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Oral Health Literacy & Clinical Communication

in a Global Era

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 Social Science & Medicine 132 (2015) 197e207

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Interpreter-mediated dentistry
Susan Bridges*, Paul Drew, Olga Zayts, Colman McGrath, Cynthia K.Y. Yiu, H.M. Wong,
T.K.F. Au
Centre for the Enhancement of Teaching and Learning, Faculty of Education, The University of Hong Kong, CPD 1.79, Centennial Campus, Pokfulam, Hong
Kong Special Administrative Region

a r t i c l e i n f o a b s t r a c t

Article history: The global movements of healthcare professionals and patient populations have increased the com-
Available online 11 March 2015 plexities of medical interactions at the point of service. This study examines interpreter mediated talk in
cross-cultural general dentistry in Hong Kong where assisting para-professionals, in this case bilingual or
Keywords: multilingual Dental Surgery Assistants (DSAs), perform the dual capabilities of clinical assistant and
Medical interpreting interpreter. An initial language use survey was conducted with Polyclinic DSAs (n ¼ 41) using a logbook
Mediated interpreting
approach to provide self-report data on language use in clinics. Frequencies of mean scores using a 10-
Conversation Analysis
point visual analogue scale (VAS) indicated that the majority of DSAs spoke mainly Cantonese in clinics
Dentistry
Oral health
and interpreted for postgraduates and professors. Conversation Analysis (CA) examined recipient design
Health communication across a corpus (n ¼ 23) of video-recorded review consultations between non-Cantonese speaking
Multilingualism expatriate dentists and their Cantonese L1 patients. Three patterns of mediated interpreting indicated
Globalisation were: dentist designated expansions; dentist initiated interpretations; and assistant initiated in-
terpretations to both the dentist and patient. The third, rather than being perceived as negative, was
found to be framed either in response to patient difficulties or within the specific task routines of general
dentistry. The findings illustrate trends in dentistry towards personalized care and patient empower-
ment as a reaction to product delivery approaches to patient management. Implications are indicated for
both treatment adherence and the education of dental professionals.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction 2010; Valero Garce !s, 2005). In dentistry, trios are the norm with
dental supporting staff routinely present during clinical consulta-
As diasporic movement patterns change across time and in tions and in multilingual environments, dental support staff may
response to global fortunes and misfortunes, so too do the linguistic also be called upon to act as lay interpreters.
demands placed upon interactants in contact e both those from the More recent communicative philosophies in clinical practice
dominant and those from the minority linguacultures. The roles of have taken a focus on how patient-centred care is enacted within
professional and lay interpreters have gained increasing attention the consultation. In working towards a definition of patient-centred
as a focus of discussion and empirical research, particularly in high care, Stewart (2001) identified the inherent tension in aiming to
stakes contexts such as medical, police and legal settings (Bot, make “the implicit explicit” with the caveat that patient-centered
2005; Hale, 2007; Bolden, 2000) with recent calls for “further ed- care “is a holistic concept in which components interact and
ucation and support for patients, clinicians and interpreters to unite in a unique way in each patient-doctor encounter” and situ-
ensure effective communication across language barriers” ated qualitative research as enabling us to come “closer to
(Fernandez and Schenker, 2010, p.140). While the dyadic encounter conveying the qualities of such care” (pp.444e445). Indeed, the
in doctor-patient consultations was the initial focus of interactional application of Conversation Analysis (CA) helps to uncover the
analysis, other multi-party configurations in medicine, particularly discursive patterns involved in the unfolding activity that consti-
those concerned with triadic encounters, are receiving increasing tutes a medical encounter (Heritage and Maynard, 2006). In the
attention (Angelelli, 2004; Brua, 2008; Clemente, 2009; Hsieh, field of medical interpreting, new work is responding to calls for
studies that “analyze interpreting as a situated, locally organized
activity embedded in a particular setting” (Bolden, 2000, p.415).
* Corresponding author.
Research on medical interpreting has mainly focused on general
E-mail address: [email protected] (S. Bridges).

http://dx.doi.org/10.1016/j.socscimed.2015.03.018
0277-9536/© 2015 Elsevier Ltd. All rights reserved.
198 S. Bridges et al. / Social Science & Medicine 132 (2015) 197e207

