On equal footing? The impact of informal interpreters on lifeworld integration and patient-centeredness in emergency consultations

doi:10.21203/rs.3.rs-4353990/v1

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On equal footing? The impact of informal interpreters on lifeworld integration and patient-centeredness in emergency consultations

https://doi.org/10.21203/rs.3.rs-4353990/v1

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Introduction – Patient companions (PCs) can have an ambiguous impact on the quality of communication during multilingual medical consultations and therefore on health outcomes. Studies of multilingual medical consultations have focused mainly on PCs’ role as interpreters, with less regard to other roles they may take up. This paper uses mixed methods to investigate PC role dynamics in multilingual PC-mediated consultations and how they affect the management of a patient’s Lifeworld, a crucial element for history taking and rapport building.

Methods – Nine recordings of multilingual PC-mediated consultations from a [city1] emergency department (ED), complemented with ethnographic notes and clinician interviews, were subjected to linguistic-ethnographic analysis and a codification of communication patterns and PC roles to explore the link between PC roles and Lifeworld management. PC roles were grouped into four stances (Linguistic agent, Lifeworld agent, System agent, and Principal). The communication patterns were grouped into three categories (“strictly medicine”, “Lifeworld included”, and “Lifeworld interrupted”).

Results – In ED consultations, patients’ Lifeworld frequently remains inadequately addressed, primarily due to physician interruptions. Significant associations are observed between roles taken up by PCs and the way patients’ Lifeworld is managed. Successful integration of Lifeworld aspects is best supported by PCs taking up the role of System agent, possibly because it allows them to link the Lifeworld directly to medical issues. Linguistic-ethnographic analysis reveals how language barriers, PC role changes and Lifeworld management strategies are taking shape organically (often implicitly) determined by a wide range of situational factors, such as the complexity of the topic, the available (non)verbal linguistic repertoire, the level of meta-communication, explicit role negotiation and timing.

Conclusion - Since poor Lifeworld management negatively impacts care, clinicians should be trained to detect and manage role dynamics and relevant situational factors in PC-mediated multilingual consultations to protect patients’ right to high-quality communication and healthcare.

The absence of a shared language between a patient and a clinician significantly contributes to health disparities (Divi et al., 2007; Karliner et al., 2012; Schillinger and Chen, 2004). Language barriers can inter alia lead to inaccurate diagnoses, improper medication administration, and inadequate follow-up (e.g., missed appointments). The literature generally recommends the use of trained interpreters to overcome challenges associated with language barriers in healthcare settings (Ramirez et al., 2008). However, using trained interpreters in the emergency department (ED) is often challenging due to organizational, time, and financial constraints (Cox and Lázaro Gutiérrez, 2016), as well as the lack of prior information on patients' language skills (Karliner et al., 2004).

In the ED, physicians frequently rely on PCs who act as ad hoc interpreters or use no interpreters at all to manage consultations across a language barrier (Cox and Lázaro Gutiérrez, 2016; Li et al., 2010; Meeuwesen and Ani, 2011). The literature considers the use of untrained ad hoc interpreters to be a bad practice; however, as they commit more errors than trained interpreters and often inadvertently omit information that is crucial to medical practice (Cox et al., 2019; Meyer et al., 2010, p. 298). These errors typically go unnoticed. Ad hoc interpreters have also been found to be highly prone to role conflicts (Boivin et al., 2013; Rosenberg et al., 2008). Furthermore, uncertainty about the companion’s relationship with the patient frequently complicates the assessment of the reliability of the provided information: clinicians may assume that companions are family members, even if they are not (Cox and Lázaro Gutiérrez, 2016; Cox and Li, 2020).

A survey revealed a strong perception among ED clinicians that the presence of PCs may hamper conversations on sensitive issues, leading to delays in care or diagnostic errors (Stoklosa et al., 2018). At the same time, research has shown that PCs enhance communication with clinicians in the ED, particularly for patients with lower literacy levels (Cooper and Stevenson, 2022; Cornelius et al., 2018; Schilling et al., 2002). One dimension that has been particularly highlighted in the literature is PCs’ role in reducing patient anxiety, shifting the power balance in the patient’s favor, increasing attention given to Lifeworld issues1 in consultations, and facilitating a truly shared decision-making process (Greenhalgh et al., 2006).

The management of Lifeworld issues in a medical consultation is an important aspect of clinician-patient communication. As set out by Greenhalgh et al. (2006, p. 1185), while there is clearly some tension between the biomedical agenda and the patient’s Lifeworld agenda, not least due to time constraints, “Lifeworld information is essential for accurate diagnosis and effective treatment decisions”, as it provides the contextual information in which health problems play out. Giving space to Lifeworld elements is key for patient-clinician rapport building and, more broadly, achieving patient-centered care and shared decision-making, especially in the case of more complex health problems (Barry et al., 2001; Greenhalgh et al., 2006) or anxious patients (Lachance, 2016; Wagley and Newton, 2010).

In the ED, misalignments between the medical world and the Lifeworld frames are intensified by, on the one hand, strict time constraints, which sometimes lead physicians to prioritize medical aspects over relationship building, and, on the other hand, patients’ heightened stress, anxiety, and need for reassurance (Wagley and Newton, 2010). Language and cultural barriers present a further exacerbating element. They challenge the communication process and therefore also the opportunities for physicians and patients to negotiate misalignments of interaction frames (e.g., voice of the Lifeworld versus voice of medicine) and expectations, making it more difficult to reach convergence (Cox and Li 2020).

A few papers have addressed the challenges of Lifeworld management in triadic consultations, notably those involving trained or untrained interpreters in multilingual contexts. Both types of interpreters have been found to offer benefits but also possible disadvantages. Greenhalgh et al. (2006) found that trained interpreters are more likely to help push the medical agenda forward, while family interpreters are more likely to offer Lifeworld elements. Leanza et al. (2013) characterize four different communication patterns with respect to how patients’ Lifeworld is included in a medical encounter (e.g., “Lifeworld rationalization”, “mutual Lifeworld”, “integration of medicine and Lifeworld”; or “referral”) based on earlier work by Barry et al. (2001). They found that reliance on a trained interpreter is likely to result in better integration between the voice of medicine and the voice of the Lifeworld than reliance on an untrained interpreter or no interpreter at all. An untrained family interpreter is more likely to contribute additional Lifeworld information but could also conceal some Lifeworld elements.

