Medical interpreting is a fast-growing specialization within the field of interpreting. In our diverse society, cross-linguistic healthcare interactions are the norm rather than the exception. According to the 2000 United States (US) Census Bureau, there are more than 224 languages spoken in California. Important changes within the medical interpreting field and the recent transformation of the population in the United States have been affecting healthcare delivery to limited-English-speaking patients. The change of the population has created numerous challenges evident in all aspects of US society, especially in the delivery of healthcare services. Furthermore, this situation has sparked the gradual emergence of academic questions regarding the nature of communication between healthcare providers and patients.

In addition to the linguistic diversity that extends to the whole of the United States (MLA map, 2008), federal mandates requiring interpreting services for speakers of languages other than English have impacted the healthcare delivery to limited-English-speaking patients. One result is an increasing need for professional interpreters in the medical setting in hospitals all over the United States. In spite of this reality, less than 25% of US hospitals are either staffed with skilled interpreters (Flores 2000) or have an adequate procedure in the system to determine who can perform the job (Angelelli 2003). This diverse situation and the difficulty that our nation faces in coping with this reality has challenged nearly every aspect of US society, especially in the access to services on the part of linguistic minorities, and, more pointedly in the delivery of healthcare services to them.

During an interaction occurring in a healthcare setting, speakers of the more dominant and less dominant cultures come into contact via medical interpreters (also called healthcare interpreters). In a cross-cultural/linguistic medical interview, a highly sophisticated language professional facilitates communication between the patient and medical professional. This individual is capable of processing and conveying information in two languages, often under conditions of critical and extreme pressure (Valdés and Angelelli 2003).

During this communicative event, interpreters are called on to balance the proper degree of professional reserve with a compassionate and caring nature that is critical to the healing process. A monolingual patient who belongs to a linguistic minority seeking healthcare from a monolingual provider faces a distinct situation of challenges and opportunities. The ways in which healthcare interpreters perform their jobs impact the kind of service offered and the patients’ access to that service. This may sometimes result in the voices of minority speakers being heard or not (Angelelli 2004a; Angelelli and Geist-Martin 2005; Bowen 2001), in patients being denied proper care and access (Cambridge 1999), or in the interpreters acting as gatekeepers (Angelelli 2004a; Davidson 2001).

Therefore, the role that medical interpreters play is considered complex and multifaceted due to the pressing situations and circumstances in the field. In this chapter, the nature of medical interpreting, the role of the interpreter, the ethics of the profession, and the current opportunities for education and certification of medical interpreters are presented.

Medical Interpreting: A Field of Inquiry in Its Own Right

Traditionally, the term Translation Studies presumably included all written and oral forms of cross-linguistic communication (Holmes 1972/1988: 70). For some scholars this term included all semantic fields of translation and interpreting (e.g., legal, medical, literary, or technical) as well as all the settings where interpreting occurs (e.g., community, conference, court, or medical interpreting) including its modes (consecutive, simultaneous) and channels (telephone interpreting, video-conferencing interpreting). Despite the intention to be inclusive and interdisciplinary, this term did not capture the research produced by scholars who focused on cross-linguistic interactions with no written form (e.g., interpreting between American sign language and English) or on issues such as agency or responsibility in talk (Angelelli 2004a, 2004b; Metzger 1999; Roy 2000; Wadensjö 1998). This research, together with studies conducted in fields with a stronger focus on cross-linguistic oral interaction such as bilingualism, cognitive psychology, interpersonal communication, and sociolinguistics (to name a few), had evolved by the 1990s into a field of inquiry currently called Interpreting Studies (still related to Translation Studies).

Within Interpreting Studies, the field of medical interpreting has been undergoing an extraordinary evolution and new developments have been made that have changed the perception of the domain. Up until the 1990s, medical interpreting was perceived as a less prestigious variety of interpreting, usually practiced in an informal and impromptu setting and situation. In addition, the set standards and principles of interpreting in general have been applied to the medical setting without an accurate consideration of its uniqueness and the highly complex tasks medical interpreting involves. Research crossing over from sociolinguistics has begun to emphasize crucial differences between types of interpreting, specifically conferences, court, medical, and community settings. These distinct settings shed light on how interpreters facilitate communication differently according to rules and contexts governing these interactions.

For example, a conference interpreter generally working in a monologic mode (Wadensjö 1998) is portrayed as less participative. An interpreter work­ing in the courts is portrayed as faithful and transparent in line with the conduit model of communication. On the other hand, interpreters working in hospitals and community settings are co-participants in the interaction and are portrayed as visible agents who may affect the outcome of the communicative event.

