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Medical interpreters are powerful

The healthcare settings where medical interpreters primarily work with diverse language           speaking backgrounds are clinics, hospitals, nursing homes, physician’s offices, rehabilitation facilities, and mental health clinics. Healthcare providers consider medical interpreters as a group of people with bilingual ability to help them to foster the communication with patients, so the expected roles placed on them are as conduit, passive participant and institutional gatekeeper. Healthcare professionals expect them to act as conduits or translation machines which is a basic role in medical settings between healthcare providers and patients by listening to what the professionals need to communicate and orally carrying out the interpretation of information into the native language of the patient without distortion. According to Flores et al. (2012), conduit refers to a channel through which something is conveyed. ‘In the conduit role, an interpreter may be perceived to be emotionless or uncaring’ (Hsieh& Hong 2010:195). However, conflicts, arguments and complaints happen frequently in medical settings which can affect interpreters’ opinion and emotion easily, thus, being as only a conduit brings challenges to medical interpreters. There are two external reasons that forms the stereotype which healthcare providers normally acquire this perception. As Clifford points out, Metzger suggested that ‘community interpreting has adopted the conduit model because of the example set by conference interpreting. In the conference hall, interpreters have limited opportunity to interact directly with the people for whom they interpret, and the speeches they work with are long, formal, text-like monologues (Wadensjö, 1998)’ (2004:92-93). Conference interpreting’s norms of ethics was established earlier than community interpreting and the studies of it are also both broader and understood broadly than community interpreting, further, it has already been acknowledged to set an example for all modes of interpreting. Clifford (2004:94) then gives the second explanation which is that the community interpreters who work with sign languages because they only transmit the disabled’s messages to others without adding additional meanings which implies one of the most arguable roles of sign language interpreter is conduit. These two explanations provide the external reasons of why community interpreters are seen as conduits. The internal factor is caused by medical interpreters themselves. In the professional interpreter training, the use of the first-person indicates the professionalism rather than the use of the third-person, especially in the medical settings, in order to prevent from misunderstanding, healthcare providers and patients communicate with each other directly and interpreters use first person singular to refer to both of them. Nevertheless, the use of the first-person minimizes interpreters’ presence and make interpreters to become ‘invisible’ (Hsieh, 2006:725). The invisibility strengthens the role of conduit which makes medical interpreters become the voice of healthcare providers and patients. The next element that medical interpreters are expected as conduit is that once medical interpreters do not act as conduits which means they take cultural factors and up-to date information into account and the interpreting process would take longer. Healthcare professionals do not schedule much time for each immigrant or foreign patient, they expect each medical interview can finish on time and only the conduit role achieve it easily, but they ignore one factor, communicative skills that manipulates their expectation on medical interpreters.
Healthcare providers are not experts of public speaking and have not received the training of interpersonal and communicative skills. When the patients receive a series of questions, their response is tend to be unclear or incomplete. To interpret faithfully, interpreters interpret the same messages back to the healthcare providers. The message being transmitted needs to be conveyed as and how expressed by the care provider and no changes are to be made in any stage of communication. This might be crucial in the light of completeness and accuracy of the messages conveyed. This eliminates chances of transmitting erroneous messages, the addition of new information and omission of critical information. The nature of the original message is not drastically changed by any means (Butow et al. 2012). Under this condition, healthcare providers doubt whether the patient misunderstands the questions or the interpreter misinterprets them and have to restate the questions again. To fit the expectation of healthcare providers, ‘the studies found that the interpreters working in medical setting tend to focus on factual information, neglecting other communicative goals at play in the encounter, which could have a negative effect on the doctor-patient relationship, challenging the development of rapport’ (Fernández 2010:220). The rapport is the core in the provider-patient relationship. Medical interpreters are not leading the communication, however, healthcare providers also expect them to be institutional gatekeepers and instructors to control, filter messages they receive and guide patients to answer in the right track and ask interpreters have no need to interpret if patients’ answer is irrelevant. ‘The challenge in interpreter-mediated encounters is that providers may not be able to control the flow of conversation as effectively or efficiently as they would have had in English-speaking conversations. As a result, of a provider does not wish to address certain topics or does not have time for the interaction, they rely on the interpreter to act as gatekeepers to control or limit the patients’ narratives. ‘The question remains as to what are the patterned ways in which the interpreter influences the discourses she interprets through these small, and in some cases not-so –small, changes in linguistic form; what is the “interpretive habit” of the socially positioned agents known as “interpreters” in a typical medical encounter, and how do they conceive of their role in achieving conversational goals?’ (Davidson 2000:2). Healthcare providers’ expectation are always founded on what they want to achieve and obviously, they view medical interpreters as helpers to their work rather than viewing them as experts on language. This expectation indicates the hierarchical working level in the relation of medical interpreters and healthcare providers. It even causes morally challenges to medical interpreters in that when they keep the most ‘useful’ messages, they neglect the ‘useless’ messages which are only useless to healthcare providers. It can be seen as discourse hegemony. Because of the language barrier, patients do not know the instructions which healthcare providers give to medical interpreters and in fact, they have already become the victim of losing the right of delivering the complete messages to other party. Healthcare providers use the power to affect medical interpreters’ neutral position to filter the messages from patients and indirectly deprive patients of their right of delivering complete messages to them.
