ETHNOGRAPHIC STUDY ON THE USE
OF AD HOC INTERPRETERS IN
MEDICAL CONSULTATIONS
A CASE-STUDY ON TRIADIC DOCTOR-PATIENT INTERACTION IN A
COMMUNITY HEALTH CENTRE IN GHENT
Aantal woorden: 12.611
Sari Goukens
Studentennummer: 01500171
Begeleider: Prof. Dr. Katrijn Maryns
Masterproef voorgelegd voor het behalen van de graad van Master of Arts in het tolken Academiejaar: 2019 – 2020
Abstract
This study investigates how an ad hoc interpreter works and translates in a medical setting. As ad hoc interpreters are used quite often during medical consultations, it is important to analyse their communicative behaviour and to identify potential communication problems. For this dissertation, one consultation was recorded in a community health centre during which a family interpreter was present. The patient was a Turkish woman who brought her daughter along as an interpreter, the doctor was a female Flemish GP. The recording was transcribed and analysed. The analysis demonstrates that, in accordance with previous studies, ad hoc interpreters engage in side sequence talks frequently, often render zero-renditions and non-renditions and tend to speak instead of the patient. The ad hoc interpreter discusses important subjects, such as treatment plans, privately with the physician, taking on her role as family member instead of interpreter. The GP has trouble managing the consultation with an ad hoc interpreter present and as a result the consultation has no clear structure. In general, ad hoc interpreters might not seem ideal to work with in the medical setting, however, GPs could possibly benefit from learning how to better collaborate with informal interpreters.
COVID-19 Preamble
Originally the data for this study was to be collected during the entire academic year by Thomas Parton and I. We had approval of a first community health centre to conduct our research in November 2019 and had gained approval of a second community health centre in February 2019. In the first health centre, we were able to collect two recordings in December 2019, however, as a consequence of global pandemic, we were never able to obtain a recording in the second community health centre nor to collect more data in the first health centre. We decided to use the two recordings that we were able to obtain for our dissertations. Thomas and I focused on one consultation each for analysis and research for our individual dissertations.
‘This preamble was written in agreement by the student and the promoter and was approved of by both parties.’
Oorspronkelijk zouden Thomas Parton en ik gedurende het hele academiejaar data verzamelen. We hadden toestemming van een eerste wijkgezondheidscentrum om data te verzamelen in november 2019, en kregen in februari 2019 toestemming van een tweede wijkgezondheidscentrum om opnames te maken. In december 2019 hebben wij twee opnames kunnen maken in het eerste centrum, maar wegens de pandemie waren Thomas en ik niet in staat om in het tweede centrum een opname te maken en om onze data uit te breiden in het eerste wijkgezondheidscentrum. We hebben besloten op de twee opnames die we verkregen hadden te gebruiken voor onze onderzoeken. Thomas en ik hebben elk één opname geanalyseerd en onderzocht voor onze individuele thesissen.
‘Deze preambule werd in overleg tussen de student en de promoter opgesteld en door beide goedgekeurd.’
Acknowledgements
First and foremost, I would like to express my gratitude for my promoter Prof. Dr. Katrijn Mayns. I thank you for lending me support, giving me advice, motivating me and helping me write this dissertation.
I would like to thank Dr. Stéphanie De Maesschalck and Judith Dugardin for establishing this study and allowing me to be a part of it.
In addition, I thank my fellow student Thomas Parton for helping collect the data and sharing his ideas and insights with me.
I express my sincerest gratitude towards the community health centres, the receptionists, physicians, patients and ad hoc interpreters without whom this study could not have taken place.
I also thank our department’s technical staff for lending us all necessary camera and recording equipment to collect our data.
Lastly, I would like to thank my best friend and roommate Elke Van de Walle for supporting me this past year and motivating me to work on and finish this dissertation in times when I lacked energy and motivation to do so. I would also like to thank my fellow roommate and Elke’s fiancé, Nick Bellemans, for providing a peaceful and quiet environment for us to work in.
Inhoudstafel
1 Introduction ... 2
2 Theoretical framework ... 4
2.1. The use of ad hoc interpreters in medical consultations ... 4
2.2. Challenges of using an ad hoc interpreter ... 4
2.2.1. Side sequence/ side talk ... 5
2.2.2. Unfamiliarity with the medical world ... 6
2.2.3. Conversation management and conversation strategies ... 7
2.2.4. Problems concerning ethics ... 9
2.3. Benefits of using an ad hoc interpreter ... 9
2.2.1. Previous knowledge of the patient’s condition ... 10
2.2.2. Relation with the patient ... 10
3 Methodology ... 12
4 Analysis & Results ... 15
4.1. Structure of the consultation ... 15
4.2. Interactional micro-analysis of the consultation ... 17
4.2.1. The patient’s knowledge of the Dutch language ... 18
4.2.2. Zero-renditions by the ad hoc interpreter ... 20
4.2.3. Side sequences ... 24
4.2.4. Interlocutors interrupting each other/ conversation management ... 26
4.2.5. Speech accommodation ... 29
4.3. Analysis of the questionnaire ... 31
4.3.1. The patient’s questionnaire ... 31
4.3.2. The doctor’s questionnaire ... 32
4.4. Discussion ... 32
4.4.1. Miscommunication during the consultation ... 32
4.4.2. Connections to the theoretical framework ... 34
5 Conclusion ... 38
Bibliography ... 41
Appendix ... 44
Transcription ... 44
1 INTRODUCTION
In December 2019, there were roughly 1.3 million people of foreign origin living in Flanders, which makes up about one fifth of the total population in Flanders (Lefevere, 2019). Approximately fifty percent of all foreigners live in the big cities in Flanders, Ghent being one of those cities with about fifty-seven thousand people of foreign origin (Lefevere, 2019).
Knowing that quite a big portion of the population in Flanders does not have the Belgian nationality and that those people tend to live in the big cities (Ghent amongst others), and might not fully grasp the (Flemish-) Dutch language yet, one cannot be surprised that professional interpreters and ad hoc interpreters are commonly used in social service encounters in Flanders, including medical consultations. Ad hoc interpreters are non-professional interpreters and are often family members or friends of the patient. However, an ad hoc interpreter can also be a stranger who is conveniently available and speaks both the language of the foreign patient and the language of the physician.
This dissertation draws on a case study of a consultation recorded in a community health centre in Ghent with a female Flemish GP, a female patient of Turkish origin and the patient’s teenage daughter who acts as ad hoc interpreter. The recording of the consultation was transcribed for the analysis. The GP, patient and interpreter were also required to fill in a questionnaire about the consultation and sign an informed consent. The analysis of the interaction focuses on the ad hoc interpreter’s communicative behaviour in the consultation and examines how the use of an ad hoc interpreter affects the communication between the doctor and the patient. This dissertation is part of an interdisciplinary study in collaboration with the Department of Family Medicine and Primary Health Care (UGent), which aims to help develop a set of guidelines that general practitioners could use when working with informal interpreters.