Nevertheless, many knowledge gaps remain in our understanding of how interpreters influence communication during healthcare consultations and, ultimately, care quality. In particular, with regard to untrained interpreters, who are usually PCs, the literature on how the different roles they take during a medical consultation affect the quality of communication and health outcomes remains relatively limited. Earlier studies on PCs have usually focused on their role as interpreters, considering other roles taken up by pPCs as digressions from good interpreter practice with potential clinical implications rather than for their own potential value (Cox et al., 2019; Flores et al., 2012; Gany et al., 2007).

To gain new insights in this area, this study explores the impact of PC role dynamics on the management of Lifeworld issues. To this extent, it combines and extends two frameworks developed earlier: one by Leanza (2005) on roles taken up by (trained) community interpreters in medical settings and one by Leanza et al. (2013) on communication patterns with regard to Lifeworld management in medical consultations (see above). These frameworks are applied to a dataset on medical consultations from an emergency department in [city1, country 1].

The three major questions addressed in the paper are as follows:

1. What roles do PCs play?

2. How is the patient's Lifeworld incorporated or excluded in communication between patients, physicians, and PCs?

3. How do these communication patterns and roles interact during consultations?

2.1 Research design

The study adopts a conversion mixed method design (Teddlie and Tashakkori, 2009). Qualitative data were collected and analyzed qualitatively and then coded and analyzed quantitatively. Both types of analysis are combined to deepen the understanding of the phenomena under study. In this study, quantitative analysis is prioritized, and qualitative analysis helps to bring meaning and nuance to the quantitative results.

The qualitative and quantitative data analyses were carried out by a multidisciplinary team of psychologists, linguists and medical professionals from [country 1 and country 2]. The combination of statistical and ethnographic analysis and the diverse backgrounds of the researchers (in terms of nationality as well as professional background) promotes cross-fertilization between disciplines and knowledge communities and ultimately a more comprehensive and nuanced understanding of the complex communicative dynamics present in the consultations under study (Cox, 2020).

2.2 Data collection and transcription

The data consisted of nine audio-recorded multilingual PC-mediated medical encounters in the ED of an inner-city hospital in [city 1, country 1]. Initially, ten recordings were selected from a larger corpus comprising 130 recorded consultations accompanied by ethnographic notes and post-consultation “after action” interviews with physicians ([author 1]). The selected recordings all represented multilingual PC-mediated consultations.2 The consultations were transcribed by the first author and translated by native speakers of the relevant language (variant). Table 1 presents an overview of the nine records included in the analysis.

Table 1

Characteristics of the consultations
#	Description	Patient		Language(s) spoken by patient	Companion(s)²	Clinician(s)
#	Description	Sex	Age¹	Language(s) spoken by patient	Companion(s)²	Clinician(s)
1	Iraqi patient with unknown condition	F	70–80	Arabic	Patient’s daughter and grand-daughter who speak only Arabic Female neighbor, also from Iraq, who speaks French as a second language	Female French-speaking surgeon Female French-speaking internist
2	Moroccan patient with unknown condition	F	30–40	Moroccan Arabic	Two women who speak French and Moroccan Arabic (relationship to patient unknown)	Dutch-speaking female medical student, speaks some French as a second language
3	Pakistani patient with kidney stone	M	20–30	Urdu Pakistani Punjabi	Man who speaks English, Urdu, and Pakistani Punjabi (relationship to patient unknown)	Dutch-speaking male physician, speaks English as second language
4	Somali patient with tuberculosis	F	40–50	Somali	Woman who speaks Somali and French as a second language (relationship to patient unknown)	French-speaking male surgeon French-speaking female nurse
5	Moroccan pregnant patient with syphilis	F		Moroccan Arabic	Patient’s Moroccan husband who speaks Moroccan Arabic and French as a second language Their baby	French-speaking male internist French-speaking Nurse
6	US patient with infected toe	M	20–30	English	Patient’s teacher from USA, English native speaker, speaks French as second language	French-speaking female nurse French-speaking female physician who speaks English as a second language
7	Moroccan man with gout	M	70–80	Moroccan Arabic	Patient’s two Moroccan sons-in-law who speak Moroccan Arabic and French	French-speaking male internist
8	Italian woman with foot sprain	F	70–80	Italian	Patient’s son who speaks Italian and French as a second language	Female French-speaking surgeon
9	Moroccan patient with mastitis	F	20–30	Moroccan Arabic Berber	Male companion who speaks Berber, Moroccan Arabic, and a bit of Spanish and French (relationship to patient unknown)	French-speaking male internist with a good command of Spanish French-speaking female gynecologist
Notes: ¹ estimate

2.3 Coding and quantitative analysis

Two coding methods were used for the quantitative analysis: one on PC roles and one on communication patterns with respect to Lifeworld management.

PC roles were coded using a role typology adapted from Leanza (2005) and extended. Table 2 presents the different roles and their definitions. The roles are grouped according to the symbolic stance they represent. The Linguistic agent stance implies a certain level of restraint, where interpretation tasks are prioritized, i.e., the conveyance of discourse and its meanings between interlocutors. As a System agent, the interpreter upholds institutional discourse, symbolically aligning with clinicians' positions. Both stances confirm the dominant discourse or status quo in practice, potentially disregarding, denying, assimilating, or denigrating potentially important Lifeworld elements, also identified as cultural differences. In contrast, the Lifeworld agent stance involves the PC acting as an explainer, advocate, or negotiator of cultural differences, aligning more closely with the patient's position. This stance validates difference and seeks meaningful compromises (Leanza, 2005). Finally, a new role/stance was added, namely, one where the PC speaks on behalf of the patient, without involving the latter. It is referred to as the Principal stance, in line with Goffman’s participation framework theory, where the principal is the one who determines the message that is conveyed (Goffman, 1959).

