Written by: Brad

Davidson

Presented by: Toyin Ola

THE INTERPRETER AS INSTITUTIONAL GATEKEEPER:

THE SOCIAL-LINGUISTIC ROLE OF INTERPRETERS IN SPANISH-ENGLISH MEDICAL DISCOURSE

IntroductionTable 1. Riverview General Hospital Patient

Demographics, by year

Background-The interpreter as conversational participant-Institutions and the mediation of post-colonial discourses -Medical discourse and medical interpretation-Methods and Data

The Interpreter in Medical Interviews-The interpreter as co-interviewer-Quantifi able patterns of interference in interpreted medical

interviewsTable 2. Treatment of Patient-generated direct responses

in 10 same-language visits Table 3. Treatment of Patient-generated direct responses

in 10 interpreted visits Table 4. Complaints addressed and diagnosed in visits 6

and 7 -The loss of patient complaints

Conclusions and Discussion

OVERVIEW

INTRODUCTION

In 1995, as part of a survey of 83 hospitals, it was found that 11% of all patients require an interpreter

The interpreter has a unique position as being the only participant who can follow both sides of a cross-linguistic interaction

Increase in view that the interpreter must act as a negotiator or point of exchange for the diff ering social contexts of the physician and patient Uncontested, yet largely under-researched, hypothesis

WHY THE INTEREST?

Confl icting expectations Hospital administrators and physicians believe that it is

possible to render an interpretation with no additions, subtractions, or changes

Research has show that perfect interpretation is “unattainable”

Management of conversational goals Inherent power differential in medical encounter Cross-cultural hospital encounters as 3 rd World immigrants

vs. agents of 1st World institutions Interpreter as institutional agent

The “interpretive habits” or patterned ways in which changes to the linguistic form of utterances influences the discourse What do interpreters think is their reason for interpreting

(i.e. how do they conceive of their role)?

PRESENT RESEARCHER’S INTEREST

The number of LEP patients seen at Riverview doubled from 1981 to 1993

Spanish-speaking LEP patients make-up 25% of all patients seen at the hospital

BACKGROUND

Oral mode of translation (i.e. conversion of written texts) Monologues “Linguistic conversions of isolated utterances”

Hymes’ SPEAKING model Interpreter as ‘spokesperson’ or ‘sender’ rather than

‘source’ or ‘addressor’

Goff man Interpreter as ‘animator’ rather than ‘author’ or ‘principal’

“Interpreter’s obligation to be a perfect echo of the primary interlocutors”

PAST APPROACHES

Consequences of interpreter’s role as a… Historical agent Linguistic intermediary Social intermediary

Interpreter’s responsibility for the achievement of conversational goals Wadensjö Effect of interpreter’s choices on the outcomes

Interpreter as a co-constructor Shaping messages “in the name of those for whom [she] speaks”

Also, consider the impact of the social and historical facts surrounding the interpreted speech event

THE INTERPRETER AS CONVERSATIONAL PARTICIPANT

Location of speech events in the historical-political timeline

Institutionally defined goals and institutionally reinforced habits Gives clear expectations of how communication should

proceed for those familiar with the institution (e.g. learned medical interview) Consider Grice’s cooperative principle

Interpreter as a double gatekeeper Conflict between providing a service and exercising control

inherent in interpreting +gatekeeping for the institution Gatekeeping =filtering information to facilitate the

achievement of certain goals

INSTITUTIONS AND THE MEDIATION OF POST-COLONIAL DISCOURSE

Main goal of this research

To examine to what extent the nature of an institutionalized, structured speech event (a hospital-based medical interview) influenced an interpreter’s “interpretive habits”

The nature of the medical interview : “The medical habit of differential diagnosis” “Reality of chronic time shortages”

INSTITUTIONS AND THE MEDIATION OF POST-COLONIAL DISCOURSE CON’T

Medical interview Learned by physicians in medical schools Consider Tebble’s schema

Elaborated goals of the medical interview1) “from the data provided, determine what, if anything, is

wrong with the patient”2) “elaborate a plan of treatment for that aliment”3) “convince the patient of the validity of the diagnosis so

that treatment will be followed”

MEDICAL DISCOURSE & MEDICAL INTERPRETATION

Diagnosis as an interpretive process “a matching of unorganized experiences against familiar

patterns or human vulnerability to disease”

MEDICAL DISCOURSE & MEDICAL INTERPRETATION

Physicians gather patient’s physical and verbal data

Physicians re-analyze this data by passing the information through a biological and social grid

‘Irrelevant’ patient data is excluded

“The story of the disease is constructed”

How do interpreters fit into this differential diagnosis process?