Based on previous studies which will be discussed in chapter two (Theoretical Framework), the following three hypotheses were built:
- Hypothesis 1: the ad hoc interpreter answers on behalf of the patient
- Hypothesis 2: the participants engage in side sequences (either between patient and ad hoc interpreter or between doctor and ad hoc interpreter and only)
- Hypothesis 3: the ad hoc interpreter does not translate everything
The community health centre in which the data was collected, is located in a neighbourhood in Ghent where a majority of the citizens are people of foreign origin and most
residents are of Turkish origin. This means that a large number of patients who visit the community health centre speak very little or no Dutch. The community health centre has one in-house intercultural mediator who assists the receptionist, doctors, nurses, physical therapists and the dietician when they interact with foreign patients of Turkish origin. As there is only one in-house intercultural mediator, she cannot always be available to interpret when there are multiple foreign patients in need of assistance at once, which is why patients are sometimes asked to bring an ad hoc interpreter or decide to bring an informal interpreter (usually a family member or a friend) on their own initiative.
Multiple studies have investigated the role of ad hoc interpreters in medical settings and the differences between ad hoc interpreters and professional interpreters, mainly focussing on why using an ad hoc interpreter might have an undesirable outcome in a medical setting (Rosenberg et al., 2008; Meeuwesen et al., 2010; Garcés, 2005; Cirillo, 2010). Not many studies have attempted to improve the collaboration between general practitioners and ad hoc interpreters, which is the aim of the interdisciplinary study of which this dissertation is a part. The theoretical framework of this study will be explored in the second chapter of this dissertation. Firstly, we will discuss the possible disadvantages of using an ad hoc interpreter in a medical setting, such as side sequences, unfamiliarity with the medical world, conversation management and the problems concerning the ethical code. Secondly, we will look at the possible advantages of using an ad hoc interpreter during a medical consultation, such as familiarity with the patient and possible relation to the patient. In the third chapter the methodology is discussed. It will explain how the data was collected for this dissertation, the method used for making the transcription, the influence of the COVID-19 pandemic on the data acquisition and hypotheses concerning the analysis of the transcription. The fourth chapter comprises the analysis and a discussion of the questionnaires in relation to the micro-analysis of the transcription. This chapter also features a general overview of the consultation, in order to make the structure of the consultation clear. The micro-analysis looks at different parts in the transcription were the informal interpreter’s interventions have an impact on the consultation, such as zero-renditions, side sequences and speech accommodation. The observations at a micro-level are then discussed from a macro-perspective.
The fifth chapter brings together some concluding remarks. It recapitulates the results of the analysis and discussion and looks upon different ways in which this study could be improved.
2 THEORETICAL FRAMEWORK
Quite a number of studies have been conducted researching how ad hoc interpreters (also referred to as informal interpreters, lay interpreters or family interpreters) perform in medical consultations. Those studies highlight the advantages and disadvantages of working with either an ad hoc interpreter or a professional interpreter. In this chapter, a number of those studies will be discussed in light of our research.
2.1. The use of ad hoc interpreters in medical consultations
An ad hoc interpreter (i.e. lay interpreter/ informal interpreter) is generally a family member or a relative of the patient. He/ she can also be a person who is not related to the patient, but who speaks the patient’s language and happens to be available in the given situation (e.g. a cleaning lady in the hospital). Unlike professional interpreters, ad hoc interpreters have, more often than not, never received interpreter training and usually do not have any specific medical knowledge. They are merely appointed as the interpreter out of sheer necessity and/ or convenience.
The lack of training or knowledge could therefore affect the quality of the communication when an ad hoc interpreter is being used. Cox & Gutiérrez (2016) have found that ad hoc interpreters often make mistakes or alter information which goes unnoticed by either patient or physician. This could have very negative consequences for the patient’s healthcare. In the next section, we will discuss some of the main issues relating to the use of ad hoc interpreters in medical consultations. We then turn to the benefits of working with an interpreter.
2.2. Challenges of using an ad hoc interpreter
Whilst ad hoc interpreters are often present during medical consultations with foreign patients, the manner in which they work and translate have frequently been looked down upon as they are generally untrained people taking on a very important role during an interaction. The most common challenges when using an ad hoc interpreter will be discussed in this subsection.
2.2.1. Side sequence/ side talk
Keselman et al. (2010) defines side sequences as sequences held between two of three interlocutors in a language that the third interlocutor does not speak or does not speak well (e.g. a side sequence between an interpreter and an immigrant in the immigrant’s language by which the immigration officer is excluded from the interaction). In their study, the interpreter would replace one of the primary interlocutors during a side sequence (Keselman et al., 2010). This means that a triadic arrangement becomes a dyadic arrangement between the interpreter and one of the primary participants, also known as side talk.
Meeuwesen et al. (2010) have researched informal interpreting in a medical setting by observing sixteen consultations where Turkish patients had a consultation with their GP and brought along an informal interpreter. They have researched levels of mutual understanding and found that side talk gives the informal interpreter more control over the conversation as the ad hoc interpreter can decide what is discussed and when a certain matter gets to be discussed or not (Meeuwesen et al., 2010). Apparently when informal interpreters initiate side talk with a physician, they will often do so to give extra information to the physician concerning the patient which the patient has not given him/herself, transforming their role into that of caretaker (Meeuwesen et al., 2010). They conclude that when an informal interpreter initiates side talk, they often will do so to elaborate what was said or to give extra information to either the doctor or the patient hoping to improve the communication. However, side talk appears to have a rather negative effect on the communication during a consultation as it always excludes a primary interlocutor, who does not necessarily know what is being said (Meeuwesen et al. 2010).
In parallel, Hudelson et al. (2013) have conducted a study, analysing the communication during eight consultations regarding diabetes with Turkish-speaking patients who brought along an interpreter (both professional and lay interpreters). They notice that when an ad hoc interpreter is present during the consultations, the ad hoc interpreter will often engage in side talk with both the physician and the patient asking for more information or directly answering in place of the patient (Hudelson et al., 2013). In addition, they also state that the doctors have more difficulty managing the consultation when an ad hoc interpreter is present (Hudelson et al., 2013).
Rosenberg et al. (2008) researched how interpreters view their roles during consultations by observing consultations where both professional and family interpreters are used. They state that while professional interpreters view their job as transferring information and bridging a
gap between two cultures, family interpreters are primarily present to make sure that the patient gets the proper diagnosis and the care and treatment necessary (Rosenberg et al., 2008). Family interpreters seem to extend their role far beyond interpreting which also implies that they will more often engage in side talk than professional interpreters. They mainly do so to discuss treatment plans with the patient, as the family interpreters are often the ones who take care of the patient (Rosenberg et al., 2008).
Garcés (2005) studied three different types of interaction between a doctor and a foreign patient, namely interaction without an interpreter, interaction with an ad hoc interpreter and interaction with a professional interpreter. She finds that when an ad hoc interpreter is present during the consultation, the interpreter will often cease to translate, add or omit information and answer in place of the patient as he/ she participates actively during the consultation and will thus interact directly with the physician (Garcés, 2005). Garcés (2005) also indicates that when the ad hoc interpreter interacts with solely the physician or the patient, he does not offer a translation of what was being said during the side sequence to the other interlocutor.
In conclusion, all researchers of the studies mentioned above would be in agreement that an ad hoc interpreter is more likely to participate or engage in side talk with one of the primary interlocutors than a professional interpreter.