The communication patterns were coded following Barry et al. (2001) and Leanza et al. (2013). In the first step, each speech utterance was coded based on whether it conveyed the voice of the Lifeworld (VoL) or the voice of medicine (VoM) (see Table 3 for coding criteria). In the second step, instances in which the VoL emerges are evaluated with respect to how it is managed, notably through interruption or through acknowledgment and/or inclusion (see Fig. 1 for the classification tree). The latter requires meaning creation based on information extracted from the VoL (Leanza et al., 2013). In instances where the VoL is absent, communication patterns are classified as Strictly medicine.

Table 2

Codification of companion's stance and roles
Stance	Role	Description
Linguistic agent	Interpreter	The companion acts like an interpreter without intervening in the dialog. • The companion is as discrete and unobtrusive as possible in order to facilitate clear and comprehensible communication.
Linguistic agent	Active interpreter	• The companion is somewhat more active in asking for clarification/confirmation from the interlocutors, with a focus on points of order or details rather than on the meaning of a particular intervention or practice. • The companion can retranslate, but with synonyms or more details to help understanding.
Lifeworld agent	Cultural informant	• The companion acts as cultural advisor for the clinician and the patient.
	Mediator	The companion tries to expand, explain, synthesize or adapt the clinician's questions and the patient's answers when the terms/expressions used are different from those used in the patient's or clinician's culture or when the terms are too medical.
	Advocate	• The companion acts as an advocate for the patient and seeks to ensure that the patient receives the best care possible, sometimes even opposing the clinician or rejecting questions that he feels minimize the severity of the patient's condition. • The companion teams up with the patient, even making decisions together – sometimes up to the point of pushing the patient to agree. • The companion can put additional pressure on the clinician to be more attentive to the patient's condition.
	Close informant	• The companion acts as a close caregiver to the patient and spontaneously provides information about the patient (e.g. cultural background, country of origin, type of work, family information, language, habits, etc.). The companion corrects an answer provided by the patient, since (s)he believes knowing him/her well enough, often without making the patient/clinician aware.
		• The companion becomes the clinician: (S)he conducts the interview in his/her own language, referring to the clinician afterwards. • The companion adds questions or gives additional medical information to the patient. • The companion may also encourage the patient to follow the physician's directions or disclose information that would be medically useful. • The companion may source from his/her own medical training, or from experience with the routine of these consultations. • This role is opposite to that of Advocate: the companion acts as agent of the healthcare system, possibly at the expense of certain values/practices of the own community.
System agent	Bilingual professional
System agent	Monolingual professional	• The companion positions her/himself as a relative and/or health and/or migration professional and expresses her point of view or hypotheses to the clinician. • The companion addresses the patient in the patient's language, positioning her/himself as a professional. • These exchanges are not translated into the other language.
Principal	Answers for patient	• The companion answers the clinician's questions for the patient, without involving the latter. • The interpreter does this, since (s)he believes knowing the patient well enough and does not add any other type of information (e.g., cultural). • If the interpreter adds information that is not solicited by the clinician, that part of the conversation is coded as Close informant.
Source: Adapted from Leanza (2005) and expanded

Table 3

Codification of the voice of medicine and the voice of the Lifeworld
Voice of medicine	Voice of the Lifeworld
• Use of specialized language (jargon) • Requests or interventions focused on specific facts or symptoms, if possible measured and quantified • Requests or interventions that exclude family, social, cultural, or emotional elements	• Use of common, popular language • Requests or interventions referring to contextualized facts, historically situated, accompanied by affective comments, somehow integrated into a set of meanings that goes beyond the usual medical framework • Patient’s or interpreter's assumptions, judgments, emotions (fear, worries, etc.)
Source: Adapted from Leanza et al. (2013)

Note

The classification presents an elaboration of a classification previously proposed by Leanza et al. (2013), following Barry et al. (2001), Leanza (2005) and Leanza et al. (2010).

The coding procedures were applied consistently to the PCs’ speech turns in all nine audio-recorded consultations. In the first stage, coding was done by two independent coders in an iterative process of comparison and discussion overseen by the last author. Following the completion of the coding for all nine cases, the second author verified the coding under the last author’s supervision. These different steps were taken to resolve any discrepancies in coding through consensus and to establish an appropriate coding framework tailored to the study context, given that the original coding frameworks were drawn from a different study context (pediatrics in the case of Leanza (2005), family medicine in the case of Leanza et al. (2013, 2010)).

To obtain a picture of the roles and patterns of communication in this corpus, a frequency analysis was conducted. The interaction between PC roles and Lifeworld management was explored through a dependency analysis. Only the PC’s speech turns were included. A chi-square test (χ²) was used to ascertain whether the PC roles and communication patterns behaved as independent or dependent variables (Rakotomalala, 2011). A significant χ² would suggest an association between a specific role and a particular communication pattern. For this analysis, roles were grouped into broader categories, notably stances: Linguistic agent, Lifeworld agent, System agent, and Principal. Communication patterns were also grouped into broader categories (Strictly medicine, Lifeworld heard/included, or Lifeworld interrupted). The analysis was performed using SPSS 26 (Statistical Package for the Social Sciences) and Excel software.

Cramer's V was calculated to determine the strength of the relationship between the variables. Adjusted standardized residuals were computed to establish the significance level of deviations from expected values for each cell (Agresti, 2012, p. 81). Positive standardized residuals indicate that the observed frequency is higher than expected, suggesting a positive association between variables. Negative values indicate that the observed frequency is lower than expected, suggesting a negative association between variables. The contribution of each cell to the total χ² was also calculated. These calculations helped to identify the primary significant contributions to the χ², defined as cells with a significant adjusted residual and an above-average contribution, as recommended by Rakotomalala (2011).

