medical Translation

1. See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/314404773 Medical translation Chapter · January 2015 CITATIONS 0 READS 12,715 1 author: Wioleta Karwacka University of Gdansk 7PUBLICATIONS   12CITATIONS    SEE PROFILE Some of the authors of this publication are also working on these related projects: Medical TranslationView project Anthropomorphism in translationView project All content following this page was uploaded by Wioleta Karwacka on 09 March 2017. The user has requested enhancement of the downloaded file.

2. Karwacka Wioleta (2015) ”Medical Translation”. In: Ł. Bogucki, S. Goźdź-Roszkowski, P. Stalmaszczyk (eds.) Ways to Translation. Wydawnictwo Uniwersytetu Łódzkiego pp 271-298. Medical translation Wioleta Karwacka University of Gdańsk Abstract: Translation is a crucial factor in disseminating knowledge and new discover- ies in the medical field. It can also be a critical factor in providing healthcare services to foreigners or minorities. The translators of medical texts face a number of challenges, some of which are the subject of research. Theyincludemedicalterminology, lexi- calequivalence of medicaltexts, readability, qualityissues. This chapter offers a general overview of the major issues in medical translation. It briefly presents the history of medical translation and the development of medical language. It also discusses certain characteristic features of medical language: terminology, including eponyms and multi- word terms, acronyms and abbreviations, affixation, word compounding, the doublet phenomenon, polysemy and synonymy. Translating for lay-readers and professional audiences is the next issue presented in this chapter. Considerable attention is devoted to problems in translating medical texts, and other issues, such as qualifications of medical translators, verification and review. Keywords:abbreviations, accuracy, acronyms, eponyms, translation error, medical terminology, medical translation, quality, translation/translator competence, user- friendliness If medical communicators are not to betray the same commitment of the very au- thors they are asked to translate –primum non nocere– we need to acknowledge and correct certain problems(…): differences in scientific terminology, deceptive lexical equivalence, misconceived readership level, out-of-focus translator training, misjudged translation expectations, etc. (Fischbach 1998:1) 271

3. Wioleta Karwacka 1.Introduction Medical translation concerns a number of subject areas, including pharmacolo- gy, medical rescue system, surgery, obstetrics, paediatrics, psychiatry, internal medicine, oncology, cardiology and other fields of specialty, as well as other disciplines, such as law or administration. Translation is a crucial factor in dis- seminating knowledge and new discoveries in the medical field globally. Medi- cal translation does not concern a single genre or a homogenous discourse. The translated texts include popularizations, such as textbooks for medical students, popular science book on medicine, but also research papers, conference proceed- ings, case studies, case histories, discharge summaries, reports and relatively simple texts for patients: information leaflets, consent forms, brochures. A number of texts are translated due to regulatory requirements concern-ing new medical products and medical devices or new applications of pharmaco- logical products. What also generates the demand for the translation of medical texts is the need to conform to the formal requirements applicable to clinical trial registration and conduct or marketing new drugs, which involves translating the registration documents and other necessary materials to the local language. New findings are published in English, which means that a number of research papers are translated. The demand for medical translation is also the result of emigra- tion. What is more, translators prepare medical files for patients who seek medi- cal help outside their own country of residence. The translators of medical texts face a number of challenges, some of which are the subject of research. They include medical terminology, lexical equivalence of medical texts, readability, quality issues. This chapter offers a general overview of the major issues in med- ical translation. 2.Medical language Medical discourse comprises a range of forms of communication. Gotti (2008: 24) uses the term specialized discourse as ”the specialist use of language in contexts which are typical of a specialized community stretching across the academic, the professional, the technical and the occupational area of knowledge and practice”. Three factors are of crucial importance: the user, the domain of use and special application of language. Medical language is used in expert- expert and expert-lay communication, with characteristic features varying from genre to genre, depending on the communicative situation and its participants. 272

4. Medical Translation Genres used in expert-expert communication such as discharge summaries, case studies and case notes, imaging reports and research papers use numerous spe- cialized terms whose semantic value is taken for granted; the only words or phrases which are explained are those coined or redefined by the author of a paper or a presentation (cf. Gotti 2008). Expert-lay communication covers pack- age leaflets, informed consent documents, patient factsheets etc., which use (or should use) less complex terminology, which is illustrated or explained when it occurs for the first time (cf. Gotti 2008). The main characteristics of specialized medical texts include terminology and syntactic features, such as nominalization, heavy pre- and postmodification, long sentences, use of passives and third per- son (Askehave & Zethsen 2000). The sections below present some of the most prominent features of medical English with particular focus on medical termi- nology and related translation problems and challenges. 2.1. Brief history of medical translation and the development of medical language The scientific world is predominantly English-speaking and major scientific journals publish papers in English. The share of scientific papers written in Eng- lish in the total number of papers published is 80% according to Montgomery (2009) and 85% according to Kaplan (2001). But long before English became the lingua franca of science, Latin was the dominant language of medicine as of the 2nd century, while Greek remained the language of instruction for medical students until the 3rd century (Fischbach 1998). In fact, Greek and Latin shaped the conventions of scientific (not only medical) writing for over 2000 years (McMorrow 1998: 14). All the great civilizations kept records of medical findings (McMorrow 1998) and translation has for a long time supported the dissemination of medical knowledge – Greek medical advances were imported to Rome thanks to physi- cian translators, Asclepaides for instance (Fischbach 1998: 2). Physicians trans- lated medical writings to other languages as well, which included Syriac, Arabic, Farsi, and Hebrew (McMorrow 1998: 15). In the 7th century Baghdad had one of the most prominent medical schools, which was also a school of translators. The works of Persian and Arab physicians were translated into Latin at Toledo School of Translators (Fischbach 1998). Jack Segura (1998: 37) observes that “Arab armies brought with them a treasure trove of medical and scientific knowledge from Ancient India, Persia, Egypt, Greece and Syria.” Arabs acted as intermediaries in disseminating medical knowledge, including the Greek medical heritage. Constantinus Africanus (1020-1087) and Two recognized translators: 273