medical consultations (Meeuwesen et al., 2010; Pasquandrea, 2011) tensions between ‘direct’ interpretation and something more so-
with very limited attention to date in dental consultations (Bridges cially engaged and ‘mediated’ (Bolden, 2000) whereby the inter-
et al., 2011). Methodologically, medical interpreting has been preter is called upon to do both normative interpretation and
examined through post hoc methods such as surveys or interviews coordinate communication.
to gain participant views on the perceived success or otherwise of Angelelli's (2004) concept of interpreter visibility in the context
interpreting in healthcare settings (Hsieh and Kramer, 2012). of community interpreting is also useful in considering the in-
Discourse-based approaches (Po € chhacker and Shlesinger, 2005) terpreter's role. Healthcare settings, she argued, are highly ‘visible’
have been employed as both corpus-based approaches for linguistic in that interpreters are more likely to become co-constructors. In
analysis to determine interpreter accuracy (Karliner et al., 2007) this role, they are less likely to maintain professional detachment as
and for conversation analysis to explore the unfolding patterns of they work to negotiate communicative events that are filled with
interactional activity (Bolden, 2000). Some CA research in dental cultural gaps, linguistic barriers and unequal power relations. This
education has examined the interactional co-construction of then raises the inevitable tension between accuracy and advocacy.
empathy (Bridges et al., 2010) and corporeal dynamics (Hindmarsh Research studies in medical interpretation that take a direct
et al., 2011). However, as a context for investigation, while prior interpretation stance tend to focus on word-to-word translation
research has considered nurses performing the dual roles of med- accuracy and criticize both professional and lay interpreters if they
ical support staff and medical interpreters, no micro-analytic deviate from the medical provider's script by engaging in, for
discourse-based investigations into medical interpreting as a example, extended, uninterpreted side conversations with patients
locally organized activity have as yet been undertaken in the field of (Meeuwesen et al., 2010).
dentistry. Early corpus-based studies in medical interpreting found the role
In what follows, we explore clinical communication in dentistry of the interpreter as problematic with issues surrounding linguistic
as the point of contact between healthcare professionals as ‘global proficiency (Karliner et al., 2007) and conflicting professional roles
academics’ (Bridges and Bartlett, 2008) following their professional (see Bolden, 2000). These USA studies found that unskilled bi-
academic careers in overseas universities and their local commu- linguals as medical interpreters in hospitals and private clinics may
nities. As previous studies have examined medical interpreting impede doctor-patient communication by ignoring, mistranslating,
mainly in the context of interactions with immigrant communities or providing their own responses to questions (Flores et al., 2003).
in English-dominant countries (Crosby, 2013), this study examines They also argued that if a nurse adopted a bilingual helper mode in a
the opposite situation e when it is the medical provider, a dentist, caregiver role, then there would be a decrease in direct doctor-
who is working in a non-English dominant speech community, in patient interaction and patient initiated turns but that if a nurse
this case, Cantonese. In particular, we focus on dental academics adopted a professional interpreter mode, there would be a similar
working in a clinical teaching hospital in one Asian context in order distribution of turns to a monolingual mode.
to understand how medical interpreting is routinely enacted and Interview-based studies of medical interpreting also conducted
interactionally accomplished in cross-cultural professional practice. in the USA have challenged the ostensibly neutral role of the
For our interest in mediated interpreting in dentistry (Bridges et al., interpreter in multilingual healthcare settings arguing that the
2011), we move to the specific and local examining the general boundary between professional interpreter and advocate is a con-
dental consultation as a locally-enacted, institutionalised, triadic tested one (see, for example, Rowland, 2008). Hsieh's (2010)
interaction in an Asian dental context. ethnography of bilingual healthcare encounters exploring the
This paper adopts a multivariate approach first to identify the issue of control in triads involving interpreter-mediated commu-
larger phenomenon of interpreter mediated consultations in a nication indicated the complexity of multiparty interactions and
clinical dental setting in Hong Kong and second to adopt CA to the need for nuanced understandings as to their formulations. She
identify the specific qualities of patient-centred care in this viewed “successful bilingual medical encounters as coordinated
multilingual context. The key aim of this study, therefore, is to achievement between the interpreters, providers, and patients”.
identify the sequential patterns of activity enacted during inter- However, these studies also acknowledge issues related to this
preter mediated talk in clinical consultations in dentistry. In doing blurring of boundaries and the tensions between the provider's
so, we shall address those aspects of mediation that compromise or medical expertise and the interpreter's cultural expertise. Jacobs
facilitate patient understanding of oral health messages. et al. (2010) argued against the use of ad hoc interpreters such as
family and friends and advocated education of clinicians in the use
2. Background of trained medical interpreters. Valero Garce !s' (2005) institutional
discourse analysis conducted in Spain and the USA contrasted three
2.1. Medical interpreting types of exchange: doctor/foreign-language patient; doctor/
foreign-language patient/ad hoc interpreter (husband); doctor/
In establishing traditions of how we communicate across lan- foreign-language patient/trained interpreter and made similar
guages and cultures, definitions of translation and interpretation recommendations viz the preferred use of trained hospital in-
vary. Hale (2007) defined ‘translation’ as focusing on written text terpreters and education for clinicians in working effectively with
and ‘interpretation’ as based on spoken discourse with community interpreters.
interpreters contrasted with conference interpreters due to contex-
tual differences in purpose, physical proximity and the focus on 2.2. Professional interpreting
team approaches in community interpreting (p.25). In exploring
spoken discourse and the work of the medical interpreter, prior Some advocate the use of professional interpreters (Bauer and
research has identified a binary between ‘direct’ interpretation Alegria, 2010) in preference to bilingual nurses (Jacobs, 2000) but
which takes an accuracy focus in measuring how close the inter- indicate a lack of a standardized definition or training (Bischoff and
preter matches the original words and ‘dialogue’ interpreting Hudelson, 2010). A clear disadvantage of professional interpreters
(Wadensjo € , 1998; Hale, 2007) which expands the interaction to is their additional cost (Bischoff and Hudelson, 2010; Ramirez et al.,
include interpreter agency in supporting meaning making e both 2008). A recent study examining efficacy in medical settings found
linguistically and culturally (see also Angelelli, 2012). Community that professional interpreters were not significantly different from
interpreting has been found to lead to a blurring of the lines with family interpreters, with the latter able to provide support for
 S. Bridges et al. / Social Science & Medicine 132 (2015) 197e207 199

emotional stress and follow-up (Rosenberg et al., 2011). Leanza Checklist (DCCC) (Theaker et al., 2000) which identified key phases
et al's. (2010) study of family practice consultations using Haber- (introduction, case history, examination and closing) and also
mas' Communicative Action Theory (CAT) found distinct differ- promoted a patient focus with checklist items related to patient
ences and identified specific risks when family interpreters impose comfort. An Australian survey on informal interpretation in
their own agenda (vs. the patient's one) and control the consulta- dentistry found informal interpreters of Italian, Chinese and Viet-
tion process. namese were the most satisfactory means of communication,
A more recent review concluded that bilingual nurses when despite the issues raised regarding dentists' “language-related
supported with a professional interpreter made fewer errors than communication barriers” (Goldsmith et al., 2005). Discourse-based
other interpreters in emergency departments (Flores et al., 2012). work in clinical dentistry, particularly research taking a sociological
In considering the quality of family interpretations in general perspective (Exley, 2009), is limited with some early sociolinguistic
medicine, Meeuwesen et al. (2010) raised concerns with regard to work (Candlin et al., 1983) setting the foundations for later eth-
miscommunication from changes in translation to side-talk activ- nomethodological studies (Anderson, 1989; Hindmarsh et al., 2011)
ities. Penn and Watermeyer's (2012) CA study, however, found and mixed-method research (Bridges et al., 2011). The latter, pilot
productive effects from such interpreter side-talk. Professional work for this study found DSAs to be key interactants negotiating
medical interpreters have been found to be highly successful in meaning in clinical dental education across integrated Polyclinics.
remote contexts using telephone-based interpreting (Price et al., As members of the oral healthcare team, Dental Surgery Assistants
2012); however, viewing interpreters as ‘smart technology’ in (DSAs) in Hong Kong were found to be an essential resource in their
face to face consultations was seen as open to possible interper- role of intercultural mediators between non-Cantonese speaking
sonal and ethical dilemmas (Hsieh and Kramer, 2012). Flores et al. clinicians and students and their Cantonese-speaking patients. The
(2012) indicated the critical training period for success with study noted that their work often required them to perform the
omission, addition, substitution, editorialization and false fluency dual functions of supporting both the ‘hands on’ and the
reduced significantly for non-trained interpreters after 100 h of ‘communicative’ aspects of clinical work when para-professional
training. Another recent study (Pasquandrea, 2011) of the physi- staff act as medical interpreters in clinical settings. The CA study
cality of medical interpretation in general consultations analysed a presented below further examines the formulation of mediated
corpus of interactions involving Italian doctors, Chinese patients, interpreting in dentistry in Hong Kong.
and an interpreter noting that:
3. Methodology
“Multimodal resources, such as gaze, gesture, body posture,
object manipulation, and spatial arrangement, allow the doctors
This team's larger health literacy research agenda (see, for
to modulate their participation, achieve mutual alignment with
example, Bridges et al., 2013) is exploring what constitutes multi-
the interpreter, display constant attention to the multiple lines
lingual clinical communication in Hong Kong. In the study reported
of actions taking place simultaneously, and show their orien-
here, a multivariate approach to data collection and analysis was
tation towards their interactional value” (p. 476)
adopted (Heritage and Maynard, 2006; Bridges et al., 2011) to
address the specific research question, How are multi-party for-
mulations involving health care workers as spoken interpreters
2.3. Bilingual nurses enacted in dentistry in Hong Kong?