2.4 Qualitative analysis

A linguistic-ethnographic analysis of excerpts from the same encounters was carried out. Linguistic ethnography provides an interpretive perspective on the local and immediate actions of actors, considering their viewpoints and examining how these interactions are embedded within broader social contexts and structures (Creese and Copland, 2015, p. 2). This approach entails observing, questioning, recording, reflecting, comparing, and reporting in a disciplined manner (Hymes, 1980, p. 105). Roles and Lifeworld dynamics are analyzed through a language and social interaction lens (Cox and Li, 2020), drawing on transcripts from the interaction, complemented with field notes from ethnographic observations and interviews with clinicians, and applying common triangulation techniques (Flick, 2018). The analysis incorporates theoretical insights from discourse analysis, interactional sociolinguistics, interpreting studies, L2 research, social psychology, and seminal work by Gumperz (1982), Goffman (1974), and Hymes (1980).

Excerpts are selected to serve as “apt” illustrations regarding the research questions at hand (Gluckman, 1961) based on their capacity to demonstrate similar types of interactional complexities, repair mechanisms, and accommodations encountered throughout the entire consultation in question as well as other consultations exhibiting comparable contextual features related to language proficiency, role dynamics, and communication.

In the nine transcripts of the consultations, 850 PC utterances or speech turns were identified. For the coding of PC roles, out of the 850 utterances, 22% (n = 185) were deemed impossible to code or irrelevant because they were either incomprehensible or directed toward the researcher/observer and were therefore excluded. The coding analysis thus draws on the 665 remaining utterances that could be coded for companion roles.

3.1 Companion roles

The coding of PC roles showed that the linguistic agent stance dominated, being observed in nearly 40% (n = 263) of the coded utterances. It was followed by the principal stance, in which the PC answers for the patient without involving the latter. This stance was observed for 37% (n = 247) of the coded utterances. Lifeworld and System agent stances each accounted for just over 11% of the utterances. Table 4 presents the frequencies of role occurrences by case.

Table 4

Frequency distribution of stances and roles by case
Stances	Roles	Case ID									N	% all turns	% coded turns
		1	2	3	4	5	6	7	8	9	N
		Nr of utterances by category
Linguistic agent	Interpreter	22	82	46	36	1	6	17	4	17	231	27,2	39,5
Linguistic agent	Active interpreter	2		8	1		3			18	32	3,8	39,5
Lifeworld agent	Cultural informant										0	0	11,7
	Mediator		3								3	0,4
	Advocate		1	2							3	0,4
	Close informant	16	23	1	4	8	2	6	1	11	72	8,5
System agent	Bilingual professional		3	2	2			5			12	1,4	11,6
System agent	Monolingual professional	13	20	5	4	4	4	9	1	5	65	7,6	11,6
Principal	Answers for patient	34	57	27	7	19	1	33	5	64	247	29,1	37,1
N/A		18	38	30	22	12	3	7	6	49	185	21,8	-
	Total	105	227	121	76	44	19	77	17	164	850	100	100
Note: N/A: Excluded from the analysis for being incomprehensible or reflecting interaction with the observer

Within the linguistic agent stance, the interpreter role was adopted most frequently by the companion, representing almost 88% (n = 231) of the category. Within the Lifeworld agent stance, the Close informant role accounted for 92% (n = 72) of utterances, with the Mediator and Advocate roles accounting for only 4% each (n = 3). The Cultural informant role was not observed at all. Within the System agent stance, the Monolingual professional prevailed at 84% (n = 65), while the Bilingual professional role occurred less frequently at 16% (n = 12).

Hence, the analysis suggests that, like trained interpreters (see Leanza, 2005), PCs primarily act as linguistic agents. At the same time, in line with previous research (Rosenberg et al., 2008), family interpreters speak more often than trained interpreters on behalf of patients instead of accurately translating patients’ words to healthcare providers and vice versa. Indeed, the second most prevalent role/stance for PCs is that of the principal, where the PC speaks for the patient, mostly without involving the latter. Together, the principal stance and the close informant role (which involves spontaneously providing information without consulting the patient) account for nearly half (48%) of PCs' utterances.

This significant proportion of interactions excluding patients raises concerns. Although contextual information on patients' emotional or physical states can be valuable for physicians, especially if PCs are well informed (Rosenberg et al., 2008), having companions answer on behalf of patients to a major extent risks relegating the latter to passive bystanders. As the companion’s perception of the patient’s situation may be partial and/or biased, the exclusion of the patient may lead to the transmission of incorrect information, with potential negative consequences such as increased medical errors, reduced patient satisfaction, or decreased treatment adherence (Flores et al., 2012). It also hampers the process of trust-building between the doctor and the patient, possibly increasing patient anxiety.

The roles of mediator and advocate are seldom used, and the role of cultural informant is never used. This finding aligns with Leanza's (2005) research on pediatric consultations. Those roles that do not support the system's goals or challenge the physician's intervention direction are likely to be discouraged or disallowed.

3.2 Communication patterns

For the coding of communication patterns about Lifeworld management, 8% (n = 68) of the utterances were not coded, as they were incomprehensible or directed toward the researcher/observer.3 This part of the coding analysis thus draws on the 786 remaining utterances that could be coded. Table 5 displays the frequency distribution of communication patterns across the nine cases.

‘Strictly medicine’ patterns accounted for 65% (n = 552) of utterances. The voice of the Lifeworld emerged in 29% (n = 230) of utterances concerning each of the nine considered consultations. The balance between ‘Strictly medicine’ and utterances involving the Lifeworld varied across consultations, ranging from 24–84% for ‘Strictly medicine’. In most cases where the Lifeworld emerged (62%, n = 142), it was acknowledged and/or included in some way. This was observed in all consultations to some extent. Most frequently, it led to a short conversation where the Lifeworld was discussed in its own right (‘Mutual LW’), which can, for instance, contribute to relationship building between the clinician and the patient (see also Leanza et al., 2013).

