English 3 (MED3)
Unit 2 - Mediating specialised
discourse in English
Lesson 6: November 3, 2023
Interpreter-mediated healthcare encounters
Prof. Jekaterina NIKITINA /
Paola CATENACCIO
Università degli Studi di Milano
Dipartimento di Lingue, Letterature, Culture e Mediazioni
Lesson 6: outline
• Healthcare context and public service interpreting
• Types of interpreters in healthcare: theory and reality
• Healthcare encounters as a communicative event
• Main information exchange stages
• Medical interpreter’s competence
• Positions and approaches towards interpreting in healthcare
• A case study
Public service interpreting
• Healthcare setting -> public service interpreting (PSI).
• ISO 13611:2014 defines healthcare interpreters as a subcategory of
community interpreters.
• Of all PSI, healthcare interpreting is the one with most variables
• Mental health, paediatric, dental, palliative care, physiotherapy, health tourism, etc.
• The setting: interview between a service provider (SP) and someone who
needs or wants the services (a client/ patient) and who has limited language
proficiency (LLP).
• The interview arises out of some sort of crisis in the life of the client/patient.
• Significant risk inherent in the situation.
• Cultural differences between a healthcare professional and a client increase the
initial risk inherent in a healthcare encounter
Interpreter-mediated healthcare encounters
• WHERE: in a range of sectors from emergency medicine to geriatrics and
psychiatry and in a range of different settings: hospital wards and clinics,
consulting rooms and patients’ homes, community health centres;
• WHO: they interpret for patients and doctors, and also for nurses,
physiotherapists and speech pathologists, occasionally administrative staff
too;
• WHAT: not only do they provide dialogue interpreting, but are asked to
translate documents or write documents and letters in the foreign
language, even contact foreign insurance companies and embassies over
the telephone.
• On-site bilateral interpreting (short-consecutive, with note-taking)
• Remote interpreting (telephone and, rarely, video)
• Sight translation
Language mediation in healthcare settings
• Effective communication in healthcare is vital
• Global world = global patients
• in most countries there is no statutory obligation for medical institutions to
provide professional interpreting services, so there is hardly any control on the
professional competence of persons used as interpreters
• In the US: 58% of serious adverse events in healthcare stem from
miscommunication (Chapter 4, p. 131)
• the interpreter is often relied on by both the institution and the patient to
provide much more than translation
• cultural factors are particularly important in medical interpreting: the perception
of pain, for instance, varies from culture to culture, and there are several taboos
in different cultures which need to be taken into consideration
• Healthcare settings are among the settings where reliance is often made not on
professional interpreters/mediators, but on emergency solutions, e.g family
members and hospital staff.
Language mediation in healthcare
Non-professional “emergency” solutions Professional solutions
“Getting by” Ad hoc Professional Cultural mediators
interpreters interpreters
using facial expressions and anyone available Professionally trained specialists not only provide
gestures, or using a few key who speaks both with excellent knowledge of interpretive services, but
words or phrases in the languages, such as both languages, trained in also interpret cultural
target language or pointing the patient’s interpreting techniques and and social circumstances
to an area of the body, friends, roommates, competent in specialized that may affect the
making grimaces as if in pain colleagues, etc vocabulary + bound by a code patient’s care
+ Google Translate of ethics/standards of practice
DISADVANTAGES: inaccuracy (e.g. information
edited, withheld or misunderstood; incorrect US: a medium-sized hospital
(225 beds) has 5-7 in-house
translation); compromising the patient’s right to
interpreters
privacy; patients’ reluctance to speak freely in Cf. Villarruel, A.M., Portillo, C.J., & Kane, P. (1999). “Communicating with limited English proficiency
front of family members (spouse, sibling or child)] persons: implications for nursing practice.” Nursing Outlook, 47(6), 262-270.
