Through interpreters’ eyes: Comparing roles of professional and family interpreters

2.1. Subjects 

For the first phase we recruited 4 professional interpreters and two individuals who regularly interpreted for family members. For the second phase, we conducted our research in primary care medical clinics in two districts of Montreal with a high concentration of recent immigrants. We studied 22 encounters involving 22 patients, 15 interpreters (6 professionals and 9 family members) and 19 physicians. Two professional interpreters participated in both phases. We approached all 17 physicians at the main practice who saw patients with an interpreter during the recruitment period. One physician refused to participate. We recruited 1 volunteer physician at each of 3 other practices. Participating physicians reviewed their appointment lists with the research associate to identify patients who came with interpreters. All five patient-interpreter pairs introduced to the project by their physicians accepted. The research associate approached 17 interpreters. Two refused to participate (one professional and one family member). All 17 patients approached about the study by an interpreter they knew consented to participate.

There were 9 encounters with a family interpreter and 15 with a professional interpreter. As indicated in Table 1, interpreters 1 and 2 participated in 3 and 6 encounters, respectively. They were interviewed separately about each encounter. The languages spoken are listed in Table 1 and are representative of the limited language proficiency individuals in these practices. Professional interpreters were not employees of the healthcare institutions where the research took place, but were provided by the Interpreter Bank of the Agence de la santé et des services sociaux, a governmental agency, and had undergone 45h of training and passed formal competence testing. Family member interpreters were usually more highly educated than their relatives, and had often been away from their native land for a longer period of time, two factors that contributed to their ability to assist their relative in the healthcare system.

Table 1. Interpreter characteristics

		Type	Relation to patient	Language	Sex	Age	Case(s)
	1	Professional		Punjabi Urdu	F		4, 6, 10
	2	Professional		Punjabi Urdu	F		1, 3, 5, 7, 8, 9
	3	Professional		Vietnamese	F		11
	4	Professional		Punjabi	F		12
	5	Professional		Farsi	M		13
	6	Family	Son-in-law	Bengali	M	40–50	2
	7	Family	Daughter	Vietnamese	F	40–50	14
	8	Family	Granddaughter	Farsi	F	18–25	15
	9	Family	Husband	Tamil	M	30–40	16
	10	Family	Daughter	Tamil	F	30–40	17
	11	Family	Brother	Bengali	M	40–50	18
	12	Family	Son	Dari	M	40–50	19
	13	Family	Son	Tchouluba	M	30–40	20
	14	Family	Husband	Greek	M	>60	21
	15	Family	Husband	Pashtu	M	40–50	22

2.2. Data 

2.3. Data analysis 

We conducted a thematic analysis of interpreter comments on their roles in clinical encounters using a constructivist approach and Atlas-ti [24], [25], [26], [27]. The three authors, bringing their separate domains of expertise, reviewed the transcripts and identified categories that emerged from the data. ER is an experienced family physician teacher of communication skills, YL is a research psychologist specialized in intercultural communication and RS is an anthropologist with expertise in migration and urban diversity. ER has extensive clinical experience with immigrants. We used a multidisciplinary inductive approach to create the categories. We came to a consensus on a list of categories through discussion within the research team. Major themes across categories were identified through extensive discussions within the group. We systematically looked for evidence of conflicting data before including any strategies in the final analysis. All 3 analysts concurred on the final themes reported below as well as the content coded within each theme.

3.1. Professional interpreters 

3.2. Family interpreters 

4.1. Discussion 

All interpreters expressed ways in which they were “visible” in the medical interview, as active participants [6]. However, the “visibility” of professionals differed from that of relatives, in the roles they reported fulfilling and the ways in which the roles were carried out. Professional interpreters, following Meyer's dichotomy [8], interact in ways that are mainly supportive, becoming primary only in the instances where they feel they must exert control over the process. Family interpreters carried out more primary interactions. They acted mainly as a third interlocutor in the interaction translating only when necessary, providing information and negotiating directly with the physician.

Our data show two trends that others have also found. The first is the limitation of the conduit model [9], [14], [28], [29], [30], [31]. Acting as a linguistic conduit is an essential role of the interpreter. However, it does not provide interpreters with guidance in emotional situations. If they are to only serve as a conduit they are not permitted to show empathy for the patient. Many professional interpreters experienced a contradiction between their social identity, as a community member, and their professional identity as an interpreter and a part of the health care system [13].

The second trend is the absence of a place for interpreters in the institution [15], [29], [32]. Professionals commented on evidence of lack of respect for their capacities or status. The interpreters in this research phrased it as a spatial, very material, absence: they had no space of their own to wait, place their belongings, make calls or receive mail, as they were relegated to the waiting room with patients. We see it as a symptom: interpreters do not have their own place in the institution. They are not part of the healthcare or the administrative staff. They are only paid for translating. Other tasks such as helping patients make appointments are not remunerated, implying that these activities are not valued by health care authorities. In brief, their place in the institution was that of a tool, not a collaborator. The result of these two trends is that, in interpreters’ eyes, their ability to act as integration and community agents depends on physician or institutional will and not on patient interest so that in practice, they act mainly as a linguistic or a system agent.

Family interpreters did not describe the tension between roles reported by professionals as they did not perceive themselves as system agents at all. While they were aware of physician expectations, in terms of time constraints and the kinds of information needed, they were mainly concerned with their relative's well-being. Interpreting is just one of many family roles family interpreters carry out. Family interpreters not only mediate the doctor-patient interaction; they also must navigate the medical system with their relative. As a consequence, and contrary to professional interpreters, family members seem oriented toward more community and integration roles [33].

Family interpreters represent a distinct sub-group of “ad hoc” or lay interpreters. They have privileged access to patient health information. As such they can be invaluable healthcare partners and they are less likely to commit the translation errors made by untrained hospital volunteers [34], [35].

4.2. Conclusion 

Professional interpreters do not operate merely as conduits: rather they are active participants in the medical interview, helping to construct meaning and to create an environment in which communication can happen. Often family members act on the behalf of the patients, in order to facilitate their diagnosis, treatment and recovery as an extension of their role as a close family member.

4.3. Practice implications 

To obtain the maximum benefit from a professional interpreter the physician must invite the interpreter to act as an advocate for the patient and a culture broker. The scientific literature emphasizes the importance of working with a professional interpreter, mainly for accuracy of the translation [4], and physicians should use professional interpreters with all patients with whom they do not share a language. In addition, we consider the collaboration with (and not the “use” of) a family member as an important element in the care of chronically ill and/or elderly migrant patients. The patient who is accompanied by a family member may have the benefit of an advocate who can continue physician-to-patient information transfer after the encounter and ensure patient care. However, because the family member is also an independent interlocutor, physicians must have and use skills for triadic interaction [36]. Practitioners should be trained to work with interpreters and members of patients’ support network in order to offer healthcare in the best interest of the patient.