“ne diyor?― (what does she say?): informal interpreting in general practice

Patient Education and Counseling xxx (2009) xxx-xxx j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / p a t e d u c o u ''Ne diyor?'' (What does she say?): Informal interpreting in general practice Ludwien Meeuwesen Sione Twilt , Jan D. ten Thije Hans Harmsen a Interdisciplinary Social Science Department, Utrecht University, The Netherlandsb Department of Dutch Language and Culture, Utrecht University, The Netherlandsc Department of General Practice, Erasmus University MC Rotterdam, The Netherlands Objective: The aim of this study was to offer a comparative analysis of informal interpreters during medical consultations with both good and poor mutual understanding between general practitioners Methods: Sixteen video-registered medical interviews of Turkish immigrant patients were analysed.
Stretches of discourse of eight interviews with good mutual understanding between patient and doctor were compared to eight interviews with poor mutual understanding. The discourse analysis focused on: (1) miscommunication and its causes; (2) changes in the translation; (3) side-talk activities.
Results: In the cases of 'poor mutual understanding', the instances of miscommunication far exceeded those in the 'good mutual understanding' group. Style of self-presentation, content omissions and side- talk activities seemed to hinder good mutual understanding.
Conclusion: Alongside the evidence about problems with informal interpreting, sometimes the use offamily interpreters can facilitate medical communication.
Practice implications: Recommendations are given in order to increase physicians' awareness of thecomplex process of interpreting, as well as to empower informal interpreters and patients to effectivelydeal with this communicative triad.
ß 2009 Elsevier Ireland Ltd. All rights reserved.
is poorly facilitated by the national government As aconsequence, the majority of immigrants from Western countries The ongoing process of worldwide migration implies that a bring an informal interpreter (mainly family members or substantial part of the patient population consulting a general acquaintances) to the physician, they talk without an interpreter practitioner (GP) has different cultural and linguistic backgrounds.
being present, or medical staff relies on bilingual employees For example, in the Netherlands about 20% of the population is . The reasons for using informal interpreters are mostly foreign-born (mainly Suriname, Turkey and Morocco). Com- practical or organisational The literature on medical parable percentages are given in other western countries for a interpreting recommends the use of professional interpreters, variety of nationalities These multicultural contacts in medical because of fewer mistakes made as well as greater physician and encounters are often complicated by cultural and language barriers patient satisfaction Although studies on communication which may influence patients' accessibility to and quality of in informal interpreting are scarce , there is a prevalent care negatively. An important portion of these immigrant negative attitude regarding the use of informal interpreters in patients have poor proficiency of the host country's language, terms of it lacking professional standards and potentially resulting which negatively influences mutual understanding between in greater miscommunication Other researchers stress that informal interpreters contribute importantly to attaining trust Countries differ in the health care policies regarding interpret- between patient and physician or they point to the care taking ing. While patients have a formal right to an interpreter, and role or to the fact that young people who interpret for their although countries differ in their policies, the use of an interpreter relatives might be doing a very good job Linguistic literaturestates that there is actually little difference in discourse structuresbetween informal and formal interpreters : apart from theinterpreter's status, payment and training, similar mental activities * Corresponding author at: Interdisciplinary Social Science Department, Utrecht (such as listening, information input and output, translation, University, P.O. Box 80.140, 3508 TC Utrecht, The Netherlands.
timing for taking turns) have to be presupposed for both Tel.: +31 30 253 6729; fax: +31 30 253 4733.
interpreter groups Thanks to professional training, formal 0738-3991/$ - see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved.
doi: Please cite this article in press as: Meeuwesen L, et al. ''Ne diyor?'' (What does she say?): Informal interpreting in general practice.
Patient Educ Couns (2009), doi: L. Meeuwesen et al. / Patient Education and Counseling xxx (2009) xxx-xxx interpreters make fewer errors compared to ad hoc or informal grounds different than doctors' may have other ways of structuring interpreters , but patients do not always prefer professionals information and managing the encounter. A relevant distinction is for interpreting, as a relationship of trust is at stake. Despite other that between language differences (such as pronunciation, conclusive research, it remains unclear under which conditions intonation, grammar and vocabulary) and cultural differences informal interpreters will do a good job.
between patient and doctor which become manifest in patient talk.
The present study may contribute to fill this gap in knowledge.
The cultural differences refer to the style of self-presentation.