5. Wioleta Karwacka Gerard of Cremona (1140-1187) lived on the Arab-Christian frontier, the former worked at Salerno and the latter – in Toledo (Ackernecht 1982, McMorrow 1998). Despite the significant role in translation, the Arabic influence on the language of medicine is relatively small (McMorrow 1998: 15), and mainly con- cerns botanic names or names of herbs. The 13th century marked the beginning of the second wave of translations of Greek manuscripts, which were now ren- dered directly and more accurately. According to McMorrow (1998: 16) “Latin had a life of about 800 years in academic medicine (1000-1800)”. In the Middle Ages both Latin and Middle English were acceptable in medical communication: Latin in academic instruc- tion and Middle English as the vernacular language. Anglo-Saxon had some basic medical terminology e.g. head, skull, brain, nose, blood, wound, sore etc. The 19th century was when the reign of Latin in teaching and writing medi- cine virtually ended. The effect of that reign, however, is visible to date in the relative similarity, or “quasi-uniformity” (McMorrow 1998: 21) of medical lan-guages in the Western world, especially in the Western languages. The importance of the exact and precise description of anatomy and disease has been emphasized since the development. (McMorrow 1998; Soubrier 2014). What is observed, however, is the heteroge-neous and dynamic character of medical language: very early stage of medicine Changes in medical knowledge and language have overtaken changes in political and social context during the past 200 years. A major change in medical terminolo- gy is well under way, one that will not wipe out the classical heritage, but enfold it with many layers of heterogeneous material (McMorrow 1998: 14). The modern language of medicine employs modern derivatives of Greek and Latin words “with no concern for etymological purity” (McMorrow 1998: 21). The corpus of Greek and Latin terminology is still the base of the contemporary medical language, which also uses new eponyms, acronyms and trade names1. 2.2 Eponyms Eponyms constitute a considerable portion of medical terminology; they include names of anatomical parts, e.g. Fallopian tubes, Adam’s apple, names of diseas- 1 For more information on the history of medical language and medical translation see Martí-Ibáñez (1962), McMorrow (1998), Segura (1998) and Zieliński (2004) 274

6. Medical Translation es Parkinson’s disease, Alzheimer’s disease, signs and symptoms e.g. Babinski sign, fractures e.g. Jefferson Fracture, procedures e.g. Heller myotomy, medical devices e.g. Bard-Parker scalpel (cf. Meals 2007). Eponyms are frequently de- rived from the names of researchers, but may also be derived from the names of celebrity patients, e.g. Lou Gehrig disease, a common name for amyotrophic lateral sclerosis (cf. Walling, 1999), fictitious characters, e.g. Othello’s syn- drome, or geographical places, e.g. Lyme disease. Eponyms may be the source of translation problems - the correspondence between eponymous terms and their equivalents does not necessarily mean that both source and target terms will be eponymous, although it may be the case: Table 1. Examples of English eponymous terms and their eponymous equivalents in Polish English eponym Achilles tendon (Achilles’ tendon) Adam’s apple Down syndrome Creutzfeldt–Jakob disease Polish eponym ścięgno Achillesa jabłko Adama zespół Downa choroba Creutzfeldta-Jakoba What may be a potential challenge for a translator is the correspondence in which only one of the terms (only source or only target) is eponymous, while its coun-terpart is a descriptive term or is formed based on a Greek or Latin root. Table 2. Corresponding pairs of eponymous and non-eponymous terms in Polish and English eponymous term Lyme disease Fallopian tube metoda Vojty odczyn Biernackiego (OB) non-eponymous term borelioza jajowód reflexlocomotion erythrocyte sedimentation rate (ESR) Concepts may be referred to with eponymous terms which also have non- eponymous equivalents, sometimes a concept will be referred to with such doublets in one language, and only eponymous or only non- eponymous terms in other languages. 275