Collaboration of healthcare professionals with
interpreters
• 81/112 HP have collaborated with interpreters
• 54 (=66.7%) “patient’s bilingual family member or close acquaintance”
• 50 (=61.7%) worked with professional interpreters in person
• 33 (=40.7%) “Professional telephone interpreting”, also known as Over-the-Phone
interpreting (OPI)
• 24 (=29.6%) “native speaker who is not acquainted with the patient”
• 23 (=28.4%) “bilingual healthcare professionals working in the facility”
• 4 (=4.9%) “professional video remote interpreting”
• 4 (=4.9%) “other” - to add Google Translate / “cultural mediator”
Montenovo 2022; Montenovo and Nikitina 2023
“How do you think the cooperation between interpreters and
medical practitioners can be improved? (QMI)”
1. “Through greater recognition of the role of the medical interpreter and the proper training of health
personnel on how to carry out their work with linguistic mediation “
2. “I think the basis is to give a preview of the linguistic intervention to be done with the patient, but I
believe that the best way to improve cooperation is by better training the healthcare staff to manage
the work with an interpreter. “
3. “If the healthcare staff knew that interpreters are prepared for this job. I have often seen healthcare
workers use macaronic English without asking for help even though I was literally 2 meters away.
Perhaps they think that the intermediation of the interpreter slows down the times too much and
they prefer to make do in order to be fast”
4. “the team should warn the interpreter before things that can be shocking happen such as opening
the rib cage for example, once I even had a surprise autopsy after a surgery course”
5. “Through interprofessional training when both parties are still at university”
6. “Trying to train medical staff to work with interpreters, to be collaborative”
Video on how to work with interpreters Montenovo and Nikitina 2023
Interprofessional training
Healthcare professionals Medical interpreters
Have you ever attended training Have you ever attended an
courses, seminars or similar on interpreting training where you had
collaboration with interpreters to practice medical interpreting with
for your profession? a real medical practitioner (acting or
student)?
What happens during a healthcare encounter?
• there are many scientific models of its structure, produced in
different disciplines (medical anthropology, psychology,
communication in healthcare, clinical sciences, ethnomethodology,
applied linguistics, etc.), mostly developed for doctor training
• an example: the Enhanced Calgary – Cambridge Guide (2002)
Suzanne Kurtz & Jonathan SilvermanKurtz. 1996. “The Calgary-Cambridge Observation Guides: an aid to
defining the curriculum and organising the teaching in Communication Training Programmes”. Medical Education
30, 83-89., available also here
Enhanced Calgary – Cambridge Guide (2002)
The interpreter-mediated medical encounter
11 stages, 3 of which are optional (in parenthesis) Cf. Tebble 1999
EC-C Guide 2002 Tebble 1999
Initiating session Greetings
Introductions
(Contract [between doctor/patient &
interpreter])
Gathering Information Stating/ Eliciting Problem
Physical Examination Ascertaining Facts
(Diagnosing Facts)
Explanation and planning
Stating Resolution/ Exposition
(Decision by Client)
Closing the Session Clarifying any Residual Matters
Conclusion
Farewell
EC-C Guide 2002 Tebble 1999
Greetings
Initiating session
Introductions
Preparation
Establishing rapport (Contract [between doctor/patient &
Identifying the reason(s) for consultation interpreter])
Gathering Information
Explorations of the patient’s problems to Stating/ Eliciting Problem
discover:
Biomedical perspective / Patient’s perspective Ascertaining Facts
Background information - context
Physical Examination
Explanation and planning (Diagnosing Facts)
Providing the correct amount & type of Stating Resolution/ Exposition
information
Aiding accurate recall and understanding
Achieving a shared understanding;
incorporating the patietnt’s illness framework
(Decision by Client)
Planning, shared decision-making
Closing the Session Clarifying any Residual Matters
Ensuring appropriate point of closure Conclusion
Forward planning
Farewell
Information exchange
Gathering information
• Doctor trying to elicit information from the patient or client by
asking questions, e.g. when taking a patient’s history or when trying
to assess the patient’s condition after surgery or other forms of
treatment. Explanation and planning
• Doctor giving the patient instructions which are essential for
preventing complications and for managing the patient’s condition,
e.g. what to watch out for after a head injury, or lifestyle changes for
a patient with diabetes.
