Framing the Narrative for Modern-Day Medical Interpreters

In the Spring and Summer of 2017, the Doerr Institute for New Leaders at Rice University awarded the HRC a leadership development grant to advance the center's medical humanities programming and promotion of undergraduate research, specifically in the area of "Medical Leadership." With supplemental support from the HRC, the HURC 306 course on "Medical Leadership" was complemented by a speaker series on the subject, bringing in experts on the topic from Houston and beyond. Read more on the speaker series here. In the Summer, the HRC awarded three research fellowships to non-graduating undergraduates, to pursue their own research projects on the topic. Working with medical faculty at Baylor College of Medicine, Augusto De las Casas worked with Dr. Ricardo Nuila to study leadership in the context of medical translators' work, Sarah Lasater worked with Dean Jennifer Christner's office to study leadership in the context of physician professional education, and Shaian Mohammadian worked with Robert Trieu's office to study leadership in the context of hospital administration.

Sarah and Augusto's work has continued in the Fall 2017 semester; they are currently going through Baylor's IRB process to continue their research.


The patient-physician relationship is dependent upon effective communication. In cases where patients are limited in English proficiency (LEP), most American providers have a need for assistance to supplement their professional expertise in this important area of the relationship. In the medical arena, the usage of in-person translators is consistently increasing and viewed as the gold standard for communication services[fn]“Physicians Comfort with Translation Services in Non-English Speaking Patients Enhances Patients' Compliance with Recommendations.” Outcomes Research. (n.d.). Am J Gastroenterol, 104(S3), S398–S431. Retrieved from http://dx.doi.org/10.1038/ajg.2009.492_1[/fn] [fn]“Professional Medical Translators and Non-Professional Translators Serve Valuable Roles in Adherence to Recommendations by Non-English Speaking Patients” Outcomes Research. (n.d.). Am J Gastroenterol, 104(S3), S398–S431. Retrieved from http://dx.doi.org/10.1038/ajg.2009.492_18[/fn]. Areas with greater ethnic diversity are more likely to be dependent on the work of healthcare interpreters; according to the most recent census data, 34% of Harris County residents speak Spanish[fn]U.S. Census Bureau. “Detailed Languages Spoken at Home and Ability to Speak English for the Population 5 years and Over for States: 2009-2014.” Web. 23 April 2017.[/fn]. This paper takes as its starting point an exploration of the importance of interpreters in the quality of healthcare delivery in multilingual environments, in order to contextualize an analysis of a divergence between the literature and training of healthcare interpreters and their actual performance as modern interpreters in a medical setting, and finally to lay out a reconsideration of the medical encounter in terms of a triadic doctor-patient-translator relationship.

Medical translators in the United States are trained to follow traditional utilitarian guidelines thatiew their role of interpreter in terms of a conduit: a channel that translates information from one language to another[fn]"Interpretation Guidelines." National Health and Nutrition Examination Survey (2011): n. pag. Web. 2 June 2017.[/fn] [fn]National Council for Interpreting in Health Care. "National Standards of Practice for Interpreters in Health Care." (2005): n. pag. Sept. 2005. Web. 2 June 2017.[/fn] [fn]Hsieh, Elaine, and Eric M. Kramer. “Medical Interpreters as Tools: Dangers and Challenges in the Utilitarian Approach to Interpreters’ Roles and Functions.” Patient education and counseling 89.1 (2012): 158–162. PMC. Web. 17 June 2017.[/fn]. In theory, having the interpreter detach themselves from the patient-physician encounter allows for communication to flow unhindered by any personal beliefs or presumptions that the third party may have. Reality is otherwise. In my own experience collaborating with medical interpreters at the MD Anderson (TX) and Memorial Regional System (FL), it is apparent that interpreters often deviate from the interpreter-as-conduit model and act in a manner that they believe will maximize patient care. Literature supports this anecdotal experience. Studies make the case that medical interpreters adopt the roles of a patient advocate, codiagnostician, and cultural mediator among other roles depending on the circumstances of the encounter6,8. More theoretically, the philosophical case has been made, regarding multilingual communication, that “a successful interpreter-mediated medical encounter is a collaborative achievement among [the patient, interpreter, and physician]”.[fn]Hsieh, Elaine. Bilingual Health Communication: Working with Interpreters in Cross-cultural Care. New York: Routledge Taylor & Francis Group, 2016. Print.[/fn] In brief, the guidelines set in place by health care councils seem outdated when examining the contrast that exists between the ideology and both the reality of and theoretical reflections on medical translation. Accepting a model for medical interpreters that clashes with the reality of the practice has consequences that can potentially compromise the wellbeing of the patient, the quality of healthcare delivered to the patient, and a misunderstanding from the provider and patient’s point of view with regards to what they can expect of a medical interpreter.