7. Wioleta Karwacka Table 3. Doublets of eponymous and non-eponymous terms and their equivalents English eponym Giardia lamblia2 non-eponymous term Giardia duodenalis Giardia intestinalis Polish eponym Non-eponymous term Giardia lamblia Lamblia jelito- wa Lamblioza ogoniastek jelitowy, wielkouściec jelitowy Giardiosis bulbouretheral glands greater glands Giardioza gruczoły cewkowe gruczoły kowe większe opuszkowo- Cowper’s glands Bartholin glands vestibular przedsion- 2.3. Acronyms and abbreviations One of the characteristic features of medical language is the presence of acro- nyms, initialisms and clipped forms. With English having the status of the lingua franca of medicine, English acronyms enter other languages and are used both by the medical professionals and patients, especially if no native acronym is commonly used in the local language e.g. MCV, TSH, INR, CRP, LDL, HDL etc. As presented in the table below, the correspondence between terms and the type of abbreviation may vary. Table 4. Examples of abbreviated forms used in English and Polish medical language English X-ray CT (computed tomography) ℞ (prescription) CNS (central nervous system) COPD (chronic obstructive pulmonary disease) pRBC (packed red blood cells) Polish Rtg TK (tomografia komputerowa) Rp. (recepta) OUN (ośrodkowy układ nerwowy) POChP (przewlekła obturacyjna choro- ba płuc) KKCz (koncentrat wonych) PD (płyn dziąsłowy) krwinek czer- GCF (gingival cervical fluid) 2 cf. Esch & Petersen (2013) 276

8. Medical Translation 2.4 Word compounding, affixation and the doublet phenomenon Word compounding, affixation and the doublet phenomenon are three features of fundamental medical English (FME) described by Salager-Meyer (1983). Com- pound nominal phrases (heart failure, patient safety, contrast medium) are common in FME (Salager-Meyer 1983: 61). Therefore, preparing a functional medical translation which uses fairly natural language may involve syntactic shifts (phrase change) (cf. Chesterman 1997). The extract below shows such shifts based on two bolded phrases, whose literal translation would result in pro-ducing the following prepositional phrases in the target units, respectively: inju-ries of the orbit, means of the protection of the head. Table 5. Example of syntactic shifts (phrase change) Source Urazy oczodołustanowią trudny pro- blem diagnostyczny i terapeutyczny a ich liczba wciąż rośnie pomimo stoso- wania wielu, różnorodnych sposobów zabezpieczenia głowy. Target Orbital injuries represent a difficult diagnostic and therapeutic problem and their number is still growing de- spite the use of a great variety of head protection means. The affixation process is not only common in the lexis of fundamental medical English (fail – failure, relate – relationship/correlation - unrelated, define – definition – undefined, improve – improvement) (Salager –Mayer 1983:61) – it is also observed in specialized terminology. What is especially characteristic of specialized terminology is the use of Latin and Greek affixes (e.g. prefixes: all(o) –another, different, adip(o) – fatty, carni(o) – of the cranium, onco- relat- ing to cancer, hyper – excessive, hypo – insufficient, suffixes: - itis – inflamma- tion, - algia – pain, -lepsy – attack, seizure, -logy – the knowledge of something), and the obvious correspondences between suffixes, roots etc. and the meaning of the term. Polish medical terminology is also heavily based on Latin and Greek affixes, besides borrowings and descriptive terms. 277

9. Wioleta Karwacka Table 6. Examples of suffixes and prefixes in medical terminology3 Affix Meaningof affix insufficient Examples of use (EN) hypothermia Concept Polish equiva- lent hipotermia Prefix: hypo- too low body temperature too low blood glucose too low serum calcium inflammation in the lining of the bronchi inflammation of the skin inflammation in the lining of the stomach inflammation of the liver hypoglyc(a)emia hipoglikemia hypocalc(a)emia hipokalcemia Suffix: - itis inflammation bronchitis zapalenie oskrzeli dermatitis zapalenie skóry gastritis zapalenie błony śluzowej żołądka zapalenie wątroby hepatitis The differences in affixation between terms in various languages lead to the differences in semantic distribution observed in pairs of corresponding terms, with a multi-word term in one language: Table 7. Multi-word terms Polish term zakrzepowe zapalenie żył zapalenie midałków tyreotropina, TSH English term thrombophebitis tonsilitis thyroid-stimulating hormone (TSH), thyrotopin rhabdomyosarcoma (RMS) mięsak prążkowanokomórkowy Recognizing multi-word terms as single translation units is therefore one of the crucial skills of medical translators. The third feature of FME described by Salager Mayer (1983) is the doublet phenomenon - terms (usually of Greek and Latin origin) which have their coun- terparts (usually of Anglo-Saxon origin) in the general language: search – inves- 3 See e.g. Soltesz Steiner (2003) for more exhaustive information on Greek and Latin affixes in medical English 278

10. Medical Translation tigate, shot – injection, heart attack – myocardial infarction. The doublet phe- nomenon is well observed in adjective vs. noun roots. That feature is of great importance in writing or translating information materials for lay readers, which is discussed in section 2 of this chapter. Table 8. The doublet phenomenon observed in adjective vs. noun roots (Polackova 2006: 131, cf. Salager-Meyer 1983) Nouns bone eye liver fat neck backbone kidney stomach forehead navel mouth windpipe ear breast lungs teeth heart brain Adjectives in use osseous tissue (Lat.) optic nerve (Lat.) hepatic carcinoma (Greek) adipose tissue (Lat.) cervical vertebrae (Lat.) spinal canal (Lat.) renal artery (Lat.) gastric juices (Greek) frontal bone (Lat.) umbilical cord (Lat.) oral cavity (Lat.) tracheal intubations (Lat.) auditory canal (Lat.) mammary duct (Lat.) pulmonary embolism (Lat.) dental caries (Lat.) cardiac muscle (Greek) cerebral cortex (Lat.) 2.5 Polysemy and synonymy The most desired feature in the terminology of any discipline is bi-univocity, which means that one designation refers to one concept and that one concept receives only one designation – thus, with this kind of control over terminology, it would necessarily have two features: monosemy and mononymy (cf. Soubrier 2002, 2014). Desired as they may be, these features are not always present in medical terminology, whose terms are, to a certain extent, polysemous, and – sometimes – synonymous. The examples of polysemous terms include: inflammation: a physiological function, a clinical condtion, a diagnosis (Soubrier 2014), all of which are expressed with Polish zapalenie 279