The aim is to offer a comparative analysis of informal interpreters Immigrant patients may show a low self-display by not saying during consultations with both good and poor mutual under- much during the interaction, or may structure the information in standing between general practitioners (GPs) and patients. We also another way than doctors do (e.g. by first explaining the context try to find explanations for poor mutual understanding, to the and at the end of the consultation indicating the main reason for degree that linguistic barriers are at stake. What kind of the visit). There also seems to be more topic overload with these miscommunications do occur? Under which conditions will the patients-more topics were introduced, sometimes even though the former topic was not yet closed. Additionally, interaction wasmarked by a lot of overlap and interrupting. Misunderstand- ings may also occur from patients' lack of institutional knowledge,which might not be necessarily caused by their cultural back- Interpreters may differ in the ways they interpret and the roles they take. Bot distinguishes two approaches on inter- As communication with immigrants and patients with poor preting, the translator-machine model and the liberal interactive language proficiency is more problematic than with indigenous model as two poles of one continuum In the first model the patients, the question arises of how an interpreter facilitates the interpreter is present as a non-person who gives equivalent mutual understanding between doctor and patient. In the present translations, while in the interactive model the interpreter takes an study the focus lies on the quality of informal interpreting in interactive stance towards the interpreter-mediated medical medical encounters. The issues that will be covered relate to encounter, leading to an accumulation of tasks (e.g. providing communication problems and their causes. The aspects of medical equivalent translations, contributing to the structure of the communication will be related to the level of externally assessed medical encounter, functioning as a cultural broker, etc.). It mutual understanding between GP and patient (see Section ).
appears that interpreters cannot always act like a translation- It is expected that informal interpreters will act not so much as a machine model-in fact, they tend to participate as a third machine translator, but far more will take an interactive role of interlocutor during the interaction. Wadensjo¨ also states that the recapitulator or responder. It is also expected that more interpreter does not function as a translation machine, but rather miscommunication might occur in the group with poor mutual participates in the interaction process on his own account. She understanding between physician and patient.
discerns three roles that the interpreter can take on within theinteraction: reporter, recapitulator and responder. In the first role of reporter, the interpreter translates the utterance of the primaryspeaker literally, which resembles the role in the translation- machine model. The recapitulator changes the original utterancebut its content remains the same. The last role, the responder, can Analyses were based on 16 transcripts of videos derived from be found when the interpreter reacts directly to an utterance of the an intervention project in Rotterdam. Nearly 1000 primary speaker; no translation takes place at all, the interpreter patients participated in this project. All GPs working in responds as an interlocutor in the discourse. In this situation, one multiethnic Rotterdam neighborhoods, and at least 25% ethnic of the primary speakers is excluded from the communication.
minority patients in their practices (a total of 178), received a Because no translations are being made, a dyadic communication mailed invitation to participate in the study; those interested takes place, also called 'side-talk activity' , which may cause a were sent additional, extensive information, and 38 agreed to feeling of exclusion experienced by the physician or the patient participate. These GPs asked 2407 patients permission to participate by informed consent; 1005 (42%) agreed. The Physicians expect interpreters to be not only translators, but to response rate was 51% for Dutch patients and 34% for patients serve as cultural brokers and intercultural mediators (formal from an ethnic minority. The final study group of 986 patients interpreters) or caregivers (informal interpreters) as well consisted of 429 (44%) patients from an ethnic minority and 557 . Informal interpreters very often also have useful additional (56%) Dutch patients. For practical and financial reasons, video knowledge of the patient and his/her symptoms. According to the registration of doctor-patient communication was realized for physicians, they can be helpful towards establishing a good contact 25% of the patient group, randomly chosen. Patients were with the whole family. The disadvantage of informal interpreters interviewed at home in their preferred language 3-8 days after might be that they also may have their own agenda during the the consultation. Each GP completed a questionnaire about the medical encounter, i.e. being present as a third person.
consultation. GPs and patients were asked to give their own Apart from the way in which interpreters try to facilitate the opinions and an estimate of the other person's judgment about communication by taking on a specific role, it is of interest to identical consultation aspects. In 50 of these encounters, the question how understanding is successfully reached in interaction patient was accompanied by an informal interpreter. For purposes of the present study, three-party data of the largestimmigrant group available was selected, i.e. the Turkish group.