Various empirical studies have been conducted on interpreted medical discourse (Angelelli 2003, 2004a, 2004b; Bolden 2000; Bot 2003; Cambridge 1999; Davidson 1998, 2000, 2001, 2002; Kaufert and Putsch 1997; Metzger 1999; Valdés et al. 2000; Valdés et al. 2003; Wadensjö 1995, 1998). These studies have focused on the most important concerns in the field, such as the qualifications that a medical interpreter should have, the role that the interpreters play, how medical interpreters deal with power hierarchy, how they bridge gulfs of cultures and belief systems, and how their various degrees of participation affect the medical interactions they facilitate. Most of these studies have been qualitative in nature and have studied a variety of different ethnic groups. The studies have varied in both the types of questions they have asked and the number of encounters analyzed. In the next section, I review current research that specifically focuses on the medical interpreter’s role that is one of the main concerns in the field today.

Studies in Healthcare Interpreting

Traditional views of interpreters who have no participatory role in the interaction, portrayed either as a conduit (adapted from Reddy 1979) or as a ghost, have started to evolve due to research that shows interpreters to be essential partners in and co-constructors of the interaction (Berk-Seligson 1990; Metzger 1999; Roy 1989, 2000; Wadensjö 1992, 1995, 1998). The powerful role of medical interpreters has been analyzed through a wide range of methods that help explore the issue from different perspectives and also allow the triangulation of data. Medical interpreters have been analyzed by quantitatively assessing their perceptions and beliefs in their roles (Angelelli 2003, 2004b), by qualitatively observing medical interpreters as they enact their roles (Angelelli 2003c, 2004a: 79–101), by interviewing and listening to them describe their roles in their own words (Angelelli 2004a: 105–32), and by conducting focus groups (Angelelli 2002, 2006). Thus, interpreting is no longer conceptualized as a communicative act between two interlocutors with an invisible interpreter but rather as a three-party interaction in which the interpreter plays a major role. The interpreter’s role during an interaction goes beyond a traditional channel that simply conveys information from one monolingual party to the other.

Studies using discourse analysis illustrate how the interpreter can act as a co-participant in the interpreted communicative event (ICE) (Davidson 2000, 2001; Metzger 1999; Roy 1989, 2000; Wadensjö 1995, 1998). These studies challenge the notion of neutrality by focusing on the participation of interpreters during interactions. For example, Roy (2000) examines interpreting as a special case of discourse process. In her work, the role of the interpreter is analyzed in terms of “responsibility for the flow and maintenance of communication” by focusing on turn taking (Roy 2000. She analyzes an interpreted American Sign Language–English encounter between a deaf student and a professor as an instance of community interpreting. She demonstrates that the interpreter is an active participant in the interaction, because of “the shifts interpreters make from relaying messages to managing and coordinating talk” (2000: 111).

In Roy’s study, the interlocutor directly addresses the interpreter, and the interpreter responds directly back to the interlocutor. Taking a similar line of argumentation while examining English–ASL medical interviews, Metzger (1999) applies frame theory and Goffman’s concept of footing (1981) to analyze the interpreter’s influence on interpreted interactions in two cases. She concludes that interpreters can misrepresent the source message footings by using their own renditions and utterances, thus giving them powerful influence over the discourse that is interpreted.

In comparison to Metzger and Roy, Wadensjö (1998) uses Goffman’s framework of roles to question the normative character of the literature in interpreting, which characterizes how interpreters should perform rather than looking at their performances in actual cases (1998: 83). Wadensjö’s study of Swedish and Russian medical interpreters and of interpreters at a police station provides evidence of the social and interactive skills that the interpreters exhibit. She looks at how responsibility “for the progression and the substance of interaction is distributed in and through talk” (1995: 112). From the discourse analysis performed, she concludes that the interpreter’s role during the interaction goes beyond a traditional channel that simply conveys information. She argues that interpreters co-construct meaning together with the interlocutors, and that responsibility during interpretation is shared by all parties to the conversation. In this sense, the co-construction of meaning and the responsibility of both the interlocutors and the interpreter as team players within a conversation shed light on other inter­preting skills that extend beyond linguistic code switching and information processing.

Focusing on a different linguistic group, Cambridge (1999) analyzes seven extempore simulated consultations between general medical practitioners and Spanish-speaking volunteer patients. Interpreting was provided by native speakers of Spanish who were untrained professional interpreters. The results show that appropriate interlocutor roles are not always occupied by all parties and that dangers exist due to a lack of common ground within the transaction. Cross-linguistic communication between English-speaking healthcare providers and Spanish-speaking patients has also been studied using the question as the unit of analysis (Prince 1986). This work has shown an asymmetric distribution in the number of questions asked and answered during a doctor–patient encounter. The doctors were asked the majority of questions, and in contrast, the interpreters only initiated 1% of the questions that were information-seeking. Three interpreter-related distortions were identified in the discourse: (1) answering the questions for the patient instead of translating (generally occurring in the patient–substitute model); (2) providing incomplete translations (generally occurring in multiple-part questions); and (3) providing inaccurate translations (sometimes related to the level of technicality of the term used and/or to the lower language proficiency of the doctor and/or the interpreter, mishearing, and failure to check information). Gathering information through the use of questions is of the utmost importance in the medical interview. However, as stated by Shuy (1976), this elicitation generally presents various problems triggered by differences in linguistic backgrounds, cultural backgrounds, and the goals and understanding of the exchange. A medical interpreted communicative event illustrates these differences unequivocally.