2.2.2. Unfamiliarity with the medical world
In an article published in the The Journal of Clinical Ethics in 2008, Anita Ho attempts to disprove the believe that family interpreters can never offer suitable help during consultations. She mentions multiple reasons as to why family interpreters might not be ideal, sometimes even harmful, the most important of which is the unfamiliarity of ad hoc interpreters with the medical world and medical jargon (Ho, 2008). While family interpreters mean well, they might do more damage than good when interpreting during a consultation as they might leave viable information out or simply translate what was being said incorrectly if they do not understand the medical jargon that the physician might use (Ho, 2008). A mistake made by a family interpreter or an unwillingness to translate certain information could have detrimental consequences for the patient as that limits their possibilities to make informed decisions regarding their possible diagnosis and treatment.
In similar vein, Meeuwesen et al. (2010) have found in their study that there tend to be more communication problems when working with informal interpreters as they often do not have a very extensive medical knowledge and thus mistakes are made more often, creating a
lower mutual understanding between the doctor and the patient. Because of this, Meeuwesen et al. (2010) recommend that the physicians check the language proficiency of the family interpreters and adjust their expectations about the communication accordingly.
To sum up, little knowledge of the medical world and medical jargon can negatively impact a medical consultation as the patient might not be aware of the extent of his/ her issues and might not be able to make informed decisions regarding treatment and care.
2.2.3. Conversation management and conversation strategies
Pasquandrea (2011) researched the interaction between physicians and professional interpreters and how physicians coordinate consultations mediated by interpreters. In non-interpreter-mediated consultations doctors already have a myriad of tasks they need to complete in order to help the patient, for example listening to the symptoms and processing the information, giving a diagnosis, writing prescriptions, asking necessary questions, etc. (Pasquandrea, 2011). When adding an interpreter to that dyadic conversation and thus making it a triadic consultation, the tasks of the doctor multiply as he/ she has to interact with two interlocutors, one of whom he/ she cannot communicate with him/herself (Pasquandrea, 2011). The interaction format changes in a triadic conversation, which complicates the management immensely as the doctor needs to undertake extra steps and strategies to coordinate the conversation so that the patient can receive the help that he/ she requires (Pasquandrea, 2011). Pasquandrea (2011) does highlight that the physicians and interpreters who participated in his study were familiar with each other, thus having already established a certain trust between each other.
Similarly to what Pasquandrea (2011) found, Garcés (2005) also discovered that doctors will use conversation strategies more often when using an (ad hoc) interpreter, such as repeating, reformulating and simplifying questions and information, to regain control over the otherwise sometimes chaotic consultations. Managing consultations during which ad hoc interpreters are present can be more difficult as they often engage in side talk with one of the interlocutors, and consequently do not interpret what was said to ensure that all parties are aware of all the information being shared (Garcés, 2005).
The role in which interpreters perceive themselves can also have an influence on conversation management, as Rosenberg et al. (2008) have found. They mention in their study that while professional interpreters often view their job as merely translating and thus not take active part in the conversation, family interpreters do take part during the conversation
establishing themselves as a third interlocutor (Rosenberg et al., 2008). As a consequence, doctors need to use communication strategies to coordinate a triadic participation format as they have to interact with two interlocuters instead of one (the patient) (Rosenberg et al., 2008). Rosenberg et al. (2008) make a distinction between using a professional interpreter and collaborating with an ad hoc interpreter as the ad hoc interpreter will most likely establish themselves as a third primary interlocutor.
Cirillo (2010) has found that (professional) interpreters tend to have more control over the consultation. She conducted a study researching how affect is managed during consultations mediated by professional interpreters (Cirillo, 2010). She states that when an interpreter is present during a medical consultation, the entire interaction becomes more complex and the roles of who coordinates and manages the consultation become more obscure (Cirillo, 2010). Cirillo (2010) concludes that the role that the interpreters play is of great importance as they direct the conversation by deciding what they will translate and what they will not translate for the other party to hear. Interpreters can decide whose voice is the most prominent in the interaction and can thus steer the conversation any which way they like; they can either stimulate the direct interaction between doctor and patient or they can hinder it (Cirillo, 2010).
Similarly, in her paper Dialogue Interpreting and the Distribution of Responsibility (1995), Wadensjö discusses who is responsible for the coordination of an interpreter-mediated interaction and for the information shared during the interaction. She states that an interpreter is always both an interpreter and a coordinator/ manager when present during an interaction as the interpreter has access to all the information being shared during said interaction (Wadensjö, 1995). The interpreter has to consider who utters an expression and for whom the expression is meant and meant to be understood, this of course has an influence on his/ her role not only as an interpreter but also on his/ her role of conversation manager (Wadensjö, 1995). What is most important about the two roles interpreters has is that they remain neutral as a coordinator and accurate as an interpreter (Wadensjö, 1995).
In short, Garcés (2005), Pasquandrea (2011) and Rosenberg et al. (2008) study conversation management by looking at the role that the doctor plays during a consultation. They all discovered that doctors need to use more conversation strategies when managing a triadic interaction instead of a dyadic interaction (Garcés, 2005; Pasquandrea, 2011; Rosenberg et al., 2008). However, Cirillo (2010) and Wadensjö (1995) look at conversation management by observing the role that the interpreter plays during a consultation. They find that an interpreter will have more coordinating power over a triadic interaction as he/ she can
understand both primary interlocutors and can decide what will be translated and what will not be translated (Cirillo, 2010; Wadensjö, 1995).
2.2.4. Problems concerning ethics
When working with an ad hoc interpreter, a big concern Anita Ho (2008) highlights is the lack of experience concerning the code of ethics. Professional interpreters are required to abide by a certain code of ethics; however, ad hoc interpreters are very often unfamiliar with ethics established to protect the primary interlocutors during an interpreter-mediated interaction (Ho, 2008). Certain medical topics are very sensitive and since ad hoc interpreters/ family interpreters do not necessarily know how to broach these topics delicately to their patient, it might not be ideal for them to translate such information (Ho, 2008). Patients also might not want their family to know certain medical information about them, but simply have to take a family member with them because a professional interpreter might not be available to them (Ho, 2008).
A doctor who works in the community health centre where the data for this dissertation was collected, shared some personal stories with me concerning ad hoc interpreters and the code of ethics. Whilst I was collecting data in the community health centre, this doctor asked what this study was about and upon learning the subject, continued to tell some personal experiences she had with ad hoc interpreters. She stated that sometimes the in-house interpreter is unavailable, and patients are required to bring their own interpreter, which has caused a patient to once bring her cleaning lady along with her as a lay interpreter. Other times patients brought their children to interpret; this is not ideal when a consultation concerns sensitive information which the child does not necessarily need to know about (e.g. unwanted pregnancies and abortions). This doctor also said that ad hoc interpreters are not ideal because it is hard to gauge if the interpreter fully understands the topic.
2.3. Benefits of using an ad hoc interpreter
Although using an ad hoc interpreter has a myriad of possible disadvantages, there are a number of counterarguments one could use to defend the presence of ad hoc interpreters during medical consultations.
2.2.1. Previous knowledge of the patient’s condition
When a patient brings a family member along to interpret during a consultation, the family interpreter will often already have some knowledge about the patient’s lifestyle and/ or conditions. Ho (2008) states that this could be an advantage to using ad hoc interpreters as they are familiar with the patient’s wishes and goals. Family interpreters often come along during multiple consultations, which means that the interpreter is possibly very familiar with the subject and the necessary vocabulary to handle the subject (Ho, 2008).