In 38% (n = 88) of the cases where the Lifeworld emerged, it was interrupted, mostly by an interlocutor who simply ignored it. Clinicians were responsible for 75% of the interruptions, and PCs were responsible for the remaining 25%. Patients never interrupted Lifeworld conversations. When PCs ignored Lifeworld interventions, they invariably (in all cases) ignored them (“LW ignored”), which could also reflect a lack of attention. Clinicians have used more varied strategies to interrupt Lifeworld interventions. Even if they fully ignored LW interventions in more than half of the cases of interruption, in the other cases of interruption, they showed some form of recognition (“LW blocked” or “LW recognized”), indicating more clearly that the interruption was strategic.

In 28 speech turns (3.6%), Lifeworld interventions were strategically transformed to extract useful information for systemic goals (e.g., differential diagnosis) (“LW rationalization”). In 25 utterances (3.2%), Lifeworld interventions were taken as an opportunity to build meaning in both the Lifeworld and the medical world, e.g., by adapting medical advice to a patient’s personal context (“Integration of LW and System”) (Leanza et al., 2013).

Table 5

Frequency distribution of communication patterns by case
	Case ID									N	% all turns	% coded turns
	1	2	3	4	5	6	7	8	9	N
	Nr of utterances by category
Strictly medicine	55	167	89	46	30	16	48	4	97	552	64,9	70,2
LW interrupted	7	42	2	14	3	0	8	0	12	88
LI	3	35		10	2		4		4	58	6,8	11,2
LB	4	6		4			2		3	19	2,1
LRec		1	2		1		2		5	11	1,3
LW heard/included	30	11	13	5	9	3	18	12	41	142		18,1
LRat	1	2		4	2	1	2	6	10	28	3,2
Integ	9		1	1			13		1	25	2,9
ML	20	9	12		7	2	3	6	30	89	10,5
N/A	13	7	17	11	2		3	1	14	68	8,0	-
Total	105	227	121	76	44	19	77	17	164	850	100	100
Note: For pattern codes, see Fig. 1; N/A: Excluded from the analysis for being incomprehensible or reflecting interaction with the observer

In most consultations, Lifeworld interventions were usually (in more than two-thirds of cases where the LW emerged) heard and included. Two consultations (Case IDs 2 and 4) involved consistent interruptions of the Lifeworld (75–80% of LW interventions). These were both consultations where the PC was more likely (than on average across the considered consultations) to take up the role of (passive) interpreter. This raises the issue of whether there is a relationship between the role taken up by PCs and the way Lifeworld issues are managed in the consultation. To formally identify such a possible association, a dependency analysis was carried out between the distribution of PC roles and the adopted Lifeworld management strategies.

Hence, regarding communication patterns, consultations predominantly employ a biomedical register, consistent with the emergency department's objective to treat acute medical problems (Lachance, 2016). When Lifeworld elements are introduced, they are mostly included in the conversation. However, four out of nine observed consultations exhibited high rates of Lifeworld interruption. Physicians primarily caused these interruptions, but companions also contributed. Ignoring Lifeworld elements constitutes a symbolically violent interruption.

Two concerns are worth highlighting in this context. First, even if interruptions are concentrated in a few consultations, they pose risks to establishing trust between patients and physicians and developing accurate diagnoses and appropriate treatments. Second, patients rarely express Lifeworld elements directly. Physicians may perceive interrupting Lifeworld elements as appropriate communication. However, exploring the Lifeworld with the patient can also provide important contextual information (Barry et al., 2001; Greenhalgh et al., 2006). In 25% of cases, companions in consultations have been observed to not transmit Lifeworld elements, a phenomenon also observed with family interpreters during family medicine consultations (Leanza et al., 2010).

3.3 Roles and communication pattern interactions

A chi-square analysis was carried out on a total of 660 speech turns that had been coded both in terms of roles (aggregated to the level of stances) and in terms of communication patterns (also aggregated in three broad groups). The chi-square test yielded a significant result: χ² (6, N = 660) = 105.71, p < 0.001, leading to the rejection of the null hypothesis. This outcome suggests that there is indeed a dependency relationship between the stances adopted by companions and the observed communication patterns. Nonetheless, the Cramer's V value of 0.283 points indicated a weak association between these variables. Table 6 illustrates the observed (N) and expected values in the case of variable independence (Expected N), cell-specific χ² values, each cell's contribution to the total χ² (%) and adjusted standardized residuals (Adj. Res.). The mean contribution of a cell to the χ² was 8.3%.

Table 6

Relationships between companion stances and communication patterns

Communication patterns		Linguistic Agent	Lifeworld Agent	System agent	Principal
Strictly medicine	N	214	40	28	200
	Expected N	188,4	57	56,2	180,4
	X²	3,5	5,1	14,2	2,1
	%	3,3	4,8	13.4^‡	2,0
	Adj.res.	4.6^*	-4.6^*	-7.7^*	3.6^*
LW interrupted	N	16	23	22	13
	Expected N	28,9	8,7	8,6	27,7
	X²	5,8	23,2	20,7	7,8
	%	5,5	22.0^‡	19.6^‡	7,4
	Adj. res.	-3.3^*	5.5^*	5.1^*	-3.8^*
LW heard/included	N	28	15	27	34
	Expected N	40,7	12,3	12,1	38,9
	X²	3,9	0,6	18,2	0,6
	%	3,7	0,6	17.2^‡	0,6
	Adj. res.	-2.8^*	0,9	4.9^*	-1,1
Note: LW = Lifeworld; ^*significant adjusted standardized residuals (]-1.96, 1.96]); ^‡contribution to X² higher than average

When the PC assumed the role of linguistic agent or of principal, this led more frequently than expected in the case of variable independence to a focus on purely medical issues. Conversely, when the PC took the role of Lifeworld or System agent, this led more often than expected to the emergence of Lifeworld issues.

The strength of each cell's contribution to χ² depends on the gap between the observed occurrence of a pairwise combination of a PC role and a communication pattern and the expected occurrence if they were independently distributed. It provides an indication of which pairwise associations are most indicative of a dependent relationship. Overall, the System agent perspective contributed the most to χ² (50.2% of the total).

