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An Examination of the Roles of Medical Interpreters

By Jillian Shiba

Senior Honors Thesis Anthropology

University of North Carolina at Chapel Hill

April 9, 2020

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INTRODUCTION

According to the Civil Rights Act of 1964, all limited English proficiency (LEP) patients have the legal right to health care access in their language of preference (Basu et al. 2017). LEP individuals are defined as those who do not speak English as their first language, and who have limited to no understanding of the language (HHS n.d.). In the increasingly multicultural society that we live in, in which about 9% of the current United States population is characterized as LEP, health care systems have a growing need to adjust their policies and practices to include medical interpreters. Medical interpreters are highly trained individuals who are able to interpret the messages of the providers, such as physicians and nurses, to LEP patients, and vice versa. The need for medical interpreters is increasing so much that the United States Department of Labor projects that employment of interpreters and translators will increase by 19 percent from 2018 to 2029, which is a much faster growth rate than the average of all other occupations (U.S. BLS n.d.).

Due to this increasing need for medical interpreters it has become all the more vital to truly understand their profession. What are their main roles? What is the nature of their relationship with the providers? With the patients? Do they take on other roles besides that of interpretation? With these questions in mind, I spent about eighteen hours shadowing

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Quinn, Alma, Jeff, Gabriel, Paul, and Carla. All of their names have been replaced by these pseudonyms to protect their identity. Additionally, all of these individuals are very passionate about their work as interpreters, and were able to all provide me with interesting insights into the key aspects of their profession.

This thesis will begin with the first chapter as a discussion of the various roles of the interpreters, which the department visualizes as a pyramid structure. It may seem obvious that the main role of interpreters must be to interpret conversation back and forth. However, while interpreters in the past have often been considered as just tools of interpretation that do not actively take part in the conversation that they are interpreting, some more recent practices of interpretation have moved away from this neutral method. These more recent practices

emphasize the need for interpretation to not be seen as a direct word-for-word exchange in order to include the interpreter as an active participant in the conversation. The interpreter department that I studied seems to work generally more like neutral interpreters, yet the rules of the

department do not strictly require them to act this way, and therefore there is a variety of approaches amongst the interpreters, which is addressed throughout this thesis.

The second chapter will examine the complex relationship between the interpreter and the providers that they work with, as well as the relationship between the interpreter and the

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interpreters believe that they should hold a more equal, participatory role in the conversation alongside the provider and patient (Davidson 2001). The interpreter department that I studied believes that they lie somewhere in between these two options, although they do seem to lean more towards the concept of a neutral interpreter. Because of an inability of interpreters to be as autonomous as providers, there is a power dynamic within their relationship which adds to tensions created due to the time constraints of the interpreters and providers, and a common view of interpreters as neutral tools. The relationship between the interpreters and the patients is also complicated by certain policies regarding eye contact and social interactions between the two individuals, which further reinforces the identity of interpreters as tools of interpretation.

Chapter Three looks at the specific roles of cultural broker and patient advocate. A cultural broker serves as a mediator and link between two different cultures in order to both resolve potential conflicts and help foster understanding and change for both the providers and the patients. Research published in the Journal of Health Care for the Poor and Underserved discusses how the availability of culturally equivalent medical information helps to combat health disparities and discrimination within healthcare, which underlines the importance of medical interpreters working as cultural brokers (Garcia-Castillo and Fetters 2007). The role of patient advocate is especially critical for the interpreters to hold because the Spanish-speaking patients are incredibly vulnerable due to their inability to speak English and due to potential fears of revealing their documentation status, which all can prevent them from receiving optimal care and access to necessary resources.

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incredible end to my time as an undergraduate, and I am very grateful for all of the support that I had throughout this long and rewarding process. I would like to especially thank my thesis advisor, Dr. Michele Rivkin-Fish, for all of the suggestions, resources, and encouragement that she has given me. The time spent working on my thesis was definitely worthwhile but

occasionally stressful, and with Dr. Rivkin-Fish’s support I was much less overwhelmed so that I could fully enjoy this research. I would also like to thank Dr. Townsend Middleton for

introducing the idea of doing an honors thesis to me at a meeting for the Society of

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CHAPTER ONE: THE GENERAL ROLES OF MEDICAL INTERPRETERS To begin to examine the medical interpreter profession it is critical to first understand the general rules that they follow and roles that they hold. This chapter will therefore explain the daily activities of medical interpreters and the qualifications that are required of them. Certain examples will be provided to underline the importance of the usage of medical interpreters versus ad hoc interpreters. Finally, this chapter will conclude with an explanation of the four general roles of interpreters; conduit, clarifier, cultural broker, and patient advocate.

Throughout the day the interpreters are constantly busy. They are always on the go, fluidly switching from one case to another, from one department to another, from a five-month old baby who will not eat to an old woman in dialysis, and from English to Spanish, and back again. The interpreters are everywhere in the hospital, and many interpreters spoke about how they are one of the only workers in the hospital who get to have patient contact with every single department. From the time that the day shift starts at 8 a.m., requests for interpreters are already coming in on their online system, which shows the requests on the phones and computers of every interpreter. Each request has the time that it was sent, the patient’s name, the department and room number of the patient, and the requesting provider. Generally, there are about fourteen or fifteen interpreters working per day shift, and all calls are equally open to each interpreter to pick up when they are free. Through this app there is a messaging system where the interpreters can privately and quickly communicate with one another, and let each other know, for example, that they will pick up calls x, y, and z because they are all in the same general area of the

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hospital is able to communicate and care for their Spanish-speaking patients. Despite the high usage of the interpreters throughout the hospital, many interpreters still feel that there is not always a great understanding by providers and patients of what exactly they are, or what they can do as qualified interpreters.

The United States Department of Health and Human Services (HHS) differentiates between qualified interpreters and those who happen to have an “above average familiarity with speaking or understanding a language other than English,” with the distinction that qualified interpreters must pass some sort of assessment by individual hospitals (HHS 2016). The competencies that HHS requires for qualified interpreters are “the knowledge of specialized terminology and interpreter ethics and the skills to interpret accurately, effectively, and impartially,” (Basu et al. 2017). The interpreter department that I studied referred me to the National Council on Interpreting in Health Care (NCIHC) in regards to the rules that they follow. In 2004 the NCIHC released “A National Code of Ethics for Interpreters in Health Care”, which says that it was financially supported by a Program Officer from the U.S. Department of Health and Human Services Office of Minority Health. Although HHS refers to interpreter ethics, I have been unable to find the specific set of ethics that they are referring to, and thus the ethics set by the NCIHC seem most likely to be the right ethics due to their association with HHS. Here are the nine codes of ethics, worded exactly as written by the NCIHC (NCIHC 2004):

1. The interpreter treats as confidential, within the treating team, all information learned in the performance of their professional duties, while observing relevant requirements regarding disclosure.

