In the ICEs they facilitate, interpreters play a wide variety of roles. In the present study, that variety was evidenced by how interpreters perceived their roles, enacted them, and talked about them. During interviews and conversations, the terms used by interpreters to talk about their roles illustrated the tension between the prescribed role (invisible) and the actual role (visible). However, this tension only seems to exist at the level of the perception or belief, because in practice, the tension gets resolved. The interpreters shadowed in this study became visible partners in their interpreted communicative events. Many of them described their varied roles using metaphors. In the following sections, we explore some of those metaphors.

Interpreters as detectives

As we saw in chapter 6, patients do not always give specific answers to HCPs' questions. Sometimes HCPs even ask interpreters to get information without giving them a specific script. Interpreters then take the lead in a line of questioning, in order to get the answer. In other words, they become detectives, questioning the patient carefully, hoping to discover the answer. Interpreters perceive this as an enormous responsibility, not just because the HCP depends on this answer to take action, but also because in many instances, interpreters have no guidance as to what exactly they are supposed to ask. In spite of this, interpreters willingly take on this responsibility.

Communication between speakers who do not share a common language or culture has always been enabled by translation or interpreting. Interpreters are one component in a three-factor equation, which consists of more-dominant speakers, less-dominant speakers, and the interpreter. The role of interpreters in a bilingual encounter can take different forms. For example interpreters may help minority-language speakers explore possibilities, thereby channeling opportunities for them. This brokering may be achieved by being attentive to the social reality of the speakers. Alternatively, interpreters may focus on the message only, disregarding how it is socially constructed by each of the parties involved in the conversation. Another possibility is that interpreters may align with the speaker of the societal language, conveying information to the less-dominant speakers without helping them gain access to it. This last possibility positions interpreters as gatekeepers (Davidson 2001) rather than opportunity channels. Regardless of the role assumed by interpreters in the cross-linguistic encounter, they are vital for the communication of those who do not speak the majority language.

Language interpreters are often portrayed as invisible language facilitators. According to this perception of invisibility, interpreters are not considered to be parties to the conversation, but rather they are seen as language-switching operators in line with the conduit model of communication (Reddy 1979).

Understanding the complexities of medical interpreting and the different roles interpreters play requires contextualized study of naturalistic data over an extended period of time. This chapter will describe how these topics are explored through an ethnography performed in a public hospital. The first part of the chapter will explain the reasons for choosing a medical setting over any other. Next, the process of obtaining consent will be described. Then, the study itself will be presented, beginning with a brief description of the city in which the site is found, the site at large (California Hope), and the informants at the specific site (the interpreters at Interpreting Services).

Finding a study site

In choosing a site, the next logical step was to look for one in which access to a wide array of interpreted medical interactions would be available. In this sense, California Hope (CH) emerged as a unique site, since the number of ICEs (both face-to-face and over-the-speakerphone) carried out per day at CH is astonishingly high.

The essence of the doctor–patient relationship

The term relationship refers to the condition of having a logical or natural association between two entities (Random House Webster's Dictionary 1997). From the cradle to the grave, human relationships are vital (Adler 2002). Every human relationship involves a connectedness between individuals, which is molded by both verbal and non-verbal communicative processes. Without communication, successful relationships would not be possible. In fact, even poor relationships depend greatly on communicative processes between individuals.

The importance of effective communication in the building of a successful relationship is well illustrated in the healthcare provider (HCP)–patient situation. Communication between HCP and patient encompasses both verbal and non-verbal interactions (Lee, Back, Block, and Stewart 2002). Although physicians of today are better educated and more scientific than ever before, they sometimes do not communicate effectively with their patients (Jacobs et al. 2001). This is particularly true in cases where HCPs and patients do not share the same cultural background. The diagnostic importance and therapeutic benefit of conversation between physician and patient has long been recognized. Research on the HCP–patient relationship tells us that better communication can improve patient satisfaction and clinical outcomes (Rosenberg, Lussier, and Beaudoin 1997).

When referring to the HCP–patient situation, it is important not to confuse the terms interaction and relationship. These two terms are not interchangeable.

The end of the twentieth century and the beginning of the twenty-first witnessed important changes affecting healthcare delivery to limited-English-speaking patients in the United States. As a result, a gradual emergence of academic questions regarding the nature of communication between healthcare providers and patients across gulfs of language and culture, especially when brokered by interpreters, began to trigger debate as to what roles the interpreters should play. This concern was echoed in practical pleas of interpreters themselves who asked: “What can I do to help, what is my role?”