Using a sociolinguistic lens, the interpreter’s role during a Spanish–English medical interaction has also been studied by looking at the participants’ construction of reciprocity and meaning in interpreted conversation (Davidson 1998). For example, the physician sees the interpreter as a human instrument that helps keep the patient, and thus the conversation, on track. However, the patient sees the interpreter as a co-conversationalist. Davidson (1998) attributes the difficulties that occur during interpreted encounters to both the construction of reciprocal understanding and the inaccurate transformation of semantic and/or pragmatic content. In later studies, Davidson (2000) has also emphasized the importance of taking into consideration the historical and institutional context in which interpreters perform their job in order to better analyze their actions and their role. He also referred to interpreters as gatekeepers for the minority-language speakers for whom they interpret, stating that these interpreters align with healthcare providers, making them active participants in the diagnostic process.

Looking at the interpreter’s role and considering day-to-day workplace pressures and ethical dilemmas, Kaufert and Putsch (1997) studied informed consent and end-of-life decisions mediated by interpreters in their study in Winnipeg, Canada. These authors disagree with the idea of a neutral interpreter, emphasizing the need for codes of ethics that would incorporate situations where interpreters “act as advocates for patients” (Kaufert and Putsch 1997: 77; cf. the California Health Care Interpreters Association [CHIA] Standards 2002: 44–7). Focusing on the role of interpreters, Kaufert and Putsch discuss the challenges of monolingualism in a medical practice that is increasingly multicultural and places a heavy emphasis on the aspects of clinical communication that involve power and dominance. They also looked at the dilemmas of identifying with one’s role when faced by medical personnel in emergency situations in addition to the clash of two cultural systems.

The focal point in their discussions is based on issues of power and dominance in clinical communication, the challenge of monolingualism in multicultural medical practice, and the role of interpreters. From these studies, the authors object to the role of neutrality prescribed for interpreters by certain interpreter organizations and their codes of ethics (e.g., the Washington State Supreme Court’s Code of Conduct for Court Interpreters) and argue for ethics that address instances when interpreters “act as advocates for patients” (Kaufert and Putsch 1997: 77).

The authors declare that

health care interpretation often occurs across major gulfs of culture, class and language, and therefore it is unlike interpretation [sic] in the courts, or in business, or international negotiation. Interpreters’ attempts to encourage mutually shared understanding on the part of monolingual interlocutors require engaging in explanation, cultural brokerage, and mediation when these actions are necessary.

(Kaufert and Putsch 1997: 75)

The conceptualization of the interpreter has evolved to perceive the interpreter as co-constructing the discourse of the communicative event together with the monolingual interlocutors and doing so by exercising his/her agency (Angelelli 2004a, 2004b). This research also has established that interpreting does not happen in a social vacuum. As interpreters participate in the interpreted event, they bring to it all the social and cultural factors that allow them to co-construct a definition of reality with the other co-participants to the interaction.

In addition, the decisions and judgment calls that interpreters make on a daily basis when working in the medical field can have a great impact on the lives of those who rely on interpreters for their daily communicative needs and those who are the most vulnerable in our society. For speakers of minority languages, access to service and information depends entirely on the interpreters who help them accomplish their communicative goals. Interpreters, as members of society, are powerful parties who are capable of altering the outcome of the interaction by channeling opportunities and facilitating access to information. To illustrate with an example, in the next section I explore the agency (or visibility) of the medical interpreter in action.

A Healthcare Interpreter in Action: Talk as Activity and Interaction

Often, cross-linguistic communication regarding illness and disease, diagnosis and treatment, caring and curing is complicated by the “collision” of cultural communities. There is a noticeable difference in healthcare beliefs and practices of persons seeking and providing healthcare, which can lead to problems when communicating with one another (Geist-Martin et al. 2003, quoted in Angelelli and Geist-Martin 2005). Members of these diverse cultural groups frequently conceive health, disease, pain, and healthcare practices differently. By using discourse analysis, studies on cross-linguistic medical interactions demonstrate how essential it is to inspect these differences and understand why they may be magnified or reduced by the presence of an interpreter. The transcript presented below is used as an example to illustrate the impact of the interpreter in the communication.

The complexity of any interaction multiplies in the healthcare setting when interpreters are needed to link the cultural communities of the provider (and medicine) and the patient. This is performed not only by interpreting the languages spoken, but also by searching for answers to questions that providers and patients raise when they communicate with one another. Research investigating this complex framework of communication with interpreters indicates that the difficulties in interpreted conversations are in the construction of reciprocal understanding, the accurate transformation of semantic and pragmatic content, and that of the role of the interpreter as linguistic facilitator (Davidson 1998). The transcript below is part of a study in which Angelelli (2004a) and Angelelli and Kezirian (2005) looked at interpreted conversations regarding the levels of pain a patient was experiencing and describing.