In response to these critiques, a newer model of medical translation known as the “interpreter-as-codiagnostician” role arose. In the “codiagnostician” approach, the interpreter plays a role in the patient-physician encounter in which the translator’s opinions are valued and legitimate. Dr. Hsieh, an expert on bilingual health communication and the professor who proposed the model, defines the codiagnostician model as a role an interpreter assumes that “enables them to provide services typically associated with providers.”[fn]Hsieh, E. (2007). Interpreters as co-diagnosticians: Overlapping roles and services between providers and interpreters. Social Science & Medicine, 64(4), 924–937. https://doi.org/http://dx.doi.org/10.1016/j.socscimed.2006.10.015[/fn] The growing number of [fn]Hsieh, E. (2007). Interpreters as co-diagnosticians: Overlapping roles and services between providers and interpreters. Social Science & Medicine, 64(4), 924–937. https://doi.org/http://dx.doi.org/10.1016/j.socscimed.2006.10.015[/fn] [fn]Hsieh, Elaine. Bilingual Health Communication: Working with Interpreters in Cross-cultural Care. New York: Routledge Taylor & Francis Group, 2016. Print.[/fn] [fn]B. Davidson. “The interpreter as institutional gatekeeper: The social-linguistic role of interpreters in Spanish–English medical discourse.” Journal of Sociolinguistics, 4 (2000).[/fn] [fn]C.V. Angelelli. “Medical interpreting and cross-cultural communication.” Cambridge University Press, Cambridge, UK (2004).[/fn] articles referencing the interpreter-as-codiagnostician model suggests a growing awareness of a tension between theory and practice in the conduit model. This paper will therefore also illustrate the implications of the “as-codiagnostician” role and relate them to the application of the theory in medical encounters and specifically how they pertain to types of leadership in healthcare.

Reasoning for Choosing the “as-Codiagnostician” Role and “as-Conduit” Model

The “interpreter-as-conduit” model will be frequently discussed in this paper because it is the dominant philosophy behind the theory of medical interpreting.[fn]National Health and Nutrition Examination Survey. "Interpretation Guidelines."[/fn] [fn]National Council for Interpreting in Health Care. "National Standards of Practice."[/fn] It is often viewed as the “gold standard” of medical interpreting - it is what theologians had in mind when they envisioned the guidelines an ideal interpreter would follow. While the “as-conduit” approach is considered a model in the context of interpreting guidelines, the interpreting practice holds that the “as-conduit” approach is one role among many that interpreters assume. Other roles, such as “patient advocate”, “integration agent”, and “cultural broker” are also likely candidates for roles that an interpreter will assume during a typical interpreter-mediated encounter.

The “as-codiagnostician” role will be compared to the “as-conduit” model because these are the two foremost styles that relay information through the perspective of a provider. This is useful because research on medical interpreting implicitly regards language concordant patient-physician interactions as the control and language discordant patient-physician interactions. In other words, medical interpreting theory suggests that a successful interpreter-mediated encounter is one that most resembles the patient-provider dyad. The “interpreter-as-codiagnostician” role places the interpreter under the provider umbrella, whereas other roles, such as “integration agent” or “cultural broker”, treat the interpreter as an intermediate. While some may argue that the “interpreter-as-patient-advocate” role maintains the integrity of the patient-physician dyad by categorizing the interpreter on the side of the patient, the ramifications of such a move are more likely to be disadvantageous for patient care given that most professional interpreters are employed by a corporation and must therefore align with their mission, not the mission of the patient.