Riverview Hospital in Northern California Internal medicine Patients with chronic illness (regular visits) Interpreters “professional in the sense that they were paid

employees of the hospital” “ad hoc vacuum of accountability”

100 visits; 50 audiotaped; 20 transcribed Questionnaires and interviews Paired bilingual and monolingual interviews

Observed both the hospital-based interpreter and the institutional setting How interpreter presence shaped (course/content) the

medical interview How interpreter mediated institutional goals (diagnosis and

treatment in a timely fashion) vs. patient goals

METHODS & DATA

Research Questions:

What is the role of the interpreter within the goal-oriented, learned form of interaction known as the ‘medical interview’?

What is the ‘interpretive habit,’ and how does one engage in the practice of interpreting?

If interpreters are not neutral, do they challenge the authority of the ‘physician-judge,’ and act as patient ‘ambassadors’ or ‘advocates’; or do they reinforce the institutional authority of the physician and the healthcare establishment, and should we create a model for the ‘interpreter-judge’?

METHODS & DATA

THE INTERPRETER IN MEDICAL

INTERVIEWS

At Riverview, it was common for the interpreter to arrive before the physician and begin gathering information from the patient Consider time constraints Consider the differential diagnosis process

Two eff ects from interpreter serving as co-interviewer Pro: from the physician’s point of view, it was easier to

discern the chief complaint since the patient’s information had been simplified

Con: the interpreter often continued to lead the interview even after the physician had arrived

THE INTERPRETER AS CO-INTERVIEWER

TRANSCRIPTION CONVENTIONS

QUANTIFIABLE PATTERNS OF INTERFERENCE IN INTERPRETED MEDICAL INTERVIEWS

Interpreter does not render an utterance even when explicitly asked to do so

Interpreter has subsumed other participants’ roles (e.g. doctor only speaks when they are looking for a stool to put the patient’s foot on)

Interpreter is running the interview and managing parallel and related conversations

Interpreter decides that the patient’s explanation about telling the doctor at a prior visit (i.e. and indirect response detailing when the symptom began) is not relevant, so she negotiates with the patient until he provides a direct response to the doctor’s question

Consider threats to institutional goals

and hierarchy

Again, the interpreter is the dominant participant in the interaction

QUANTIFIABLE PATTERNS OF INTERFERENCE IN INTERPRETED MEDICAL

INTERVIEWS

QUANTIFIABLE PATTERNS OF INTERFERENCE IN INTERPRETED MEDICAL

INTERVIEWS

(To what extent) Are interpreters answering patient questions to insulate physicians from patient challenges to their authority?

Why is it problematic that patients’ questions aren’t being answered? • Patients seen as passive (more likely to be diagnosed as having

psychosomatic illness) • Physicians cannot follow-up (because the are unaware of the issues)

THE LOSS OF PATIENT COMPLAINTS

CONCLUSIONS & DISCUSSION

What is the role of the interpreter within the goal-oriented, learned form of interaction known as the ‘medical interview’?

What is the ‘interpretive habit,’ and how does one engage in the practice of interpreting?

If interpreters are not neutral, do they challenge the authority of the ‘physician-judge,’ and act as patient ‘ambassadors’ or ‘advocates’; or do they reinforce the institutional authority of the physician and the healthcare establishment, and should we create a model for the ‘interpreter-judge’?

RESEARCH QUESTIONS RE-VISITED

Lack of Status & Funding 7 full-time Spanish interpreters to service 33,000 patients Explicit discouragement of drawing attention to the need

for more interpreters because there were no funds to do so

Lack of Training Interpreters only required to have self-professed fluency in

English and Spanish + the ability to translate 50 medical terms on a written assessment

No training for staff on how to work with interpreters

Lack of Time Short-staffed throughout the hospital

Ex: over 100 nurses fired during the data collection Physicians expected to see an increasing number of patients in

the same amount of time

INSTITUTIONAL PROBLEMS

Role of the interpreter

Expected: Physicians, researchers, etc. believe that interpreters often

serve as patient advocates on ambassadors Interpreters also expected to keep patient “on track” and save

time

Observed : Selective interpreting in a patterned fashion Based on the interpreter’s belief that she is an

informational/institutional gatekeeper meant to keep the medical interview “on track” (i.e. minimize the amount of time that interpreted interactions take)

Interpreter-judge

DIFFERENT PERCEPTIONS

Idea of “neutral” conduit is unrealistic Differences in conceptual conveyance of information between

linguistic systems Interpreter as social agent and (special category of)

participant in an interaction“Good job at a bad task”

Must consider context of the communication (e.g. time pressure) when viewing transcripts of failed interactions

No institutional support No clearly defined expectations No training for the tasks they’re expected to do (e.g. establish

therapeutic rapport, gather information, etc.) Invisibility of co-diagnostician role Unethical to align “wholesale” with the institution (i.e.

the hospital) Cannot discard other responsibilities to serve as a time saver

INTERPRETER FAILURE?

CONTINUE TO ACTIVITY!