2. The interpreter strives to render the message accurately, conveying the content and spirit of the original message, taking into consideration its cultural context. 3. The interpreter strives to maintain impartiality and refrains from counseling,

advising or projecting personal biases or beliefs.

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5. The interpreter continuously strives to develop awareness of his/her own and other (including biomedical) cultures encountered in the performance of their professional duties.

6. The interpreter treats all parties with respect.

7. When the patient’s health, well-being, or dignity is at risk, the interpreter may be justified in acting as an advocate. Advocacy is understood as an action taken on behalf of an individual that goes beyond facilitating communication, with the intention of supporting good health outcomes. Advocacy must only be undertaken after careful and thoughtful analysis of the situation and if other less intrusive actions have not resolved the problem.

8. The interpreter strives to continually further his/her knowledge and skills. 9. The interpreter must at all times act in a professional and ethical manner.

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advocacy is necessary and specifies that it can be done if “less intrusive actions have not resolved the problem,” which suggests that advocacy is an intrusive act. IMIA says that all interventions must be unobtrusive, which to them would also pertain to advocacy, and therefore the two organizations have different views of the nature of advocacy and how it should be carried out. Another difference in the ethical codes is that NCIHC’s fifth ethical code discusses the need for interpreters to continually work to recognize and understand different cultures, which they describe in their report as necessary for the interpreters to “be able to facilitate communication across cultural differences,” (NCIHC 2004). IMIA’s seventh ethical code also discusses the interpreter role of cultural broker, but IMIA does not specifically require

interpreters to have increasing knowledge about other cultures. A deeper discussion on cultural brokering and patient advocacy by medical interpreters will be found in Chapter Three.

To ensure that applicants can be qualified interpreters, the interpreter services department in the hospital has them all complete interviews and examinations that evaluate their knowledge of Spanish, English, and medical terminology. As Andrea, the director of the department said, they are primarily looking to hire someone who is “fully bilingual”. Although being fully bilingual in English and Spanish is a key requirement for the job, conversations with the interpreters have suggested that there is more to it. For one, medical interpreters must have an awareness and understanding of medical terminology. This knowledge has to be quite vast, as interpreters handle cases in any and all departments of the hospital. With frequent advances in healthcare, this also poses a bit of a challenge, as there is always more to learn for the

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a few seconds to look it up on her phone. This was not an issue to anybody in the room, and the interpreter later told me that while unfortunate, it does happen every so often but is generally easy to move on from, and the process of looking up a word is always respected by the providers.

One of the frustrations that many interpreters have is that providers will often assume that any knowledge of Spanish and English makes one an available and qualified interpreter.

Interpreters have recounted situations in which providers made off-hand comments such as “Ah, this ten-year-old can have your job- he speaks Spanish,” thus undermining the training and expertise that they have as professional medical interpreters. I was also told of instances in which an interpreter picked up a call, only to arrive and be told that the case was “already done”, meaning that a provider with an unknown level of Spanish knowledge or a family member acted as an untrained, or ad hoc interpreter. Some of the interpreters who spoke about this occurrence said that they would then check with the patient to make sure that they understood the

conversation, while others said that they would just accept that they were no longer needed and move on, as there appears to be no real protocol for these situations.

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Provider: Do you think you would be able to move your body over here today? Interpreter: ¿Señora, cree que hoy podría mover su cuerpo aquí?

Family member: Yes, she can. (Said while nodding to the doctor.) Ven, muévete por aquí. (Directed at the patient.)

The interpreter is providing a more accurate interpretation of the way that the provider is gently checking with the patient to see if she would be willing to try a certain movement that day, whereas the family member is saying automatically that she would be able to and then commanding the family member to move, without the formal verb conjugation and gentler phrasing that the interpreter uses on behalf of the provider. Therefore, without the interpreter, the patient may think that they do not have much of a choice to move or not. The more direct version of the message that the family member provided speaks to their non-neutral state, as they likely want their relative to move so that they can begin their healing process and regain their strength, and they do not have the sort of medical neutrality that understands that you cannot necessarily force a patient to get better. In this case, the individual is not purposefully modifying the

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would accompany her parents to appointments to be their ad hoc interpreter, but now, even though she is a professional medical interpreter, she lets the interpreter at the office do all of the interpreting so that she can just “be there as a family member”. She said that in these difficult situations where family members are reluctant to sit back she will remind them of that fact, which is to say that they should be with their family members as a known source of emotional support instead of working hard as an interpreter.

Relatives are not the only ones who may feel inclined to act as ad hoc interpreters. Providers, as all of the interpreters told me with some measure of exasperation, sometimes feel that they know enough Spanish to be adequate interpreters. At the hospital, providers can actually be tested by the interpreter services department in order to officially be listed as a bilingual provider, but some seem to ignore this step. Rosa told me of a time when she came to a call and was told that it was already handled because one of the members of the care team spoke Spanish. She decided to see if the patient needed anything from her and when she checked with the patient about what the providers had spoken to him about he said that he had no idea, because he did not understand what they were saying. I also heard other particularly memorable cases in which providers were overly confident in their Spanish skills. Alma told me that an obstetrician was helping a woman deliver a baby when he started yelling “¡Puta! ¡Puta!” at her. Immediately the woman was shocked and started saying, “But doctor, this baby is my husband’s, I’m

married!” The reason for her total confusion and distress over the doctor’s words is because puta means whore in Spanish. The doctor meant to say “¡Puja! ¡Puja!” to encourage the woman to Push! Push! but instead insulted her as she was giving birth. In another instance, a man received

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recounted the patient as being both scared and incredulous as he kept telling the doctor that “I only have pain in my leg!” Like the previous example, the doctor made a phonetically small mistake in his interpretation that ended up being totally incorrect, quite rude, and extremely confusing for the patient. Huevos in Spanish literally means eggs, but is used as crude slang to mean balls, or testicles. In this case, the doctor meant to tell the patient that he broke his bones, or huesos, but he actually ended up telling him that he broke his balls.

A comparative study on the medical errors between trained and untrained medical

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In the hospital, all of the interpreters view their specific roles in the form of this pyramid diagram, which is from a

“Foundations of Professional Interpretation for Health and Human Services” manual from a different public university (UNCG 2008). I was given this manual by Jeff, and “the pyramid” was referenced by all of the interpreters when they were describing the different roles of their profession.