• Doctor giving information about a procedure for which he requires
the patient’s Informed Consent. Explanation and planning /
decision by patient
Crezee 2013: 12-13, see also Wadensjo (1998, 2002), Meyer (2000, 2003) and Tebble (1998, 2004)
Information exchange Explanation / Clarifying any
residual matters
• The patient may be asking for further information in relation to the
proposed benefits of the procedure, as well as its side-effects, risks
and any possible alternatives.
• The patient may also ask for information, e.g. about the disorder, the
disease process, further treatment options and medications.
• The interpreter may be needed in a counselling situation.
• the interview between the client and the health professional or counsellor
will revolve not so much around an exchange of information, as around an
expression of feelings and emotions on the part of the client, and an
understanding of these on the part of the professional.
Crezee 2013: 12-13, see also Wadensjo (1998, 2002), Meyer (2000, 2003) and Tebble (1998, 2004)
Medical interpreter’s competence
• a good knowledge and understanding of anatomy and physiology of
the main body systems;
• E.g. cervix, abdomen (belly), mammary glands
• Collo (dell’utero); addome (pancia); ghiandola mammaria
• intestino, caviglie, clavicola, protesi dell’anca
• Guts /bowels /intestines; ankles; collarbone / clavicle; hip replacement
• most common diseases and/or disorders, assessments and
treatment methods, including pre-operative instructions;
• E.g. measles, mumps, whooping cough, ECG, nil by mouth after midnight
• Morbillo; parotite / orecchioni; pertosse; ECG; niente per bocca dopo la
mezzanotte
• A digiuno, pap-test, gonfiore, ecografia
• On empty stomach; cervical smear test; swelling; ultrasound scan
• Knowledge of the institutional differences (e.g. professional titles,
positions, hierarchies to address all parties appropriately) and procedures
Medical interpreter’s competence - 2
• informed consent procedures;
• E.g. major surgery vs. minor operation
• commonly used healthcare terminology, including their Latin and Greek
roots, prefixes and suffixes;
• E.g. “ec” = out, “post” = after Scientific English, anyone?
• Drug names and categories
• Prescription drugs, over the counter, painkillers
• Culture-specific and idiomatic language:
• the perception of pain varies from culture to culture
• E.g. throbbing pain (pulsating pain)
• there are several taboos in different cultures which need to be taken into
consideration
• The language of emotions is very hard to render (see, e.g. Wierzbicka 1992 on
variability in the semantic meaning of emotion concepts across lexicons)
Crezee 2013: 37
Pain • A dull ache a belt is tightened
• Niggling = nagging round the chest
• Superficial vs. deep- • Like a knife – sharp/
seated stabbing/ piercing /
cutting
• Stinging
• Pulsating – coming
• Dragging and going like a pulse
• Severe – excruciating, • Pounding / throbbing
unbearable, – beating or
intolerable, agonizing drumming
• Slight / mild / • Hot – like a burning or
moderate searing sensation
• Heavy – crushing, like
Doctors’ POV on challenges in healthcare communication
• prelinguistic: the difficulty in expressing one’s internal sensations
• e.g. concerning the psychiatric or obstetric-gynaecological field, pain;
• linguistic: no common language;
• metalinguistic: symbolic associations of a certain word
• cultural: patients must be considered outside their context of origin
because they live halfway between their land of origin and that of
adoption;
• metacultural: implicit cultural aspects (cf. the underwater part of the
iceberg) (Rasetti & Zanella 2012:4)
Issues and challenges in healthcare interpreting
• Inevitable mutual conditioning between health professionals’ professional
discourses and the interpreter’s discursive production
• PSIs interpret from and into both languages -> bidirectionality
• Power imbalance between the HP and the client: impact of interpreter-
mediation on discursive dynamics
• no pre-fixed rules governing the process, typically, goal-oriented, to reach the
diagnosis / improve the patient’s health
• Not having a clear vision of one’s own role is a common cause of
miscommunication -> lack of regulation, unclear profile and competences,
overlapping professional figures, see also code of ethics
• Other issues: Time, trust, control vs. co-power (see Chapter 4, reading
materials)
Dialogue interpreting in healthcare: two extreme positions
Direct approach Mediator-interpreter approach
• interpret each utterance accurately & • interpreters are assigned a role not only of
almost literally to allow the doctor and translation but also of acting as cultural
the patient to communicate effectively brokers, mediators and advocates (Meyer
• doctors maintain responsibility for et al. 2003: 78)
directing the consultation, picking up on • interpreters have the freedom to decide on
cues from seemingly irrelevant material what is and is not relevant in the
provided by the patient utterances of each speaker
• patients maintain the right to decide on • Interpreters may add information that in
what to say and how to say it (Hale their opinion was missed by any of the
2007) participants (Angelelli 2004)
A continuum rather than a dichotomy
• In practice interpreters, especially if untrained or improvised (ad
hoc), often do not interpret utterances accurately, but rather act as
gatekeepers in deciding what information is relevant, or answer
doctors’ or patients’ questions directly.