Another study of telephone counselling (Kim et al., 2011) found 3.1. Data collection
that the use of bilingual nurses in phone-monitoring and coun-
seling contributes significantly to hypertensive control among first Ethical approval was obtained from the Institutional Review
generation Korean immigrants to the US. In face-to-face nursing Board of the University of Hong Kong/Hospital Authority Hong
encounters, the notion of ‘dialogue’ interpreting arose from one of Kong West Cluster. First, a language use survey was conducted with
the CA studies of RussianeSwedish interactions (Wadensjo € , 1998). Polyclinic Dental Surgery Assistants (DSAs) (n ¼ 41) using a logbook
Another CA study (Bolden, 2000) of Russian nurse interpreters approach to provide self-report questionnaire data on language use
critiqued the more proscriptive model of direct interpretation as in clinics (see also Bridges et al., 2011). Frequencies of mean scores
??? the translating machine model finding that, when in the role of were reported using a 10-point visual analogue scale (VAS). The
interpreter, the nurses are “full-fledged social actors” taking on visual analogue scale (VAS) is a psychometric response scale for
social agency and weaving between ‘direct’ and ‘mediated’ inter- measuring participants' subjective response. Participants specify
pretation in order to support the institutional agenda. Bolden their level of agreement by indicating a position along a continuous
(2000) coined the term ‘mediated’ interpretation as a manifesta- 10 cm line between two end-points; the 'continuous' aspect of the
tion of “the interpreter's systematic orientation to the particular scale differentiates it from discrete scales such as the Likert scale.
activity” (p. 394). Second, full consultations (n ¼ 23) between consenting dentists
In sum, the reviewed studies on medical interpreting have (non-Cantonese speakers) (n ¼ 4), DSAs (trilingual) (n ¼ 5) and
established a dichotomy between perspectives that illustrate a their patients (Cantonese L1) (n ¼ 19) were video recorded. Criteria
deficit model of imperfect direct interpretation and mis- for selection of cases was based upon whether these clinical in-
communications and more dialogic models of co-constructed teractions would be interpreter-mediated. Video recordings were
meaning which view interpreters as “cultural brokers, mediators transcribed using Transana™ software. Transcriptions and trans-
and advocates” (Meyer et al., 2003, p. 78). lations were verified by team members and analysed according to
the perspective and methods of conversation analysis (CA).
2.4. Dental communication and interpreting
3.2. Conversation analysis (CA)
Significant to understandings of the enactment and sequential
unfolding of a dental consultation is the standardised norm as CA is a largely qualitative methodology (but on quantification
assessed in clinical communication studies in dentistry using in- see e.g. Heritage et al., 2010) for investigating the patterns of
struments such as the Dental Consultation Communication interaction that serve as a window onto the practices underlying
200 S. Bridges et al. / Social Science & Medicine 132 (2015) 197e207

how something is said, the matter of how it was designed for the
addressee or particular recipient of that turn-at-talk, i.e. recipient
design (Drew, 2013; Schegloff, 1979; Markaki and Mondada, 2012).
Accordingly, those interactions selected for inclusion in the study
were reviewed to identify all cases in which: i) something that the
dentist said was interpreted by the DSA to the patient; ii) some-
thing that the patient said was interpreted by the DSA to the
dentist; and iii) the DSA initiated talk either to the patient or
Fig. 1. Language background of dental support staff. dentist, without having been ‘prompted’ by one or the other. These
cases were then examined closely in order to determine the pattern
of mediated interpretation involved, and particularly to identify
what immediately preceded the mediated turn e including what
the construction and understanding of action (Drew, 2005). Such was said, by whom and how (including accompanying bodily
actions include enquiring about a patient's dental problem (verbal conduct, gaze, dentist's manipulation of the patient's mouth etc.).
and physical examination), describing the procedure that is taking
place, or explaining to the patient how best to take care of her teeth. 4. Results and discussion
We explore the techniques used in conducting such actions (the
design of the turns-at-talk in which such actions are managed); the 4.1. Questionnaire data
relationships between the talk between participants and their non-
vocal conduct, gaze and bodily configurations; the contingent na- The sociolinguistic survey of DSAs (n ¼ 41) in Hong Kong was
ture of the response by one participant to another's talk (and/or based on frequencies of mean scores from a 10 cm visual analogue
non-vocal conduct); and the emergent outcomes of interactions scale (VAS). Results indicated in Fig. 1 show that the majority had
between participants. Interaction is thereby understood to be a Cantonese as a first language and spoke mainly Cantonese in their
collaborative enterprise in which each participant's turn displays primary schooling with more DSAs having moved into English-
an understanding of the other's prior turn; and by responding to speaking secondary education.
that prior turn, simultaneously forms the context for some ‘next’ The majority of DSAs reported spoken interactions during the
action in a sequence (Heritage, 1984, p. 242). Hence speakers three reporting days to be in Cantonese and spoken with fellow
perform actions through their turns-at-talk, actions that are con- DSAs and patients. English was the next most frequently spoken
nected through sequences in which what one speaker says/does is language in clinics, and this was recorded as being predominantly
generated by and dependent upon what the other has said or done. with postgraduate and undergraduate students, patients and cli-
CA is particularly well suited to capturing the contingent and nicians (see Fig. 2). While the focus of this paper is on English-
collaborative nature of face-to-face interaction, including medical Cantonese medical interpretations, it is notable that the demand
interactions (Drew et al., 2001); for this reason CA is now widely for spoken Putonghua is highest with patients (Fig. 2), reflecting
employed in investigating medical interactions, including identi- wider socio-political changes in Hong Kong since the ‘one country
fying the practices that may be used during the physical exami- two-systems’ policy upon the return to Chinese governance in 1997.
nation for avoiding unnecessary antibiotic prescription (Heritage These survey data, while from a modest sample (n ¼ 41) and
and Stivers, 1999; Heritage et al., 2010); for reducing the patients limited to 3 days of data collection, nonetheless provide some in-
unmet concerns or unvoiced agenda (Heritage et al., 2007); iden- dications as to: language backgrounds of DSAs; their clinical in-
tifying practitioner styles that may facilitate or inhibit patient teractants; and the linguistic resources drawn upon in the larger
participation in treatment decision making (Collins et al., 2005); clinical setting of a multilingual dental teaching hospital. In what
and even in the differential diagnosis of epilepsy and PNES among follows, we explore in greater depth how multilingual clinical in-
seizure patients in neurology clinics (Schwabe et al., 2007; Reuber teractions are enacted in the context of medical interpreting. Spe-
et al., 2009). cifically we examine the sequential patterns of activity enacted
The key to CA's methodology is not only what is said, but how during interpreter mediated talk in clinical consultations in
that is said and, especially, how that came to be said - what pre- dentistry and the specific qualities of patient-centred care in this
ceding talk or conduct generated a given turn at talk. We include in multilingual context. Interactional analysis will also support

ref.