The larger sections of this pyramid denote that they constitute a greater portion of the duties of interpreters. The role of a

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amongst Spanish-speakers, which the interpreter was aware of, so he interpreted the message to the patient as something like “This was really a big warning sign to me”. The ability of the interpreters to interpret these phrases and keep the same meaning by not producing a literal word-for-word interpretation hints at their other role as a cultural broker. The concept of the cultural broker comes with the acknowledgement that “conveying the meaning of the text is often difficult because cultural differences arise,” (Garcia-Castillo and Fetters 2007). Therefore, interpreters must occasionally take on the cultural broker role, which “[strives] for cultural equivalence and [considers] sociodemographic issues when translating,” (Garcia-Castillo and Fetters 2007). The aspects and practices of the cultural broker role will be discussed in greater depth in Chapter Three.

The second-largest role as a clarifier is used almost constantly by the interpreters. Jeff underscored the importance of the interpreters working as clarifiers when he told me that, “what can hurt the patient is if I miss something. It can’t hurt to ask.” The chart describes clarification as explaining things with no equivalence across languages, but the interpreters often act as a clarifier to make sure that patients understand the complex medical terminology that they are told. Although interpreters are required to replicate the register of the speaker, as detailed in the “National Standards of Practice for Interpreters in Health Care”, they are able to step into their clarifying role to try to adjust the register as needed. Interpreters will ask the providers to “lower their register”, as providers can tend to speak with too much advanced medical terminology and ideas. In my interview with Gabriel, he described this challenge that interpreters face as they must make sure that patients are understanding the provider’s messages even though they contain words and concepts that the patient has never heard.

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off-balance. You have a patient who may or may not have had any formal education, might have literacy difficulties, or no literacy whatsoever, is here undocumented and living in a general state of fear, and you have a person who has been going to school for over twenty-five years. Who has achieved the highest level of education any American can achieve, talking to a person who doesn’t know what the liver is. So, I feel like it’s my responsibility to bring that, that person up to the same level so they can have a conversation. And if I feel like the doctor’s register is way above, and this happens all the time in genetic or any kind of technical conversation, when they start talking about chromosomes and alleles, and we can interpret that all day into Spanish, it’s not going to make a lick of difference if the patient doesn’t know that inside a cell there is a nucleus, and there are chromosome, and genes, so I, at that point I’ll stop the conversation. I’ll tell the provider like, you need to lower the register, you need to simplify this. Because I can tell by body language that your patient is not getting a word that you are saying. And that happens all the time, like a lot.

This act of ensuring that the patient is comprehending what the provider is telling them also overlaps a bit with their smallest role as a patient advocate, which calls on interpreters to intervene when necessary to protect the rights and safety of the patient. Clarifying works to properly communicate the message of the provider to the patient and to attempt to even out the power imbalance, and without a correct understanding of the provider’s words, the well-being of the patient and their right to receive equal medical care could be at risk.

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Rosa told me that a major place for clarification is in dialysis. She said that many patients often have this misunderstanding that dialysis is a curative process, rather than a mechanism that simply keeps them alive. Rosa said that doctors will sometimes “tip-toe” around this truth, so that it is unclear to the patient whether or not they will ever be able to stop dialysis without endangering their health. While I was shadowing her she actually got a call to a patient who was undergoing dialysis, which was my only experience shadowing an interpreter in this area. The patient kept asking when they might be able to go home, and Rosa realized that she was equating going home with never having to do dialysis again, so she interpreted the patient’s question and added her own question, which was, “Her kidneys aren’t going to get better, right?” Because Rosa clarified the true meaning behind the patient’s question, she was able to provide the patient with a clearer understanding of the treatment that she was receiving.

Overall, the interpreters face incredibly busy days that can be additionally challenging when providers and patients misunderstand the superior knowledge and greater efficacy of interpreters over other bilingual individuals. The interpreters do follow key standards and ethics of their profession that emphasize confidentiality, impartiality, continued learning, and accuracy, but they lack a set of concrete rules set by one singular organization, which can arise in

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perspectives and practices of being a cultural broker and/or patient advocate in comparison to the pyramid structure, which will be examined in Chapter Three. However, before that discussion can take place, I would like to describe the relationships between the interpreter and the

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CHAPTER TWO: THE RELATIONSHIP OF MEDICAL INTERPRETERS WITH PROVIDERS AND WITH PATIENTS

The key individuals that the interpreters interact with are providers and patients.

Therefore, the work of the interpreters is very much shaped by their relationships with these two groups. This chapter will first discuss the relationship with the providers, which is the term that interpreters use to generally refer to any medical professional that attends to the patients. Then the chapter will examine the relationship with the patients. Both of these relationships face challenges due to the dominant perspective of the interpreters as tools and the resulting policies that reinforce this idea.

RELATIONSHIP WITH PROVIDERS

Each call is placed by a provider so that every time that the interpreter interprets for a patient, they are interpreting the conversation between a patient and a provider. Like the providers, the interpreters are employees of the hospital, and therefore the providers and

interpreters could be seen as co-workers. However, there is a complex power imbalance between the medical interpreters and providers due to the overall hospital system as well as the rules of the profession that these interpreters follow.

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from making the call to the interpreter arriving and the interpreter has to message the provider to let them know that they are ready to begin. Rosa told me that they are generally supposed to only wait for ten minutes before they have to leave to move onto the next call, or everything will get way too backed up. In all of the times that I observed, Rosa was the only interpreter who ever had to wait for more than ten minutes, and no interpreters had to leave due to time constraints without taking the call. Despite the lack of these direct conflicts, this wait time can still be problematic for both the interpreter and the provider. It seems as if, in the eyes of the providers, that the interpreters take much too long to arrive, which is why they do not bother to stick around and wait for them. The interpreters aim for a response time of fifteen minutes, although the average tends to be more around eighteen minutes during extremely busy times. On various occasions that I observed, the interpreter would show up to the room and when the provider came around they would make a comment like, “You’re really backed up today, huh”. Although this was not a statement meant to directly criticize the interpreters, it emphasizes to the

interpreters that the providers are often impatient when they have to wait, which they always have to do. In my interview with the director, Andrea, she explained how this waiting period that providers experience before the interpreters arrive creates tension between the interpreters and providers that further challenges their working relationship.

I think one of the problems also is that, we are doing our best. But it’s a lot of requests for us to cover. And that makes, that makes, the relation between the two groups difficult. So I think if we were able to respond faster that will kind of relax them a little bit and they will feel better. They appreciate our services but all the time they are saying, “well we need more interpreters.” But the problem is that there really is not the number. What happens if you look, look just look at that list there. 15:41, that’s the time that they place the request, 15:46, 15:48, 15:56, 15:59. There are days that if I have 14 interpreters during the day and I get 15 requests like that with a minute between them, even if we had 20 interpreters, there is no way I can cover it.