Providers’ expectations, however, contradicts with interpreters’ training in following the conduit model as the default role’ (Hsieh& Kramer 2012:161-162). The value of referring to medical interpreters to promote communication between patients and healthcare professionals is discussed in numerous discussion. Juckett and Unger (2014) argue that the applicability of interpreters in the present medical domain, in contrast to merely permitting the exchange of information, is essential as they need to give attention to the successful flow of information. It is the medical interpreter who is responsible for communicating the needs and responses of both the parties in an efficient manner. What is vital in this regard is that there has to be a smooth flow of information taking place that is of prime importance. Poor flow of communication is the cause of misunderstandings which are not at all wanted in the medical field. This is because improper communication flow leads to misdiagnosis of a condition, incorrect prescription and miscommunication of the complexity and severity of a medical issue. As stated by VanderWielen et al. (2014), for ensuring that data interpretation is correct, any form of bias is to be eliminated, and specialised knowledge is to be applied by the professionals.  Interpreters are required to demonstrate skilful interventions so that there is no interference with the flow of communication in a triadic medical setting. Hsieh (2011) opines that medical interpreters are to manage the flow of communication for preserving completeness and accuracy and building and rapport between patient and provider. They also need to turn their attention to the dynamics of the interpersonal interaction between provider and patient, such as arising conflicts and tensions and to provide assistance in establishing a communication process. ‘In short, the interpreter’s ability to adhere to a conduit role is dependent on other speakers’ communicative skills and behaviours (Hsieh 2006:729).
According to Okrainec et al. (2014), professional medical interpreters have the suitable training for playing the default role that is the conduit model known for adopting a neutral and passive presence as the interpreter faithfully transfers the information from one language to another. Hsieh et al. (2012) also state that interpreters are expected to serve a neutral, faithful, and passive role in provider-patient interactions. Obviously, being a passive role is what medical interpreters must do to not only fit the healthcare providers’ expectation but also the expectation in this field.  Interpreters have the belief that the role they play requires them to be emotionless, and detached from any emotional thoughts, and they are to avoid any form of interaction with others while executing their role. As passive participants, they would not need to pursue issues diagnostically relevant. Rejection of information offerings of the patient is common. There if often a lack of active participation in the communication taking place between the two parties. This implies that the interpreter is not supposed to put forward any of his own opinions and thoughts while communicating the piece of information. This is referred to as passive participation (Larrison et al. 2010). ‘It is important to re-examine the institutional policies and expectations that we place on medical interpreters. For example, it is unrealistic to expect interpreters not to have any direct interactions with their clients when they have to stay in the same exam room with a patients for a long period of time’ (Hsieh 2006:729). Medical interpreters who work within languages do not merely interpret the wordy languages, they interpret the body language, facial expression, emotions and cultures.  The generation of these interpretation is all through interpersonal skills. By communicating with patients, medical interpreters can acquire more information which is helpful to establish the rapport with healthcare providers.
Medical interpreters are powerful originally yet they lose and give up their power purposely to fit the expectation. ‘What is power? Power simply means “the ability to act”. You have power when you can make decisions and implement or act on those decisions’ (Baker-Shenk 1991:120). In medical settings, interpreters do not own power to influence any decision and interrupt the interaction, the power they acquire are limited by healthcare providers. From healthcare providers’ overall expectation, they do not seem to mind the harmony of the communication with patients, if it contradicts with medical interpreters’ training or patients’ feeling. It shows the professionalism is undervalued that can break the balance of the triangular relationship among healthcare providers, patients and medical interpreters and it causes the distrust from patients. As Russell and Shaw note, ‘Mishler explained that in any given event, context shapes the interactional and linguistic choices made by its participants’ (2016). This statement indicates that the healthcare providers have not placed the expectation on medical interpreters, it is the medical setting to shape this expectation. On the contrary, Jimenez argues that ‘many have characterized the client-provider relationship as exceptionally complex. It involves, for instance, individuals in non-equal positions; it is often non-voluntary; it usually concerns issues of personal suffering and sometimes of life and death; and it is thus intrinsically emotionally charged’ (2004:1-2). How to retake the power is a crucial lesson for medical interpreters in that it is involved with overthrowing of the hierarchical working level (Hsieh and Kramer 2012) in the relationship of healthcare providers and interpreters. Medical interpreters should have the awareness to establish the fair position in medical settings that if the role they are asked to play and the behaviour they are asked to perform lower their position or unable to maximize their ability, it is necessary for them to correct healthcare providers’ requirements on time and should not fear of being the offender.