Fig. 2. Language survey: Spoken languages in clinics with Different Interactants.

 S. Bridges et al. / Social Science & Medicine 132 (2015) 197e207 201

identification of those aspects of mediation that compromise or (continued )

facilitate patient understanding of oral health messages. 00:18:11 248 DSA >唔聽得明啊<?(0.7)嗰個牙::Y一定<用返個軟毛>(.)>整
係嗰隻牙啫<[吓::[(.)其他用返正常牙擦::[(.)得唔得?(.)
咁而嗰個::(.)ehh::Y另外擦完哂牙之後啦(.)再用埋個牙縫
4.2. Interactional data 擦:[(.)應該紅色都o:kay嘅啦Y((short pause))好唔好
啊?(.)>嗰兩支俾<(.)俾埋你(.)又買返兩支俾我:he he
Direct interpreting was identified in the form of summaries ((laughing; patient nod))((short pause))好唔好?
which are exemplified in 4.2.1. However, in terms of mediated hmmY((laugh))
>you understand that<?(0.7) this tooth::Ymust< be
interpreting, three distinct patterns emerged across the data set of
brushed by a soft bristle toothbrush> (.) > just this
review cases (return visits for ongoing care). Criteria for inclusion one<[huh::[(.)usual toothbrush::[ for other teeth.
were that: (1) the dentist was an expatriate clinical staff member Okay? Then as for the:: (.)ehh::Yin addition after
for whom English is the lingua franca of clinical conversations, and toothbrushing, use this interdental toothbrush:[. The
(2) for whom DSAs must regularly provide spoken interpretations red one should be o:kayY. Alright? (.)>these two<(.) are
for you(.)You can buy me two new ones:
during assisting with operative procedures.
hehe((laughing; patient nods))(.) Alright?
hmmY((laugh))
4.2.1. Direct interpreting
Direct interpretations frequently occur as a summary provided 4.2.2. Mediated interpreting
after chunks of interpretable utterances have been provided by the In examining other, non-summary interpretations which fol-
dentist. The following excerpts (Case 61 and Case 60) illustrate this lowed a mediated pattern of talk (Bolden, 2000), the entry point for
summary formulation. CA analysis was to examine recipient design (Drew, 2013) in order to
Summary interpretation: Case 61 “We will have to wait” understand how interpretations came into being during the complex,
unfolding activity of the dental consultation. Three distinct patterns
of interpreter-mediated talk were identified across the corpus.
00:04:55 139 D ((short pause; inhale)) NowY(.)((inhale)) Very goodY(.)
so::[(.) as soon as he ((she))has the:se:: two::[
extracted:[ 1. Pattern 1 e is seen as expansions where the dentist has desig-
00:05:00 140 DSA ((short pause)) yeah::(.) yeahY((leaning forward to have a nated that something is to be interpreted. In such cases, much
good look)) relies on the DSA's ability to infer the correct transition rele-
00:05:01 141 D ((short pause)) yes::(.) thenY we can discuss about the
vance place for interpretation. The assistant is recognised as
implant but >probably will have to wait for about four::[
[weeks:[(.) after the]<¼
having autonomous skills and experience, and her role as a co-
142 DSA [emmY]¼ constructor in the routine activity of the dental consultation and
00:05:06 143 D ¼extraction::[¼ delivery of patient care is understood implicitly.
00:05:06 144 DSA ¼yeah¼ 2. Pattern 2 e is dentist initiated, whereby the dentist explicitly
00:05:07 145 D ¼then we'll make an x-ray (.) and then I can tell here::(.)
directs the DSA to interpret. This may be done verbally through
more of less::(.) how::Y(.) the plan can be::[¼
explicit lexical choices or non-verbally through the use of gaze.
00:06:15 181 DSA ((short pause; to patient))咁樣呢::[(.)嗰度呢::[(.)醫生 3. Pattern 3 e is DSA initiated; the assistant acts autonomously and
話:Y(.)<種牙都應該冇乜問題嘅::Y(.)有機會>(0.4)不過
呢:[你一定要剝牙((doctor working on computer))(.)通常
initiates unprompted expansions or actions. This, again, is seen
四個禮拜後我哋再影X光片:[(.)睇睇佢>嗰個<::<牙骨嗰度 in the data as a response to her professional status as DSA. She
有:[>幾多啊[?¼ may respond to evident patient difficulties, initiate routine,
(.) (to patient)) So here::[(.)these here::[(.)according to task-oriented talk suited to her own repertoire of skills and
the doctor:Y(.)<the implant should be fine::Y. There's
institutional roles. While the majority of such talk may be in
such a possibility>(0.4)but:[you have to have teeth
extraction((doctor working on computer))(.) Four weeks response to perceived patient needs, she may also address such
after the extraction we will look at your x-ray spontaneous turn-taking to the dentist.
results:[(.)((and)) see how much[ <teeth bone>
remnants:[ >there is<::¼
4.2.2.1. Pattern 1. The nuanced orchestration of co-constructed
patient care is evident across the corpus. Particular to pattern 1
are instances where the DSA aligns with the dentist's talk to illus-
Summary interpretation: Case 60 “No need for Chlorexidine” trate or elaborate the content of the dentist's turn (see Case 60
below). Additionally, such elaborations may be made at a transition
in the dentist's activity in performing a procedure (see Case 20
00:17:53 236 D ((short pause)) o:kayY(.) so::Y no need for the
below) or they may be in response to silence during a routine ac-
Chlorexidine(.) anymore::[ ((patient sitting up))¼
00:17:56 237 DSA ¼hmmY¼ tivity (see Case 56 below). These may be in anticipation of pre-
00:17:56 238 D ¼he can continue using the soft " tooth:" brush (.) only in paring a patient's physical comfort or in anticipating patient
this pa::rt:[ ((pointing to his own left cheek))¼ anxiety and initiating talk to reassure or express empathy (Bridges
00:18:00 239 DSA ¼[hmmY]¼ et al., 2011). They may also be instantiations of displays of profes-
240 D [and]¼
sional expertise, specifically in areas of oral hygiene instruction (see
00:18:00 241 D ¼>the rest of the mouth with a normal
toothbrush::[<¼ Case 20 below).
00:18:02 242 DSA ¼hmmY¼ Case 20 “It's firmly glued”
00:18:02 243 D ¼and< the red::[(.) ehh::(.) interdental spare uhh::
brush:::Y(0.3) every timeY al::so:Y>
00:21:48 236 D: Great open again[
00:18:06 244 DSA ((short pause)) >emmY(.) emmY (.) [emmY]<
00:21:49 237 ((working in silence))
245 D [uh-]
00:22:01 238 D: Great! Close together[
00:18:07 246 D ¼-der the tooth and beside the tooth(.)> inter:dental<
((doctor keeps a distance from the patient, giving
dental [space::Y]((DSA taking the napkin off from the
room for DSA to bring in hand mirror for patient))
patient))
00:22:05 239 DSA: 嗱¼
247 DSA [>係啦聽<]
here¼
[>okay can<]
(continued on next page)
202 S. Bridges et al. / Social Science & Medicine 132 (2015) 197e207