In a similar vein, Rosenberg et al. (2008) state that family interpreters are very aware of the health of the patient and will thus want to ensure that the patient receives the correct treatment. Family interpreters do not shy away from having a discussion with the physician if it ensures proper care and diagnosis (Rosenberg et al., 2008). Having a greater knowledge of the patient’s lifestyle and care preferences gives the family interpreter an advantage as it creates a certain level of trust between the patient, doctor and interpreter (Rosenberg et al., 2008).
To sum up, while some might see the previous knowledge of a patient’s conditions as a negative influence, Ho (2008) and Rosenberg et al. (2008) find that previous knowledge is a benefit when using an ad hoc interpreter. Family interpreters are familiar with the patient’s issues and needs and can thus better guarantee proper care (Ho, 2008; Rosenberg et al., 2008).
2.2.2. Relation with the patient
Chan et al. (2010) have conducted research on the different types of interpreters who were employed in the emergency departments of hospitals. They found that while professional interpreters are preferred by physicians and medical staff, that patients will often prefer family interpreters because they will be there to take care of them after they leave the hospital (Chan et al., 2010).
Rosenberg et al. (2008) have found a similar result in their study. As mentioned before, patients will often trust a family member to interpret for them during a medical consultation as they know that the family member is aware of their situation and will likely be the person who will take care of them once they go home (Rosenberg et al., 2008). Family interpreters will advocate for the patient’s care because they do not see their role as merely being an interpreter, they also want to fulfil their social role of family member and providing care for their family (Rosenberg et al., 2008).
In her article Not Just “Getting by”: Factors Influencing Providers’ Choice of Interpreters (2014), Hsieh defends family members acting as ad hoc interpreters as they find that family
members are not just there to help with the communication, but also to lend emotional support during a stressful time and prioritise the patient’s wishes and needs.
Ho (2008) has made similar statements saying that family interpreters can be beneficial as they have a relationship with the patient, thus being able to provide additional information, emotional support and care for them. Furthermore, Ho (2008) states that patients will sometimes be more comfortable keeping certain medical information in the family, and so they will prefer using a family interpreter because they do not want a stranger to hear that information. Patients will also often worry how their health and their decisions impact their family, and thus it might be preferable to have a family interpreter by their side to help make balanced decisions, should that be necessary (Ho, 2008).
Overall, it is clear that for purely communicative purposes, using ad hoc / family interpreters might not seem beneficial as they tend to engage in side talk more frequently, they might not be sufficiently familiar with the medical world, they might try to overtake the consultation and might not handle sensitive subjects in a delicate way. However, there are some benefits to using ad hoc interpreters: they are familiar with the patient who trusts them to translate everything important and on whom they can count for emotional support, decision making and caretaking. The use of an ad hoc interpreter or a professional interpreter often comes down to availability (Hsieh, 2014). A lot of medical workers use ad hoc interpreters simply because a professional interpreter is not available, either for that language or at that moment (Hsieh, 2014). Having more in-house professional interpreters could possibly help, although that might not be possible for every medical institution.
3 METHODOLOGY
This dissertation is part of an interdisciplinary master thesis project in collaboration with the Department of Family Medicine and Primary Health Care in the Faculty of Medicine at Ghent University. The project examines the use of informal interpreters in consultations between general practitioners and Turkish patients in several community health centres in the city of Ghent. On the basis of observation and analysis of interactional data and questionnaires, the project aims to develop a set of guidelines that may assist general practitioners in working with informal interpreters.
Together with a fellow interpreting student, Thomas Parton, I was involved in the collection and the analysis of ethnographic data that was collected in one community health centre. We were leant camera and recording equipment by our department’s technical staff, which we took with us every time we went to visit the community health centre. At the health centre, the receptionists would alert us when there were Turkish patients with an ad hoc interpreter who were visiting either one of the two GP’s who had agreed to participate in the project. Thomas and I would then approach the patient and their ad hoc interpreter and ask them whether they would like to participate in our study and would not mind being on camera and having the consultation recorded. Before and after the consultation, the patient (with the help of their ad hoc interpreter) had to fill in a questionnaire about the consultation and sign an informed consent document; and the doctor was also asked to fill in a document regarding the communication aspect of the consultation after they had finished. Recorded consultations were transcribed and, as I am studying Turkish, I had the task of translating the Turkish turns.
The data acquisition for this dissertation was a very slow and difficult process. We could only start the collection of data at the end of November 2019 and it could not be continued after February 2020 because of the global COVID-19 outbreak. As a result of that we were only able to acquire two recordings, which Thomas Parton and I decided to divide between the two of us. Thomas Parton analysed the first recording and I the second.
The consultation I analysed took place in December 2019. It is a consultation between a Flemish female GP and a Turkish female patient in her late forties. The reason for the consultation appears to be a discussion of the results of blood tests taken to check up on the
patient’s diabetes. The ad hoc interpreter during the consultation is the patient’s daughter, a teenager. The patient seems to speak very little Dutch but does at times seems to understand the Dutch language quite well. Her daughter (i.e. the ad hoc interpreter) speaks Dutch as well as Turkish. Dutch appears to be her second language, as she speaks it very well, but she does make some grammatical mistakes. The doctor’s native language is Dutch, and she appears to have no knowledge of the Turkish language. The length of the consultation is approximately 22 minutes.
Transcription of the recordings is based on the transcription system developed by Gail Jefferson, and where relevant, information regarding non-verbal communication was added. It is striking that throughout the consultation, the interlocutors frequently change the subject of the conversation. In the questionnaire, the daughter/ ad hoc interpreter who filled in the documents, states that the original purpose of the visit was to check up on the patient’s blood test results and diabetes, although this might not be clear when reading the transcription as they switch from one subject onto the next throughout the entirety of the consultation. Therefore, the transcription of the consultation was analysed by firstly dividing the conversation into different phases according to the subjects discussed by the interlocutors, to make the structure of the consultation clear. After having divided the transcription into different phases according to the subjects discussed in the consultation, the most prominent observations were selected for interactional analysis of the consultation at a micro-level. The following themes have been selected for analysis:
- the patient’s proficiency in Dutch - zero-renditions of the ad hoc interpreter - side sequences
- interruptions
- speech accommodation
Particularly the behaviour of the ad hoc interpreter was observed and analysed for this dissertation and subsequently compared to previous studies on the use of ad hoc interpreters in medical settings as well as studies regarding the code of ethics of professional interpreters. The following observations were expected to be made when analysing the behaviour of the ad hoc interpreter, in this case the daughter of the patient:
- Answering in turn of the patient: Meeuwesen et al. (2010) have conducted a study observing Turkish patients using family interpreters during medical consultations. They have found that because the interpreter is a family member, they try to take control of the consultation and become an advocate for the patient, giving information to the physician that the patient might not have necessarily given themselves (Meeuwesen et al., 2010).
- Talking privately with the patient (i.e. side sequence talk): Meeuwesen et al. (2010) have observed that family interpreters will often engage in side talk with the patient in order to ensure that the patient understood everything that the GP has said. These side talk sequences do, however, exclude the physician from the conversation (Meeuwesen et al., 2010).
- Talking privately with the doctor (i.e. side sequence talk): Rosenberg et al. (2008) studied the difference between professional interpreters and ad hoc interpreters in the medical setting, and have found that family interpreters will often engage in side talk with the GP to discuss for example the patient’s treatment as they saw the insurance of proper treatment as a part of their role as family member/ caregiver. Meeuwesen et al. (2010) have found a similar result in their study in which the ad hoc interpreter would often provide information about the patient for the GP which the patient themselves had not given.