11. Wioleta Karwacka  arm: a structure, a region (PL: ramię) or a study group in a clinical trial (PL: grupa badana),  discharge: secretion (PL: wyciek) or release from hospital (PL: wypis)  opuszka: fingertip (finger pulp) or (aortic) bulb  badanie: a test, a trial or an examination Several of synonymous terms are presented above in the section on eponyms, but they do not by any means complete the list of synonymous medical terms, which also includes e.g. Hashimoto’s thyroiditis or chronic lymphocytic thyroid- itis, osteoarthritis also referred to as or degenerative joint disease or osteoarthro- sis or degenerative arthritis. This section is only a brief overview of certain features of medical lan- guage, which is the focus of more detailed research papers published in Advanc- es in Medical Discourse Analysis edited by Gotti and Salager-Meyer (2006) or Vol. 4 No. 7 of JAHR (2013) devoted to medical language. 3.Translation of medical texts for lay readers Expert-lay communication constitutes a large portion of medical discourse, en-compassing documents prepared for patients by medical professionals, quite often in order to comply with regulatory requirements. A frequently translated doc-ument, which is the focus of a number of research papers (cf. Sand, Eik-Nes and Lodge 2013) is the informed consent form (ICF) / informed consent docu-ment (ICD)– a document explaining the nature of the procedures a patient or a clinical trial participant is to undergo. In Poland, for instance, approximately 450–480 clinical trials are started, with the total number of participants reaching 30 thousand patients (Sikora 2010). Under the Declaration of Helsinki every patient or every study participant has to be informed on the treatment-related risks. An ICD provides a patient with the necessary information – by signing it a patient declares that he or she understands the nature of the procedure or the study. Consequently, a patient needs to be provided with an ICD in his or her first language. The text needs to be clear and easily understood. Readability and user-friendliness are of key importance in the case of informed consent forms as ambiguity undermines the “informed consent” concept and breaches the provi-sions of the Declaration of Helsinki. The ICDs, however, are often written in a language which is too complex for lay readers (Pilegaard 2014). Pilegaard (Ibid.) notices the absence of research into the linguistic manifestation of ethics in ICDs and emphasizes the need for a deeper understanding of lay-friendliness and 280

12. Medical Translation readability which would employ applied linguistics approaches and the paradigm of patient-centredness. Apart from the Declaration of Helsinki, there are a number of national and international laws which regulate access to medical information in patient’s na- tive language; they include regulations concerning the package leaflet (PPI) Directive 2004/27/EC provides that the package leaflet must be written and designed to be clear and understandable, enabling the users to act appropriately, when necessary with the help of health pro- fessionals. The package leaflet must be clearly legible in the official language or languages of the Member State in which the medicinal product is placed on the market. What is more, “the package leaflet shall be drawn up in accordance with the summary of the product characteristics”. Under Directive 2001/83/EC the lan- guage of PPIs should be easily understood: the package leaflet must be written in clear and understandable terms for the users and be clearly legible in the official language or languages of the Member State where the medicinal product is placed on the market. Package leaflet is the subject of research especially for its user-friendliness (cf. Askehave & Zethsen 2000; Hall 2006; Ezpeleta 2012; Montalt & Garcí a- Izquierdo 2014; Pilegaard 2014). The lack of user-friendliness may be a result of two factors: inter-linguistic translation (between two languages) and inter- generic translation (from one genre to another e.g. transferring information from the product summary to package leaflet) (Askehave & Zethsen 2000: 64). The requirements under Directive 2001/83/EC mean that PPI should contain the same information as the product summary (PS). That requires structural and lexical simplification, determinologizing, synthesizing information, expanding relevant information, and adjusting tenor (Ezepleta 2012, 2014). Table 9. Corresponding passages from PS and PPI. Product summary (PS) Acute overdose could lead initially to hypoglycaemia and subsequently to hyperglycaemia. Due to the prolonged- release characteristics of this medicinal product peak levels of growth hormone can be expected approximately 15 hours after injection, see section 5.2. Long Package leaflet (PPI) If you use more Somatropin Biopart- ners than you should, you should con- sult your doctor. If you have used too much of this medicine, initially your blood sugar may decrease and become too low. Subsequently, it may increase and 281