Interpreting Guidelines and the Styles of Interpretation

In 2006, the National Health and Nutrition Examination Service created a set of “Interpretation Guidelines” intended to outline how medical interpreters and clinicians should act during a physician encounter.[fn]National Health and Nutrition Examination Survey. "Interpretation Guidelines."[/fn] In “Interpretation Guidelines”, the medical interpreter is expected to behave according to the conduit model,[fn]Roy, C. B. "A Sociolinguistic Analysis of the Interpreter’s Role in Simultaneous Talk in a Face-to-Face Interpreted Dialogue." Sign Language Studies, vol. 74, 1992, pp. 21-61.[/fn] which includes translating everything that is said between the provider and the patient without adding, omitting, or changing any of the words uttered, having no side conversations, and speaking while respecting the patient’s privacy and culture. Guidelines are also provided for the physician, who should speak at a moderate pace, pausing between sentences and cueing the medical interpreter to convey the message. The clinician is to speak to the patient directly, as if there was no third party, and the interpreter is to translate in the first person, using words like “I” when speaking. The interpreter-as-conduit model is often referred to as the utilitarian model, as the interpreter is used as a tool whose opinions are not essential in the patient-physician interaction8. The interpreter-as-conduit model assumes that there is no shift in the dynamics of communication in the introduction of a third party and that the physician and patient will behave as they would if the interpreter was absent, and they spoke the same language.

This dominant, utilitarian, interpreter-as-conduit approach has been challenged by a second, more novel “co-diagnostician” approach in which the interpreter plays a role in the patient-physician encounter. Their inputs are recognized and their opinions are valued as legitimate. Given that the “interpreter-as-codiagnostician” role implies that the interpreter aligns their interpreting style with that of a provider,[fn]Hsieh, Bilingual Health Communication.[/fn] interpreter’s inputs, whether good or bad, are more likely to be accepted by the patient because of the association the patient creates between the interpreter and the intent of delivering the best patient care. While this may seem favorable for the team of providers given that this approach inclines the patient to listen more attentively and more willingly, advice solicited by a member of the healthcare institution without the adequate healthcare credentials that physicians have can put the patient at risk at the expense of the doctor and the institution. The former model, which supplies the theory behind the guidelines, emphasizes absolute physician authority, given that they are the only party whose professional opinion matters; the latter calls for a mixture of physician and interpreter leadership, authorizing the interpreter to submit their own perspective into the encounter.

In the world of medicine, leadership is an assembly of healthcare workers with different skills who seek to achieve the shared goal of patient welfare.[fn]Gardner, John William. “On Leadership”. New York, NY: Free Pr., 1993.[/fn] [fn]Reinertsen, James L. "Physicians as Leaders in the Improvement of Health Care Systems." Annals of Internal Medicine 128.10 (1998): 833.[/fn] In the context of communication in a medical setting, this concept of leadership would translate to the willingness and confidence of a provider (physician, interpreter) to do everything in their power to obtain the patient’s trust (despite the language barrier) with the end goal of maximizing patient care. The differing models of translation we have discussed affect what leadership means in this context. In the conduit model, physician leadership could look like a clinician taking the initiative to conduct the rapport-building small talk that gives them greater insight into the background of their patient while making them feel more comfortable in spite of the communicative obstruction. It is important to realize that medical interpreters cannot execute leadership during the consultation, though they can research relevant terminology for their next encounter before it takes place. For the “as-codiagnostician” role, physicians can also begin to recognize and play off the strengths of their fellow co-diagnostician, the interpreter, in addition to taking the necessary steps to achieving a seamless encounter in terms of communication. Medical interpreters can now take the initiative of conducting their own rapport-building small talk, better manage the flow of the conversation, etc. while maintaining the physician’s opinion as more important than their own and keeping the original principles of cultural respect and providing the best patient care. Tension, as in times of emotional distress for a patient, would reduce, as interpreters can console and advise them instead of being absentminded bystanders. Interpreters could also be more inclined to point out any remarks that a physician or patient may have missed.