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interpreters see when they decide which calls to pick up and learn where to go for each call. As she points out, the calls are extremely close together in time, and it is important to also note that the duration of each call really varies. For some calls, the interpreter is just there for a few minutes during a quick wellness-check. Other times, the interpreter has to be on the call for hours, and some interpreters have told me that certain calls have taken their whole day. Because of the unpredictability of the call lengths and the frequency at which calls come in, there is rarely a time in which even one interpreter is just waiting around to pick up a call. In fact, the

interpreters are often so busy that it can be hard for them to even take a lunch break without feeling that they are leaving the rest of the interpreters with too many calls to efficiently handle. As Andrea suggests, the inability of the interpreters to arrive at calls right after they are placed is due to the system that the interpreters work in, in which they are in high demand and unable to manage the time of each of their calls. Overall, the situation with the arrival of these calls shows that providers expect the interpreters to work on their time, and not the other way around, as the providers often make the interpreters wait for them but dislike having to wait in return.

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explained to him how technically the interpreters could only interpret when they were

responding to a call that was made through the online system, but the doctor was insistent that it would be so easy for her to just interpret for this patient, and so she did. Although this was only for a very short time, it still pulled her away from responding to the next call in a timelier fashion, which made the next provider wait longer than they wanted to. Also, she was again unable to assert her power within her duties as an interpreter in order to place her obligations over that of the provider’s. To me this suggests a fault in the system, where interpreters have a call structure in place, but are occasionally prevented from following this ordered structure due to the desire of the providers.

Another aspect that takes place before the interpreter and provider enter the room that further demonstrates the power imbalance is in regards to the case briefing that providers go over with one another before talking with the patient. The calls are always just attended by one interpreter, but there can be multiple providers present who form the care team for the patient. Before this care team of providers enters the room, they go over relevant details of the patient and their situation so that everybody knows what is going on, but interpreters are often excluded from this briefing. Even when there is just one provider at the call, the provider always has access to and knowledge of all of the patient’s records, and they enter the room with an adequate background of the patient’s condition. I only observed one time in which an interpreter was briefed by the care team before going in the room. Of course, sometimes the interpreters are familiar with the patients and their health situation due to having interpreted for them before, but there is no obligation of the providers to fill them in, nor is there an expectation for the

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and therefore not provided with the knowledge that the other providers are given, and they are instead expected to just walk right in and start interpreting.

This can lead to some complications, especially in calls that are sensitive in nature. Two of the interpreters mentioned how this lack of a briefing from the provider has led to issues within the labor and delivery unit. To me, the following quote from Carla really highlights the importance of the interpreters being able to receive some information about the case before they enter the room, and the problematic way in which the providers see the interpreters as these unemotional tools.

I usually walk into rooms, especially if it’s maternity you know, with a big smile because everybody is happy they just had a baby! Everything is beautiful and pink and blue and all that. And I remember I walked into this room and I was like “Hi! How are you guys doing!” you know, and then the, the provider came right behind me and said, “I am so sorry for your loss,” and I was like, I didn’t know the baby was a stillborn. A stillborn. You know, you are pushing for hours to deliver this baby and the baby was born dead. And I didn’t know! And here is the baby with the little hat and wrapped up! And you know, with the hands here and I was like, why didn’t you tell me? Maybe somewhere else? And I, I kept on telling myself, you need to get in control, you can do this, you can do this, you need to keep on interpreting, focus on the words, and I made it but it was so horrendous.

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spoke to about this topic stated that they never expect any sort of run-down of information before they go in, and I did only see one example of this, so it seems as if these suggestions were not widely shared amongst the providers or the hospital system. The way in which these providers had not thought to give the interpreters a heads up about the emotional nature of the call shows how the providers do not really see the interpreters as other human beings in the room.

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The final example that I have to comment on how providers fail to fully recognize the work of interpreters was told to me by Paul. He said that one of his biggest pet-peeves occurs when providers are counting down to administering something to a patient or to move a certain part of the patient’s body. Before giving the shot, a provider would tell the patient, “On the count of three I am going to give you this injection. One, two, three.” If the provider had a correct sense of what the role of the interpreter is, and slowed down their job as a provider enough to give the interpreters time to do their own job, the provider would wait until the interpreter counted to three in Spanish before injecting the patient. Instead, Paul said, the providers can be so focused on quickly completing this little task that they often administer the injection at the end of their own count in English. This completely defeats the purpose of the interpreter and is unfortunate for the patient as well, who may not have been totally aware that they were about to receive their shot at that exact time. This again shows how the provider’s focus on efficiently using their own time leads the interpreters to hold a subordinate position to the providers, which can in turn negatively affect the patient.

Overall, the neutrality of the interpreter and the relationship between the interpreter are very much linked. If the interpreter must be a neutral object between the patient and the

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providers to undervalue the interpreters as co-workers and human beings, while also affecting the relationship that the interpreters are able to have with the patients.

RELATIONSHIP WITH PATIENTS

A major aspect of the relationship between the medical interpreter and the patient that they are interpreting for is eye contact. The interpreter department believes that the interpreter should not make eye contact with the provider or the patient, whether they are listening or speaking. To me, this was an unexpected aspect of interpretation, and it was also not immediately apparent upon observation, due to the difficulties that interpreters have in

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go through to receive their CMI certificate, but others do not, as the department does not have completion of this program as one of their job qualifications. Therefore, the department appears not to place much emphasis on the National Board and its CMI program. The NCIHC and IMIA are both American-based organizations of relevant individuals to the medical interpreter

profession that exist to better the profession, and they do not claim to be adversarial

organizations to one another. IMIA developed the first national standards of practice for medical interpreters in 1998, which the NCIHC initially advocated as the “best statement of standards for medical interpreters presently available” and then developed their own in 2005 (IMIA 1998). I was referred to both of these organizations by Andrea, the department director, which means that the interpreters follow the knowledge of both of these organizations. The specific statement on eye contact by NCIHC that IMIA lacks may be due to the NCIHC standards being based on and therefore essentially an extension of the IMIA standards. The adherence of the interpreter department to this guideline of eye contact could therefore be because of the more recent date of these NCIHC standards, or simply because without this NCIHC statement, there is no other guideline on eye contact, and thus adherence to this sole guideline may seem like the best and easiest practice.