This allowed for a more or less homogenous group, from theviewpoint of interpreter needs. Further, to optimise the Communication problems may arise in intercultural medical comparison a selection was made based on the lowest and encounters, as well as in three-party talk, where an interpreter is highest quartiles of level of mutual understanding between GP involved Roberts et al. describe that most immi- and patient (see Section ), which resulted in 2 Â 8 = 16 grant patient-doctor interaction problems in London GP surgeries medical interviews. The interpreters were partners, family have to do with patient talk Patients with cultural back- Please cite this article in press as: Meeuwesen L, et al. ''Ne diyor?'' (What does she say?): Informal interpreting in general practice.
Patient Educ Couns (2009), L. Meeuwesen et al. / Patient Education and Counseling xxx (2009) xxx-xxx Transcripts were made in Dutch, and the Turkish fragments a. Wrong pronunciation of words and sentences can lead to were written in Turkish as well as translated into Dutch. This was misunderstanding between participants.
conducted by a second-generation Turkish research assistant. All b. Problems occur because of the unexpected usage of intonation, observations were coded from video and transcript by one rhythm and melody in the official language.
researcher, who was blinded for level of mutual understanding c. Flawed use of grammar rules, vocabulary, time markers and of the medical conversations. Because of the exploratory character sentence construction can lead to misunderstanding between of the study, observations from different angles are made by d. Features of the style of self-presentation are a low self-profile, information-structuring style, topic overload and overlapping speech. The ways in which the speaker presents himself throughhis language use may lead to misunderstanding between In order to answer the research questions, data was gathered on participants. These ways are often culturally determined.
level of mutual understanding between doctor and patient,externally assessed, and on four main communication subjects: The observation of changes in translation were derived from types of miscommunication, causes, changes of the translation, and side-talk activity, as described so far in relevant observationalstudies This enabled making a comparison a. Content revisions: the interpreter changes the content of the between the two levels of mutual understanding, in terms of translation by altering important information.
communication processes as they unfold in the actual discourse b. Content omissions: the interpreter leaves out important infor- c. Content reductions: the interpreter reduces the content of the 2.2.1. External assessment of mutual understanding utterance of the primary speaker. In this category the interpreter The effectiveness of the communication in terms of mutual synthesises the utterances of the speaker, mostly following a understanding was measured by the Mutual Understanding long utterance of the primary speaker. These three categories Scale, which was developed and validated by a multiethnic and are not mutually exclusive, e.g. revision implies omission multidisciplinary expert panel using nominal group technique However, these changes in translation give a rough indication of The level of mutual understanding was calculated by the quality of the translation-revisions and omissions may be comparing the answers of doctors and patients on roughly five serious flaws in the translation, while content reductions seem components of the consultation: main symptom, cause of the illness, diagnosis, examination and prescribed therapy. Mutual The presence of side-talk activity gives and indication about understanding was present if both doctor and patient gave the interpreter's degree of control during the interaction because similar answers as assessed by two judges independently for the he can initiate, maintain or stop the activity. Side talk may refer to open questions, or by computer for the yes/no answers. The the interpreter-patient dyad as well as to the interpreter- judges (one researcher with a Turkish background, the other physician dyad. The elements of the transcripts in which at least with a Dutch background) were blinded for patient and two turns of the interpreter as well as the patient or physician physician characteristics. Agreement about the topics between followed subsequently without interference of the physician or physician and patient in the five consultation components was patient were counted as side-talk activity. In the case of not necessary, but they had to be informed about their mutual interpreter-physician side talk, the interpreter offers additional opinions for a good mutual understanding score. In 70% of the knowledge about the patient to the physician, that is not initiated cases there was independent agreement. All remaining cases by the patient but by the interpreter. It concerns intimate (30%) were discussed until consensus was reached. This knowledge about the situation of the patient that is being procedure resulted in an overall score for level of mutual transferred by the informal interpreter, which distinguishes him understanding for each consultation on a scale between À1 from a formal interpreter This extra information also partly (very low) and +1 (very high). For purposes of this study, constitutes the role-taking of the informal interpreter, who is not consultations with scores in the lowest (between À1.0 and only translator but also takes on the role of caregiver and À0.40) and highest (between +0.55 and +1.0) quartiles were 'responder' He/she is the direct source of the information, without selected. This resulted in eight consultations with poor mutual verbal interference of the patient.
understanding (low MU group) and eight consultations withgood mutual understanding (high MU group).