The dilemma of looking at different constructions of pain while facilitating communication can affect how pain is measured and perceived. Angelelli (2004a) demonstrates the challenges faced by Spanish-speaking patients, English-speaking providers, and Spanish–English interpreters who attempted to measure pain with the use of a pain-rating scale. As will become evident from the transcript, interpreters play a vital role in the co-construction in the understanding and communication of pain during an encounter. The burden is placed on healthcare interpreters when facilitating talk concerning pain between patients and providers in a cross-linguistic medical setting when a language and/or culture is not shared (Angelelli 2001, 2003, 2004, 2006; Bolden 2000; Davidson 2000, 2001; Metzger 1999; Wadensjö 1998).

The transcript (Angelelli and Kezirian 2005) permits an examination of the predicaments healthcare interpreters faced when they were confronted with challenging situations during the construction of pain. The transcript also shows how interpreting is activity and interaction, rather than text. It shows an excerpt of medical interpreting performed over the phone and involves a Spanish-speaking mother who makes a call for her 17-year-old son who is experiencing severe pain due to a tumour on his spine. The interaction spans a period of twenty-five minutes. During the call, the son is asked to speak to the nurse over the phone in order for her to ask questions to gather more detailed information about the patient. The nurse asks questions concerning his previous doctor visits specifically related to this issue, his current state, and then proceeds to asks him to rate his level of pain. Vicente, a medical interpreter, brokers the interaction between the English-speaking nurse and the 17-year-old Spanish-speaking patient. The conversation in segment 1 pertains to the nurse telling the interpreter to ask the patient to rate his level of pain on a scale from one to ten. The following segment is an example to illustrate the role a medical interpreter plays in the co-construction of an encounter.

Example 21.1 Segment 1 (Tape 16. Vicente. Side B. Call 3 078-405 – Angelelli 2004a)

1	N	You discussed the pain with your doctor?
2	I	¿Usted le dijo al doctor que tenía dolor? (you told your doctor you had pain?)
3	P	Sí “yes”
4	I	Yes he did
5	N	How much pain are you having on a scale of one to ten, how strong is it?
6	I	¡Carlos!
7	P	Aha …
8	I	Cuando hablamos de dolor en el hospital, hablamos de número de la siguiente manera … (when we talk about pain in the hospital, we talk about it in this way)
9	P	Aha …
10	I	Del uno al diez … un dolor que es tan pequeño que uno lo ignora que es uno … un dolor que es fuerte podría ser cuatro, cinco, seis … ¿me entiende? (From one to ten … a pain that is so little that one can ignore it, is a one … a strong pain could be four, five, six … do you follow me?)
11	P	Aha …
12	I	Tengo que ver al doctor, tengo que tomar algo … un dolor que me hace gritar es entre entre ocho y diez … (I need to see the doctor, I need to take something … a pain that makes me scream is between an eight and a ten … )
13	P	Aha …
14	I	¿Qué número sería su dolor ahorita? (What number would your pain be now?)
15	P	Pues … en las noches sería entre el ocho … porque en las noches es cuando no me deja dormir y es más dolor … (Well … at night it would be between eight … because it does not let me sleep at night, and it gets stronger)
16	I	Yeah, ¿y ahorita? (and now?)
17	P	Y ahorita seria … ¿dice cuál era el núme[ (and now it would be … which did you say was the num[
18	I	[Okay, uno es tan poquito que no le hago caso, okay … fuerte es entre cuarto y seis, podría ser cinco ¿no? … muy fuerte es entre ocho y diez … (OK, one is so little that I do not pay attention to it, ok … a strong pain is between four and six, could be a five, right? … very strong is between eight and ten)
19	P	No entonces diría que entre cuatro y cinco … (No, then I would say it is between a four and a five … )
20	I	Okay so he is saying that now it’s between four to five and at night it’s when it is worst, because it prevents him from sleeping, and at night it’s about number eight …
21	N	Does he take any Motrin or Advil?
22	I	¿Carlos está usted tomando Motrin o Advil? (Carlos, are you taking Motrin or Advil?)

As demonstrated in the segment above, it is important that the nurse knows how much pain the patient is experiencing and therefore asks the patient to use the pain scale (turn 5). Vicente, the interpreter, anticipated that the patient would not be familiar with the institutional way of rating pain. He explains how he perceives pain (turn 8) and also provides some examples of what the ratings represent to him (turns 10 and 12). After offering explanations concerning the pain-rating scale and the possible scores, he continues to ask the patient to rate his pain at that time (turn 16). The patient, overwhelmed with the new scale, forgets the ratings and requests further assistance from Vicente (turn 17).

For a second time, Vicente explains the scale for the patient who proceeds to rate his current pain in turn 19. Segment 1 illustrates how the co-construction process functions between the interpreter and the patient by providing examples of what the patient may feel (e.g., little or strong pain), or what he could do with the pain (e.g., he could ignore it, he could not sleep, he needs to call the doctor). The interpreter takes responsibility to broker the scale for the patient when the patient cannot use the scale to rate his pain by himself. The nurse does not take responsibility, and the patient does not provide a self-directed answer.