• They frequently use third person and reported speech (cf. narrator:
the doctor says …)
• If they are part of the permanent staff, they tend to behave as
(deputy-) care providers (cf. pseudo-principal: we think that the best
course of action...
• however, most scholars agree that accurate rendition and a
detached attitude, with intercultural interventions kept to a
minimum, are most desirable. (cf. animator / reporter footing)
An interpreter-mediated medical consultation Talking to the
interpreter, not the
INFORMATION GATHERING (HISTORY TAKING) patient
1 D Can you ask her about chronical illnesses, diabetes … ‘all that’ → relying on
interpreter’s
all that?
knowledge of the
‘usual questions’
2 I Signora, nessun dottore anche in passato … 10 o 20 anni
fa le ha mai detto che ha il diabete?
3 P no
Gathering information by breaking down
4 I che ha la pressione alta? original (incomplete) question into a series of
questions eliciting yes/no answers
5 P no
More on rendition strategies -> Lesson 7
6 I che ha mal di cuore?
7 P no::::
A medical consultation: a case study
8 I che ha problemi di fegato? Di reni? Di stomaco?
9 P no
10 I ha mai subito operazioni chirurgiche o è mai stata in
ospedale? Qui o là?
Moving past chronic illnesses (interpreter’s
11 P no::: knowledge of what the doctor needs to
know)
12 I ha mai avuto malattie?
13 P beh:::: sono stata malata sono stata de… ho avuto la
depressione nervosa non ho mai avuto nient’altro
Elicits information
14 I per la depressione è stata ricoverata in ospedale? about depression
A medical consultation: a case study
15 P sì
16 I Qui o là?
17 P a Elgin
18 P dove?
19 P a Elgin, vicino a Aberdeen
More on rendition strategies -> Lesson 7
20 I she is saying that she denies diabetes, denies
cardiovascular disease, denies blood pressure, denies
ehm problems with her stomach and liver … she say she
was … denies surgery … she was admitted once eh close
to Aberdeen ehmm for depression
A medical consultation: a case study
21 D OK but she doesn’t take any medicine now?
22 I signora, attualmente prende farmaci?
23 P no
Same strategy – question breakdown to
24 I nessun farmaco da banco? ascertain information
25 P no
26 I che ha portato dall’Italia o che le hanno dato magari le
sue amiche?
27 P no, nessuno
28 I negative … negative
A medical consultation: a case study
EXPLANATION AND PLANNING
29 D Ok, all right… sounds just like she has the blues …
her lungs are clear, she is breathing fine and her colour
looks good I’ gonna check her oxygen saturation and
then probably send her home with advice and give her
the number to call .. Leaving the patient alone with the
interpreter, who has to «replace» the
30 P OK la nostra dottoressa dice che [ doctor
31 D [ I’ll be right back
32 I [le ha ascoltato i
polmoni e non c’è alcun problema
33 P sì:::::
A medical consultation: a case study
34 I dice che ha un bel colorito … che … e che misurerà
l’ossigeno che ha nel sangue
35 P OK
36 I non le farà male … le applicherà per un attimo una
lucetta al dito e poi dice che la manderà a casa con alcuni
consigli
Additional procedural
information -> lay
33 P OK explanation
Bibliography (not obligatory)
• Crezee, Ineke H. M. et al. Introduction to Healthcare for Interpreters
and Translators. Amsterdam Philadelphia: Benjamins, 2013.