Consequences of Interpreting Ideologies

It is important to understand what the shortcomings of both philosophies are. The utilitarian approach overlooks two important things: 1) that interpreters are often put in a situation in which some of the physician’s professional values are compromised, and 2) that interpreters are supposed to act in such a way as to respect the patient’s culture. These oversights make interpreter-mediated encounters prone to a sense of tension and are a likely cause of decrease in follow-up rates.[fn]Bernstein, J., Bernstein, E., Dave, A., Hardt, E., James, T., Linden, J., … Safi, C. (2002). Trained Medical Interpreters in the Emergency Department: Effects on Services, Subsequent Charges, and Follow-up. Journal of Immigrant Health, 4(4), 171–176. https://doi.org/10.1023/A:1020125425820[/fn] Interpreters are often subject to unfavorable situations where even their roles as conduits are compromised by either their institution or by the physicians they are working for. For instance, in encounters where time is highly constrained, a doctor may ask an interpreter to push the pace of the meeting, omitting some responses that the patients give that don’t directly contribute to the diagnosis, causing them to deviate from the idealized model. The following excerpt is derived from a study conducted by Dr. Hsieh in "Medical Interpreters as Tools: Dangers and Challenges in the Utilitarian Approach to Interpreters’ Roles and Functions”:

“‘Okay, I am going to ask a question, you give me the answer. If it doesn’t deal with my question, I don’t want to hear it.’ I have that kind of doctors before.”

The previous quote came from an interpreter’s recollection of a direct quote from a doctor she worked with. In this case, the doctor asked the interpreter to withhold translating what the doctor deemed to be useless information in order to push the pace of the session. This strictly violates the code of interpreters as they have been taught to translate everything that has been said to them to the physician and the patient. The interpreter is faced with the dilemma of going against the clinician’s orders or compromising patient care if the interpreter’s judgement is not right.

The prior anecdote gives us a deep insight into the consequences of the discrepancy between the “as-conduit” model and the reality in practice. In the snippet, the physician asks the interpreter to pretend as though the words that the patient has said that does not fit the physician’s criteria has not been said. In other words, the details the physician claims to be “of no use” are shoved out of existence. This distorts the idea of transparency in interpreter-mediated consults and creates a fundamental contradiction. when an interpreter is asked to not fully interpret and to select only the important parts of a response, one is asking for the interpreter to both interpret and not interpret. In reality, this physician calls not for the elimination of the language barrier, but the eradication of many aspects of communication. Cultural difference, instead of being mediated and negotiated, is ignored. The consequence of this is that when a physician is scheduled to meet with a patient with limited English proficiency, the language barrier is not treated as a surmountable obstacle. Instead, the doctors see the culturally-different patients as a problem. This represents a crucial downside to the “as-conduit” role because research shows that in order for the process of coordinated communicative activity to succeed in cases of cross-cultural care, all parties must be actively aware and respectful of the cultures of those present in the encounter.[fn]Saha, S., Arbelaez, J. J., & Cooper, L. A. (2003). “Patient–Physician Relationships and Racial Disparities in the Quality of Health Care.” American Journal of Public Health, 93(10), 1713–1719. https://doi.org/10.2105/AJPH.93.10.1713[/fn]

The interpreter-as-codiagnostician role is not without its own problematic implications. Two important changes stand out by assuming this role over the “as-conduit” role: 1) the interpreter must quickly be able to assess the goals of a physician and proceed in such a way that those goals are met and 2) the interpreter’s newfound power directs them to pursue a role of patient advocate that may push them to give advice that is not coming from a medical professional. Interpreters deal with the first change by assuming that the provider’s communicative goals are to provide accurate diagnoses efficiently.[fn]Hsieh, Interpreters as co-diagnosticians.[/fn] However, it is easy to slide from assumptions about the physician’s broad intent to his or her intended meaning in a specific setting. In other words, by giving the interpreter a voice of their own, they become a liability with respect to potential diagnostic errors; this leads us to the second problem, which stems from the interpreter’s own attempt to provide the best patient care. Interpreters have been shown to interact with patients outside of the patient-physician session16. Interpreters have also been found to give patients information not provided by the clincians.[fn]Ibid.[/fn] Translators, however, are not qualified medical professionals and there are malprac28tice implications for the lack of set regulations that take into account inaccurate information transmitted to patients from a healthcare institution.[fn]Ibid.[/fn] Furthermore, the interpreter may assume the role of patient advocate, which could result in invasion of privacy.[fn]Ibid.[/fn] It is clear that the “as-codiagnostician” role for medical interpreting, while it may seem more appealing at first glance because it gives a voice to otherwise overlooked aspects of the medical encounter, has tremendous implications that cannot be overlooked and should come with exhaustive and comprehensive standardized training.