In addition to this eye contact rule, many said that, “according to the rules”, the

interpreter is supposed to stand behind the patient, which I never actually observed, and which was also admitted to me by an interpreter to be difficult given the general room arrangement of the calls. In my interview with Gabriel, who has been an interpreter for about six years, I asked him about his take on eye contact, and he replied with an interesting practice of his.

Well, it depends on what’s happening in the room...if the provider is sitting at the

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behind, if possible, the patient, and looking down. Just being as disconnected as possible. My opinion, if the provider is tapping away at the computer, and I’m looking down at the ground, nobody is paying attention to the patient. And that is not good quality care. That makes the patient feel isolated, it makes them feel like they don’t really exist...so I’ll provide that human connection until the provider stops taking notes...at which point I’ll disengage, and I’ll just let them have their connection.

Gabriel, like all of the interpreters, refers to some rules that state that interpreters should not make eye contact, while also admitting that he still does it in certain cases. Furthermore, this practice of his in switching his eye contact was explained as being his personal practice due to his belief that this is the most ethical practice to achieve quality patient care, and not a set rule by the department. Therefore, technically there could be times when the provider is speaking to the patient without looking at them and the interpreter, doing their job, will not be either. I never noticed a situation where this happened, and for the most part I would say that every interpreter made eye contact with a provider or patient while listening or speaking at least once per call. This is not to say that the interpreters were not doing their jobs correctly, but more to point out that eye contact is a very embedded social norm in conversation that conveys attention and respect, so that it is almost impossible to expect the provider and patient to look away from the interpreter while being aware that they are listening or speaking to them. Another interpreter, Alma, even spoke to me about the discomfort of patients when interpreters try to avoid eye contact.

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In my observations of Alma at work, her personal preference to maintain eye contact never seemed to interfere with her ability to interpret. She still made sure that the provider and interpreter were making eye contact with one another when they were speaking to each other, and she was not inappropriately inserting herself into the conversation. I did also observe some interpreters who were very focused on avoiding eye contact, and although their interpreting was well-done and very professional as well, Alma’s practice was more natural in the sense that it did not stand out to me that she was making eye contact, but I definitely noticed when other

interpreters were avoiding eye contact, because it is such an uncommon practice in conversation. Even with knowing the rules about eye contact, there is something very uncomfortable in

watching the interpreters look at the ground while speaking to their audience of the provider or patient.

I thought it most interesting that both Gabriel and Alma realize the importance of eye contact to a positive patient experience, yet they have different takes on when to do it. Gabriel even speaks about the avoidance of eye contact as helping him remain “as disconnected as possible” and when he stops his temporary eye contact he refers to it as disengaging. Gabriel believes that there should always be someone in the room who is engaged with the patient in order for the patient to have the best care, but he places an emphasis on that person being the provider, and so if the provider is engaged, he will choose not to be, but if the provider is not paying attention to the patient, Gabriel will switch to make eye contact with them in order to become the individual who is engaged with the patient. This really suggests how he understands eye contact to be a key part of making a connection with another person in conversation, which is then interesting that he, and the whole department, do not wish for the interpreters to

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than as a person in the conversation, and seems to therefore dehumanize the interpreter while also inadvertently dehumanizing the patient, who may wonder why this professional is refusing to look at them. Similarly, when the patient is asking Alma why she is acting like a robot, they are realizing the way in which the rule on eye contact reinforces the treatment of interpreters as tools of interpretation rather than as human beings. Their unease with this dehumanization of the interpreters suggests that this is not the best way to utilize the interpreter services.

Another interesting aspect of the interpreter-patient relationship is that the interpreter is also not supposed to hold side conversations with the patient. While it does make sense that the interpreter not be encouraged to carry on lengthy conversations with the interpreter for the sake of the medical activities and important conversations that the provider must perform and have in their limited time, it is strange that interpreters are unable to have a quick personal conversation with the patient. Oftentimes when I was with an interpreter and we walked into the room, it was clear that the patient was so happy and grateful for the help of the interpreter, and perhaps also for the presence of somebody who they might be able to identify with and feel more comfortable with than their provider. Therefore, many of the interpreters said that patients are often very interested in getting to know who they are, and they often ask them where they are from, or in the case of the white interpreters, why they speak Spanish so well. This again shows the

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harmless and occasionally helpful to ease the tension that can be common in the hospital environment. I shadowed Paul and never observed him participating in any side conversations, nor did I observe any other interpreters doing so, which is not to say that they never do, but could be in part because they were aware that I was observing them. Also, because of the way that providers are in control of the appointments and constantly have something else to do after each appointment, the appointment works on the time of the providers, and thus there never really is a clear opportunity for a side conversation to happen, and so I find it hard to imagine a scenario in which the interpreter is even able to chat with the patient without preventing the provider from continuing to talk. Regardless, without the ability to freely talk to the patients, or to even respond to them, the interpreter cannot create as close of a connection to them because they are never able to address the patients as an individual, but always as a tool of interpretation.

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One final and more noticeable aspect of this relationship is that interpreters are not supposed to be in the room alone with the patient. When I was shadowing Quinn, the provider had to step out of the room three times, twice because he had to get a new pen, and all three times Quinn had to leave with him, even though by the time she closed the door the provider was basically ready to enter again. This rule emphasizes and reinforces the ban on side conversations, as it was explained to me by all interpreters as preventing unwanted or possibly harmful

conversations between the interpreter and patient. Jeff told me about how once he “was lazy” and stayed in the room when the provider left and the patient started asking him if he thought what the doctor had been telling him about his medical condition was serious. Of course, Jeff said that he was unable to answer that question because he was not a doctor, but he told me that it is for that exact reason that interpreters are not allowed to stay in the rooms alone. Apparently while providers have an easy time with identifying the interpreters as being outside of the care team, patients often assume that they are, and therefore they want to get the medical opinions of the interpreters as well. On the importance of leaving the room with the provider, Carla also

underscored the inevitability of being asked medical questions, but also brought up that this rule helps to protect the patient.

So, chances are that if you stay in there there’s going to be some conversation.

