The interpreted diabetes consultation

Language barriers are a significant cause of health disparities in minority ethnic groups (Pottie et al, 2008), which we have reviewed with regard to the treatment and management of diabetes (Seale et al, 2013a). Diabetes healthcare is holistic and individualised with a large self-management component, described by some as “hard work” (Hinder and Greenhalgh, 2012). For diabetes management to be successful, there generally needs to be support and encouragement from the healthcare provider, as well as a mutual understanding between him or her and the individual with diabetes. Good communication is, therefore, essential.

However, little direct research has been carried out that considers the way language barriers can affect the consultation between the clinician and patient. With this in mind, we carried out the only significant observational study of interpreted healthcare consultations in the UK. We analysed video recordings of diabetes review consultations filmed in inner London, with many of the people we sampled requiring an interpreter (Seale et al, 2013a). Our findings, along with what is currently established in the field, are discussed below.

Qualitative differences
When we reviewed the recorded consultations, we found that, compared with the consultations conducted in fluent English, the interpreted consultations involved: fewer questions from patients; less affective talk or humour (which can get lost in translation); less discussion of patients’ “lifeworlds”; and less investigation by healthcare providers of patients’ knowledge or health beliefs. This means that there can be a social distance between provider and patient and little shared empathy in consultations where there is an interpreter present.

Outside the UK, an observational study of interpreted diabetes consultations considering Turkish immigrants in Switzerland reported similar findings (Hudelson et al, 2013), and Gustafsson’s (2013) study of children’s diabetes consultations included two interpreted cases that also concurred with our findings.

Interpreter roles
Maria Stubbe’s team in New Zealand has observed a range of health providers, interpreters and individuals with a variety of health conditions, including newly diagnosed diabetes, in various settings (MacDonald et al, 2013; Stubbe et al, 2013). Their early analyses have explored issues in the way participants in the consultation negotiate role boundaries.

The interpreter’s basic role is to act as a conduit of communication, conveying the sense of what he or she hears, rather than word-for-word translating (Hsieh, 2006). However, interpreters are rarely simple conduits. As “co-diagnosticians” (Hsieh, 2007) and cultural brokers, they transform, editorialise or filter out talk they believe is not helpful for the patient or provider (Gavioli, 2012). For this, interpreters draw on their “epistemic authority” (Heritage, 2013).

In our own observations, we sometimes  found that interpreters transformed talk to a more prescriptive or paternalistic style that they thought patients might prefer, although published evidence for this is mixed (Blackhall et al, 1995; Hawthorne et al, 2003; Roberts et al, 2005).

Several past studies have found that some providers delegate general advice-giving to the interpreter, although this is without necessarily disengaging from the conversation. Information from body language, gaze and features of speech, such as pauses, minimal tokens (e.g. “okay” or “um”), prosody, pitch and so on, help the provider to determine when to rejoin the conversation or attend to the interpreter or patient (Al-Sarraj et al, 2012; see also Davitti and Pasquandrea, 2013). In this way, the provider remains in overall control even when analysis of their verbal behaviour does not show any sign of direct participation.

However, providers may remain unaware of inaccurate translations. Interpreters are not healthcare professionals, despite often having basic training in diabetes management. Also, in our study we found that editorialising by interpreters may prevent patients’ issues being explored, which contrasts with English speakers’ consultations (Seale et al, 2013b). On the other hand, editorialising may keep the consultation moving (Davidson, 1998) and may aid understanding. Interpreters we interviewed said they wanted to maximise efficiency and ensure the patient was satisfied in relation to the main business at hand (the control of blood glucose levels). Nonetheless, the risk remains that non-conduit roles can lead to problems. The key here is for interpreter and provider to recognise their limitations.

Two’s company
Interpreted encounters are essentially triadic.  But frequently, dyadic moments may be shared between patient and interpreter or interpreter and provider, and much more rarely between provider and patient (because most patients will have at least a smattering of the provider’s language). Dyadic talk is often not translated, and usually consists of: small talk about mundane topics; explanations of bureaucratic procedures or service access that are deemed irrelevant for the other person; or explanation or clarifications of what one person said to aid further understanding (Seale et al, 2013b). Some interpreters in our study appeared familiar with people who had diabetes from encounters in the local community or previous appointments, and so they sometimes took it on themselves to answer for the patient, perhaps to maximise efficiency through dyadic talk. Though often helpful, dyadic talk sometimes results in loss of sharing and rapport (Seale et al, 2013b) between the patient and provider, or prevents the patient from accounting or apologising for missed appointments or medications, or lapses in self-management.

Further, dyadic talk may lead to some marginalisation of the person left out of the dyad, who has no idea what is going on, what is being kept from him or her or whether it is actually irrelevant.

Oversimplification
Our research also shows that providers may reduce the usefulness of the interpreted consultation by using oversimplified terminology when compared with English language consultations (Rivas et al, 2014). This may be to more easily facilitate translation, or because the patient might be seen as less educated. Talking through an interpreter can make it hard for the provider to understand the level of knowledge the patient has and, therefore, how to pitch the discussion appropriately.

Training for all
From our research, we have shared data with the communications skills team at Queen Mary, University of London, on how to best communicate when using interpreters, which have contributed to the training of medical students (see Box 1 for some points raised). These skills can quite easily be trained for (Cushing, 2003) and are now well understood within the college; however, they still too often remain unimplemented in practice.

Concluding remark
There is no question that without interpreters, patients would have greater problems in accessing services and would receive a worse quality of care (Karliner et al, 2007). It is important to recognise that the consultation is co-constructed by all participants (Hudelson et al, 2013). Research such as that reported here can be used to help health providers, patients and interpreters reflect on how communication in the consultation room can be improved.