(continued ) (continued )

00:22:05 240 D: ¼Great!¼ 00:02:58 89 DSA ((to patient)) 你知道嗰隻牙 (.) 拎走咗出嚟呀啦¼
00:22:06 241 DSA: ¼俾個鏡你[((to the patient)) ((to patient)) You do know the tooth has been
¼a mirror for you[((to the patient)) extracted already huh¼
00:22:06 242 D: I'll just let you sit up[¼ ((moving dental chair)) 00:03:00 90 P ¼我知啊 (.)我知啊¼
00:22:07 243 DSA: ¼黐黐實嘅(0.5) 宜家我哋試咗架啦 ¼I know (.) I know¼
¼ It's firmly glued. (0.5) We tested to confirm that. 00:03:01 91 D ¼but there may be a little bone [or something (.)
00:22:10 244 D: yupY¼ We'll have ] (.) we'll have a look and see¼
00:22:10 245 DSA: 我哋會再商量工作(.)[情況] 92 P [宜家冇嘢啦(.)宜家冇啦]
We will discuss our next (.)[step] [now it's fine (.) it's nothing] ((everything's okay))
00:03:04 93 DSA ¼幫你望一望先¼
¼We will have a look first
00:03:05 94 P ¼唔
Taking turn 238 as a cue to bring a hand mirror to the patient, ¼Emm
the DSA also uses this patient viewing period as an opportunity at 00:03:06 95 DSA 吓(.)眼鏡戴住先
turn 243 to assure the patient of the stability of the prosthesis, It's Right (.) please wear the spectacles first

firmly glued and the professional rigor of the dental process un-
dertaken with We tested to confirm that. At turn 245 the DSA initi-
ates a new topic which is transition relevant as it aligns with the Turns 85e92 “she can be assured that the whole tooth is out”
routine structure of a dental consultation where participants will (turn 85) are directly taken as action requested and the perfor-
move to Treatment Plan and Closure (Theaker et al., 2000). mative is in the form of an interpreted utterance (turn 89). The
Case 56 “We found a little plaque” physical configuration then shifts with the activity and Line 91 “but
Pattern 1 elaborations are done not as exact, voice-box trans- there may be a little bone or something” is physically parenthetical
lations. The examples above illustrate how expansions verge on as an additional thought directed to DSA. This is not delivered as for
having an autonomous role, especially where oral hygiene in- interpretation. It is phrased as a collegial, parenthetical think-aloud
struction is topically relevant, e.g. for improved tooth brushing. during preparatory activity and delivered out of mutual eye gaze
with the DSA moving aside to instrument tray.

00:10:27 517 D I'll just use a perio ((periodontal)) probe on that

(3.2)
4.2.2.2. Pattern 2. Distinct to the notion of recipient design in
00:10:33 518 DSA 我哋呢(.)都撩到一尐牙菌膜啊(.)嗰個位唔知係唔 mediated interpreting in dentistry is the turn-taking behavior of
係因為痛呢::(.)自己都擦唔甩啊(.)唔得甩啊Y the dentist, through which he indicates when an interpreted turn is
We (.) found a little plaque(.)((there))not sure if to occur. In this pattern, the dentist is seen as seeking interpretation
it's due to the pain::(.) You can't brush that off
through direct instruction or through more subtle formulations
ahhY (.) ((during teeth brushing)) can't be
((brushed)) off such as pronominal shifts. These may occur topically in the form of
00:10:39 519 P 係啊(.) [好窄啊Y] a directive such as “tell her…”, through pronominal shifts from
true(.) [it's narrow over thereY] ‘you’ when directly speaking to a patient to ‘she’ when talking
520 DSA [要擦啊Y] about the case at hand.
[gonna brush it as wellY]
00:10:41 521 DSA 係啊(.)要擦架嚇[((short pause))就算唔舒服都要
Case 56 “She's doing a very good job with the others”
輕輕擦下佢架(.)如果唔係嗰尐細菌儲咗喺嗰道嚟
呢::[(.)你就會發炎架啦::[
True(.) gonna brush it too huh[(.) Even though 00:15:50 709 DSA ((to doctor)) She need use the mouth wash::[?
it might be uncomfortable, still have to brush 00:15:52 710 D (.) No I think she'll be okay with just::[ the brushing
that spot lightly(.) if not when the bacteria stays with it coz she's doing a very good job with the
there::[(.)you may have an inflammation::[ others:Y
00:15:57 711 DSA 唔::需要[用住::Y((short pause))]其他牙齒呢(.)都做
得¼
No::need [to use that first::Y((short pause))]as for
In case 56 above, the dentist provides an online commentary the other teeth(.) you've done quite a ¼
(Heritage and Stivers, 1999) of the operative action being under- 712 D [really good job[ on the others:Y]
00:16:00 713 DSA ¼[唔錯嘅啦]
taken. This can also be viewed as a request for an instrument, the
¼[good job]
periodontal probe. The ensuing 3 s of silence during the dentist's 714 D [it's just::]
activity is heard by the DSA in the recipient design (“perio” being 00:16:01 715 D ¼a little unusual along the back::[
designed to be understood by a colleague, not a patient) as tran- 00:16:03 716 DSA HmmY((nod))
sition relevant; the DSA inserts new, but topically relevant talk 00:16:04 717 D ((short pause)) What's happening is the root[
00:16:06 718 5> DSA y:es::[¼
directed at the patient about oral hygiene and the causal pathway of 00:16:07 719 D ¼has come down and she's seeing the littleY(.) she's
gum inflammation. going in to the a:rea: in between the [rootsY(.)so
In such instances across the data set, it was noticeable that, in that's]¼
terms of recipient design, there were occasions where the dentist's 720 DSA [emmY emmY]
00:16:11 721 D ¼what's causing her the pain::[
talk is not designed to be interpreted and is understood as such by
00:16:13 722 DSA ohh:Y(.) [yes::[]¼
the DSA. One such example occurred in Case 26 below. 723 D [as she[]¼
Case 26 “There may be a little bone or something” 00:16:13 724 D ¼jerks in with the ((short pause, DSA nodding))
with the wooden stick[ or whateverY¼
00:16:17 725 DSA ¼yes:Y
00:16:17 726 DSA ((short pause))嗱(.)因為呢[(0.6)其實>" 隻" <隻
00:02:55 85 D ¼but she can be assured the whole tooth is [out]
牙((short pause))其他位置都擦得唔錯啦(.)啊閂埋個
00:02:57 86 P [呀呀]
嘴先[(.)咁呢度呢(.)因為係個牙肉縮咗上去[暴露咗尐
[ya ya]
牙腳出嚟(.)咁你係敏感(.)你用牙簽篤落去呢(.)就係啱
00:02:58 87 P [係呀]
啱嗰個(.)嗰個(.)ehh:Y嗰個牙腳暴露咗出嚟嗰個三角
[yes]
位嗰個窿" 窿" 嗰個嚟(.)咁就唔使擔心唔明
88 D [we] (.) we
 S. Bridges et al. / Social Science & Medicine 132 (2015) 197e207 203