1.2 Healthcare users’ view
As Ciordia notes, Jacobsen explained that ‘the topic of the interpreter role has dominated the field of community interpreting, and studies within this particular sphere have traditionally centred on perceptions and expectations among users of interpreting services and interpreting practitioners’ (2016:67). Kai, Beavan and Faull (2011) believe that patients in a clinical settings have a different perception of the medical interpreters in comparison to what the professionals perceive of themselves, whom they consider as an integral part of their care process. Their expectation placed on medical interpreters are active participants and educators, to a certain extent, contradicts with both interpreter training and healthcare providers’ view. ‘Patients, in general, consider the availability and the quality of interpreting services as very important; the use of the interpreter and the perceived quality of the interpreter’s translation are strongly associated with the quality of care overall’ (Sleptsova 2014:168). Ciordia (2016:68) claims that although interpreters’ official role is a passive participant, community interpreters are active ones because of the presence at the speech. As per the authors, the theory of bilingual health communication presents that for the patients the communication done through the interpreters is effective and appropriate, thereby giving them the status of active participants. For the patients, they depend to a large extent on the medical interpreter not only delivering their messages to healthcare professionals but also for conveying their feelings to them because the medical interpreter is the only person know both languages, hence, the additional responsibility is added to medical interpreters’ work. In patients’ point of view, the active participants means participating in the discussion. In words of Cross and Bloomer (2010), an interpreted conversation can be correctly attributed as a “triadic,” i.e., the interpreter is an active participant in a three-party conversation. Because of the limited English proficiency, patients still do not have enough confidence to communicate with healthcare providers and totally trust healthcare providers, even if with the help of medical interpreters. It is the issue that triggers the speculation of whom patients should trust more, interpreters or healthcare providers? ‘Importantly, from the literature regarding a shared worldview arises the issue of clinician credibility. Fischer et al. (1998) note that clinicians are seen as more credible when the client has more similarity with the clinician, leading to greater satisfaction levels by both client and clinician, and reduced likelihood of discontinuance with treatment’ (Cross, and Bloomer 2010:270). Unfortunately, due to the language barrier, it is problematic for patients to trust the healthcare providers who have different cultural background, so before the doctor-patient encounter, patients expect there is time for them to have a quick chat with medical interpreters to inform them about their background and questions. During the medical encounter, medical interpreters are expected to act as the spokesman of patients to have the direct interaction with healthcare providers and patients. Once the healthcare providers instruct patients what to do, they may turn to medical interpreters for additional information which contains cultural-specific explanation and second opinions regarding their interventions. Furthermore, when playing active participants, medical interpreters have the potential to shorten the communicative exchange when engaged in a direct communication with the medical professionals. Additionally, to demonstrate interpreters as active participants in provider-patient interactions, it can be theorised that communicative goals of the patients compel the interpreters to speak for the patients and advocate for their needs and rights. ‘The idea of an interpreter advocating for the patient is in many ways frowned upon by U.S. healthcare institutions. Language intermediaries are at clear risk when they act on the patient’s behalf; for instance, formal complaints against interpreters have emerged when they attempt to explain certain culture-bound issues to healthcare providers’ (Jimenez 2004:3). However, this issue can be viewed in two aspects, who is the client, patients or healthcare providers and which version of norms to obey. If medical interpreters are hired by the hospital, the hospital is the client, obviously, before conducting the assignment, interpreters are told to obey the regulation formulated by the hospital. Under this condition, medical interpreters are impossible to advocate for patients and as a consequence, fail patients’ expectation. On the contrary, if medical interpreters are hired by patients, inevitably, interpreters are asked to help patients. The norms of ethics followed by them is the one in the interpreting training program. It is medical interpreters’ duty to evaluate the risk for advocating patients’ right. Most importantly, in the entire medical interview, patients expect medical interpreters to act as the stage managers, determining, guiding the stages for them and managing the stages to evade conflicts between patients and healthcare professionals. It can be concluded that patients expect medical interpreters as active participants since they view interpreters as tools to facilitate the communication to gain better rapport and medical service.
