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Medical settings include private practice, hospital settings and consulta-tions with other health care professionals, such as speech patholo-gists, dieticians or physiotherapists. Interpreters working in this field are often referred to as medical interpreters or health care interpreters. The focus of the research into medical communication has mostly been on doctor–patient interactions (Candlin and Candlin, 2003). Interpreters are involved in the consultation between the health care professional and the patient; therefore, research into medical discourse is of utmost relevance to their work. Just as it is crucial for interpreters to under-stand the purpose behind language use in the courtroom in order to avoid interfering unnecessarily with the process (see chapter 3), so it is important for them to understand the significant role language plays in a medical consultation and other related health settings. Such an understanding will help the interpreter to make informed decisions in the course of their work.

2.2.1 Communication in doctor–patient interaction

Successful health care provision depends largely on successful commu-nication between the health care provider and the patient, with language

playing a central role. Successful communication relies on a number of factors, among which are the health care provider’s ability to ask appropriate questions in the most effective way; to listen attentively and empathetically to all a patient has to say, not only to what directly relates to the questions posed, including indirect clues that may lead to further understanding of the patient’s problem (Cordella, 2004; Vásquez and Javier, 1991); and to build up a positive and collaborative relation-ship with the patient (Candib, 1995; Ong et al., 1995; Ferguson and Candib, 2002; Zoppi and Epstein, 2002). When interpreters are involved in medical consultations, they are required to interpret the health care provider’s questions and the patient’s answers. It is therefore crucial that interpreters understand the significance of questioning style and the importance of patients’ answers, not only in providing direct informa-tion in response to quesinforma-tions, but also in providing clues for the health care provider.

2.2.2 The significance of questioning style in achieving effective communication

Questioning style and technique have been prominent in the literature about successful doctor–patient interaction. Cambridge states that ‘the patient may well present symptoms unrelated to the real problems, and the diagnostic skill of the doctor relies heavily on skilful questioning’

(1999: 201). Cordella suggests that ‘the way in which the question is presented, therefore, can pre-determine the reply’ (2004: 32). A number of researchers have looked into the different questioning techniques to determine which types are more successful in achieving the aims of the consultation, which, according to Ong et al. (1995), are to create a good interpersonal relationship, to exchange information and to make correct treatment-related decisions.

Cicourel (1999: 183) argues against the use of leading questions, stating that this type of question renders patients powerless. He proposes that patients who feel included in the decision-making believe that they have some control over the outcome of the consultation, and this in turn leads to better clinical results. This sense of inclusion is more likely to be achieved by the use of open questions. He also explains that the consultation does not consist of a rigid set of questions, but that the physician will make guesses about possible trouble-spots that will trigger other questions which may relate to the main problem. The patient’s answers will also prompt further questions from the doctor, causing a change of direction in the question-and-answer sequences many times during the course of the consultation.

Harres (1998) analysed the use of tag questions in medical consulta-tions, which fall under the category of leading questions. Harres did not dismiss this question type altogether, however. The study found that doctors used these questions not only to elicit information from patients, but also to summarise their answers and seek confirmation of their understanding of them, to express empathy and to give positive feedback. The timing of the leading or tag question may have much to do with how effective its use is.

Byrne and Long discuss the ‘broad opening’ technique, where doctors allow the patients to speak freely until clues are detected for the real reason for the visit:

patients confronted with direct questions at the start of a consultation rarely give complete answers. By forcing the patient to talk, it is claimed that the process of relationship building is continued to the point where the patient feels sufficiently confident to make the real purpose of the visit apparent. (Byrne and Long, 1976: 37)

Bergmann (1992) agrees that often medical specialists use means other than direct questions, such as a simple assertion or the use of body language, to encourage patients to volunteer information.

Some have argued that the uneven distribution of questions in medical interactions can detract from building up a collaborative rela-tionship between doctor and patient, and encourage an asymmet-rical relationship. As in the courtroom, the questioner has potential control over who speaks and on what topic. One major difference between these two settings is that, in the courtroom, participants are bound by the rules of evidence, which stipulate that questions can only originate with lawyers and never with witnesses. In the medical consultation, however, patients are free to ask questions at any time.