(continued ) (continued )

((misspoken “唔係” into “ 唔明”))(.)<唔係蛀牙> 唔係叫做蛀牙((short pause))咁只不過係:::Y牙肉塞(.)縮低

((short pause))nah(.)as[(0.6) in fact>" every" every 咗((short pause))引致到有尐牙腳暴露咗出嚟(.)啱啱個三角
other teeth ((short pause)) on other spots are 位暴露咗出嚟(.)咁樣囉[
cleaned well(.)ah close your mouth first[(.)here(.)as ((short pause)) now you (.) do know what the professor >
your gum recedes[exposing a bit of your teeth is doing, right ? And you've been anaesthetized so you
root(.) hence the sensitivity(.)when you use a tooth won't feel anything (.) Ah but (.) we know that in fact as
pick to reach here(.) it coincidentally reaches(.) the gums recede hence you describe it as if it's a hole:[(.)
the(.) ehh:Ythe exposed triangle root of the teeth(.) what toothpick (.) feels like a hole (.) In fact that (.) we
so no worries not)(.) <((it's)) not a tooth decay> don't see it as tooth decay (.) It's just::Y gums (.) recede (.)
((misspoken “not” into “ not understand”)) causing the exposure of the teeth roots (.) and
coincidentally the triangle spot is exposed (.) something
like that[
The dentist signals that the talk at turns 709e724 is about the
patient by use of the pronominal, ‘she’. The DSA hears this as talk to
be interpreted and provides a summary with some expansion of In the above case, the same dentist, through emphatic tone of
what the dentist had said at turn 726. In terms of recipient design, voice at turn 826, instructs the DSA to interpret the key message
she has performed the action requested by the dentist and this is omitting the scientific term, ‘furcation’ (turn 824) which is the
held as one of the standard patterns of mediated interpretation natural branching of the tooth roots. The core message is then
across the data set. delivered by the DSA with the scientific term replaced with a lay
Case 60 “Can we close a little bit?” phrase ‘the triangle spot’.
Case 53 “All arrived”
00:02:40 77 D (.)Can we close:: a little bit[?¼
00:02:41 78 DSA ¼合埋小小[
¼close up a bit[ 00:16:44 214 ((Inter-com Voice)) >三<點到埋(.)全部到哂
> three o'clock is here<(.) all of
the patients are here
Turn 77 in case 60 above is formulated as a request using
00:16:45 215 DSA 好 ah ((short pause))
another pronominal formulation, ‘we’. The dentist requests an ac- ((turning her attention back;
tion in the form of closing the patient's mouth but the inclusion of saying to the doctor)) all arrived
all present by ‘we’ is heard by the DSA at turn 78 as an invitation to okay ((short pause)) ((turning
interpret. her attention back; saying to
the doctor)) all arrived
Such dentist-initiated requests for interpreting were often
00:16:48 216 D ((short pause)) what is that[?
manifested in prosodic non-verbal behaviours, specifically in cases 00:16:49 217 DSA "
emm" (.) all arrived
26 and 56 below, through the use of gaze.
Case 26 “That's just the consequence”
In the above case with a UK dentist, the DSA initiates a direct
72 Dr ¼but that's just the consequence of interpretation of the internal message delivered via intercom in
((gazing at the DSA)) having the Cantonese. The dentist does not hear this as an interpretation and
tooth extractedY ((gazing at the DSA)) seeks clarification at turn 216. The DSA hears this as troubling. This
is signaled by the hesitation at turn 217 with a hesitation marker
" emm" followed by a short pause. Her response is a repetition of
00:02:41 73 DSA 因為呢(.) 通常呢(.)剝完牙之後呢都會
有陣時有一段日子¼ her pronouncement all arrived at turn 215.
Cause (.) normally (.) after extracting
a tooth (.) sometimes there're
some days 4.2.2.3. Pattern 3. In this pattern, we see the DSA acting autono-
mously but in a manner appropriate to her role as para-professional
In the excerpt above, the dentist explicitly directs the DSA to caregiver. This autonomy is, however, most often seen as part of the
interpret through non-verbal instruction using gaze following the larger script of the routine activities of the dental consultation. In
emphasized use of consequence (turn 72). Para-linguistic meaning- terms of mediated interpreting, it can also be seen as anticipatory to
making tools employed include the dentist's use of eye gaze, the dentist's review questions.
stressed intonation and nod to DSA. The combination of these Case 60 “Are there any other abnormalities?”
provides powerful illocutionary force and the DSA responds with
an interpretation at turn 73. The patient's eye gaze also responds to
the dentist's directions and she turns to the DSA for interpretation. 00:00:41 17 DSA (.)>今次返嚟覆診嘅啫[<(.)吓::Y(.)冇乜嘢啊嗎?(.)近排:?
Case 56 “These are not holes” ((putting on the napkin for the patient))(.)>個傷口嗰尐
(.)口腔入邊有冇唔舒服嗰尐啊<?¼
(.)> This visit today is just a follow up review[<(.)huh::
00:20:37 822 D <she can al::so feel: where I am working now::[ but that Y(.) Is there any other abnormalities? (.) lately:?
she doesn't feel the pain::> ((putting on the napkin for the patient))(.)>
00:20:41 823 DSA emmY hmm[¼ the wound (.)the oral cavity any discomfortness<?¼
00:20:42 824 D ¼that's the furcation of the root as well[ 00:00:47 18 P ¼冇
00:20:44 825 DSA yeahY ¼no
00:20:45 826 D ((short pause)) so these are not hole::s[(.) these are 00:00:48 19 DSA ((short pause))都冇吓::[(.)冇就好啦::Y(.)哎:::Y((sigh))
natural(0.6) ehh:Y(.)that(.) defectsY where the ((short pause))everything's okay huh::[(.)that's
root[((short pause)) in between the two rootsY(.) That's great::Y(.)ahh:::Y((sigh))
what's happening. 00:00:51 20 ((silence; DSA moves on for tools preparation))
00:20:55 827 DSA ((short pause)) 嗱宜家你(.)知道教授做>緊尐嘢嘅嗎(.)係唔 00:00:59 21 D emmY hmm[
係(.)落咗麻醉藥所以你啊唔會痛嘅喎 ((short pause))啊不過 00:01:00 22 ((silence))
呢(.)我哋知道呢原嗰度因為個牙腳縮低咗啊所以引致呢你形 00:01:01 23 DSA 較低你嘅凳吓::[
容到好似有個窿:[(.)就牙尖(.)掂到有個窿(.)其實嗰尐(.)我哋 let you back down here huh::[
204 S. Bridges et al. / Social Science & Medicine 132 (2015) 197e207