As stated by Hsieh, ‘it is important to note that often these patients not only need interpreters to help them communicate with physicians, they also need interpreters to help them to communicate with nurses and staff, and to help them get around in the hospital’(2006:179). Though the function of the medical interpreter is to allow communication between the healthcare provider and the patient, the nature of participation and involvement of the individual in this process has always been under speculation and debate. In the interpreter training, interpreters are taught and trained to be neutral and have proper interaction with healthcare providers and patients. The unfamiliarity with the foreign hospital environment, the words on billboard and the prescription are all problems for patients and it is the part that the interpreter training do need to take into account. ‘Some had worked with bilingual link workers and appreciated their assistance not only with communication during encounters, but also outreach and education’ (Kai et al. 2011:920). For patients admitted at healthcare settings where the primary language of communication is dissimilar to what the patient is acquainted to, it is the medical interpreter who is relied upon for educating them about the health complications they are facing and the interventions that they be suitable for achieving the desired health outcomes. Patients, out of their emotional needs, believe that the goal of interpreters would also encompass educating the patient about the building process of their care process or probably a diagnosed disease of which there is little or no information given before to the patient. For example, a patient suffering from diabetes can be educated about what lifestyle changes can be brought about, what health complications are to be checked for and what dietary requirements are prominent or the correct concept relevant to the disease. ‘The fact that the patients for whom these interpreters are speaking are recent immigrants, mostly from the Third World, highlights the fact that what interpreters are mediating in hospital discourse is not only the diagnosis and care of patients, but also a form of cross-cultural encounter between immigrants and agents of the institutions of the First World; it is these agents who both provide services to these immigrants while simultaneously educating them as to their role within the modern nation-state (cf. Gupta and Ferguson 1997)’ (Davidson 2000:3). Besides facilitating the communication, patients from the Third World expect medical interpreters to guide them to immerse in the First World medical setting involved with the culturally difference and even the expectation on how to behave in this setting from the healthcare providers. They are the concerned entities who are committed to foster a culturally competent interpretation of medical information. In addition to solely transferring information, patients are presented with a safe and secured care environment when interpreters take up initiatives to broaden their duties and educate the care consumers on different aspects related to health care (Duncan and Murray 2012). Changes in health condition can be identified by the interpreters under certain situation. Patients might want to engage in a discussion about the main goals and values around the quality of life (Burnard 2013).
It is noted that to facilitate the communication between healthcare providers and patients, medical interpreters have to balance the expectation placed on them. The expectation implies the roles and standard set for interpreters that can be attributed to define whether they are qualified or not. However, when the expectation turns to be requirements, it causes medical interpreters are under great pressure when doing the assignments. Being neutral and impartial in the communication is impractical especially in the medical setting which is involved with legal issues since interpreters are not conduit role. Interestingly, being neutral is an attitude rather than a behaviour that is necessary in the certain condition, such as advocating for patients’ right. Interpreters are easily caught in the dilemma that implies the pre-education is not comprehensive, however, they are ‘chameleons, they have to lend themselves to the topic under discussion, and blend themselves with the general decor’ (Cremona and Mallia 2001:301).  ‘The linguistic data, both quantitative and qualitative, points strongly away from a conclusion that interpreters are acting as “advocates” or “ambassadors” for interpreted patients, but are rather acting, at least in part, as informational gatekeepers who keep the interview “on track” and the physician on schedule’ (Davidson 2000:22). This dissertation suggests that the interpreting training program should be designed and modified to fit the current trend because more and more new modes of interpreting has appeared in medical settings that interpreting for immigrants and foreign patients are not the only tasks which require rather than good interpreting skills but the ‘role play’.
Feedback from the tutor
1) I would recommend that you include a brief introduction to each chapter explaining what you will discuss in that chapter and include a ‘mini’ conclusion at the end of chapter summarising the outcomes of your discussion and providing a link to the next chapter.
2) Your paragraphs are sometimes a little long and lack focus e.g. see first paragraph of 1.2
3) Sometimes cohesion in your writing could be improved. For instance, try to integrate your quotations into the flow of the discussion more e.g. see again opening of 1.2 and end of page 7
4) Check the presentation of quotations handout e.g. quotations longer than 4 lines should be indented e.g. see end of page 7 to beginning of page 8

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