Sometimes they are going to tell you something that you don’t want to hear. Whatever they tell you, you are going to have to report it. So I protect them if I stay outside...So, I, I don’t want to get them in trouble, I don't want to get in trouble, so I just stay outside. And I don’t want to give them the opportunity to tell me something if there’s something going on about, um, I don’t know, “This is my kid, and I have to hit him,” Sometimes discipline is very different from one culture than the other, so if you have to spank your kid and I’m there, I’m going to have to go outside and say, “Hey, this patient is…”

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patient to carry on a brief side conversation that could either be light-hearted and relaxing to the patient, or may actually glean important information about the patient that they did not tell the provider. If the interpreter was to stay in the room, it would just be even more vital that the interpreter thoroughly explain to the provider and patient that it is in their job duties to interpret everything that they hear or are told. Therefore, the patient would be aware that they should not reveal anything to the interpreter that they would not want the doctor to know, while also being aware that they could privately tell the interpreter something that they would like the doctor to know, but are maybe more comfortable with directly telling the interpreter. The fact that

interpreters have to leave when the providers do also would seem to emphasize to the patient that the interpreters work more on behalf of or with the providers than they do for the interests of the patient, as the interpreter arrives with the provider and leaves with them as well.

The rules that the interpreters have regarding eye contact, side conversations, and room presence hinder the ability of the interpreters to have a close emotional connection to the patient, and further underscores the interpreter as a tool of the care team instead of part of the care team. All parts of the care team, which are the providers, are able if they wish to build an emotional connection to their patient through a free ability to have side conversations and to express their emotions. Furthermore, the rules about eye contact and side conversations seem to be especially confusing to adhere to by the interpreters, as the rules are so absolute (i.e. that there should be no eye contact and no side conversations) yet so naturally difficult to follow that it can leave interpreters in uncomfortable or problematic situations. Gabriel chooses to use his judgement on when a patient needs eye contact from him or not, which can be an issue because it involves him having to make these quick decisions as he is trying to focus on interpreting while also

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by sustaining eye contact, but she believes that eye contact is more important. While she is generally comfortable with her decision, others may not be, and thus these interpreters can experience an inner conflict between the rule and their personal feelings about what is right. Rosa knows that she is not supposed to have side conversations with the patient, so she refuses to respond to the communication as herself. Paul enjoys side conversations, even though he is aware that they are not to be outright encouraged. What these examples show is that the

interpreters are well aware of the rules, and try to follow them where they can, but there is a lot of grey area, which is challenging because it leaves the interpreters to have to individually judge when and by how much to adhere to the rules. This adds in another complication to the

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CHAPTER THREE: CULTURAL BROKERS AND PATIENT ADVOCATES All of the interpreters that I spoke to had some sort of medical interest or previous involvement with the medical field in their lives before they chose their profession. Many interpreters grew up speaking Spanish with their families and many are also immigrants.

Therefore, many spoke about their desire to help out their community here as a driving factor for why they do what they do. Both NCIHC and IMIA, two medical interpreter organizations, contain ethical codes that delineate cultural brokering and patient advocacy as parts of the medical interpreter profession. These roles can be seen as specifically enabling the interpreters to help out the community of Spanish-speaking patients beyond just interpretation. According to the pyramid of the various interpreter roles found in a manual called “Foundations of

Professional Interpretation for Health and Human Services” from a different public university, there are four roles of the interpreter profession. At the bottom, which denotes the role as being the one that interpreters should devote most of their time to, is conduit, then clarifier, and then at the very top are the smaller roles of cultural broker and then patient advocate. The interpreters are well-aware that the pyramid marks the roles of cultural broker and patient advocate as the smallest part of their job, yet, as with the other rules on subjective matters such as eye contact, there is variation on how interpreters approach these roles and perceive their importance.

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practices of patient advocacy due to the policies of the department will be explained, as well as the complications that can arise due to these different approaches.

CULTURAL BROKER

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places the cultural broker role squarely on the shoulder of medical interpreters instead of the providers (NCIHC 2004). Gabriel spoke to me about how he dislikes the way in which the cultural broker role can be misinterpreted by providers when they expect the interpreters to have cultural knowledge of all of the Spanish-speaking countries. This is a narrow-minded view that would incorrectly suggest that all Spanish-speaking countries are the same and that being from a certain country automatically makes one fully knowledgeable on the diverse array of cultures within their home country. In terms of the United States, it would be like assuming that an American from Northern California inherently understands Boston culture. Therefore, there can be an inappropriate expectation placed upon the interpreters by the providers who expect them to be Latin American cultural experts. In fact, Gabriel pointed out that while he best knows the cultural customs of his home country, he, and the other interpreters, have really been able to become effective cultural brokers through the experience of working with the hospital’s diverse patients.

The first quote from Garcia-Castillo and Fetters explains how medical interpreters are needed to take on their cultural broker identity when the exact meaning of the words that are being said would not make sense to the intended recipient due to some cultural difference. One of the more basic ways in which interpreters deal with this situation is with idioms. This example was provided in Chapter One but it is relevant to repeat again in the context of the role of

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“cultural equivalence”, some interpreters did mention that it can be difficult to do so but that they always try to do the best that they can, which suggests that they generally believe that there will be an appropriate equivalent way to phrase things. No interpreter spoke to me about a situation in which they were unable to do so, nor of a protocol that they would follow in such a situation. The usage of idioms by the providers when they are trying to communicate with their Spanish-speaking patients is also an interesting aspect that suggests that providers are not trying to be culturally aware of what they are saying. Paul said that once after a provider used an idiom and he interpreted it, the provider actually asked him what he said, which shows that the provider realized that he was using an incomprehensible phrase for his patient to understand, but expected the interpreter to do the work of appropriately changing the words to retain the meaning.

Oftentimes, the interpreters take on their cultural broker identity when culturally-driven misconceptions arise between the provider and patient, or when the interpreter realizes that a problematic situation is occurring or will occur due to cultural differences. Alma gave me a very clear example of the ways in which interpreters, as cultural brokers, can step in to mediate conflicts that arise because the provider and the patient are unable to reach the same understanding because of certain cultural traditions or values.

One day a patient was going to have a surgery. And they put on the child like this

bracelet, with this, uh I guess it’s a seed...It’s like for the mal de ojo, for the evil eye. And then the surgeon is like, “Oh, you need to remove that.” And the mom is like, “No!!! I cannot remove that!” So I told him that, you know, in their, in her culture, she believes in that. She believes if you remove that, something is going to happen to the child. So, he’s like, okay just leave it on then.

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was so resistant to removing this, to him, seemingly insignificant item, and the surgeon was respectful in that he allowed the child to keep the bracelet on. Without Alma’s act as a cultural broker, one could infer that the surgeon may have just remained confused or gotten annoyed with the mom’s refusal, and he may have just taken the bracelet off anyways, thus traumatizing the mom and possibly the child into thinking that the surgery was now doomed. Or, the mom could have been able to effectively articulate to the surgeon why she needed the bracelet to be kept on her child, and the mom and the surgeon could have reached the same respectful conclusion to leave the bracelet on without the cultural broker assistance of Alma. Essentially, this role does require the interpreter to make their own judgements on when they are needed as a cultural broker and when they are not, which has resulted in some interpreters being more active in this role than others.