In the above excerpt at the opening phase of the consultation, Again in case 60, the expansions at turn 204::a bit of bacteria
the DSA begins patient history questioning as she prepares the inside and turn 208 [(.)quite some <food remnants> accumulated
patient, chair and tools for the consultation. This sequence is in- hereY] illustrate DSA autonomy. The DSA designs these turns as an
dependent of the dentist and is conducted entirely in Cantonese. elaboration of the direct interpretation at turn 189 there's some
Case 59 “I'm afraid that … I will hurt you” inflammation inside huh::[ The design of turns 204, 208 and 209
moves into oral hygiene instruction educating the patient on the
causal mechanism of the inflammation that the dentist has
00:27:36 409 DSA 嗱你一陣呢::[(.)你入去::(.)個洗手間
identified.
嗰度(.)抹下個嘴((short pause))因為
個嘴呢(.)有尐膠黐喺嗰度(.)我驚太 Case 56 “No need to use mouth wash”
大力[啦]¼
Here hold it::[(.) You can go to::(.)
the washroom(.) to wipe your 00:15:35 699 D ((to DSA)) I'm just going to <clean out the area >
mouth clean((short pause))because [will be] a lot better:Y
there's (.) some impression material 700 DSA [o:kay[]
on it(.) I'm afraid that I will be 00:15:39 701 DSA ((short pause))>嗱幫你洗乾淨嗰度先啦< ¼((to patient))
using too much force that¼ ((short pause))>nah we will clean this up first< ¼((to
410 P [ohhY]¼ patient))
411 DSA ¼整到你好痛Y((short pause)) 00:15:40 702 DSA ¼ so you will:: tea:ch her::[ [use[] the id* brush?
吓:(.)((wiping away the impression 703 D [yup]
material on the patient's face)) 00:15:43 704 D ¼id brush(.) now(.) maybe it will be a good[ [idea::[]¼
嗰尐(.) 嗰尐其實(.)一(.)一搣就得架 705 P [買嗰尐漱]¼
啦(.)但係你要用隻手去慢慢搣囉 [is buying mouth]¼
[((short pause)) [知唔知啊[? 00:15:45 706 P ¼口水好 [唔好][¼
¼I will hurt youY((short pause)) ¼wash [okay][]¼
huh::(.)((wiping away the 707 DSA [ai ya]¼
impression material on the 00:15:46 708 DSA ¼唔好用漱口水住(.)唔係樣樣都用架(.)最緊要清潔乾淨
patient's face))it's(.) it's actually 先[
(.)easy(.) easy to be peeled off(.)but ¼no need to use mouth wash(.) Not everything is a must
you have to use your hand to have (.) What's most important is to brush the teeth
peel them slowly[ ((short pause)) well[ ((to doctor)) She need use the mouth wash::[?
[okay[?] 00:15:50 709 DSA ((to doctor)) she need use the mouth wash::[?
00:15:52 710 D ((short pause)) No, I think she'll be okay with just::[
the brushing with it coz she's doing a very good job with
the others:Y
00:15:57 711 DSA 唔::需要[用住::Y((short pause))]其他牙齒呢(.)都做得¼
In the excerpt from case 59 above, the DSA takes interactional No::need [to use that first::Y((short pause))]as for the
control as part of the routine activity of the consultation e here, other teeth(.) you've done quite a ¼
712 D [really good job[ on the others:Y]
caring for patients in the clean-up phase after clinical treatment. In
00:16:00 713 DSA ¼[唔錯嘅啦]
turns 409e411, the dentist has moved away from the locus of pa- ¼[good job]
tient proximity allowing the DSA both physical and interactional
*interdental brush.
space. In this space, she takes control of the clinical activity of post-
procedural cleaning-up and the interactional turn. At turn 409, she
proffers tissues and rinse and offers advice to the patient about
cleaning up, justifying this with her repeated concern of I will hurt In the excerpt from Case 56, the DSA's autonomy is displayed
you (turns 409, 411). when she draws upon her knowledge and experience of oral hy-
Case 60 “There's a bit of bacteria inside” giene to respond directly to the 50 year old male patient's new line
of inquiry at turns 705e706 Is buying mouthwash okay? with a topic
relevant exclamation of ai ya, a Cantonese utterance denoting sur-
00:16:01 188 D (.) still quite some inflammation on the::Y(.)
prise. She then moves into an extended turn (turn 708) focusing on
insideY
00:16:04 189 DSA (0.4)入邊都仲有發炎吓::[ the preference for good tooth brushing habits over mouthwash. Of
(0.4)there's some inflammation inside huh::[ interest is her next confirmation-seeking from the dentist at turn
00:16:30 204 DSA ((short pause))你話呢(.)呢[邊::Y(.)都有::尐尐菌
709 after her oral hygiene advice.
喺入邊(.)>直情好::污糟(.)即係喺(.)嗱(.)個你見唔 Finally, the DSAs were also found to take initiative with non-
見到啊[?< verbal activity supporting verbal directives.
((short pause))he said(.)well:: Y(.)there's::a bit Case 56 “Close your mouth and rest a bit first”
of bacteria inside(.)> it's not::clean(.) that
means(.) here(.) this can you see that[?<
00:16:34 205 DSA [(.)堆咗尐<食物>出嚟啊Y]
[(.)quite some <food remnants> accumulated
hereY] 884 DSA: 嗱(.)一" 陣" 間唔係打針(.)只係攞尐消
206 D [you can see it (.) yupY] 炎漱口水同 ((using her hand to
00:16:36 207 D [(.) can you see the(.) there's a lot of (.)blocking close the patient's lower jaw)) 你沖
there:Y] 洗>下((using her hand to close the
208 DSA [>(.)見唔見到:[啊[?((short pause))見唔見 patient's mouth))個位(.)閂埋嘴唞下
到:[啊[?<(.)係囉啊(.)<好::多:[>] 先<]((patient follows suit))here (.)
[>(.)can you see that:[ahh[? ((short pause))can "
later" there's no injection (.) but
you see that:[ahh[?<(.)yup(.)< quite:: a lot of: just use anti-inflammatory mouth
[>] wash for ((using her hand to close
00:16:38 209 DSA 食物(.)插((short pause))縮咗落去個窿入邊啊(.)因 the patient's lower jaw)) irrigation>
為你清潔唔到啊¼ that part (.) close your mouth and
food(.)in between((short pause))in this hole (.) rest a bit first<] ((patient follows
because you haven't cleaned them¼ suit))
 S. Bridges et al. / Social Science & Medicine 132 (2015) 197e207 205

In the excerpt from Case 56 above, the DSA takes independent Table 1
action through both spoken and physical directives to guide the Overview of interactional patterns in interpreter-mediated dentistry.

