The important and challenging task for the language interpreter is to find a balance between active and passive involvement, understanding what is happening while attempting to interpret, word for word, what is said.
Many interpreters accomplish this fairly well and I do not often believe they are actually influencing my patients in any particular direction for or against prenatal testing, terminations, cancer testing, etc. But, recently, an interpreter declined continuing because my French speaking patient from Africa and I were discussing abortion. The interpreter hung up, “exercising her right to decline continuing”.
After 30 minutes of rapport had been built, everything went into limbo for 10 minutes as I worked to find a new interpreter. I do not know exactly what the patient was thinking in those 10 minutes, but my thoughts went something like this…
“What kind of question did the patient ask that finally made the interpreter uncomfortable? Does my patient feel judged by this 3rd party who is probably sitting in her cozy ‘interpreter chair’?! I am angry! Don’t they screen for personal beliefs when they sign up people up for this service?! I am going to black list this interpreter from ob/gyn services…Wait, I have to focus on the patient’s reaction..”
I composed myself and apologized profusely to the patient. She was gracious and reiterated her question to our new interpreter. I heard, “Would the hospital be supportive of a decision to terminate a pregnancy with Down Syndrome?”
Clearly, the interpreter would not be.
But the interpreter is not actually a part of the hospital. That is known to me, but not necessarily to the patient. We spent some time clarifying the mixed signals the patient was receiving. The patient eventually decided to decline further prenatal screening. Did the interpreter influence her decision?
I could not survive my prodigiously diverse hospital setting without the aide of the language line. I have been suspicious that some interpreters are not translating word for word. I even hang up if I am uncomfortable with the interpreter’s style. However, this scenario forced me to further question whether or not the service actually influences the patient’s decision making.
A conference this weekend regarding medical decision-making published an abstract about this issue and the authors say:
“Common challenges were additions, omissions and modifications in terminology resulting in miscommunication of clinical and cultural concepts, and ethical concerns during conflicting values between providers, interpreters and patients.”
How do we overcome this? Can we? If we start using computers to translate for patients and providers, we would lose some of the essential humanness that great interpreters provide i.e. using a more compassionate voice when the room is full of tears, recognizing when a patient is lost and asking to rephrase.
As a genetic counselor, my primary goal is to facilitate informed decisions rooted in self-understanding. This often requires a non-directive and supportive environment. Anyone who assists us must have this goal as well. I implore interpretation providers to assess your beliefs before becoming involved in cases that might be morally offensive to you.
There is little worse than negative judgment when you are most vulnerable. Ask the patients. Ask yourself.
Please share your thoughts about the influence of language providers on your patients. I am reminded of “The Spirit Catches You and You Fall Down”. Maybe I should revisit this book, other suggestions?
The DNA Exchange 
I recently met with a Vietnamese couple with an interpreter. Initially her demeanor walking to my office was very uningaged. Trying to create rapport with the couple, I began by asking basic questions which the interpreter answered directly instead of asking the couple to answer. I reminded her of her role and what I expected. I started again and a second time had to ask her to translate what I said directly. And then, as I began to explain the CVS procedure, she had to stop and ask what a placenta was. I had had it. I stepped out of the room to think for a moment and then came back in and asked her to leave. I was very conflicted about doing this until the replacement arrived and everything was as smooth as silk. It was a reminder to me that our patients are not well served if the interpretation is poor. It is very hard to judge this in some circumstances, making the task that much more difficult. This interpreter is no longer allowed at our institution. The family was incredibly greatful to me in my ability to correct a bad situation!
The issue of the unspoken powers that interpreters hold has been written about extensively, and in a growingly pluralistic, multi-ethnic health care system, it warrants further attention. The “space” or role taken by the interpreter is amorphous at best; the agent is human after all, with cultural and personal values that are indispensable to his or her identity. Regardless, the role of the interpreter (despite the name) is not to interpret but to literally translate, allowing the others in the room to interject their cultural and personal values in the form of questions and concerns. Although the task of removing oneself sufficiently to do this may be difficult for some, it must be enforced by training programs and supervisors. In the end, however, the “black box” of interpretation is lost to both clinician and patient, by definition as there is a clear language barrier, and the interpreter’s subtle influences are not only possible, but actually probable. Simple suggestions include asking the interpreter to clarify or repeat areas that elicit doubt, asking the patient if they themselves can repeat certain points or statements, and reporting any incidents such as the one described by the blogger to higher-ups.
At last! Someone who unerdstnads! Thanks for posting!
I’ve yet to find another book like “The Spirit Catches You and You Fall Down,” although I’ve seen similar topics discussed in medical anthropology texts.
I found this post very interesting as the hospital where I work has been working on a campaign to find out every employee’s mother tongue, to increase their pool of potential interpreters. Although this may be useful in some urgent situations where a professional interpreter is unavailable, I have concerns about the ability of many employees to accurately (and non-judgmentally) translate in such circumstances. Few people have experience with simultaneous translation or are aware of the need to be absolutely neutral–I imagine training will be available for those called upon for this service, but it will be interesting to see how it plays out, and if they manage to avoid the kind of problems you wrote about in this post.