Power Shifts in the Introduction of an “as-Conduit” and “as-Codiagnostician” Interpreter

When an interpreter assumes the conduit stance, the translator becomes the healthcare provider in the eyes of the patient. All aspects of information are portrayed through the interpreter; it is as if the physician came out of his body and entered the interpreter’s. No real power shift occurs with regards to the “provider-physician” dynamic during an interpreter mediated consultation because the patient is equally dependent on the skills of the interpreter for translation as they are dependent on the training of a clinician for treatment. In theory, the patient should feel equally compelled to submit to the words of a well-trained interpreter as much as they would listen to a well-trained physician. However, that is not always the case. Studies show that patients who identify a language barrier are less likely to listen to the instructions of a clinician during an interpreter-mediated appointment than patients who do not identify a language barrier or use an interpreter.[fn]Bernstein et al., Trained Medical Interpreters in the Emergency Department.[/fn] [fn]Flores, G. (2006). Language Barriers to Health Care in the United States. New England Journal of Medicine, 355(3), 229–231. https://doi.org/10.1056/NEJMp058316[/fn] [fn]Sarver, J. and Baker, D. W. (2000), Effect of Language Barriers on Follow-up Appointments After an Emergency Department Visit. Journal of General Internal Medicine, 15: 256–264.[/fn] Some might say that these studies may have overlooked a few factors in focusing their research on a subset of the population that does not represent the economic resources of the entire population, and therefore those patients may simply not abide by the instructions of providers because of external circumstances.[fn]“Pew Research Center.” Pew Research Center, 16 Aug. 2017, www.pewresearch.org/.[/fn] Yet another viable explanation sprouts from the legitimacy that groups in a position of power (in this case, healthcare providers) must obtain in order to delegate to their audience (patients). Legitimacy is a voluntary form of authority given to the subset as a result of their superior performance and other ethical or occupational standards that society may hold.[fn]Starr, Paul. The Social Transformation of American Medicine:. New York, NY: Basic, 1984.[/fn] Patient-physician encounters involve a patient who is at an institution willing to receive treatment and a physician with years of training and experience prepared to care. Because there is no nationally standardized requirement or training set in place to become a medical translator, an interpreter who may appear hesitant may receive a lesser degree of approval from their audience and thus be less likely to confide in the words of their provider, whom the patient views to have a greater grasp on healthcare than an unsure interpreter would on their subject. This, however, is also the case when the interpreter is effectively executing his job, but the physician views the culturally different patient as a problem, which also compromises patient care.

The “as-codiagnostician” role would not have the same effects. Giving an interpreter a voice in an institution known for delivering patient care holds the institution responsible for any medical advice spoken by its employees. The interpreter in this role would assume a position of power, and therefore require a standardized set of professional norms, training, and accountability to its institution and to society, or in other words would “profess”. Even then, interpreters would still not be licensed medical practitioners or have the adequate background or credential to produce trustworthy medical advice. Under this model, interpreters should be viewed as subordinate to their doctor and no conversations should take place between an interpreter and a patient unless interpreters “profess” and all parties agree. This could lead to a power struggle in the discourse. In addition, this model erodes physician autonomy by forcing doctors to think about their professional authority in a team-based setting. Making the third-party interpreter a legitimate participant in the conversation means that the physician must now work with another authority figure in order to accomplish the duo’s communicative goal. If the interpreter and physician’s communicative goals do not align seamlessly, conflicts will likely arise. While it is worthwhile noting that this new collaborative, two-person dynamic is done in the best interest of patient, it does come with an expense to physician autonomy.