13. Wioleta Karwacka become too high. Prolonged overdose may result in a greater than normal growth of ears, nose, lips, tongue and cheekbone. term over-dosing could result in signs and symptoms of gigantism and/or acromegaly consistent known effects of hGH excess. Treatment is symptomatic and support- ive. There is no antidote for somatropin overdose. It is recommended to monitor thyroid function following an overdose. with the Nevertheless, PPIs are still notorious for being vague and overcomplicated. The main problem areas include: the use of synonyms, syntax and complicated sen- tences, the use of passive, impersonal style and information overload (Askehave & Zethsen 2000: 64). As a result, PPIs simply support management and trade strategies of pharmaceutical companies rather share knowledge and empower patients (Hall 2006), possibly because their main purpose is to meet requirements and not to educate lay audiences (cf. Pilegaard 2007). There are also a number of regulations which should secure the rights of ethnic minorities and immigrants with regard to full access to medical services. They result from the Universal Declaration of Human Rights, International Con- vention on the Elimination of All Forms of Racial Discrimination, Convention on the Rights of the Child, International Covenant on Economic, Social and Cultural Rights, European Constitution, European Convention on Human Rights, Framework Convention for the Protection of National Minorities and respective constitutions and laws applicable in particular countries (Baráth et al. 2007). In the light of those regulations, patients should be granted with access to relevant documents in their native language and interlingual communication with medical staff should be facilitated. In reality, however, foreign patients with limited L2 skills are not always sufficiently assisted, which may lead to significant prob- lems – there is sufficient evidence that language barriers may severely affect the quality of medical services (Heine 2003; Flores et al. 2003; Chung 2006; Sanchez 2007; Chen 2009). Apart from the genres discussed above, there are other texts translated in order to ensure interlingual communication in healthcare settings – brochures, patient diaries, questionnaires, forms etc. Medical translation can bridge the linguistic gap between medical professionals and patients, thus becoming a fac- tor in improving the overall quality of medical services. Ongoing research will hopefully shed more light on achieving lay-firendliness of original and translated materials (cf. Pilegaard 2014; Montalt & Garcí a-Izquierdo 2014). 282

14. Medical Translation 4. Problems in the translation of specialized medical texts Regulatory requirements do not only concern medical documents for lay readers Under international regulations, instructions for use (IFU) and user manuals of medical devices also have to be translated, even if a given device is a highly specialized tool only used by specially trained professionals, unless a formal approval is granted for the English version of the documents. Exhaustive EMA (European Medicines Agency) documentation covering the characteristics of pharmaceutical products needs to prepared in the twenty-four official languages of the European Union. Pharmaceutical dossiers are also translated into the languages of countries outside EU – and that is only the European perspective, with medical research and development activities, being a global issue requiring international communication and thus translation worldwide (cf. Andriesen 2006). Clinical trial documents, including clinical trial synopses are also a large portion of the translation turnover. The most typical features of specialized medical texts, i.e. terminology, nominalization, heavy pre- and postmodification, long sentences, use of passives (cf. Askehave & Zethsen 2000), hedges ( Salager-Meyer 1994), metaphors and rich images4, and, occasionally, the language of evidence-based medicine (EBM) (cf. Gajewski 2003; Górnicz 2007, 2009) may constitute the areas of the greatest challenge to translators, as presented in the passages below – extracts from research papers translated from Polish to English by the native speakers of the source language. Extract (a) is an example of terminological density, the use of English acro- nyms in a Polish text. The beginning of the target sentence is not written in natu- ral English, posing more problems than highly specialized terminology. Sen- tences (b) – (e) show the use of EBM lexis, with the controversial choice in (e) – intervention vs. investigated. Target sentences in (c) and (d) are more explicit than their source counterparts. Extract (f) is an example of information and ex- plicitness changes, possibly related to significance threshold (cf. Chesterman 1997): przyspiesza osiągnięcie celów terapeutycznych – improves rates of blood pressure control and requires less time to achieve target blood pressure, kwesti- ami –benefits, korzyści ekonomiczne –cost savings, efektywniejsza współpraca z pacjentem – better compliance; the linking expression z tego względu is omit- ted, by most patients with hypertension is added, information that the monother- apy concerns antihypertensive drugs is removed (but can still be implied). 4“rich images are metaphorical expressions that are ‘rich’ in detail and in associations” (Shuttleworth 2014: 35) 283

15. Wioleta Karwacka Extract (g) is an example of transediting (cf. Chesterman 1997); a number of shifts are observed in the translation of this text and their purpose seems to be following target conventions and achieving better reader-friendliness. The topic sentence is added. The strategies employed in this sentence include: emphasis change najistotniejszą – important, the addition of female (explicitation - both men and women can be diagnosed with androgenic alopecia), unit change (cf. Chesterman 1997) and addition of newly developed techniques: Współcześnie możliwości diagnostyczne poszerzyły się o fototrichogram, tricho- skan, trichoskopię oraz refleksyjną mikroskopię konfokalną in vivo. Newly developed techniques enlarge the spectrum of possibilities in diagnosing hair loss. These include the phototrichogram, trichoscan, trichoscopy and in vivo reflectance confocal microscopy. Such maneuvers influence the explicitness of the text and its cohesion. The sen- tence„Fototrichogram jest metodą rzadko stosowaną w praktyce” is not ren- dered in the target text. The subsequent sentence is where clarity and cohesion seem to be prioritized in the translation, and are achived also by means of a unit change, information change skóry owłosionej głowy–a shaven scalp area and adding allow the percentage of telogen hairs to be assessed: Opiera się na obserwacji, że włosy anagenowe rosną, natomiast włosy telogeno- we są niezmienione, gdy obserwuje się kolejne makrofotografie tej samej okolicy skóry owłosionej głowy. The basis for the phototrichogram is the observation that growing hairs are in the anagen phase and non-growing hairs are in the telogen phase. Subsequent mac- rophotographs of a shaven scalp area allow the percentage of telogen hairs to be as- sessed. Information changes, explicitness changes and other pragmatic strategies are also observed in the remaining part of the text, a transition is added (another recently developed method), some unit-content manipulation is observed – the information that it is not necessary to remove hair is moved to the sentence which introduces the part about trichoscopy, and the term trichoscopy is explained. Explicitness change is visible in the segment łodygi włosów, lejków mieszków włosowych i skórę otaczającą mieszek włosowy–hair thickness and structure, and the perifollicular area. What is also observed in this segment is that the source elements are richer images than those in the target version.Information on zoom val- ues is omitted, and so is the penultimate source sentence, which is partly a 284

