining needsofinterpreters andclinicians Toensuretrained professionalswhowork welltogether ProfessionalgroupLearnerprofiling, trainingneeds analysis
Matchbetweenwhatis formallytaughtandwhat isneededforthejob. Hence, fitness-for-purposeof competencyframeworks andcoursecurricula Tebble(Australia),78 Harmsen (Netherlands),85Kalet (USA)86
168
patient and interpreter. Celia Roberts’ team from King’s College London, for example, studied videotaped consultations between London GPs and limited English-speaking patients, as well as consultations without a language bar- rier. They undertook detailed sociolinguistic analysis (see Section 6.2) of the transcripts of the consultations and supplemented this with an analysis of the
‘body language’ seen on the videotape.76In one study from this large dataset, they focused on the opening sequences in the discourse – the moments during which the patients have to report on why they have come. They found that English-speaking patients typically presented three things during the opening moments of the consultation: a description of symptoms, the context in which the symptoms occurred and an affective or epistemic stance (e.g. a comment on how much the symptoms mattered). These ‘micro discourse routines’ were framed in a particular way and associated with the presentation of a ‘moral self’
(e.g. a conscientious patient who had taken the medication as directed or a car- ing and concerned parent). Whilst some patients from non-English-speaking backgrounds used similar micro discourse routines, the majority configured the relationship between symptoms, context and the moral self in different and apparently less ‘orderly’ ways. With these patients, the opening moments of the consultation were typically protracted, frustrating and harder work inter- actionally for both sides. These findings suggest that the ‘accurate translation of what is said’ will not enable the consultation to proceed in the same manner that typically occurs in the absence of cultural and linguistic diversity. Rather, clinicians may need to be trained to expect, and respond to, a seemingly ‘dis- orderly’ presentation of self and symptoms in patients from certain cultural backgrounds.
My own team interviewed people (GPs, nurses, patients, professional inter- preters and family member interpreters) who had been involved in interpreted consultations in inner London GP surgeries. We asked them to tell us some sto- ries about recent interpreted consultations that had gone well and some about consultations that had gone less well.77,78 We analysed these narratives for insights into the different social roles and relationships as viewed by the par- ticular party we were interviewing. Our most striking finding was how difficult (and unusual) it was to achieve what Habermas called open communicative action (see Section 6.2). Very commonly, the constraints of the consultation – especially pressure of time and profound power imbalances – appeared to drive all parties towards a more strategic form of communication. For exam- ple, rather than giving the doctor an honest account of their symptoms and expecting to receive a possible diagnosis and a suggestion for next steps, pa- tients typically entered the consulting room with a particular goal in mind (prescription, referral, sick note) and attempted (with more or less success) to draw the interpreter into this strategic action. More commonly, however, the interpreter ‘sided’ with the clinician and appeared to collude in professionally led efforts to limit the patient’s agenda and get him or her out of the consulting room within the time allocated. A study by Leanza and colleagues in France produced very similar findings.79
An interesting finding from this research, which was also found indepen- dently by Judith Green’s team in a study of child interpreters,80was the very positive light in which the lay and family member interpreter was usually de- picted. Whereas the professional interpreter tended to align with the ‘voice of the system’(e.g. ‘editing out’when a patient mentioned using alternative reme- dies), friends and family member interpreters aligned strongly with the ‘voice of the lifeworld’ (see Section 6.3). They described an advocacy role – using their power in the consultation to ensure that the patient’s concerns were voiced and addressed, and articulating important lifeworld issues such as the impact of pain and disability even when the patient herself had not raised these.77Chil- dren who interpreted for relatives in healthcare consultations were generally proud of their role and saw it as an integral part of their bilingual identity80; patients who brought their children to interpret claimed they did it partly be- cause they could control what the child said more effectively than they could control the input of a professional interpreter!78
The growing body of research that draws on sociological and sociolinguistic theories adds richness to the study of the interpreted consultation and offers scope for defining new dimensions of quality in healthcare interpreting. The interpreted consultation is a key quality issue in the ‘globalised’ world of the twenty-first century and can be studied at multiple levels of analysis. Table 6.2 gives examples of researchers who have used epidemiological techniques to measure language need, organisational sociological techniques to study the administrative procedures and routines that support the provision of inter- preters and economic techniques to weigh the costs and benefits of different service models of interpreting.
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