- When interpreting, only translating part of what was being said: Rosenberg et al. (2008) have found in their study that omissions do occur quite frequently when ad hoc interpreters are interpreting during a medical consultation. They claim that the omissions are a result of insufficient knowledge of vocabulary (and sometimes grammar) when translating for either the patient or the physician, thus making it difficult to structure all the information given in a clear way (Rosenberg et al., 2008).
4 ANALYSIS & RESULTS
4.1. Structure of the consultation
For the analysis, the transcription (see appendix) has been divided into different phases according to the subject matter of a particular part in the consultation. This table maps out the general structure of the consultation, divided by the topics, and shows which turns (T) were spent discussing the particular topic:
Topic 1 Blood test results T 1-7; 7a; 109-127a; 187-244
Topic 2 Menopause T 8; 7b-58
Topic 3 Breathing and choking issues T 59-108; 245-265
Topic 4 Cholesterol treatment T 109-127a
Topic 5 Stomach issues T 129-186
Topic 6 Medication and treatment T 264a-395; 424-449
Topic 7 Aching throat T 396-413
Topic 8 Interpreter’s health T 416-423
1. Beginning of the consultation and topic 1 (blood test results) (T 1-7) 2. Subject change 1 to topic 2 (menopause) (T 8)
3. Resuming of topic 1 (T 7a) 4. Subject change 2 to topic 2 (T9) 5. Discussion of topic 2 (T 7b- 58)
6. Subject change 3 to topic 3 (breathing problems and choking) (T 59) 7. Discussion of topic 3 (T 61-108)
8. Resuming of topic 1 & topic 4 (cholesterol treatment) (T 109-127a) 9. Subject change 4 to topic 5 (stomach issues) (T 129)
10. Discussion of topic 5 (T 131- 186) 11. Subject change 5 to topic 1 (T 187) 12. Resuming of topic 1 (T 187a- 244) 13. Subject change 6 to topic 3 (T 245) 14. Discussion of topic 3 (T 245-265)
16. Discussion of topic 6 (T 264a- 395)
17. Subject change 8 to topic 7 (aching throat) (T 396) 18. Discussion of topic 7 (T 397-413)
19. Subject change 9 to topic 8 (interpreter’s health) (T 416) 20. Discussion of topic 8 (T 416-423)
21. Subject change 10 to topic 6 (T 424) 22. Resuming of topic 6 (T 426-449) 23. End of the consultation (T 450-454)
1: The consultation starts with the patient giving the doctor a urine sample, which she was asked to bring for another employee at the community health centre. The doctor then starts to explain why the patient was asked to bring a urine sample.
2: The ad hoc interpreter immediately interrupts and asks about the patient’s menstruation. 3: The doctor tries to resume her explanation, at which point it becomes clear that the urine sample is needed for a routine check-up concerning the patient’s diabetes.
4: The ad hoc interpreter then interrupts again and says that the patient wants to know if she is going into menopause.
5: The doctor explains to the ad hoc interpreter what the symptoms of menopause are, which the ad hoc interpreter then explains to the patient. After the conversation about menopause and possible treatment options continues, the patient suddenly changes the subject of the consultation again.
6: The consultation now concerns her breathing problems when eating or turning her head. 7: The doctor asks the patient several questions, which the ad hoc interpreter translates and the patient answers (in Turkish, which the ad hoc interpreter then translates into Dutch for the doctor). The doctor tries to establish when exactly the patient’s breathing problems occur and what causes said problems. The doctor continues asking questions, which now the ad hoc interpreter at times answers instead of the patient.
8: The consultation topic is then changed again (by the doctor) to discuss the results of a blood test previously taken to check up on the patient’s diabetes. The patient appears to have high cholesterol results, so the doctor discusses a possible treatment to lower the cholesterol. 9: The ad hoc interpreter changes the subject of the consultation again to some stomach issues that the patient might be having (the patient does not mention those herself).
10: The doctor inquires after the patient’s stomach issues. They discuss possible causes and talk about the patient’s diet.
11: The doctor resumes talking about the blood test results and mentions that the patient’s blood sugar levels are far too high.
12: They discuss treatment possibilities.
13: Patient brings up problems with the medication, which are too big for her to swallow causing her to choke.
14: The doctor and the patient discuss other forms of medication and settle on one which will not cause the patient to choke.
15: The doctor settles on one type of medication and goes on to explain the future treatment plan.
16: The doctor and patient discuss all the medication that the patient is currently on and discuss treatment possibilities to lower the patient’s blood sugar levels and improve her overall health. 17: The patient asks the doctor to look at her throat after the ad hoc interpreter ignores her previous request.
18: The doctor examines the patient’s throat and refers her to a specialist. 19: The doctor inquires after the ad hoc interpreter’s health.
20: The doctor asks how the ad hoc interpreter how she is and asks her to make an appointment to discuss her blood test results.
21: The patient inquires after a document the doctor has given them.
22: The doctor tells them what to do with the documents and when to come back for a follow-up.
23: The doctor, patient and ad hoc interpreter say their goodbyes.
4.2. Interactional micro-analysis of the consultation
Interactional micro-analysis of the consultation focuses on the following themes that directly or indirectly have an impact on the communication between the doctor and the patient:
- the patient’s proficiency in Dutch - zero-renditions of the ad hoc interpreter - conversational exclusion
- speech accommodation
4.2.1. The patient’s knowledge of the Dutch language
Throughout the consultation, the patient uses Flemish-Dutch a number of times, not only to answer a question but also to bring something up herself. A good example of this can be seen in excerpt 1, where the patient says that her throat feels sore.
Excerpt 1
396 P: keelpijn *wijst naar keel*
397 D: ik ga een keer kijken
398 P: sunu af doen /dit af doen/
399 D: ja, je mag even zitten en je mond open doen, een keer ademen. Je hebt wel wat grote amandelen, maar dat zit niet ne- denk ik niet dat dat de oorzaak is.
400 P: ne diyor? /wat zegt ze? /
After the patient repeatedly asks the ad hoc interpreter if she can ask the doctor to check her throat, the patient decides to ask the doctor herself (T396) by saying “keelpijn” (throat ache) and pointing to her throat. The doctor immediately understands what the patient is trying to say and goes to check her throat. In that same fragment, the patient uses Dutch a second time in turn 398, in which she asks the doctor if she should remove her scarf. However, while this fragment gives a clear indication that the patient has some knowledge of the (Flemish-) Dutch language, it also shows that she does not grasp the language fully, as she has to ask her interpreter what the doctor is saying to her in turn 400.
Turn 396, however, is not the only example of the patient using Flemish-Dutch herself during the consultation. Other examples can be found in turns 2, 35, 96, 161, 164, 170, 180, 198, 212, 217, 223, 229, 232, 234, 265, 292, 310, 312, 386, 388, 396, 398, 402, 439, 446, 450 and 454. While quite a few times the Dutch she uses are simple words (e.g. “ja”, “nee”, “oei”, “dank u”,
etc.), it does show that the patient understands the doctor better than we might at first perceive, which is very important to note when we consider the ad hoc interpreter’s repeated zero-renditions, i.e. instances where the interpreter does not interpret what the doctor has said (4.2.2.). An example of this can be seen in excerpt 2.