16. Medical Translation repetition of the information which is presented in preceding segments. Although translators are frequently required to produce a target text which is very close to the original, such shifts are not uncommon in trans- lating research papers – pragmatic shifts may improve the readability of the text, without misinforming the expert readers, who probably know the implied information. Table 10. Extracts from medical research papers translated into English5 Source Ustalenie choroby (VTE), na którą składają się za- krzepica żył głębokich (DVT) i zator tętnicy płucnej (PE), wyma- ga zarówno oceny klinicznej, jak i wykonania dodatkowych badań obrazowych, a w wybranych sytu- acjach klinicznych —także testów laboratoryjnych. Przeprowadzone w ostatnich latach duże próby klinicznedowodzą, że terapia złożona tętniczegoma już ugruntowaną pozycję. W grupie kobiet z otyłością stwierdzono istotne statystycznie zależności pomiędzy złości a dążeniem do szczupłości oraz symptomami depresyjnymi i lękowymi. Target Making a diagnosis of venous thromboembolism (VTE), mani- festing as deep vein thrombosis (DVT) and/or pulmonary embo- lism (PE) requires clinical assess- ment, as well as imaging and — in selected clinical settings —labora- tory tests. a) rozpoznania zakrzepowo-zatorowej żylnej Large clinical trials performed in the last few years prove that com- bined therapy of essential hyper- tension has reached a secure posi- tion lately. In the clinical sample of women with obesity revealed significant statistical correlations between an- ger expression and drive for thin- ness, depressive and anxiety symp- toms. b) nadciśnienia c) ekspresją Total number of randomly chosen hospitalized patients engaged in the study was 152. The glycaemia in the investigated group was significantly lower than in the control group in 180, 330, 420, 450 and 480 minute. Do badania zakwalifikowano 152 osoby. d) Glikemia w grupie interwencyjnej była znamiennie mniejsza niż w grupie kontrolnej w 180., 330., 420., 450. i 480. minucie. Większość pacjentów chorujących Most patients with hypertension e) f) 5See the ‘References’ section for details 285

17. Wioleta Karwacka na nadciśnienie tętnicze wymaga leczenia więcej niż jednym lekiem hipotensyjnym. Dotyczy to szcze- gólnie pacjentów z innymi współ- istniejącymi chorobami. Z tego względuterapia nadciśnienia tętni- czego przy użyciu preparatów zło- żonych jest konieczna do osiągnię- cia właściwych wartości ciśnienia tętniczego. W wielu przypadkach terapia ta przyspiesza osiągnięcie celów terapeutycznych przy po- równywalnej lub lepszej tolerancji niż w przypadku monoterapii wyższymi dawkami leków hipo- tensyjnych. Dodatkowymi kwe- stiamimogą być korzyści ekono- miczne takiej terapii oraz efektyw- niejsza współpraca z pacjentem. Współcześnie możliwości diagno- styczne poszerzyły się o fototri- chogram, trichoskan, trichosko- pię oraz refleksyjną mikroskopię konfokalną in vivo. Fototricho- gram jest metodą rzadko stoso- waną w praktyce.Opiera się na obserwacji, że włosy anagenowe rosną, natomiast włosy telogeno- we są niezmienione, gdy obserwu- je się kolejne makrofotografie tej samej okolicy skóry owłosionej głowy. Trichoskan to cyfrowy, zautomatyzowany fototrichogramu. Trichoskopia jest cyfrową metodą opierającą się na technice wideo- dermoskopii. Najczęściej stosowa- nymi powiększeniami są powięk- szenia 20-krotne i 70-krotne. W trichoskopii ocenia się łodygi wło- sów, lejki mieszków włosowych i skórę otaczającą mieszek włosowy. Metoda umożliwia ocenę struktur włosa bez konieczności pobierania require more than a single antihy- pertensive agent, particularly if they have comorbid conditions. Combination therapy of hyperten- sion with fixed-dose combination pills is required by most patients with hypertension to reach target blood pressure. In many cases, combination therapy improves rates of blood pressure control and requires less time to achieve target blood pressure with equiva- lent or better tolerability than high- er-dose monotherapy. Additional benefits may include cost savings and better compliance. Recent years have brought signif- icant progress in hair diagnostic techniques. Classic methods of hair evaluation, other than clinical exam- ination, include evaluation of daily hair loss, hair weighing, pull test, wash test and the trichogram. Histo- pathological examination of the scalp skin remains an important method in differential diagnosis of hair loss, in particular in differenti- ating female androgenic alopecia from chronic telogen effluvium and in diagnosing alopecia areata or cicatricial alopecia. Newly devel- oped techniques enlarge the spec- trum of possibilities in diagnosing hair loss. These include the photo- trichogram, trichoscan, choscopy and in vivo reflectance confocal microscopy. The basis for the phototrichogram is the observation that growing hairs are in the anagen phase and non- growing hairs are in the telogen g) odpowiednik diagnostyczną tri- 286

