Q J Med 2002; 95: 711-712
© 2002 Association of Physicians
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Interpreting illness
The first piece of research I ever did was a study of interpreters. I did it during a student elective in northern Nigeria, with an Medical Research Council grant that paid my fare (just). I made audiotapes of out-patient consultations between patients who spoke Hausa and doctors who spoke English but used non-medical staff as interpreters. Once I had made the tapes, I asked some local medical students, all perfectly bilingual, to listen to them and translate all the Hausa statements. I looked at what the patients had actually said and then compared this with what was transmitted by the interpreters.
Not surprisingly, I found all sorts of deviations between the patients' utterances and what the interpreters conveyed. Some of these deviations were quite legitimate. For example, skilled staff could run through part of a systems inquiry on their own initiative and then report, quite accurately: ‘His urine's normal’ or ‘He doesn't have any breathing problems’. On the other hand, I discovered some alarming errors, where interpreters had reported that the patients had said something they had not. Also, the interpreters were pretty selective in what they wanted the doctor to know, and occasionally they even berated patients for apparent inconsistencies.
I wrote some guidelines for using interpreters, based on what I found. They went as follows (please excuse the sexist language—it was the 1970s): ‘Greet the patient to establish direct contact. Be seen to be in charge of the interpreter. Assess the interpreter's English and try to find out how well he speaks the patient's language. Assess his interests: he may be an anxious relative or an indifferent auxiliary. Give only short sentences for translation, and get the interpreter to explain that the patient must do the same. Make sure everything is translated. Check every answer by asking questions in two or three ways. Finally, use the interpreter to tell the patient everything you would tell him if he could speak your language.’1
Nearly 25 years later I would stand by a few of these rubrics, especially the first and last. But I would recant most of the others. Through experience of using interpreters a great deal myself, I have lost my conviction in what one might call the more obsessive, even dictatorial parts of this guidance. Nowadays it seems to me that the presence of an interpreter, whether in person or by phone link, radically changes the nature of a medical encounter, so that it may be an error to try and force it to resemble something it is not—a one-to-one conversation in a single language. I have even come to think that using interpreters may teach us something important about the nature of all medical encounters and how to conduct them.
I have noticed, for example, that patients speaking in their own language do not like to have their narrative flow interrupted for translation, even when the doctor believes that this needs to happen for diagnostic or therapeutic reasons. To put it at its simplest, it appears that patients want quite literally to be heard, and they may care relatively little whether the main hearer is someone with medical skills or not. I have also noticed that most interpreters, whether they are close relatives of the patient or paid professionals, have personal resources that go beyond the skill of literal, word-for-word, translation. They usually bring to the conversation a welcome freight of shared cultural associations, and thus an ability to contextualize utterances that might otherwise evaporate into meaninglessness. Such resources, of course, give the lie to the notion that ‘pure’ translation actually exists, independent of deeper interpretation—a delusion that no professional literary translator would ever suffer from.
As I have become aware of these things, I have gradually learned to sit back and to watch with respect as consultations of apparent intensity and effectiveness unfold between patient and interpreter in spite of—or because of—my passivity. For several minutes at a time, I remain content to understand very little, at least in the linguistic sense. I do this particularly with interpreters whom I have used on many occasions before, and have learned to trust. In such instances, I follow one principle only, asking myself: ‘How little do I need to understand, to be confident that no harm is being done here?’. That aside, I take the risk of believing that the exchange is serving the purpose that the patient needs, and I try to suppress a wish to intrude my own professional purposes instead.
I suspect that many of my medical colleagues may feel uncomfortable with this confession. Equally, I have no doubt that many anthropologists and sociologists would strongly approve. Much contemporary social science research shows how we as doctors are being naïve when we imagine that patients tell us their histories chiefly so that we can formulate an accurate diagnosis or recommend a treatment. These are usually our main preoccupations, but they may not be the patient's. Illness narratives serve far wider, and perhaps far more urgent and essential purposes. For example, they allow patients, through the very act of speaking, to fashion their memories and sensations into a coherent shape. They provide people with opportunities to assign causation, purpose and direction to their experiences, and to claim moral legitimacy for their own actions.2 Like all personal narratives, they enable people to describe who they are, discover who they are becoming, and define who they wish to be.3
Telling a story to another person about ones' experiences is the principal way of locating the self, perhaps even of constructing it. For such a task, it may be that an interpreter is at least as good a collaborator as a doctor, and may be considerably better. Perhaps we should all have interpreters present when we visit our physicians.
References
1. Launer J. Taking medical histories through interpreters: practice in a Nigerian outpatient department. Br Med J1978; 2:934–5.
2. Bury M. Illness narratives: fact or fiction? Soc Health Illn2001; 23:263–85.
3. Mattingly C. Healing Dramas and Clinical Plots: The Narrative Structure of Experience. Cambridge University Press, Cambridge, 1998.
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