This transcript has allowed us to see how talk gets constructed among the participants and how each participant contributes to the activity of communicating and understanding (or not understanding) what is being discussed. A transcript is also a window to examine how the role of the healthcare interpreter gets enacted. This example, which is representative of medical encounters, clearly depicts the interpreter as an engaged participant who co-constructs the conversations together with the other two monolingual interlocutors. In this engagement, this exercise of power that is generally exhibited by healthcare interpreters is a contested site. In the next section I explore the individual agency that characterizes healthcare interpreting.

The Role of the Interpreter: A Continuum of Visibility as Enactment of Agency

In the last two decades of the twentieth century, we witnessed a shift in the perception of the interpreter’s role, especially in the field of medical interpreting. As the demand for culturally competent medical interpreters increases, we see a departure from the conceptualization of the interpreter, as language conduit and a move towards one of the interpreter as an essential partner in the interaction, as illustrated by the segment above.

Historically, language interpreters have often been portrayed as invisible language facilitators who act as language coders/decoders. In line with this idea, interpreters are expected to pay close attention to the meaning of the message expressed by the parties in a conversation and to convey that exact same meaning into the other language, without omissions or additions. However, recent research that has investigated the role of the interpreter has shown that interpreters perceive their role as visible, not invisible, in their work settings (Angelelli 2004b). This establishes the concept of how interpreters acknowledge their agency (Angelelli 2004b) as they perceive themselves as participants in the interaction who organize various tasks during the verbal exchange such as controlling the flow of communication between the two interlocutors, facilitating mutual respect between co-participants and communicating not just the linguistic aspect of the message, but the social and culture-sensitive elements embedded in it as well.

In the course of their jobs, medical interpreters must be able to comprehend and produce language of various degrees of complexity, alternating between target and source languages of rural and urban varieties for speakers whose level of education ranges from second grade to graduate school. Therefore interpreters not only identify their role as visible agents, rather than transparent conduits, but their visibility is evident when they perform in this role, specifically in the medical setting (Angelelli 2004a). The visibility of interpreters is evident in one or more of the following behaviors: (1) introduce or position the self as a party to the ICE, thus becoming co-participants (Metzger 1999; Roy 2000; Wadensjö 1998) and co-constructors (Davidson 2000, 2001) in the ICE; (2) set communication (for example, turn-taking) rules and control the traffic of information (Roy 2000); (3) paraphrase or explain terms or concepts (Davidson 2000); (4) slide the message up and down the register scale (Angelelli 2001); (5) filter information (Davidson 2000); (6) align with one of the parties (Wadensjö 1998); and (7) replace one of the parties to the ICE (Roy 2000).

In addition to the concept of visible interpreters who hold power as active participants in the interpreted interaction, recent studies (e.g., Angelelli 2004a, 2004b; Davidson 2001; Metzger 1999; Wadensjö 1998) take into consideration the agency that interpreters possess.

When Spanish–English medical interpreters were interviewed on their roles (Angelelli 2004a) many turned to the use of metaphors to describe their jobs. One traditional metaphor is of interpreters as multifaceted bridges, while other metaphors used by participants reveal a more visible and proactive role. One group of medical interpreters compare their work to that of a detective who searches for the necessary answer, a mine digger who excavates until the answer is found, and a diamond connoisseur who must possess the ability to distinguish relevant information (diamonds) from the less relevant information (dirt). As roles become more participatory, the tension between what interpreters do in their practice and what professional associations prescribe they should do through their code of ethics increases. In the next section we explore that tension.

Ethics in Medical Interpreting

Various professional organizations in the US (e.g., the California Healthcare Interpreters Association [CHIA], the Massachusetts Medical Interpreting Associa­tion [MMIA], which changed its name in 2008 to become the International Medical Interpreting Association [IMIA], and the National Council on Interpreting in Health Care) have published their codes of ethics, which in general terms prescribe what the role of the interpreter should be as well as what responsibilities, rights, and duties are associated with it. It is not unusual to see some discrepancy between the prescriptions established by the healthcare interpreting organization’s code of ethics and the norms enforced at the interpreters’ workplace by the institutions hiring them. For example, although the interpreters’ code of ethics establishes that interpreters communicate with monolingual parties during encounters only when both monolingual parties are present, some hospitals require interpreters to interact with the patient when the provider is not present (e.g., help patients using wheelchairs access elevators). Another situation where tension may exist between conflicting guidelines is when interpreters, observing their code of ethics, insist on holding a pre-session (CHIA 2002: 28) to inform the monolingual parties of their duties of interpreting everything that is said during the encounter. Many times the pressures of the workplace do not allow the time for this pre-session to take place, and interpreters are caught in a difficult situation.