There was a negative association between the System agent stance and the Strictly medicine communication pattern (1.6 times the average contribution), suggesting that if the companion takes up the role of System agent, the conversation is less likely to focus on medical issues alone, despite the System agent being defined as a role where the PC acts as a representative of the healthcare system.

Similarly, a positive association could be seen between the System agent stance and communication patterns where the Lifeworld emerged (irrespective of whether they were interrupted or acknowledged/included). Lifeworld interrupted patterns contributed strongly to χ2 (54.5% of the total), with a positive association with the System agent stance (2.4 times the average) as well as the Lifeworld agent stance (2.7 times the average).

Thus, PCs who act as System agents seem to succeed more often in bringing Lifeworld issues to the fore and achieving their acknowledgment in medical interactions than PCs who act as Lifeworld agents. It could be that taking up the role of agent of the medical system allows the companion to establish a stronger link between the patient’s personal experience and his/her medical condition. Linguistic agent and Principal stances contributed less than average to χ² in their interaction with communication patterns. The remaining communication patterns shared percentages almost equally, with no notable contributions beyond those mentioned.

The consultation with Case ID 7 was selected as the basis for an illustrative linguistic-ethnographic case study, as it presents (at par with Case ID 9) the broadest variety of PC roles and communication patterns.

Like the other consultations considered in the analysis, the consultation with Case ID 7 was recorded in an inner-city emergency department in [city 1]. It took place on a Friday evening after 8 pm, outside usual office hours, when standard entrance triage procedures are not being conducted. It concerns a medical interaction involving five participants. An elderly Moroccan man (PAT) of 74 years’ old presented to the Emergency Department with ambulatory difficulties due to swelling of the limbs. His limited proficiency in French requires him to rely heavily on language intermediation by his two sons-in-law (COM1 and COM2) for communication. The man is seen by a male internist who is fluent in French (DOC). The researcher/observer was also present at the consultation.

The interaction primarily transpires between the physician and the translating family members, with occasional input from the patient to validate or endorse the conveyed information. The physician suspected gout as a potential diagnosis, and the discussion centers around this medical concern. The patient intermittently participated to confirm or agree with information being discussed. The conversational structure aligns with traditional patterns of medical consultations: inquiry into symptoms followed by evaluation of responses. The language barrier complicates the interaction. Both sons-in-law attempt simultaneous translations, resulting in confusion and additional pressure on the physician. One son-in-law also tends to respond directly to inquiries without involving the patient.

The first excerpt, which is taken from the start of the consultation, illustrates how COM1 indeed speaks for the patient without involving him (Excerpt 1). This part of the consultation aimed to gather information on the symptoms (location, timing, etc.). The focus is fully on medical issues (symptoms): it is an example of the Strictly medicine communication pattern where the Lifeworld does not emerge. As soon as the physician opened the conversation with a first question, the COM1 voluntarily provided information. The clinician accepted this role attribution, as he seemed to consider COM1 to be a close (enough) informant at risk of receiving incorrect information.

COM1 does not take up the role of interpreter. The patient remains fully excluded from the participation framework. No one undertakes an attempt to change that, suggesting that everyone is comfortable with the situation. It seems that both the patient and the physician trust the PC, at least to provide this first round of information.

Excerpt 1: Close informant/Strictly medicine

1	DOC	Ça va ? (.) Donc, c'est votre docteur qui vous envoie, ... <0,5> ... c'est ça? ? ... <0,5> …	Are you ok ? (.) So, it is your doctor who has sent you, correct?
2	COM1	= = Oui, si j'ai bien compris	Yes, if I have understood it correctly.
3	DOC	= = D’accord, il y a ma collègue qui m'a raconté qu'il a des gonflements au niveau des jambes et des articulations ˄	Ok, my colleague told me that he has swellings at the level of his legs and his joints
4	COM1	°Il y a sa main en faite° ... <0,5> …	There’s his hand actually.
5	DOC	Ses mains aussi?	His hands as well?
6	COM1	= = Non˄, pas les deux, juste la droite	No, not both of them, only the right one.
7	DOC	= =Juste la droite. Et ça fait combien de temps ça?	Only the right one. And how long has it been this way?
8	COM1	= = Eu: : hm bon depuis dimanche	Euhm… well, since Sunday.
9	COM1	Mai: :s plus exactement, ça fait déjà quatre mois depuis que ça commence et ça part mais ses derniers temps ça a vraiment commencé à gonfler	But to be more precise, already for the last four months it has come and gone but lately it has really started to swell.
10	DOC	(0.3) Et dimanche le plus?	And mostly so on Sunday?
11	COM1	Depuis dimanche ça a commencé petit à petit (.) mais depuis hier ça a gonflé vraiment fort	Since Sunday, it has started little by little, but yesterday, it has really swollen a lot.

The clinician’s approach changes in the second excerpt, where he tries to inquire about the patient’s pain experience (Excerpt 2). When prompted at first, COM1 again starts to volunteer information. However, conscious of the fact that pain is a very subjective experience and that it is necessary to receive a first-hand account of it, the physician explicitly asks COM1 to take up the role of interpreter and convey the question to the patient.

Excerpt 2: Close informant/Lifeworld interrupted

12	DOC	Ça fait très mal? / ... <1> ...	Does it hurt a lot?
13	COM1	Oui oui, franchement... ((speaks on the phone))... / ... <3> ...	Yes, yes, frankly…
14	DOC	Vous voulez lui demander si ça fait mal ? / ... <1.5> ...	Can you ask him if it hurts?
15	PAT	((groans)) / ... <2> ...
16	COM1	((speaks in Arabic)) ... <4> ...	You’re in pain, aren’t you? A lot of pain?
17	COM2	((speaks in Arabic)) ... <1> ...	Yes, a lot of pain. A lot, a lot.
18	COM1	Oui, oui/ /	Yes, yes

The Lifeworld is interrupted because the patient is not given the floor despite the clinician’s efforts in turns 12 and 14 and COM1’s efforts to translate the clinician’s question to the patient in turn 13. The patient emits an audible groan. COM1 then takes up the role of interpreter, accurately translating the clinician’s question into Moroccan Arabic. This type of role negotiation was rarely observed in the broader corpus on multiparty interactions in the Emergency Department. Indeed, an earlier related study by [author 1] revealed that clinicians seldom explicitly assign a specific role (such as an interpreter) to a PC.