The field of medical interpreting, in particular, has been undergoing an extraordinary evolution. First, Title VI of the Civil Rights Act of 1964 established the need for professional interpreters, in order to ensure meaningful access to healthcare for patients with limited English proficiency. As a result, government-funded programs for healthcare institutions have been mandated to provide interpreting services to limited-English-speaking patients (Allen 2000). At the same time, medical interpreter organizations are writing and publishing codes of ethics and pursuing certification efforts (California Healthcare Interpreters Association 2002; Massachusetts Medical Interpreters Association 1995). Funding agencies are increasingly paying attention to issues of cross-cultural and linguistic communication. In 2001, the Robert Wood Johnson Foundation funded Hablamos Juntos, an 18-million-dollar national initiative to improve healthcare communication for the Latino population in the United States.

During my stay at CH, I spent a lot of time with the informants, asking questions, observing, shadowing them, and taking notes on what they do and say. While doing this, I continuously followed “hunches – which we could call hypotheses – that helped [me] figure out why things happen as they do” (LeCompte and Schensul 1999:11). The recursive nature of questioning, obtaining answers, refining questions, getting more detailed answers, and searching for ways to corroborate, negate, clarify, or expand original formulations allowed me to reorganize my sense of what was happening at CH. In doing this, I paid close attention to negative evidence, i.e. behaviors, instances, or other facts that appeared to disconfirm the construct of a visible interpreter that I had already found. This was especially important, in order to avoid the temptation of dismissing these facts as anomalies. Instances when interpreters would step out of role and argue with providers on behalf of the patient were difficult to discern, and the process was time consuming. However, they were worth it, because they helped me refine and modify my search (Miles and Huberman 1984).

This recursive analysis started as soon as I entered CH and continued for three years. It was guided by copious inscriptions (head notes), descriptions (field notes that turned into conceptual memos for myself), and transcriptions. Throughout the course of my fieldwork, I tried to remain conscious of any biases about the field of interpreting that I might harbor.

The nature of the ICE at California Hope

The ICEs at CH cover a range of activities and, as we have seen, occur either over the speakerphone or face-to-face. Patients or HCPs need interpreters to assist them in performing various activities and carrying out communicative functions. Examples of activities include: making or canceling an appointment; delivering news or results; conducting a verbal examination (speech pathology); conducting a physical examination (physician); conducting a procedure (e.g. CT scan); and calling to remind about an appointment. In these activities, any of the following communicative functions can occur: complain, request, reprimand; explain, express support, justify, advise; ask and answer questions, express solidarity; instruct; inform; and remind. The length of the ICE also varies significantly, according to the nature of the event (which varies from two minutes to over two hours). For example, an appointment cancellation or a reminder call may take under three minutes. These ICEs are generally conducted over the telephone. A check-up visit may take fifteen minutes, with the interpreter present or at a remote location (over the speakerphone).

In sorting out the puzzle of the role of interpreters during an ICE, a crucial piece of information is the interpreters' perception of their role. This emic perspective (Van Maanen 1988) allows us to triangulate the evidence of the role at play (discussed in the previous chapter) and the self-reported data obtained from the IPRI. This perspective made it possible for me to contextualize my observations on the role that interpreters play (chapter 6).

My conversations with the informants on their role were in the form of semi-structured interviews. As mentioned in chapter 4, I explored three issues during the interviews: (1) their perceptions of the parties with whom they work (patients and HCPs); (2) sources of stress and tension at work; and (3) their role. Each interview lasted approximately forty-five minutes.

In the following sections I synthesize my analysis of each interpreter's interview. During these interviews, the interpreters interjected anecdotes, stories, and examples, while the manager focused on the skills that are required of interpreters who work at CH. Of the eleven interviewees (ten interpreters and the manager), seven chose Spanish as the language for the interview and four chose English. For the sake of brevity in this chapter, most of the Spanish quotes are translated into English. Informants, except for the manager, are presented in alphabetical order.

Roberto, the manager

Roberto perceives the parties with whom he works as very different from one another: HCPs are educated and powerful, pressed for time, and in need of accurate information.

Looking at the interpreter's role through different lenses

In chapters 1 and 2, we have examined a paradigm shift: from the interpreter as a conduit of information to a co-participant in the interaction. This shift helps to describe how interpreters do their jobs, but it does not tell us why interpreters make the choices they make. If they are co-participants, then what triggers their participation? Interpreters are full participants in communicative interactions together with doctors and patients. Like any of the other co-participants, interpreters bring their social baggage (their beliefs, attitudes, and cultural norms) to the medical encounter, and they exercise their agency. Interpreters, like all other human beings, participate in an interaction that does not happen in a social vacuum. Regardless of whether they perform the prescribed role or whether they become more visible by directing the flow of communication, their performance is constrained by the institution and the society in which the interaction is embedded. This inescapable fact has not yet been fully addressed (the exception being Davidson 2001). The interpreter's agency is present at three levels: interpersonal, institutional, and societal.

In the case of a doctor–patient interview in a public hospital, the doctor most likely belongs to the more dominant culture while the patient may belong to the less dominant culture.