Although the first code of ethics was published by MMIA in 1995, it was not until CHIA published its own in 2001 that we saw the whole ethical dilemma surrounding the role of the interpreter addressed. In 2001, CHIA assembled researchers, trainers, and practitioners to create a shared understanding of interpreting standards. The product was the 2002 California Standards for Healthcare Interpreters: Ethical Principles, Protocols and Guidance on Roles and Intervention (the Standards) published by the California Endowment, which was intended for medical interpreters, healthcare providers, patient advocates, hospital administrators, and government agencies.

Like other associations, CHIA is dedicated to improving the health and well-being of patients. The goal of the organization is to provide equal access to healthcare services by developing and promoting the profession of healthcare interpreter, advocating for services that are culturally and linguistically appropriate, and providing education and training to healthcare professionals. Unlike other associations, CHIA took a stand on the role of the interpreter. Rather than characterizing it as invisible and transparent, CHIA embraced its complexity and described possible enactments of the role that range from message converter to patient advocate. Those roles are discussed in detail in Section 3 of the CHIA Standards (2002). The difference in the roles is based on an increasing interpreters’ intervention. The role of the “message converter” (2002: 36) is to interpret the meaning of an utterance in the other language. The “message clarifier” (2002: 36) takes over when the utterance in the other language needs clarification in order to be understood – this implies the interpreter intervenes more. The “cultural clarifier” (CHIA 2002: 37) comes in when the utterance needs to be contextualized in a different culture, or within a competing set of beliefs; the interpreter intervenes even more to do this. The patient advocate (CHIA 2002: 38) is the most intrusive role of all and is enacted when, for example, the interpreter witnesses discriminatory treatment of a patient, steps in for the patient, and reports unethical behavior on the part of the provider. CHIA acknowledges that the patient advocate is an extreme role and that proper training is required before exercising it (CHIA 2002: 39–40).

In spite of taking this stand on how the interpreter is a co-participant to the interaction and impacts the construction of meaning through incremental interpreter interventions, the underlying assumption suggested by statements of CHIA’s code of ethics and/or standards of practice is that in any given utterance there is only one meaning. This is not subject to co-construction by all participants to the interaction, including the interpreter, but rather that meaning exists independently of the parties. This assumption underlines the conduit mode discussed earlier.

This underlying assumption suggested not only by CHIA but also by other associations’ statements in their codes of ethics and/or standards of practice (e.g., Association internationale des interprètes de conférence [AIIC], MMIA, National Association of Judiciary Interpreters and Translators [NAJIT]), is that meaning exists independently of the parties. These statements assume that not only meaning but neutrality and accuracy are monolithic concepts. In other words, by stating that the interpreter’s responsibility is to convey the meaning of the message into another language, we are denying the fact that meaning is not monolithic and that all parties to a conversation work together to generate this meaning. The interaction during which the meaning gets constructed can take on different formats; for example, giving or requesting information, clarifying or re-stating concepts, repeating, paraphrasing, expanding, or summarizing statements.

When one takes the time to listen to interpreters describing their job (e.g., CHIA focus groups study [Angelelli 2007]) it is evident that many times interpreters experience tension as they are asked to navigate in contested waters. They need to be aware of their standards of practice that could possibly contradict the policies of the employers and/or agencies. One example could be the challenge to an interpreter of following the ethical principle of impartiality when, in many of the healthcare institutions and interpreting agencies where they work, they are asked to play the role of an advocate or a social worker. Placing interpreters in demanding moral situations is a result of prescriptions and opinions that surpass the dearth of empirical studies that focus on interpreting in healthcare. This poses ethical dilemmas for interpreters who are trying to do their jobs. These ethical dilemmas have been reported in recent research (Angelelli 2007).

Although progress in bridging theory and practice is slow, the results of empirical research have just begun to influence the practice of the profession. Evidence of this is the incipient involvement of researchers in the writing of the codes of ethics or standards of practice of healthcare interpreting associations (e.g., the California Healthcare Interpreting Association, and the National Council for Interpreters in Healthcare), the efforts to participate in professional development opportunities offered by community agencies (e.g., California Health Collaborative Connecting Worlds), and recent conversations on the need to test medical interpreters appropriately. However, this minimal amount of dialogue between practice, theory, and research is not enough. Healthcare interpreters continue to be either portrayed as (in the case of the codes) or taught to be (during workshops) conduits during medical interactions.

By encouraging and/or supporting research in the healthcare interpreting field, funding agencies have also participated in this discussion or have channeled efforts towards professionalization (Angelelli 2006). The California Endowment (TCE) and the Robert Wood Johnson Foundation (RWJF) are two examples of agencies that have, to a certain extent, supported the interests of linguistic minorities in the healthcare setting. The California Endowment has supported CHIA for the writing and publishing of the Code of Ethics and Standards of Practice. Furthermore, the training programs for healthcare interpreters offered by San Francisco City College and Mount San Antonio College had their distribution funded by TCE for the CHIA Code through limited professional development opportunities. In addition, TCE organized a research symposium at the national level, and assisted in the funding of the development of national standards of practice and a code of ethics that built on previous efforts at the state level. The Robert Wood Johnson Foundation funded the program “Hablamos Juntos” to examine and improve Latino access to healthcare. A main focus of this program was medical translation, interpreting as well as signage in hospitals.