Nevertheless, the patient does not reply; instead, COM2 takes the floor and replies affirmatively in Arabic, revealing himself as a close informant as well. His message was subsequently translated to French by COM1. However, the translation does not convey the same sense of gravity of the pain: it confirms that the patient is in pain but not that he is in a lot of pain. In combination with the patient's groaning, the physician infers significant pain. However, due to the absence of direct interaction with the patient, there is a risk of missing crucial data.

This could be interpreted as an instance where the patient’s Lifeworld briefly emerges but is subsequently ignored as a result of an incomplete translation. While the clinician and COM1 have made explicit efforts to bring in the patient’s perspective—the first by renegotiating the participation framework, the latter by taking up the role of interpreter as requested—the patient turned out not to be very forthcoming in providing information. This illustration underscores the role of the patient’s engagement in shaping patient-centered consultation.

Excerpt 3: Monolingual Professional – Lifeworld Rationalization

60	DOC	Et là aussi? Ah oui, ça c'est classique./ / ... <2> ... Mais monsieur il a la goutte en fait. / ... <2> ... Vous saviez ça / ... <1> ... Ça, c’est connu? // ... <2> ... Il a déjà eu ça?	And there as well? Oh yes, that’s common. But sir has gout actually. Did you know? Was it known? Has he already had that?
61	COM1	Oui, il a déjà eu ça / ... <5> ...	Yes, he has already had that.
62	COM1	Aussi chez le frère et le papa / ... <1> ...	Also with the brother and the father
63	DOC	Ah oui, c'est familial alors // ... <1> ...	Oh yes, then it runs in the family.
64	DOC	Ok, ça va. // ... <3> ... Je vais regarder le ventre /	Ok, that’s fine. I am going to have a look at the stomach.

In the third excerpt, the history taking process has been going on for a while and the physician adopts the candidate diagnosis of gout, a type of inflammatory arthritis (Excerpt 3). He then addresses COM1 directly, asking whether he was aware that his father-in-law was suffering from gout (“Did you know?”). COM1 confirmed this immediately, answering on the patient’s behalf, by taking up the role of monolingual professional as he discusses medical information with the physician. He then spontaneously expresses the voice of the Lifeworld (line 62): as a close informant, he indicates that the patient’s brother and father have had the same problem. The clinician embraces this piece of information without hesitation as if it came directly from the patient, concludes that the issue must then run in the family, and proceeds with the physical examination of the patient. As such, the voice of the Lifeworld is successfully integrated into the voice of medicine: relevant information is extracted from the voice of the Lifeworld and used to support the diagnostic process.

Excerpt 4: Bilingual professional – Lifeworld recognized

73	DOC	Tu as mal? ... <2> ... Ok, super	Does it hurt? Ok, super
74	COM1	((speaks in Arabic))	If it hurts somewhere, you need to speak up…
75	COM1	J’ai dit 'si: : tu as mal, il faut dire'	I said ‘If it hurts, you need to speak up’
76	DOC	= =Oui oui ((pauses))	Yes yes
77	COM1	((sighs)) ... <25> ... ((performing physical examination))
78	DOC	Vous pouvez vous asseoir? ... <1> ... Ça fait mal?	Can you sit ? Does it hurt?
79	PAT	= =Non	No

Finally, in the last excerpt, the clinician performs a physical examination of the patient’s stomach (Excerpt 4). This stage of the medical consultation creates a direct physical link between the clinician and the patient, as the clinician touches the patient and looks at his face to identify nonverbal signs of pain. When the physician touches the patient’s stomach, he asks whether it hurts. The subsequent reaction (“Ok, super”) suggested that the patient had shaken his head. COM1 then takes up the role of bilingual professional, encouraging the patient in Arabic to speak up when he is in pain. When the clinician asks the patient to sit up and asks whether he is in pain, the latter replies “No”, showing more engagement than in any of the previous excerpts.

The excerpts illustrate how the PC’s role is coconstructed by the participants in the interaction. The clinician has leverage over role dynamics through the way he prompts his questions; the patient influences the situation by modulating his level (or lack thereof) of proactive engagement. In some situations, this can lead to patients remaining excluded. In the post-consultation interview, the physician indicated that interaction with the patient and two companions was challenging due to frequent simultaneous speech and translation.

In the excerpts above, the voice of the Lifeworld seems to emerge only occasionally and to be managed in a rather indeliberate way. If it turns out to be relevant, it is taken on board in the medical diagnostic process, but not always to the full extent, including because of omissions in interpretation.

The case study illustrates PCs' roles and communication strategies in real-world situations, demonstrating the swift role changes that companions undergo during interactions. The physician's stress levels were observed to rise due to simultaneous conversations from two companions, leading to cognitive overload as the physician attended to the patient while conducting the clinical reasoning process. Efforts by the physician to address the patient directly through translations by family members proved difficult, involving multiple participants speaking different languages, playing different roles and having varying communication levels. The situation showcases interactional complexity and how roles and communication patterns are interconnected within a complex system involving body language and subject-matter discussions.

This study presents and documents the different roles assumed by companions in companion-mediated multilingual medical interactions and the communication patterns that arise. It also explores, through dependency analysis, possible patterns of association between companions' roles and communication patterns. The linguistic ethnographic approach illustrates the contextual and interactional context in which these roles and patterns take shape.

