Interruptions and resistance: A comparison of medical consultations with family and trained interpreters

Abstract

While working with trained interpreters in health care is strongly recommended, few studies have looked at the subtle differences in communication processes between trained and “ad hoc” interpreters, such as adult family members. Using Habermas’ Communicative Action Theory (CAT) which distinguishes between the Lifeworld (contextually grounded experiences) and the System (decontextualized rules), we analysed 16 family practice consultations with interpreters, 10 with a trained interpreter and 6 with a family member. We found clear differences in communication patterns between consultations with a trained interpreter and consultations with a family member as interpreter. In both cases the Lifeworld is frequently interrupted and the outcomes are similar: the Lifeworld is rarely heard and acknowledged by the physician. Physicians interrupt the Voice of the Lifeworld significantly more with a trained interpreter than with a family member. Family members and trained interpreters also interrupt the Voice of the Lifeworld just as much. However, these interruptions differ in their functions (both physicians and interpreters interrupt to keep the interview on track to meet the biomedical goals; family interpreters interrupt to control the agenda). We have identified patients’ resistance when physicians ignore their Lifeworld, but this resistance is usually only transmitted by professional interpreters (and not by family interpreters). We identified specific risks of working with family interpreters: imposing their own agenda (vs. the patient’s one) and controlling the consultation process. Even if the collaboration with trained interpreters becomes more widespread, work with “ad hoc” interpreters will continue to occur. Therefore, institutions should provide training and organizational support to help physicians and patients to achieve communication in all situations.

Introduction

Language barriers are frequently present in health care in developed countries. In the US over 24 million residents are unable to speak English fluently, with over 55 million residents speaking a language other than English (U.S. Census Bureau, 2000). In England, there are an estimated 2,520,885 general practice visits per year where interpreting services might be required (Gill, Shankar, Quirke, & Freemantle, 2009). In Canada, where our work took place, 520,000 people (1.7% of the population) cannot speak either of the official languages (English and French) at all (Statistics Canada, 2007).

Interpreting in institutional settings for service providers and individual clients who do not speak the same language is fundamentally different from conference interpreting as the interpreter is inside, not outside the interaction. Because the interpreter may share the patient’s culture and is also part of the medical system (Robb & Greenhalgh, 2006), she can serve as a bridge between the two cultures. The presence of an interpreter can provide access to the patient’s culture and experiences and promote a bond of trust between the professional and his/her client (Raval & Smith, 2003). Some professionals are concerned about the quality (exactness and completeness) of translations (e.g. Robb & Greenhalgh, 2006) and report negative feelings associated with working with interpreters, such as loss of control (Greenhalgh et al., 2006, Leanza, 2005), and exclusion from the conversation (Hatton and Webb, 1993, Leanza, 2005).

The quality of work of interpreters is frequently assessed in terms of translation errors. Trained interpreters make fewer errors than their untrained counterparts (Karliner, Jacobs, Hm Chen, & Mutha, 2007) and as such are considered more reliable. This reinforces the image of the interpreter not participating in the interaction but merely relaying information from patient to physician and vice-versa, the famous “conduit” metaphor. It also supports a simplistic dichotomy between trained and “ad hoc” interpreters.

There are, however, two reasons to understand the specificities of the work of all sorts of interpreters. First, health care may benefit from interpreters who play roles other than translation in the clinical conversation such as cultural informant and culture broker (Leanza, 2005). Judgements of the quality of this work should not be based on the accuracy of translation (Pöchhacker, 2004). Second, many clinical consultations occur without trained interpreters. The existing literature does not differentiate between the many different kinds of ‘ad hoc’ interpreters although the strengths and weaknesses of adult close family members, minor children, health care staff, institution non-professional employees, strangers in the waiting room and volunteers from community organisations vary enormously (Hsieh, 2006, Rosenberg et al., 2007).