The Education of Healthcare Interpreters

In the days immediately following World War II, the education of interpreters was triggered by the need to ensure communication between heads of state or delegates of international organizations. This need was urgent, and therefore almost no research preceded implementation and no theory guided the practice. Consequently, many of the curricular decisions were made on the basis of trial and error. When this occurs, logistical questions directed to conducting training take precedence over questions that are intended to understand what a well-rounded education of interpreters might look like and how it would account for the differences in settings where interpreters work. For example, as a result of personal experiences and opinions, many courses on healthcare interpreting are reduced to teaching terminology related to the field. Although it would be pointless to argue that terminology is not relevant, it is only a part of the whole package and not sufficient enough to drive the entire curriculum. It may be misleading for students to focus on de-contextualized terminology, i.e. a bilingual list of terms stripped from the discourse in which it was embedded. Terminology and glossaries are derived from ways of speaking in a contextualized setting. They need to be studied in context and should not constitute the centerpiece of any curriculum.

Even though healthcare interpreting has obtained significant attention in the US, this new awareness is not centered on the availability or lack thereof of educational opportunities for those individuals who seek to pursue them and advance their careers. During the last decade, organizations in the medical interpreting field (e.g., the California Healthcare Interpreting Association, the Massachusetts Medical Interpreters Association, and the National Council on Interpreters in Healthcare) have joined efforts to plan for national certification of medical interpreters, and currently a national coalition has been formed. In this discussion of professionalism, the issue of education, which creates part of any professional foundation, has been overlooked.

Fees charged by healthcare interpreters were and still are considerably lower than those received by conference and court interpreters. Although opportunities currently exist to further the education of conference and court interpreters (e.g., Monterey Institute of International Studies and the University of South Carolina at Charleston, respectively), there are no undergraduate or graduate programs that would permit students to pursue an education in healthcare interpreting (see Jacobson quoted in Kennen 2005). Accordingly, individuals practicing in the medical field cannot show evidence of an advanced degree, which generally guarantees higher pay. Education is the process of acquiring general knowledge of a field and/or particular knowledge or skills for a trade or profession. It will develop the powers of reasoning and judgment, in order to prepare oneself or other intellectuals for such a profession. Training implies practical learning to do, or practice, usually under some type of supervision. Reducing the education of healthcare interpreters to training (1) assumes that their knowledge of the field is sufficient for them to contextualize the newly acquired information, and (2) provides a limited opportunity to focus specifically on an objective (e.g., tips on how to use portable equipment). In addition, a broader conceptualization of education is essential to all providers in the bilingual medical encounter. Because health care providers (HCPs) practice in a multicultural environment, it is essential that they be educated on cross-cultural issues and how to work effectively with an interpreter. As a result the education of HCPs should include aspects of speaking with, to, and through an interpreter.

Most schools that offer interpreting courses taught by practitioners perpetuate the ideology of the conduit model mentioned above. During the course of an interpreting class, it is normal to hear instructors tell students in one way or another that the job of an interpreter is to understand the meaning at hand and state it in the other language. One should not have a part in what is said because the job is to convey the meaning stated by one speaker into the language of the other speaker. When the interpreter’s role is reduced to that of a language decoder-encoder, its capacity for complexity becomes limited, thus making it easier to teach by focusing only on the information-processing skills. The current status of interpreter education seems more in line with the status quo. A notion developing within the medical interpreting field is to assist students in the exploration of the different facets of their job and become aware of their power and responsibility (Angelelli 2000). Rather than studying, exploring, problematizing, understanding, and describing the role of the interpreter, most professional organizations and educational institutions continue to abide by an unchallenged belief system. Interpreters themselves are also characterized as subscribers to this belief of invisibility (Wadensjö 1998). Paradoxically, this false piety of professional organizations hinders the important aspects of the interpreter’s power, and it prevents them from discovering and understanding the complex role that they play.

Angelelli (2004a, b) has argued that the standards and regulations applicable to one type of interpreting cannot be blindly transferred to others since there are considerable differences among the settings where interpreting is performed. Yet, all have one element in common: the need for education. This need was identified by Conference Interpreting in 1953. By the following decade, conference interpreters, who used to be graduates of university programs in linguistics, had graduated from university programs in their field (Seleskovitch 1962). When discussing professionalism and meeting minorities’ linguistic needs in the US, the issue of education of healthcare interpreters has almost always been disregarded.

A characteristic of a profession is the access to a body of knowledge contributed by its members. This body of knowledge is constituted by theories and research that inform pedagogy. In the interdisciplinary turf of healthcare communication, healthcare interpreting falls at the junction of cross-linguistic/cultural healthcare. Students expand their access to this body of knowledge through education, as noted by Gile (1995); very few individuals can perform interpreting tasks without education.