Excerpt 2
308 D: als ze combineert ja, als ze eentje verhoogt plus combinatie van een keer gaan zwemmen en een beetje op de voeding letten gaat dat zeker helpen ja
309 T: ah oké
308a D: het is vooral die voeding en dat bewegen dat belangrijk is. We gaan binnen twee maand controleren, niet in april maar in februari al, ik ga het aan Petra doorgeven-
310 P: februari çok uzak, gelin önceden degistiyorsa /februari is nog ver, kunnen we eerder komen/
311 T: euhm zij-
312 P: korktum artti, ik ben bang *lacht* /ik heb meer angst, ik ben bang/
313 T: ah ze zegt dat eigenlijk vroeger ook- vroeger kan komen allé-
In turn 310, the patient reacts to something the doctor says in turn 308a while the interpreter has not yet translated what the doctor has said. The patient clearly understands that she had to come back for a follow-up in February and is displeased about that news, so she chooses to interrupt and state her concern (turn 312: “ik ben bang” (I am afraid)). Because she immediately reacts and shows her worry, one can assume that during the entirety of the consultation, she understands more of what the doctor says than she might lead on to the other interlocutors.
Excerpt 3 shows another instance in which the patient reacts to something the doctor has said without the ad hoc interpreter having translated what was just said. In this excerpt, however, the patient does not react verbally.
Excerpt 3
177 D: weet dat er hier een dietist is hé, en weet dat ook beter is dat dat ook voor je suiker goed is en voor je cholesterol, voor het gewicht, voor je bloeddruk, eigenlijk voor alles euhm los van alle waarden heeft een dieet voordeel-
178 T: ja
177a D: zelfs al is de cholesterol niet lager, gewoon door gezond te eten weten we dat je al minder kans hebt op hart- en vaatziekten. En bewegen hé-
179 T: ja
177b D: bewegen en- 180 P: *lacht*
177c D: voeding *lacht*
Here the doctor explains that the patient should exercise more often as it will help lower her cholesterol (turn 177a and 177b). The patient hears the word ‘exercise’ (‘bewegen’) and begins to laugh (turn 180). The interpreter had not yet translated to the patient that she should exercise, however, the patient must have understood what the doctor said as it elicited a reaction.
4.2.2. Zero-renditions by the ad hoc interpreter
During this consultation, there are a number of instances where the ad hoc interpreter does not interpret what is being said by either the patient to the doctor or by the doctor to the patient. This is also known as a zero-rendition, a concept which Wadenjsö (1998) explains as an expression which is not interpreted or translated by the interpreter. Aside from zero-renditions, Wadensjö (1998) also discusses a concept known as non-renditions, which can be explained as follows: an expression uttered by the interpreter which is not a translation of what the ‘source speaker’ has said and is initiated by the interpreter.
When looking at previous studies on the same subject, it is noticeable that zero-renditions reoccur when observing ad hoc interpreters. Rosenberg et al. (2008) noted the same reoccurrence in their study, in which they compared the role of professional interpreters and family interpreters in clinical environment. They claim that family interpreters would often not interpret what was being said because they often take care of the patient, so the information is only important to them (Rosenberg et al., 2008). The researchers also reported that often family members acting as lay interpreters discuss treatment plans directly with the doctor instead of
interpreting for the patient and giving the patient more control over their own treatment (Rosenberg et al., 2008). This phenomenon can also be seen in this particular consultation, where the ad hoc interpreter (daughter) will often speak for the patient (mother), particularly when it comes to the treatment plans. In excerpt 4, the patient tries to interrupt the doctor several times (turns 295, 295a and 299) because she has questions about her treatment, yet neither the doctor nor the ad hoc interpreter listens to her as they continue to discuss the treatment plan.
Excerpt 4
294 D: ja dan kunnen we eigenlijk maar eentje verhogen-
295 P: öglende aliyor muyum? /moet ik het ’s middags nemen? / 294a D: dus dan neem je ’s morgens twee, ’s avonds twee en ’s middags eentje
295a P: *onverstaanbaar, praat terwijl arts spreekt*
294b D: dus eigenlijk maar eentje, dan is de kans wel heel groot dat dat niet voldoende zal zijn
296 T: ja dus vijf keer?
297 D: vijf keer best want vier keer wat meer dan dat mogen we niet geven, als dat niet genoeg helpt moeten we eigenlijk naar een volgende medicament gaan. Nu ondertussen als je probeert te zwemmen ondertussen en toch een beetje op je voeding probeert te letten, kunnen we de volgende keer zien of dat er iets anders nodig is maar ik vrees van wel.
298 T: ja
297a D: negen komma een is echt te hoog maar dan gaan we- 299 P: *onverstaanbaar, praat terwijl arts spreekt*
297b D: *onverstaanbaar* controleren hé, na zes weken best al hè.
Unfortunately, zero-renditions reoccur during this consultation. In excerpt 5, for example, the doctor even seems to implicitly wait for the interpreter to translate what was being said, but the interpreter does not react to this clue and refrains from interpreting the doctor’s utterance.
Excerpt 5
201 D: het is van zeven komma acht naar negen komma één gegaan, dat is echt heel hoog euhm
202 T: ja
201a D: dat moet ook lager, waarom? Hoe hoger dat jouw suiker is, hoe erger dat dat is op lange termijn, wat betekent dat? Dat je meer kans gaat hebben op euhm oogproblemen, nierproblemen euhm, bloedvatproblemen, dus eigenlijk is dat echt wel belangrijk dat dat suiker zo laag mogelijk zit. In eerste instantie is het opnieuw voeding, dieet blijft belangrijkste, gewichtsverlies euhm, sport, maar ook je medicatie gaan we moeten verhogen hè-
203 T: ja
201b D: jij neemt nu drie keer vijfhonderd-
204 T: ja
201c D: ja, dat gaan we verhogen naar drie keer achthondervijftig… ja
205 P: yüzmeye gitsem, yüzme mi yapar miyim? /als ik zou gaan zwemmen, mag ik zwemmen?/
206 T: euh
In turn 201c the doctor pauses before saying “ja”, which seems to indicate that she was waiting for the interpreter to start translating the explanation she just gave regarding high blood sugar levels and possible dangers of having high blood sugar. Instead, the patient interjects with a question, which the interpreter again does not translate for the doctor. One could assume that the interpreter was potentially still processing all the information that the doctor had just given, however, the patient does have the right at all times to know what was being said, although it
could seem that the patient in this example might have understood enough of the doctor’s explanation to ask a relevant question (i.e. if swimming could be beneficiary to her health).
Zero-rendition can also be quite detrimental when the interpreter fails to mention something of importance to either party during the consultation, resulting in the patient not getting the adequate care. This appears to happen in excerpt 6.
Excerpt 6
379 P: bogazimi bakacak mi? sorsun? /gaat ze naar mijn keel kijken? Vraag jij het? /
380 D: en neem je elke dag die medicatie?
381 P: ne diyor? /wat zegt ze? /
382 D: voor de euh hartkloppingen?
383 T: euh kalp çarpintisi olan her sey- her zaman aliyor musun? /neem je altijd dat voor hartkloppingen? /
384 P: aksamlarda aliyorum, o iyi geliyor bana /ik neem het ’s avonds, dat werkt goed voor mij/
385 D: of enkel als het nodig is?
386 P: ’s avonds
The patient explicitly asks the ad hoc interpreter if she can ask the doctor to check her throat, but the ad hoc interpreter does not seem to listen (turns 379-380). The fact that the patient does ask to have her throat checked must mean that it bothers her enough to interfere in her day-to-day life. Later on, during the consultation, the patient decides to ask the doctor herself to check her throat (as seen in excerpt 1 in 4.2.1.).