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less willing to reach an understanding or compromise with the mom because of her low cultural health capital, and specifically her inability to explain her situation in biomedical terms.

Therefore, the miscommunication between the mom and the surgeon could actually have been driven by cultural health capital, where the mom may have also felt unable to argue with the surgeon about her desire to keep the bracelet on her child due to her lesser power in the situation. Essentially, she may have been hesitant to fully explain to the surgeon about her beliefs for fear of disrespecting the surgeon or being intellectually unable to do so. In this case, Alma’s work as a cultural broker shows her not only mediating between cultures but also between the power differences of the provider and the patient. Alma’s intervention could also be seen as patient advocacy, because she advocated for the mom’s needs because the mom was unable to, which also shows the intertwining of the cultural broker and patient advocate roles.

Gabriel had another excellent example of when an interpreter can take on this cultural broker identity, although in his case, there was no conflict happening, but he knew that an issue could arise if he did not act as a cultural broker.

When it comes to cultural dynamics, and I keep bringing up diabetes because our population has a huge problem with it. But gestational diabetes is a huge problem for pregnant moms. But, the provider doesn’t just have to convince mom to take the Metformin, she’s got to convince grandma. Because the matriarch in certain situations has a really high standing, high ranking, and between the doctor, between the resident and grandma, grandma is always going to win. You know, so if grandma wants the baby to grow big and strong and wants to fatten mom up because she wants her to eat as much as she possibly can, when the provider tells the patient like, “Listen, you have diabetes, if you keep going at the rate you’re going, you’re going to have a ten pound baby,” That is great news for grandma. You know, coming from a developing country where

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Therefore, Gabriel’s knowledge on the power of the grandmother and the misconception that fat babies are healthy babies makes him aware that the provider will be unsuccessful in preventing the mom from eating too much if he is not also aware of these cultural factors. By stepping in, he makes the overall mission of bettering the health of the mom and her baby possible, while being culturally respectful of the hierarchical power that grandma holds.

A study of the utilization of medical interpreters also found that when interpreters are acting as cultural brokers, they are helping the patient increase their own health literacy, which works in the long-run to prevent or diminish health disparities between those who speak English and those who speak English as their second language (Blay et al. 2018). Shim also describes cultural health capital as “a collective achievement of patient-provider interactions” and explains how providers help produce cultural health capital for patients as they educate them in

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providers assume that their patients do not have this misconception that dialysis cures, and patients assume that it does, so neither individual asks any clarifying questions. She also says she feels like providers can tip-toe around the fact that dialysis keeps patients alive, and therefore when she feels that it is necessary she will say something like “Can we explain it a little more like this,” to make sure that the provider is accurately getting the point of dialysis across to their patient.

I was fortunate enough to actually see this situation play out while I was shadowing Rosa. The patient was asking the doctor when she would be able to go home, and the doctor told her that it would be in a few days. Based on Rosa’s knowledge of the cultural misconceptions that arise in dialysis, she spoke to the doctor as herself to clarify and asked if dialysis will cure the patient, knowing that it would not, but needing the doctor to say that fact out loud to the patient. When Rosa interpreted his negative answer to the patient, the patient started to realize that when the doctor said she could go home in a few days, he did not mean that it would be the last time that she would be in dialysis. Therefore, the patient was able to ask more clarifying questions to the provider in order to fully understand her treatment, which shows how a quick intervention by interpreters can increase patient autonomy. This is an especially interesting example of the cultural broker role in action because it relies a bit on an assumption by the interpreter that the patient was not understanding something. It could have been that the patient just wanted to know when they would be going home from the hospital in the near future and not forever, and the interpreter’s act of clarification on behalf of the patient could have potentially been insulting to the patient. However, because Rosa feels like dialysis is an area where she is greatly needed to step into her cultural broker identity, she was specifically looking out for this area of

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within this role, where another interpreter could have not intervened in that case and would still have been doing their job, or an interpreter could have intervened based on an inappropriate or incorrect assumption. Essentially, there is sometimes no clear way for interpreters to pinpoint if they are needed as cultural brokers, and it is only through experience, like Gabriel said, that they can be the most effective at it.

Another take on the purpose of the cultural broker role is that it helps the interpreter to serve as a sort of institutional gatekeeper to the American healthcare field, by allowing the patient to understand the process and ideas in their native language (Davidson 2001). Carla provided me with an insightful theoretical example of the ways in which Spanish-speaking patients may misunderstand the American hospital system, which confuses the provider, and then how an interpreter can help mediate this situation as a cultural broker.

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the doctor, and then they’re like, “Ohhhhh, I understand.” And then I have to clarify with the patient, you know, “It’s not that they don’t want to see you, it’s not that they don’t want to treat you, but the emergency room here works completely different here than in our countries.” So then I have to go through, you know… “This is a place that you come when you cannot breathe, when you have a matter of life or death.” And so they’re like, “Ohhh, I see. Then well, the most important thing right now is this.” “Okay, so the other things we are going to give you information, you can get in touch with this doctor.” So I have to show them how to navigate the system. Because the system is a blur. This is completely different than what they’re used to.

Here Carla highlights how she can assist the patient in understanding how to properly use the American healthcare system, while explaining to the doctor where the misunderstanding comes from, which helps the appointment to run smoothly and helps the patient receive the best care that they can. It also hopefully helps the patient build a long-term knowledge of how the hospital works, so that they will not experience this conflict again. While this intervention was explained by Carla as belonging to her work as a cultural broker, in this case she is not so much mediating between cultures but helping to address a misconception that has occurred because of the low cultural health capital of the patient, which is likely due to their lower class and resultant lower level of education.

PATIENT ADVOCATE

There are a number of areas where patients need advocates. They might need someone to check and correct the practicality of a prescription, or to direct them to the next hospital unit that they need to go to. They may need someone to notice that they are not receiving food and to help them get it. Or, they may need financial assistance, but are afraid to ask for it due to their

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hospital as well as difficulties receiving resources due to a lack of knowledge or money. Because a need to advocate for the patient can come from cultural differences between the patient and the providers or the overall Western medical system, the role of a patient advocate can seem very similar to that of a cultural broker. One major difference however is that when interpreters step into the cultural broker role they focus on mediating conflict between cultural perceptions or adjusting the exact words spoken due to cultural differences, which is integrated into the back and forth communication. Interpreters see the role of a patient advocate as actively stepping in on behalf of the patient to look out for their well-being or to essentially go out of their way to help them. Andrea, the director of the Interpreter Services department, had one of the most eye-opening quotes on the way in which the interpreters are told to be patient advocates. Her response began after I had asked her if there were certain ways in which she tried to encourage the interpreters to take on the patient advocate role.