Currently, most of the courses offered by institutions (e.g., universities, community colleges) or organizations (hospitals, community agencies) focus on the practice. They do not focus on the education of the individuals who facilitate communication across cultures but rather on training how to interpret. Regardless of the length (from a forty-hour to a one-semester course) or mode (face-to-face, online, via telephone) of instruction, the courses are limited and, for the most part, of a practical nature. The focus is on training in specific areas, such as information-processing skills or terminology, and not on educating a well-rounded interpreter. Education is often confused with “training.” Research questions about this practice, its practitioners, and their education, which are essential to guiding pedagogy and in the recognition of the fundamental complexities of the interpreted communicative event in a medical encounter (Angelelli 2000; Metzger 1999; Roy 1989, 2000), are deferred to the market need of practitioners. Another key element that may be impacting “training” discussions is the current focus on a national test for healthcare interpreters. We can only hope that encouraging more dialogue between practitioners and researchers will narrow the gap between research and practice in interpreters’ education (Angelelli 2008).

Certification of Healthcare Interpreters

As a result of Title VI of the Civil Rights Act of 1964, government-funded programs for healthcare institutions have been mandated to offer interpreting services to limited-English-speaking patients (Allen 2000). Moreover, legislation has banned the use of children in healthcare institutions (Yee et al. 2003), and there have been publications denouncing the use of untrained bilinguals such as janitors (Cambridge 1999) or any other bilingual in the language in need who is asked to step in as an interpreter (Allen 2000; Marcus 2003), which have fueled the debate on the quality of access available to speakers of non-societal languages in a multilingual society. Quality of access definitely assumes professional healthcare interpreting. Consequently, healthcare organizations as well as individuals who want to put their talents to serve the needs of linguistic minorities are struggling with a variety of important questions, including: How does one become a professional healthcare interpreter? Where do individuals who want to serve the needs of linguistic minorities in the healthcare setting get their education and/or certification? Where can one find professional healthcare interpreters? What makes one a professional healthcare interpreter? Is it simply experience in the field? What is the difference between a gifted bilingual and a professional interpreter? Is it education in the field, or is it just membership in a professional organization? Can passing a test guarantee professionalism? Or is a professional an individual with a degree who can demand higher fees?

At present, there is no national certification for medical interpreters. In fact, medical certification only exists in a few states (e.g., Washington) and often interpreters certified for the courts claim ability to work in a medical setting. Current certification tests for interpreters (e.g., in court) measure interpreters’ ability to interpret consecutively and simultaneously and to sight-translate. In addition, certification exams test memory and terminology in each language for which the interpreter is seeking certification. The underlying assumption is that the skills that merit testing are linguistic and information processing.

Certification procedures should be rooted in the fact that interpreting is an interaction (Wadensjö 1998) as well as a discourse process (Roy 2000). The role of the interpreter needs to be integrated in the assessment of the profession. Rather than being ignored, the issues of alignment, affect, trust, and respect should be present in the certification and assessment of interpreters (Angelelli 2004a). Aligned with integral education, this broader view of assessment would result in healthcare interpreting professionals who are better prepared to serve the communicative needs of individuals at all levels of society. The implementation of a comprehensive assessment program cannot afford to ignore education and it should be resolutely embedded in it. Bridging research and theory with practice in medical interpreting (Angelelli 2007) becomes even more crucial in certification discussions.

Exploring the link between empirical research in healthcare interpreting and assessment (Angelelli 2007), TCE supported the advancement of the first empirical tests for healthcare interpreting in Cantonese, Hmong, and Spanish (Angelelli 2003, 2005), as well as the corresponding reliability studies. In 2001, the RWJF through “Hablamos Juntos” piloted these tests in their ten experimental sites; analysis of results has not been concluded.

Conclusion

As has become apparent from the discussion above, medical interpreting involves communication between two monolingual interlocutors who do not share language, culture, or worldview. Linguistic-minority patients and healthcare providers who speak the societal language come into contact via interpreters who juggle distinct social factors in addition to processing information under pressure. In order to accomplish the communicative task at hand, these interpreters play a variety of roles that range from language converter (CHIA 2002: 36) to patient advocate (CHIA 2002: 38). Even though more recent empirical studies have shown an interpreter who is a co-participant (Roy 2000; Wadensjö 1998) with agency (Angelelli 2004a, 2004b) in the interaction, the conceptualization of the interpreter as a conduit (Reddy 1979) or a ghost is still prevalent. Sometimes this conceptualization becomes a professional ideology (Angelelli 2004a; Wadensjö 1998).

In this chapter I have attempted to capture the essence of medical interpreting and the evolving changes that have occurred within the field in the past few decades. It has discussed the education and certification of medical interpreters, as well as the ethics that medical interpreters observe and the roles they play. In terms of role, I have compared the traditional views of an interpreter as just an invisible communicative conduit between two interlocutors and the current view that portrays the interpreter as a visible influential co-participant in a communication who must manage many distinct and challenging roles and social factors while facilitating, constructing, and repairing talk. This role is one of the main focuses of current studies in medical interpreting.

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