Excerpt 8 (4.2.3.) shows an example of a non-rendition, during which the ad hoc interpreter mentions a stomach problem that the patient is having without the patient bringing this topic
up herself. The ad hoc interpreter thus initiated the utterance herself, without consulting with the patient during the consultation.
4.2.3. Side sequences
When patients and the ad hoc interpreters know each other and are related, they very often hold little private conversations during a ‘main’ conversation, also referred to as side sequence talk (Keselman et al, 2008). Meeuwesen et al. (2010) have also taken note of this during their research. However, as Meeuwesen et al. (2010) have stated, side talk only involves those participating in the sequence, which in this case is often the ad hoc interpreter and the patient, thus leaving the doctor out of the conversation. Side talk can seem harmless if it is used by the interpreter to provide more information about something the doctor might have said, but can be harmful when they are discussing subjects relevant to the ‘main’ conversation but choosing not to share them with the third interlocutor. Side talk can create a bond between two parties of a conversation, which might be harmful for the overall flow of the conversation including a third party.
During this consultation, however, the patient and the interpreter do not engage in side talk very often and when they do, it is a very short conversation that they take part in while the doctor is busy on her computer filing in documents, which can be seen in excerpt 7.
Excerpt 7
429 P: çarsamba günü olsa seni *mompelt* bu se /als het woensdag kan *?* dat/
430 T: sey imzalarsin /je moet dit ondertekenen/
431 P: bu sefer dime diye yazmama de de diye de yazisin karismasin çok vaktime var burada /hier zal ik niet schrijven, maar daar is er veel tijd om het in te vullen/
432 T: nereye yazdin *niet verstaanbaar*? /waar heb je dat geschreven *?* ? /
433 P: *lacht* suraya vaktime *niet verstaanbaar* yazmami karismaz için /daar tijd *?* om te schrijven/
434 T: ah tamam *niet verstaanbaar* /ah oké/
435 P: önemli oldu- /is het belangrijk- /
While the doctor is busy typing up prescriptions on her computer, the patient and the ad hoc interpreter go over some paperwork very briefly, engaging in a short side talk.
During this particular consultation, the two interlocutors most frequently engaging in side talk are the doctor and the ad hoc interpreter, leaving the patient out of the interaction. This occurs when discussing ailments and possible treatments, as can be seen in excerpt 8.
Excerpt 8
127 D: ja, nu op zich euhm je cholesterolbehandeling is vooral noodzakelijk als er nog andere risicofactoren zijn, bijvoorbeeld bij mensen die euhm niet alleen suikerziekte hebben maar ook vroeger al een hartinfarct hebben doorgemaakt of mensen met euhm ja o- overgewicht plus hoge bloeddruk plus diabetes, allé alles-
128 T: ja ja
127a D: van alles samen, maar het is niet omdat je diabetes hebt dat je noodzakelijkerwijs tabletjes moet nemen voor cholesterol. In eerste instantie is het op voeding letten hè dus eigenlijk echt euhm het dieet gaan aanpassen
129 T: zij heeft ook echt veel als zij ook niet zo veel eet, heeft ze zo’n gezette buik, zo van maar echt niet normaal en ja. Dus ook als zij niet veel eet-
130 D: ja
129a T: is dat gewoon echt zo
131 D: veel lucht in de buik?
132 T: ja
134 T: ja veel lucht in de- ja
135 D: ja en diarree of constipatie?
136 T: diar- sey diarree oluyor musun? Ishal falan oluyor musun? Nee hè? /heb je diarree? Heb je diarree of zo iets?/
In this excerpt, the doctor explains why the patient does not necessarily need to talk medication to manage her cholesterol but a simple change in diet can already help (turns 127 and 127a). The ad hoc interpreter does not interpret the doctor’s explanation and instead brings up another problem that the patient is having with her stomach, which the patient herself does not mention (turn 129). Only in turn 136 does the ad hoc interpreter translate for the patient, however, she only translates the last question that the doctor has asked (turn 135) and does not translate the information given regarding the patient’s cholesterol problems.
Hudelson et al. (2013) have conducted a study in which they observed consultations mediated by both professional and ad hoc/ family interpreters and they found that family interpreters will engage in side talk more often with the physician to either ask questions regarding the patient’s care or to answer the doctor’s questions themselves instead of giving the patient the opportunity to answer to question. In this consultation we can see a similarity as the ad hoc interpreter often answers questions instead of translating and letting the patient answer for herself.
4.2.4. Interlocutors interrupting each other/ conversation management
The most obvious observation that can be made during this consultation, is that all three interlocutors tend to interrupt each other very frequently. They all seem to fight for the most “managing/ leading” position in the conversation, which is usually attributed to the doctor in a consultation. However, when working with an interpreter, Wadensjö (2017) believes that it is the interpreter’s job to guide the conversation as the interpreter has to listen to each interlocutor and translate for the other interlocutor to be able to take their turn.
In this transcription, interruptions are made clear by dividing the main turn by the interrupting party’s turns and adding letters (e.g. a, b, c, etc.) to the number of the main turn, which can be observed in excerpt 9.
In this particular consultation, the interruptions often bring subject changes with them, for example in excerpt 9.
Excerpt 9
7 D: waarom urine? Dat is controle van de eiwitten in de urine - 8 T: ah ja want dat maandstonden dat komt ook in de -?
7a D: dat maakt niet uit, bloed maakt niet uit. Dat gaan we euh- dat gaat niet beïnvloeden. Als je suikerziekte hebt, moeten we ook elk jaar kijken of de nieren nog goed werken en een van die testjes daarvoor is kijken of dat de eiwitten-
9 T: ah ja want ze wil weten of dat ze in de menopauze zit of niet
7b D: ah ja, dat kan je niet zien in de urine, euhm je kan dat zelfs niet goed zien in het bloed. Je kan testen, dat wordt soms aangevraagd, maar eigenlijk is dat niet betrouwbaar. Euhm de volgende als we jouw bloed prikken, kunnen we dat op zich wel aanvragen of je kan het ook nog bijvragen want het laatste onderzoekje is van 4 december-
10 T: ja
7c D: je kan het op zich nog bijvragen, euhm maar eigenlijk is dat ook niet betrouwbaar. Wanneer weten we dat je in de menopauze zit? Als je een jaar geen menstruatie hebt gehad 11 T: ah ja
Already from the very beginning of the consultation, in turn 8, the ad hoc interpreter changes the subject from protein content in urine to menopause. In turn 7a, the doctor tries to change the subject back to the reason why they need to analyse the patient’s urine. However, in turn 9, the ad hoc interpreter asks about menopause again, a subject which the patient might have brought up before the consultation but not during the consultation itself.
One could explain the interruptions in this particular consultation by saying that the doctor is merely trying to give the information for which the patient made the appointment in the first place, and that she resolutely wants to explain the importance of the tests and implications that the possible results bring. The patient (and her daughter/ ad hoc interpreter), on the other hand, seems to address as many ailments as possible during one consultation, as if they want to limit potential future consultations, should the patient not be treated or examined now. This could be linked to the research of Meeuwesen et al. (2008) who state that a family interpreter will often try to control a medical consultation as they want to ensure that the patient receives all the medical care they could need.