Why these Two Styles are Competing Philosophies

When weighing the pros and the cons of the interpreter-as-codiagnostician, it seems like the scale is tipped heavily towards the cons. Risking malpractice and the invasion of patient privacy for an extra set of eyes doesn’t seem like an equal trade-off. But if that’s the case, then why is this becoming the norm?

If the interpreter-as-conduit mode was suitable, there would have been no need for the rise of this approach. In other words, the limitations of the former role gave rise to the codiagnostic interpreter. There are two possible reasons for this: 1) the interpreter’s perspective is extremely valuable to either or both the physician or the patient during the encounter and 2) interpreters believe that doctors are not taking the appropriate communicative steps to optimize patient care. It is likely that the reality is a hybrid of both reasons. The first reason proposes that people are realizing that interpreters have a new perspective to bring to the table that can not only often make physician-patient encounters more effective, but also help in patient care delivery (i.e. pointing out something the patient said that the doctor may have forgotten). The fact that we know that the “interpreter-as-codiagnostician” role exists shows that interpreters have spoken up; the fact that a greater number of articles are being published about this role shows that the interpreters’ voice is being heard; the fact that this shift has not stopped or slowed indicates that the interpreter's voice could be correct.

It could also be the case that interpreters are taking it upon themselves to bridge a communicative gap they see that the “as-conduit” role is not satisfying. The “as-conduit” model degrades interpreters to tools, so in order for patient care to be at its best, doctors must do the things necessary to make things run as smoothly as they would in an ideal, monolingual encounter. For instance, this entails that the physician introduce himself as he would to an English-speaking patient and conduct the rapport-building small talk that he was trained to do. If an interpreter identifies a potential problem in communication that they believe may harm the patient’s experience, interpreters could opt to take action in ways that may deviate from the script of their training in an effort to provide optimal care. While this can lead to an improvement in patient care and satisfaction, other issues, like intrusion of privacy or providing unwarranted medical advice, can arise. Either way, this suggests that the current model of interpreting could have come about as a response to a need for stronger physician leadership rather than by mere coincidence.

Conclusions

This analysis of the “as-conduit” model and the “as-codiagnostician” role have shown that: 1) professional norms of medical interpreters must be better defined before considering giving interpreters a larger, more influential role and 2) the criterion for the ideal interpreter-mediated encounter must be revised and updated. During the early years of medicine as a practice, individuals would take personal oaths dedicating their work to doing what is best for patient care and taking it upon themselves to prioritize healing over any other factors which today would include race, availability of insurance, gender, etc. They would act in a way that strayed away from technical norms - the guidelines that were in place - to do what they thought was best. In essence, it is this thinking that created the physician profession. After years of patients receiving not only great care but individualized attention from their conversations with doctors, these patients, which by and large comprised society, agreed to reward doctors with greater freedom9. Just as doctors had to do in their emergence as a profession, interpreters have to prove themselves as assets to the community in a sea of ambiguous rules. Medical interpreters, with newer, targeted training, could become analogous to these physicians, not in a sense where they become certified to prescribe drugs, but as a useful resource for advice and a valid participant in the patient-physician encounter. Not enough is currently known to determine whether medical interpreters are ready for more autonomy, and if they even want the greater, attendant responsibility.

Abstract problems, such as patient culture, physician culture, socioeconomic status, income, become visible during interpreter-mediated encounters. It becomes increasingly evident that professionalized healthcare workers often see patients with limited English proficiency as a problem. In the roles that legitimize the presence of the interpreter, the doctor and interpreter are being charged with dealing with a systemic problem. The inherent problem with the comparisons being made when judging whether a particular role an interpreter takes is beneficial or detrimental is that they are being juxtaposed with a faulty “gold standard”. Instead of upholding the un-mediated patient-physician encounter as the rubric for these other models that recognize the encounter as a three-person meeting, a newer, idealized form of the interpreter-mediated encounter should be created and applied. This means shifting away from the “transparency” model, in which everyone believes they are being told everything that is being said, and towards a team-based communicative model that guarantees that everyone in the encounter leaves feeling as though they have been understood with respect to medicine.