Actually, we don’t encourage that. The advocate role, it should be the least used. Unless it’s absolutely necessary. But let’s say, for example, I’m going, I’m in the peds clinic, and the doctor tells the mother so, this is the prescription and this is the prescription, uh, it will be for a month and I’ll see you in three months. So you go to the front desk, and they are making the appointment for three months, then you think, hmm that’s not going to be enough medicine. Then, you can advocate. Then you say, excuse me, could you check with the doctor? Because the doctor said to come back in three months, but the medicine is only for one month. That’s the type of advocate that we need. We don’t want the interpreters trying to solve every single problem. Now, another way to advocate is to direct the patients to the right departments that provide the help. Instead of us trying to solve the problem, solve the world, because we won’t be able to do that...There is a triangle, and the advocate is the tip, very little. So you have to keep that in mind. There is a group of interpreters that don’t agree with that. And it’s kind of divided that they think that they should be an advocate and there is another group that says absolutely not. So, I, I agree with no. Yes, just a little bit. But, not yes, something in the middle.

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interpreters, but also because it really highlights the difficulties that can arise for the interpreters when they are deciding whether or not to act as an advocate in a certain situation. First, Andrea specifies that this role should only be utilized when absolutely necessary, which again relies on the interpreters to make their own judgements on when to step in. This is similar to how IMIA’s seventh code of ethics states that “interpreters will engage in patient advocacy and in the

intercultural mediation role of explaining cultural differences/practices to health care providers and patients only when appropriate and necessary for communication purposes, using

professional judgement,” (IMIA 2006). Like Andrea, IMIA believes that interpreters should only act as patient advocates in limited situations, which depends on the subjective “professional judgement” of interpreters. There is also the idea, as stated by Andrea, that interpreters cannot solve every issue, which seems as if it can be used for interpreters to justify a perceived inability to help the patient with something, as real or valid as that inability may or may not be. Patient advocacy was described by Rosa as “going above and beyond” her roles as an interpreter and by Quinn as something that you need to really think a lot about before doing. Paul however, told me that “one of the roles of interpreter is patient advocate, and I try to do that as much as I can...I know that people don’t always do that, but I am a patient advocate”. Therefore, some interpreters do not see many instances in which it is “absolutely necessary” for them to act as patient

advocates because they want to focus on being an interpreter, but some people, like Paul, see themselves as always needing to be a patient advocate while being an interpreter. This creates a large variety in the types of services or assistance that are provided to the patients by the

interpreters.

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One area that some interpreters are able to be patient advocates during the call is in regards to food. Sometimes, patients or their families are unsure how to order food to eat. I observed Rosa asking a patient if they had eaten yet, asking a patient if they needed help ordering food before she left the call, and asking a provider if the patient needed help ordering food. She said she paid extra attention to the possibility of patients being unable to receive food because she once was at a call and the patient told her that he did not know how to order food, and he had been in the hospital for multiple weeks, meaning that he had not received his free hospital food during that entire time. Carla also spoke about how sometimes parents with babies or children as patients in the hospital may be so focused on watching over their kid that they do not think about leaving the room to get food, and are unaware that they can order food from the hospital to be delivered to the rooms so that they do not have to leave. In this case she said she would inform the parents how to access this food from the hospital, as it seems as if the

providers often do not inform their patients or their family members about this fact. Parents or family members can order food to purchase, but patients can order as much food as they want for free, so some interpreters told me that they will tell parents about a trick to receive free food for everybody. If the family orders meals that are kind of spread out in time, and claims that all of the meals are for the patient, they can slyly order enough free meals for all members of the family, which can be critical when families are facing huge economic costs for the medical care of their loved one.

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patients are accepted based on Area Median Income, and if the patient makes less than a certain amount compared to a certain number of families. The only thing patients have to pay is a $10 co-pay for each visit. Here is a quote from Gabriel that explains why it is especially important for interpreters to act as patient advocates by discussing this program to patients.

A lot of our patients who are here undocumented...are terrified of filling out any kind of information that would reveal themselves as being undocumented. But by the same token, a lot of our patients are also uninsured. So, by advocating for the patients to apply for Charity Care, help them fill out the application, explain to them the logistics of it by saying like, “You know you can be here illegally and still qualify for this program. So I don’t want you to feel like you shouldn’t apply for it. We don’t report to immigration, we don’t communicate with immigration, in fact it’s illegal for us to even do that, [the hospital] does not have anything to do with it, I just need you to be honest on the application, then you will get all of your previous debts erased.” And that’s like a huge relief. That’s not interpreting...that’s something that a lot of the caseworkers don’t do, they just say, “Here, fill this out.” ...But, I like to take it a step further and try to facilitate that.

While Gabriel’s explanation of Charity Care does show why interpreters should advocate for their patients to apply for it, it also again shows how the importance that he personally sees in being a patient advocate leads him to continue to discuss the program with patients. He sees this advocating as a step further than what caseworkers do, which highlights how patient advocacy is seen as doing more for the patients than what is normally provided. Therefore, other interpreters could view helping the patients apply for Charity Care as not “absolutely necessary”, which is the wording Andrea used to define instances in which being a patient advocate was actually encouraged.

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because the Spanish-speaking patients that they work with are seen as being more vulnerable to cultural or power conflicts between the providers or more in need of advocates who are

specifically looking out for them. As cultural brokers, interpreters are able to further ensure communication between providers and patients, but they also are able to increase the health literacy of patients, and to familiarize them with the American healthcare system. Interpreters are most needed as cultural brokers when there is a misunderstanding that is occurring or will occur due to differences in cultural beliefs between providers and patient, which can be seen in simple ways such as re-wording idioms or more complex ways such as explaining to the provider the importance of the grandmother in making decisions for the family in regards to their health. Additionally, as seen in the case of the bracelet against the mal de ojo, interpreters acting in the cultural broker role to mediate between what they see as cultural differences can actually be mediating between a power imbalance due to the lower cultural health capital of patients, who are then more vulnerable to the desires of the providers. In many cases, such as the previous example, the cultural broker role starts to blend with that of patient advocate. Some situations in which interpreters identified there being a need for advocacy come about due to sheer lack of attention by the provider, such as the example of a too-short prescription. However, most of the situations in which patients need the interpreters to act as their advocate arise because of the patient’s inability to speak English or their documentation status. All patients can have

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