Interruptions do not always bring subject changes with them of course. For example, in excerpt 10 the doctor interrupts the ad hoc interpreter to approve of the patient’s plans regarding exercise.
Excerpt 10
225 T: ah zaterdag- euh in het weekend zal zij dan gaan zwemmen en zo ze wil-
226 D: ja maar dat is super, als je al begint met zwemmen is dat goed eigenlijk hè zoveel mogelijk wandelen euhm of zwemmen is inderdaad goed, waarbij dat je probeert wat baantjes te trekken dat je ook echt wel merkt dat je sport doet,
227 T: ja
226a D: dat je hart wat f- versnelt euhm dat is de eerste stap. Fietsen? Fiets jij?
In turn 225 the ad hoc interpreter mentions that the patient has plans to go swimming each weekend to help lower her cholesterol rates. Before the ad hoc interpreter can finish her translation the doctor interrupts her (turn 226) to approve of the patient’s plans. In turn 226a, however, the doctor resumes her interruption (turn 226) and finishes her turn by asking a question and changing the subject from swimming to cycling, although the main subject (i.e. exercise) does not change.
Throughout the entirety of the consultation the doctor and ad hoc interpreter frequently interrupt each other shortly to confirm that they are in fact listening to each other, most often by saying ‘ja’ or another confirmation (e.g. ‘oké’, ‘ah’, etc.) while the other interlocutor is speaking. This is shown in excerpt 11.
Excerpt 11
314 D: awel maar je moet zes weken wachten totdat je het merkt het verschil 315 T: aah oké
314a D: als je het te vlug controleert, weten we het eigenlijk niet dus- 316 T: ah ja
314b D: ik ga het na zes weken- ik ga aan Petra vragen om jullie te contacteren om na zes weken een afspraak te boeken
314c D: is dat goed?- 318 T: ja
314d D: euhm
In excerpt 11 the doctor is explaining why they need to wait six weeks to have the next check-up to the ad hoc interpreter. The ad hoc interpreter “interrcheck-upts” the doctor’s explanation four times (turns 315, 316, 317 and 318) to confirm that she is listening and understands what the doctor is saying to her (and the patient, respectively). The last ‘ja’ (turn 318) that the ad hoc interpreter says, is an answer to the question that the doctor asks in turn 314c but can be seen as an interruption as the doctor does not wait for her to answer the question and immediately wants to continue her turn (turn 314d).
When discussing the conversation management in this particular consultation, one could say that the doctor and the ad hoc interpreter are “fighting” to take control. As previously stated, in a medical consultation the doctor is usually the interlocutor who controls the conversation as they have to discover what the problems are and how they can help the other interlocutor (i.e. the patient). When working with in interpreter, however, the doctor cannot have full control over the conversation as they to do understand the patient and are thus in need of a third interlocutor (i.e. an interpreter) to help them. Pasquandrea (2011) conducted a study observing consultations using a professional interpreter and found that physicians, aside from the task of listening to the patient and helping them, had the task of coordinating a more complex participation framework as they have to manage a conversation between three instead of two interlocutors, one of whom they do not understand. He states that interpreter-mediated consultations require a GP to develop extra communication strategies than when there is no interpreter involved in the consultation (Pasquandrea, 2011). With this knowledge, one can only assume that a physician would need adapted communication skills when coordinating a consultation mediated by an ad hoc interpreter (either a family member or a nonprofessional interpreter).
4.2.5. Speech accommodation
When talking to a person who does not speak your language either at all or not as well, one might be guilty of using the strategy called ‘speech accommodation’. Giles (1987) distinguishes two different types of speech accommodation, speech convergence and speech
divergence. Speech convergence means that you adapt the manner in which you speak so that you speak in a manner which is more similar to the speech of your interlocutor (Giles, 1987). Speech divergence refers to you not making the effort to adapt your language to that of your conversation partner (Giles, 1987). When talking to a person whose native language differs from yours, you might favour speech convergence as that could indicate to your interlocutor that you want to remove any cultural (or linguistic) hurdles between you two (Giles, 1987). Knowing this, you could expect a doctor to use speech convergence as a strategy to talk to a patient whose native language is different, even during interpreter-mediated consultations.
During this consultation, however, the general practitioner does not use speech accommodation when talking to either the patient or the ad hoc interpreter. Even when the patient speaks in her “broken” Dutch, the doctor does not accommodate her language to that of the patient. This can be seen in excerpt 12.
Excerpt 12
170 P: ik ben *lacht* ik ben- sey /*tussenwerpsel*/ altijd dieten *lacht* diyetisyen- /dietist-/
171 T: zij eet graag-
170a P: *niet verstaanbaar* 172 T: ja zij- ja zij ma- zij ja-
173 D: je ziet dat inderdaad aan de cholesterolgehaltes *lacht* 172a T: zij kookt graag en zo
174 D: maar dus ja jouw cholesterol inderdaad, dat verklaart ook waarom dat *niet verstaanbaar*
175 P: Türk sarma- Türk kü- *eet gebaren* /Turks -, Turks -/ 174a D: veel suiker en veel vet he
In turn 170 the patient attempts to say that she tries to watch her diet (‘ik ben altijd dieten’), and when the doctor answers (turn 173) she does not change the manner in which she speaks to make it “easier” for the patient; she speaks Dutch correctly. Some doctors might have had the tendency to react in “broken” Dutch to adapt their manner of speech to that of the non-Dutch speaking patient.
Even in excerpt 1 (4.2.1.), when the patient indicates that her throat hurts by saying ‘keelpijn’, the doctor just answers that she will check her throat and does not adapt her speech. Other physicians might have answered with ‘doet je keel pijn?’ (‘does your throat hurt?’), which could possibly sound like they are talking to a child because they are simply repeating what was said in a question format.
The fact that this particular doctor does not engage in speech convergence does not necessarily mean that she does not wishes to communicate clearly with the patient. The GP has indicated in the questionnaire (4.3.2.) that she trusts the ad hoc interpreter to translate correctly and thus this could potentially explain the absence of speech accommodation.
4.3. Analysis of the questionnaire
As mentioned in the methodology section, the doctor and the patient were asked to fill in a short questionnaire before and after the consultation. In this section, we will discuss these questionnaires regarding the communication aspect of the consultation (see appendix) that the patient (with the help of the ad hoc interpreter) and the doctor have filled in.
4.3.1. The patient’s questionnaire
The ad hoc interpreter filled out the questionnaire for the patient and did not state an initial reason for their visit to the doctor. In the portion of the questionnaire they had to fill out after the consultation had finished, the ad hoc interpreter did write that they went to the doctor’s office because the patient suspected her blood sugar levels to be too high.
They mentioned that they received a diagnosis and a treatment plan and that they were expected to come back two months later for a second check-up. The most interesting part of the questionnaire of the patient, is that for question ten they indicate that the doctor has not asked if they have any additional questions, which coincides with the transcription of the consultation.
In the questionnaire that the patient and ad hoc interpreter filled out, there is no question regarding the communication aspect of the consultation as that might have made the ad hoc interpreter suspicious about the intention of the research. This means that we cannot know how