This study aims to contribute to strengthened awareness among clinicians of their communicative behavior during consultations, the impact of small communicative events on the diagnostic process, and how they can leverage PCs’ contributions to make the communication process more effective. Awareness can be built by incorporating ethnographically informed research into clinical training and policy development (Cox & Li, 2020).

The results indicate that during ED consultations, over 40% of Lifeworld occurrences are inadequately addressed, primarily due to physician interruptions to refocus the conversation back on the world of medicine. Even when PCs take on an active stance, such as Linguistic agent, System agent, or Lifeworld agent, Lifeworld interruptions are frequently observed. The Lifeworld is best acknowledged when brought up by a System agent, who may have the comparative advantage that (s)he can link the Lifeworld directly to medical issues and, as such, encourage its integration.

Future research should explore whether this propensity to interrupt the Lifeworld is justified in emergency settings and examine the causes and consequences of these disruptions. As cognitive strain can impede effective communication during ED consultations, adopting patient-centered approaches adapted to ED communicative ecology is essential (Lachance, 2016). It would also be interesting to explore whether the results of the study carry over to other medical contexts, especially those with lower time pressure.

A key element to improve work with PCs is to clarify the companion’s relationship with the patient. In the consultations studied in this paper, only one physician inquired about the relationship between the patient and companion and the reason for their presence. Clinicians often presume that companions are family members to circumvent intrusive questions and maintain privacy. However, this approach may adversely affect care quality, as the companion-patient relationship can influence the companion's role as a valid medical history source. Moreover, the emotional and cognitive impacts on the companion of information disclosed during a medical consultation may differ based on whether they are a family member, neighbor, friend or another person. As suggested by Diamond (2022, pers. comm.), clinician hesitancy to inquire about the companion's relationship with the patient could be alleviated through the use of the phrase ‘who did you bring today?’

To avoid misalignment in expectations, clinicians should be encouraged to engage in role negotiation with companions, especially as the latter may not see themselves as interpreters and lack relevant training, potentially leading to role confusion (Cox et al., 2019; Rosenberg et al., 2008). Ethnographic observations revealed that clinicians were often frustrated when companions answered questions on behalf of the patient rather than relaying questions; however, they did not explicitly ask the companion to relay these questions during consultations. The quality and credibility of information provided by companions should be evaluated during consultations, and clinicians should insist on accurate translation when necessary.

Practical implications include the need for physicians to be better informed about working with companions and receiving specific training in this area. If additional training is not feasible due to healthcare system constraints, clear procedures should be established regarding information gathering and instructions for companions. Finally,; the use of trained interpreters should be encouraged because they reduce confidentiality breaches, support the integration of Lifeworld elements (Leanza et al., 2013) and facilitate communication tasks in general (Rosenberg et al., 2007) in comparison with situations mediated by family interpreters or no interpreters at all.

Ethics approval and consent to participate: For the collection of the data considered in this study, ethics approval was obtained as per the requirements of the hospital ethics board (Comité Local d’Ethique Hospitalier—O.M. 007; Centre Hospitalier Universitaire CHU Saint-Pierre, Rue Haute 322, 1000 Bruxelles; approval number AK/12-10-81/4181). The informed consent procedure was designed in compliance with the World Medical Association Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects.

Consent for publication: Not applicable

Availability of data and materials: Data used for the analysis in the paper consist of transcripts of audio-recorded medical consultations. For reasons related to privacy and confidentiality, ethical restrictions prevent us from making them publicly available.

Competing interests: The authors declare no conflicts of interest.

Funding: Funding for this study was provided by the Brussels Institute for the encouragement of scientific research and innovation (INNOVIRIS), Belgium; Research Foundation-Flanders (FWO), Belgium and Fonds de Recherche de Québec (FRQ), Canada; and Vrije Universiteit Brussel (VUB), Belgium.

Authors' contributions: AC collected and prepared the data for analysis, carried out the qualitative analysis, provided input for the quantative analysis, and led on the drafting of the paper. YL coordinated the quantative analysis, provided input for the qualitative analysis, and contributed to the drafting of the paper. MCL performed the quantitative analysis and contributed to the drafting of the paper. ND contributed to the data collection and the drafting of the paper. All authors reviewed the manuscript.

Acknowledgements: We gratefully acknowledge the patients, companions and staff who participated in the consultations and conversations. We thank Ellen Rosenberg, Audrey Marcoux and Paulina Gonzales Orea for their help with the coding of the audio-recorded conversations and Philippe Humblé, Luc Huyghens and Pierre Mols for making the data collection possible. We gratefully acknowledge the valuable feedback and suggestions provided by the conference participants at the 2022 1er Congrès International de l’ÉDIQ (Université Laval). Finally, we are grateful to Anneleen Vandeplas for proofreading the manuscript.

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See Mishler (1984) for a seminal description on how the Voice of Medicine (the technical side of medicine) and the Voice of the Lifeworld (the more personal context of health issues) interact during a medical encounter. To Habermas (1987), the ‘Lifeworld’ represents the background of ordinary life: the everyday social world in which individuals interact with others and organize their lives, in contrast with the ‘system’, which refers rather to the more institutional sphere that comprises the economy and the state and is characterized by strategic action, as in a medical consultation.
The study makes use of a convenience sample, which was collected over a long period of time from an Emergency Department. While there is no clear argument to assume the sample carries a bias, it is not possible either to fully substantiate the claim that the sample is representative of the hospital's ED visits.
For a number of speech turns, coding was difficult in terms of identifying the interpreter role, but the communication pattern could be established based on the previous and following speech turns.

No competing interests reported.

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On equal footing? The impact of informal interpreters on lifeworld integration and patient-centeredness in emergency consultations

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Abstract

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1. Introduction

2. Methodology

2.1 Research design

2.2 Data collection and transcription

2.3 Coding and quantitative analysis

2.4 Qualitative analysis

3. Quantitative analysis

3.1 Companion roles

3.2 Communication patterns

3.3 Roles and communication pattern interactions

4. Qualitative analysis

5. Conclusion and implications for practice

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References

Footnotes

Additional Declarations

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