18. Medical Translation phase. Subsequent macrophoto- graphs of a shaven scalp area allow the percentage of telogen hairs to be assessed. A trichoscan is a computerized form of this technique. Another, recently devel- oped method, trichoscopy (hair and scalp dermoscopy), allows evalua- tion of the whole scalp without the need to remove hair. Trichoscopy allows one to analyze hair thick- ness and structure, and the peri- follicular area. In a recently pub- lished study, the usefulness of reflectance confocal laser scanning microscopy in diagnosing hair shaft abnormalities was docu- mented. włosów. Trichoskopia pozwala na różnicowanie łysienia androgeno- wego kobiet z przewlekłym łysie- niem telogenowym oraz umożliwia rozpoznanie włosów dystroficz- nych, resztkowych i ułamanych. Nowoczesną metodą wymagającą dalszych badań jest nieinwazyjna technika obrazowania włosów i skóry owłosionej głowy metodą refleksyjnej konfokalnej mikrosko- pii skaningowej in vivo. What seems to be a noticeable tendency is avoiding the excessively impersonal tone of a paper: a) wyniki badań wskazują our findings show b) Celem niniejszej pracy było ustalenie, jaki odsetek stanowią wśród nich pacjenci, u których potwierdzono rozpoznanie… The aim of our study was to determine the percentage of children with confirmed diagnosis of osteoporosis… c) W pracy terapeutycznej warto zwrócić uwagę na rolę, jaką odgrywa negatywny obraz ciała oraz sposób wyrażania złości przez osoby z otyłością. We should take into account the large role that negative body image and anger expression play in treating obesity. d) Autorzy niniejszej pracy uważają, iż rekonstrukcja lewej żyły nerko- wej jest stosunkowo prosta technicznie i jeżeli jest to tylko możliwe, powinno się ją przeprowadzać w każdym przypadku. We consider the reconstruction of the left renal vein to be technically relatively easy and it should be performed in every possible case. e) przedstawiono przypadek 16-letniego sportowca we present a case of a 16-year old cyclist vs. w niniejszej pracy 287

19. Wioleta Karwacka f) Podsumowano dotychczas prowadzone i trwające badania kliniczne poświęcone terapiom komórkowym w udarze mózgu. Finally, we report recent and on-going clinical trials on stem-cell therapy in cerebral stroke. The variety of strategies used by medical translators is neither greater nor poorer than that of translators who deal with other disciplines. The key factors here are the requirements and conventions of particular genres –translators of informed consent documents are expected to be very accurate and close to the original, while translators of research papers need to consider e.g. the stylesheet used by a particular publisher. Various aspects of the translation of specialized medical translation are discussed in Translation and knowledge mediation in medical and health settings edited by Vicent Montalt and Mark Shuttleworth (2012). 5. Qualifications of medical translators The dynamic development of medicine and natural sciences as well as the global nature of the international community, the demand for medical translation is significant, but it still remains a controversial question who should translate medical text – a medical professional or a linguist or a linguist with some medi- cal background (cf. O’Neil 1998; Heine 2003; IMIA 2009; Nisbeth and Zethsen 2012). Ideally, a medical translator would not be a medical professional, but an especially trained translator, i.e. a linguist who underwent appropriate training, a view which is also supported by IMIA (2009: 4-5). According to IMIA (Interna- tional Medical Interpreters Association), medical documents should be translated by professionals who have “a native or near-native, formal level of language proficiency, analytical capabilities, and deep cultural knowledge in the source and target languages” (2009: 3), other requirements include at least college level formal education covering courses in translation theory and practice, proficiency in the source and target languages, expert knowledge of the subject matter ter- minology, terminology research skills and adequate writing skills. Other compo- nents of medical translator competence include: application of translation strate- gies, relevant procedures, conventions or standards, use of medical databases, text banks, dictionaries, CAT tools etc. as well as certain psycho-physiological features such as decision making, thoroughness, honesty etc. (cf. PACTE 2011; Nisbeth & Zethsen 2012; Karwacka 2012, 2014) A medical translator’s command of medical English and his or her writing skills involves a range of genres and registers. Transferring medical information 288