Applying triangulation by discourse analysis enables perfor- The coding of communication included the following topics: mance of simple statistics and offering a qualitative description of miscommunication and causes, changes in translation, and side- the differences between the two groups (the low MU versus high talk activity. The observation of miscommunication included the MU). In that sense, the analysis explains causes for poor mutual understanding. The main findings will be illustrated by fragmentsof transcripts and commented in detail.
a. immediate recognition of the problem, with or without comment (e.g. using the word ''chwach'' for the word b. latter recognition of the problem, with or without comment (see c. no recognition of the problem, only recognized by an external Miscommunication occurred nearly five times more in the low MU group than the high MU group (83% versus 17%) ). Inthree cases, the problems were not recognised by the participants To determine the possible causes of these communication (and therefore were not solved). All examples of miscommunica- problems, the categorisation of Roberts et al. was used tions in the high MU group were recognised by the participants.
Please cite this article in press as: Meeuwesen L, et al. ''Ne diyor?'' (What does she say?): Informal interpreting in general practice.
Patient Educ Couns (2009), doi: L. Meeuwesen et al. / Patient Education and Counseling xxx (2009) xxx-xxx Table 1Number of communication problems in 16 encounters.
1. Immediate recognition of the problem, with or without comment 2. Latter recognition of the problem, with or without comment MU = mutual understanding between doctor and patient.
Box 1. [consultation number 111001] 'Patient with earache'; Box 2. [210717] Turkish speaking mother with her 11-year-old the translation of Turkish is written in italics.
son (=patient), who has an infection; the translation of Turkishis written in italics.
simdi sey varm? intablanma? disariya dogru pislik? now is there thing? an infection? dirt to the there is some dirty inside(the ear) that itch yok yani. sey olarak su gibi cikan pislik no mean. just like thing dirty that it goes out no, because it's in the air a bit, and it iscontagious, it can A substantial number of the miscommunications was caused by style of self-presentation (), where the interpreter showed a low self-profile, e.g. by having difficulties in structuring the information given by the patient. Other causes were the inability to pronounce words or form words or sentences in the Dutch shows an example of a communication problem that came up, which was later recognised and eventually solved.
The cause of the communication problem lies in the lack of Dutch vocabulary of the interpreter, who is the son of the patient.
The GP's question about ear lavage is translated as 'an infection' (line 99), which is the onset of the miscommunication between has come here (xx) it hasn't stopped, her's patient and doctor. Later on, the communication problem was recognised and eventually solved (not shown). As the patient says hm.let's have a look, hm and which is your that he had received an ear lavage once, the physician then makes the problem visible and discusses with the interpreter what went wrong before in the translation process.
okay, so I'll give you something for that contains an example of unrecognised miscommu- nication, which may have serious consequences. A young boy (age 11) is accompanied by his mother, who does not speak Dutch. The boy is the patient as well as the interpreter for his mother. He has acontagious infection on his head, and the GP asks if there are morechildren in his environment who have it (line 4,6,8-9). The boy miscommunication showed up only for the researcher, after the mentions his sister Fatima (line 12,17). In line 17 he says that 'it has Turkish spoken part of the conversation was translated.
already stopped', however his mother interrupts in Turkish that ithas not stopped yet (line 21). The boy does not translate, and the GP does not ask further. In this consultation, the mother isexcluded from the conversation by her son as well as by the GP; she Content omissions, leaving out important information, hap- asks her son repeatedly 'what does she (= female GP) say?' ('ne pened most frequently (48%). These changes in translation diyor?' in Turkish), but her claims remain unanswered. In terms of occurred twice as often in the low MU group than the high MU Goffman the mother is regarded as a non-person by both the other participants. She conveys important information (that shows an example of a content omission. During Fatima is still infected) which does not reach the GP. This this encounter a married couple visits the GP and their adult Table 2Causes of communication problems.
MU = mutual understanding between doctor and patient.
MU = mutual understanding between doctor and patient.
n.s. (because of large standard deviation).
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Patient Educ Couns (2009), L. Meeuwesen et al. / Patient Education and Counseling xxx (2009) xxx-xxx an adverse effect, evidenced in a lower level of mutual under- Box 3. [consultation number 310714] Husband is patient; he is accompanied by his wife and adult daughter, who translates.