Another major difference is that questions asked in the courtroom do not seek new information. For the most part, lawyers ask questions that elicit the answers they need in order to create a story that supports their case. The information is normally already known to the ques-tioner. In the medical setting, physicians are genuinely interested in obtaining information that will enable them to help the patient. As Ainsworth-Vaughn (1998) comments, questions in the medical setting cannot be interpreted simply as claims to power over the emerging discourse, but can in fact be the means by which power is shared. By asking a question, the doctor hands over the floor to the patient to speak. If the doctor is genuinely concerned about the patient, then

much interest will be placed in the patient’s answers. In 1979 Frankel conducted a quantitative and qualitative study on questions in medical interviews and found that less than 1 per cent of questions were initiated by the patient. His definition of patient-initiated questions, however, was limited to those that were first in the sequence and introduced new information. Frankel excluded what he called ‘normal troubles such as requests for clarification, information, etc.’ (1979: 239).

Ainsworth-Vaughn (2001: 463) comments that ever since Frankel’s work on ‘patient-initiated’ questions, there has been an overgeneralisation in the literature that stereotypes all patients as passive and powerless.

Later work on the distribution of questions between physician and patient with broader definitions of the term ‘question’ have shown higher percentages of patient-initiated questions (Roter, 1984; Roter et al., 1988; Ainsworth-Vaughn, 2001). In a study of Chilean doctors and patients, Cordella found that ‘both doctors and patients used a remarkably similar number of words in the discourse and suggests that both participants had the opportunity to take the floor during the consultation and to elaborate on their speech’ (2004: 58). Cordella also found that patients could be divided into three distinct categories:

compliers, apologisers and challengers, with the latter type being the most vocal.

The level of patient participation, therefore, seems to be related to a number of factors, including the patient’s personality and social background, the context of the consultation, and the relationship between the physician and the patient. Nevertheless, the important finding is that a low level of patient participation leads to a sense of powerlessness, which contributes to unsuccessful communication and inappropriate medical provision. The subordinate role of patient is believed to be accentuated by doctors employing ineffective ques-tioning techniques, by excluding the patient from the decision-making process, by talking about the patient to others in their pres-ence, by disregarding their suggestions, by not answering their ques-tions adequately and by using incorrect registers (Wodak, 1997). A number of studies have shown that medical outcomes are concretely improved when the patient feels empowered (see Ainsworth-Vaughn, 1998).

The register doctors use in addressing their patients has also been linked to power differentials. Shuy (1976) speaks of the need for doctors to discontinue the use of highly technical language which results in complete misunderstandings. On the other hand, Wodak comments

that the doctor’s use of child-like language when addressing an aged, difficult patient

only serves to reinforce the difference in power and the patient’s assumed mental inferiority. The frame conflict and the language barriers separating the two participants render cooperative face-to-face communication virtually impossible and, in the end, the patient falls silent. (Wodak, 1997: 186)

2.2.3 Patients’ compliance with treatment

A number of authors have investigated the reasons behind lack of compliance and agree that a good doctor–patient relationship can help considerably in ensuring full cooperation with doctors’ suggested treat-ments (Frey, 1998; Tebble, 1999; Adler, 2002; Ferguson and Candib, 2002; Zoppi and Epstein, 2002). Others have found that the amount of information provided to patients can help increase the level of compli-ance (Heath, 1992; Cordella, 2004). As discussed in the previous section, appropriate communication skills are essential in building rapport with the patient and in being able to provide the relevant information in a way that is clearly understood by the patient.

Much has been written to indicate that monolingual doctor–patient communication can be problematic and that physicians would benefit from acquiring better communication skills to achieve optimum results (Byrne and Long, 1976; Todd, 1983; Heath, 1992; Wodak, 1997;

Ainsworth-Vaughn, 1998; Cicourel, 1999). When a third participant, the interpreter, is added to the interaction, a further layer of complexity is added. The crucial question to be considered is how to ensure that this extra complexity does not exacerbate the communication problems that may exist in monolingual health care provider–patient interactions. The following sections address this question with the use of authentic examples.