20. Medical Translation for patients means avoiding unnecessary jargon, complicated syntax, or highly specialized vocabulary. Translating documents which are written for medical professionals, on the other hand, requires specific terminology and discourse markers typical of similar texts produced in the target language. Therefore, a translator’s linguistic competence involves general and specialized languages. That is why medical training is not limited to acquiring medical knowledge (cf. O'Neil 1998: 73). Having said that, background knowledge of medicine is necessary to ensure that a message is transferred without distortions, which is one of the critical is- sues in interlingual and intercultural knowledge mediation (cf. Montalt and Shut- tleworth 2012; Karwacka 2014). Medical translators do not only acquire medical knowledge through medical studies and they are not always physician- translators: “there will always be more medical translations than can be handled by the relatively few physicians who translate (and) medical translation will perforce be done by non-physicians” (O’Neil 1998:69). Some information on the background of medically knowledgeable linguists is provided by the results of a survey Marla O’Neil (1998) conducted among translators who are not physicians, but specialize in medical translation. Her study revealed that medical translators acquire background knowledge by study- ing medicine, participating in medical courses, working in a position indirectly related to healthcare or medicine or participating in medical translation courses. Other factors included access to medical professionals, medical professional relatives, and a medical condition which resulted in doing background research and contact with medical professionals. Most respondents to O’Neil’s question- naire admitted that their translation was hardly ever verified. The reality of medical translation too frequently shows that translators must assume sole responsibility for the quality and accuracy of medical translations, which seems to be one of the factors behind the often poor or substandard quali- ty of medical translation, rather than merely the question of medical versus lin- guistic educational background of the translator (cf. Karwacka 2014), especially if it is medical translators themselves that decide whether they are qualified enough to perform a particular translation task that they are considering to take on. 6. Verification and review in medical translation Another related issue is quality assurance in medical translation since the quality of translation may have clinical consequences (cf. Flores et al. 2003). The verifi- 289

21. Wioleta Karwacka cation guidelines involve a pre-translation preparation and analysis of the ST, its actual translation and multi-step verification of the TT (cf. IMIA 2009). A valid verification process also involves the conventions and requirements regarding various text types and functions (cf. Mobaraki and Aminzadeh 2012), including readability and clarity in expert-lay communication. IMIA (2009: 6-11) suggest the following steps in the translation process: preparing the final version of the ST (poorly written or confusing passages are likely to be awkward and ambiguous in the target language), which is followed by commissioning a translator who decides if she or he is qualified to translate the text, then - translation, and finally - verification: the translated document is reviewed and edited by another professional, who ideally should have more sub- ject area expertise and be more experienced than the translator. It is then proof- read, ideally by a third person. That, however, is not actually the final stage of the process, as it may be necessary to adapt the TT to local requirements con- cerning a informed consent documents and other medical texts (cf. Fernández Piera and Ardura Ortega 2012: 291). A fairly frequently applied but controversial method of translation review is back-translation, i.e. the of translation the TT ‘back’ into the source language by an independent translator who did not handle the original 'forward' translation of a given text. IMIA advise against applying back-translation as a method for verification for the reason that it might not reveal “the target language contextual and usage nuances” (IMIA 2009: 2) or awkward literal translation. On the other hand, what may appear as an inaccurate rendition in the back-translation is actu- ally a passage written in idiomatic language (IMIA 2009: 3). Nevertheless, the blind back-translation technique is frequently used to verify the accuracy of translation (cf. Andriesen 2006; Fernández Piera and Ardura Ortega 2012), and its advantages have been proven (Berkanovic 1980; Andriesen 2006). The back- translation method is widely used in the sector of medical research and clinical trials, as it is required by Ethics Committees and regulatory authorities in a number of countries (see Grunwald and Goldfarb 2006: 2), but it should not be implied that the sole purpose of back-translation is compliance with formal re- quirements. If it is handled in a professional manner, it can be a useful error detection tool (Andriesen 2006: 15-16). The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) has developed a complex review method which involves two parallel forward translations, reconciliation, two back-translations, comparison and reconciliation, a review and harmonisation of the target text. As effective as the method may appear, it is not frequently employed possibly due to time and budget constraints (Andriesen 2006: 15-16). 290

22. Medical Translation Parallel translation can also be applied as a standalone quality assurance method: two parallel translations are produced, then compared and adjusted, if necessary. The outcome of the process is the final TT which is a compilation of the two parallel translations. This method affects the budget of a translation pro- ject, but: “in this case the additional cost has a much more direct and positive effect on the quality of the final document than is the case with a back- translation” (Andriesen 2006: 16). Another quality assurance method is cognitive debriefing. It is used as an assessment tool for instruments such as questionnaires or scales. It involves gathering feedback from a sample group of patients to learn how they under- stand the wording of a given question. The purpose is to verify if the wording is lay-friendly and reflects the intended concept at the same time (cf. Ploughman, Austin, Stefanelli & Godwin 2010; Karwacka 2014). 7. Summary This chapter is a brief overview of medical translation-specific problems rather than an exhaustive presentation of all the issues in detail. Medical translation is a complex and interesting phenomenon in which linguistic, sociocultural, scien- tific, economic and other factors are at play. That is probably why multidiscipli- nary approach is so useful in approaching medical translation in research. Recommended reading Bartolucci, S., Stedman T., Forbis P.: Stedman's medical eponyms. Baltimore, Md.: Lippincott Williams & Wilkins, 2005 Dorland 2011 Dorland's Illustrated Medical Dictionary Dorland 2012 Medyczny słownik angielsko-polski, polsko-angielski. Elsevier. Eudralex 2009 A guideline on the readability of the label and package leaflet of medici- nal productsfor human use. Online: http://ec.europa.eu/health/files/eudralex/vol- 2/c/2009_01_12_readability_guideline_final_en.pdf. Accessed: 02.07.2014. Fischbach H. 1986 ”Some Anatomical and Physiological Aspects of Medical Transla- tion”. Meta. 31:16-21. Fischbach H. 1998 Translation and Medicine. Amsterdam / Philadelphia: John Benja- mins. Gotti M., Salager-Meyer F. (eds) 2006 Advances in Medical Discourse Analysis: Oral and Written Contexts. Peter Lang. 291

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