The translation of Turkish is written in italics.
surdan soyleydi (xxxx) ben birseye bastiydim from here it was so (xx) I stood on something According to expectations, there were more instances of miscommunication in the low MU group than in the high MU don't say I stood on something. Quiet, let her group. Causes for this miscommunication were mainly due to yes. well it isn't purple now, fortunately interpreters' low-profile presentation, recognised in hesitating behaviour and problems structuring the information. Omissions of content occurred most frequently in the translation process, whichis in line with Aranguri's findings. Furthermore, theinterpreter's frequent conveyance of background information to daughter functions as an interpreter. The patient (husband) is the physician as well as side talk between interpreter and patient trying to explain his symptoms: he has a painful, purple foot. His make it difficult for the patient or the physician to follow the wife also joins the discussion. Earlier in the encounter the patient interaction as well as for the interpreter to coordinate it. Informal tells the story that he stood on something, which may have caused interpreters form the essential link in the intercultural constella- tion of the medical encounter, and they try to control and In line 876 the patient points out where the foot was purple and coordinate the medical conversation. They are thus active says that he stood on something. The interpreter translates the part participants performing multiple roles; these findings confirm 'and then over here' (line 879), but leaves out the part where the present theories of interpreting , which claim that patient 'stood on something'. The patient's wife (v) comments on interpreters are not just translation machines but have an active the request of the patient in line 880-882. She directs him not to role in the interaction. We have seen that these roles cover more mention the incident and to wait for the GP to look at the foot. Both than translating alone, as they include aspects of being an advocate the wife and the interpreter may think that this request has of the patient, and in that role contributing to a trustful nothing to do with the symptom. However, this seems important relationship between patient and physician. However, for the patient, because prior to this fragment he also mentioned informal interpreters differ from each other in their role this request. The doctor did not receive this information during the performance, which may lead to facilitation or hindering of the medical encounter Hindrance indicators are the In sum, more linguistic problems occur in the low MU group interpreter taking the role of 'responder' while giving background because the interpreters' language proficiency appears to be information (volunteering, adding facts and information), and insufficient, or because of selectivity. Changes in translation, frequent side talk between interpreter and patient. These issues especially omissions, may lead to a decrease in mutual under- have been identified by physicians as difficulties when confronted standing between doctor and patient during the discourse. The with a patient and an informal interpreter. They wonder what majority of the communication problems was related to style of patient and family interpreter are discussing together, especially if they receive brief bits of information after a long stretch of sidetalk. When family interpreters become the direct source of information, it should be considered that this is not always bevery effective , especially in the case of precarious issues In the low MU group, side talk happened nearly four times more (e.g. relational problems, sexual or genital problems).
than in the high MU group (52 versus 14). In the low MU group the Some methodological remarks need to be made. Because of the interpreter did provide background information to the GP more exploratory character of the study, it was not intended to generalise regarding quality of informal interpreting. The small One may speculate that the interpreter complicates the research sample provided more understanding of relevant inter- communication with this topic overload. Background information actional mechanisms in the process of interpreting. By applying provided by an informal interpreter does not always seem to be triangulation - the observation techniques used here more or less effective. Instances of side-talk activity between interpreter and pointed in the same direction in terms of differences between low patient happened twice as often in the low MU group than in the and high MU groups - the study reaches accountable reliability. By high MU group. This kind of side talk resulted in exclusion of the conducting a comparative analysis, this study offered more insight physician from the interaction. The frequent occurrence of side talk into informal interpreters' interactional behaviour during con- seems to complicate the interaction between doctor and patient.
sultations with both good and poor mutual understanding, and The interpreter explains and talks more to the patient, to make the explained causes for the differences. We did not focus here on physician's contribution more understandable, but in fact this has cultural factors (e.g. in terms of values, norms) or medicalcommunication factors in general.
Only Turkish interpreters participated in this study. To what degree are the findings applicable to other migrant patient groups? As relevant patient variables (education, Dutch language profi- ciency, and cultural views) resemble those of other migrant groups, there is no reason to believe that the results would not be valid for other migrant groups as well. It would be interesting to conduct research where different migrant groups are compared which each other. It is recommended to repeat similar research with largergroups and with patients of different origins, and to make MU = mutual understanding between doctor and patient.
* One-sided t-test, t = 1.569, p < 0.10.
comparisons between informal and formal interpreters.
Please cite this article in press as: Meeuwesen L, et al. ''Ne diyor?'' (What does she say?): Informal interpreting in general practice.
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