patient in closing her mouth for the dentist. Pattern Agency Characteristics Linguistic &
Case 58 “Don't be scared” non-vocal features

1 Dentist Expansions rely on Activity transitions;

designated/ DSA autonomous Silence as relevant to
00:03:33 73 D goodY (1.0)((breathing in))o:kayY(.) everything is::he(.) DSA initiated skills; DSA gives a recipient design;
healing nice::Yly:[¼ fuller and embodied Stress and intonation
00:03:37 74 DSA ¼okay 吓[(0.2)有小小::[ 漱口水(.)可以合埋小小(.)吞咗唔驚 account as an
吓[¼ interpretation of
¼okay huh[(0.2)((there's))a little:: [mouth wash(.) Can the dentists'
close ((your mouth)) a bit(.) Don't be scared ((to)) swallow it utterance/instructions
huh[¼ 2 Dentist Indicates to DSA Directives; pronominal
00:03:41 75 D ¼it is still early though[ (0.3) so::it will continue healing for initiated which turns or shifts; indexical
quite some timeY(.) ((breathing in))nowY(.) we need to parts of turns are expressions; gaze
continue with the Chlorhexidine(.) ehh::: mouth rinse for to be interpreted;
another three weeks::[¼ 3 DSA initiated Unprompted Cantonese L1
00:03:51 76 DSA ¼(0.3) three weeks(.) so we have to prescribe [for::]Y expansions rely dominance;
on DSA's knowledge proxemics e physicality
of the routine; and gesture
anticipatory, pre-emptive
In case 58 above, the DSA again takes on her autonomous role in
switching codes at turn 74 to introduce a new topic in Cantonese.
She hears turn 73 as the dentist's online commentary rather than a 2004). The results, therefore, counter essentialist arguments pri-
request for interpreting and her linguistic switch engages in not oritising accuracy from a direct interpreting stance and support a
only routine talk but also empathetic talk (Bridges et al., 2010), more complex and nuanced notion. As Angelelli (2012) argues,
Don't be scared. The dentist continues discussion of healing and
“As the demand for culturally competent medical interpreters
treatment planning at turn 75. In terms of mediated interpreting
increases, we see a departure from the conceptualization of the
and recipient design, turn 75 is still heard by the DSA as online
interpreter as language conduit and a move towards one of the
commentary rather than a request for interpreting. This is indicated
interpreter as an essential partner in the interaction” (p.438)
in her language choice of a direct reply in English at turn 76. Turn 74
can, therefore, be seen as autonomous behavior in line with the
normative actions of operative dentistry i.e. rinsing the mouth after The subtle interplay between the interpreter and the profes-
oral investigations or procedures. Turn 74 also sees enactment of sional has been indicated in related studies in other professional
her duty as caregiver in a patient-centered view of dental care. contexts (Penn and Watermeyer, 2012). Nakane's (2011) examina-
Stewart (2001) denoted patient-centred care as occurring where tion of the pragmatics of silence in legal interpreting, for example,
the interaction: (a) explores the patient's main reason for the visit, found that, by controlling questioning to some extent, the power of
concerns, and need for information; (b) seeks an integrated un- the legal interview became shared between both the interpreter
derstanding of the patient's worlddthat is, their whole person, and the police officer. This delicate and nuanced balance between
emotional needs, and life issues; (c) finds common ground on what interpreter and professional is also evident in the analysis above.
the problem is and mutually agrees on management; (d) enhances However, in addition to the existing notions of mediated inter-
prevention and health promotion; and (e) enhances the continuing preting, what became more distinctly evident in the analysis of the
relationship between the patient and the doctor (p. 445). The work interpreted clinical interactions in dentistry above was the signifi-
of Turn 74 can be seen as the fifth condition where the multilingual cance of the clinician's role in contributing to the turn-taking
nurse draws upon her linguistic and cultural resources to support pattern of interpretation. The international clinicians as global ac-
the dentist in providing patient-centred care. ademics (Bridges and Bartlett, 2008) provided key contextual cues
In summary, the three patterns identified held distinct attri- to direct when and how much interpreting was provided. The
butes with regard to agency, characteristics, and, at times, non- dental surgery assistants as co-interlocutors both understood these
vocal features (see Table 1). signals and acted upon them.
Significant to this study were the non-linguistic aspects of
5. Discussion interpretation, particularly the role of gaze and gesture in affecting
the turn-taking structure and indicating what was to be heard by
Sociological research in dentistry and oral health has been the interpreter as interpretable. Mason and Ren's (2012) study of
limited (Exley, 2009). This study has examined, through textured power in face-to-face interpreting events with immigration in-
analysis of talk-in-interaction, the phenomenon of clinical in- terviews noted that these provide the interpreter with “scope for
teractions which draw upon the linguistic resources of clinical departing from strict neutrality, for exercising interactional power”
supporting staff to act as interpreters. The sociolinguistic survey (p.248); however, in this study in dentistry, we saw variation in this
illustrated patterns of interpreting in a Hong Kong dental hospital pattern. Non-linguistically, the clinician retained interactional
context and identified the key interactants for whom Dental Sur- control particularly when using gaze to indicate an interpreted
gery Assistants (DSAs) provide interpreting. The ensuing interac- turn; however, as evident in Pattern 3, the DSA exercised autonomy
tional analysis of video data using Conversation Analysis (CA) in taking extended turns accompanied with routinized care-
supported a turn-by-turn uncovering of the contingent and oriented gestures with the tacit approval of the clinician as part
collaborative nature of interpreting by multilingual nurses for of her role as co-caregiver.
clinical academics in the dental context. While lay interpreting has Whilst acknowledging that this study was based on a conve-
been critiqued from a direct translation perspective, the analysis nience sample given the modest available number of expatriate
presented in this study supports other studies on ‘mediated inter- academic dentists operating in the only dental hospital in Hong
preting’ (Bolden, 2000) which indicate the autonomy of the nurse Kong, the research team sees the uniqueness of the data set and
translator as a healthcare professional and advocate (Angelelli, context as contributing to the value of the study. As noted in the
206 S. Bridges et al. / Social Science & Medicine 132 (2015) 197e207

literature review, the majority of interpreting studies have focused (6), 872e888.
Collins, S., Drew, P., Watt, I., Entwistle, V., 2005. ‘Unilateral’ and ‘bilateral’ practi-
on the patients speaking a non-dominant language (see also
tioner approaches in decision-making about treatment. Soc. Sci. Med. 61,
Roberts et al., 2005); however, this study has examined the issue of 2611e2627.
clinical interpretation in an environment where the clinician does Crosby, S.S., 2013. Primary care management of noneEnglish-speaking refugees
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dx.doi.org/10.1001/jama.2013.8788. http://dx.doi.org/10.1001/jama.2013.8788.
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6. Conclusions of Language and Social Interaciton. Erlbaum, Mahwah NJ, pp. 71e102.
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