Introducing medical translation
A personal and professional interest in healthcare strategies, medical devices, biotechnology, regulatory matters and patient information provision is my starting point for investigating the multi-faceted field of medical translation. Firstly, I will offer an overview of LSP features and a number of related theoretical contributions, translation brief and medical translation categories. Then, I will proceed to address the key aspects and potential pitfalls in medical translation in greater detail, with a particular focus on the translation of medical texts from English into Italian. Finally, the financial and regulatory implications of medical translation will be discussed in depth.
Medical translation is one of the most ancient and complex fields of translation. Since the dawn of time, physical and mental ailments have been the focus of human attention, sparking keen interest among patients and medical experts alike. Because of the profusion of medical nomenclature in the ancient Greek and Roman worlds, as reflected in the etymological derivation of numerous medical terms used today in most European languages, the figure of the medical writer developed and evolved over the centuries. With the advent of English as the lingua franca mid way though the 20th century, there has been an ever-increasing demand for medical translators, who aside from mastering two languages, are required to grasp the intricacies of medical language. The most common medical genres a translator might come across include clinical trials, case reports, patient information leaflets, biomedical research articles, medical device manuals, study-specific protocols and patient-centric validation procedures.These text-types are endowed with different functions, communicative purpose and target readership expectations. The medical translator should therefore have a clear understanding of both source text (ST) and target text (TT), textual purpose and recipient-specific requirements.
LSP features and theoretical premises
Let us first of all dwell on the theoretical premises of medical translation. Medical writing is distinctly aligned with LSP (language for specific purposes), used in specific fields in relation to genre, style and technical lexis. Text-types belonging to the same sub/genre share elements of content, structure, style, register and target audience. Accordingly, PROs (patient-reported outcomes), QoL (quality of life) instruments, study information sheets and consent forms, medical abstracts and package inserts may be defined as medical sub/genres since their content is distinctively health-oriented. As pointed out by Cacchiani (2006, p. 28) in her contrastive analysis of Italian and English PILs, the implications for the translator are great when faced with linguistic, cultural and social discrepancies between two languages. She gives prominence to the notion of functionally adequate translations whereby the onus is on fulfilling the intended communicative purpose of the translation itself. This cross-cultural divergence is also considered intrinsic to LSP, which may be defined as:
“a formalized and codified variety of language, used for special purposes with the function of communicating information of a specialist nature at any level in the most economic, precise and unambiguous terms possible” (Picht & Draskau, 1985, p. 3).
It follows that medical translators should possess professional competence in any special (bio/medical) field as well as discernment of LSP in both their source and target languages. A combination of solid linguistic abilities and familiarity with specialist texts enables medical translators to overcome issues relating to technical terminology, domain-specific concepts, accurate subject-matter interpretation, stylistic requirements and phraseological patterns. In particular, LSP phraseology is the study of specialised (technical/scientific/medical) terminology based on collocation content and recurring word combinations (Méndez-Cendón, 2009). In her paper on genre and LSP translation in medical case reports Méndez-Cendón suggests that “LSP phraseology is the study of specialised word combinations that occur frequently in technical and scientific language” (2009). LSP phraseological units (LSP PUs) characterising medical text-types may include routine formulae, fixed expressions, collocations and combined interdisciplinary terms. Hence, an in-depth knowledge of the specialised field is expected in order to achieve proficiency in LSP-based approaches. Garzone argues that specialised knowledge relating to specialised vocabulary and discourse is key to achieving translational proficiency in the LSP medical genres and sub-genres (2006, p.13). Consequently, medical translators should bear in mind that, for instance, the language encountered in PILs, IFUs and medical review articles differs greatly from LGP (language for general purposes) at the lexical, morpho-syntactical, con/textual level. Specifically, in her paper on the distribution of information in LSP translation based on an Italian corpus study, Musacchio (2004, p. 91) suggests that:
“linguistic research in the distribution of the elements making up a message in different languages shows that the representation of the information is language-specific and that there are language-specific focus-attributing positions within the syntactic structure of sentences”.
In this regard, and with reference to English versus Italian texts, Gotti argues that in medical disambiguation and translation “the major difficulty derives from the fact that Italian relies on left-to-right construction, whereas in English the right-to-left pattern is very common in LSP” (1991, p. 73). An example of this element of difficulty in translation is given by the following left-branching English segment versus an Italian right-branching segment referring to a concept frequently abbreviated by the medical community via the acronym LAD:
English:
left anterior descending coronary artery
1 2 3 4 5
Italian:
arteria coronarica discendente anteriore sinistra
5 4 3 2 1
By glancing at the numbers placed below each lexical item in both languages, it may be observed that the left-to-right sequential pattern in the English segment is entirely inverted in the Italian LSP combination. Different end-weight and front-weight presentation across both languages affects the way information is processed and assimilated by the reader. In this case, the structural balance and the perceived focus of the ST are entirely transposed in translation. As related by Musacchio (2004, p. 90) in her paper on LSP translation:
“... the naturalness of LSP translations derives from a blend of different elements, lexical as well as syntactic – not to mention stylistic conventions as to text types. Moreover, if special language texts are considered that are not drafted in English – the international lingua franca of science and technology – they reproduce the information structure that is typical of their language”.
It becomes clear to what extent a grasp of the semantic chronological order in both languages is paramount in LSP translation and for the production of a coherent and usable TT. As in other specialised subject-fields, medical texts present a set of conventional patterns and LSP phraseology whereby certain terms co-occur and behave in a fixed manner according to the communicative intent of the text itself. In both English and Italian medical texts, it is common to encounter several combinations which work as natural collocates and the usage of which is widely endorsed by pharmaceutical and medical device companies, medical experts and the public alike. However, Scarpa (1999, p. 317) suggests that the concept of naturalness in LSP domains remains subjective and argues that because of the increase in LSP translation work, several imports are no longer being considered anomalous but typical of a particular LSP. Examples of such imports include ‘posizionare’ used to translate ‘to position’ and currently preferred over ‘collocare’ or ‘situare’ in Italian medical case reports or implanting procedures, and ‘evidenza’ recently favoured in lieu of ‘indizi’ or ‘prove’ to translate the existence or absence of medical ‘evidence’.
Medical texts: the translation brief
As in other fields of specialised expertise in which LSP and considerable specialised domain background are quintessential, the precise communication requirements of a given scientific text-type are crucial. In this sense, it is possible to apply skopos theory (Vermeer, 2000, in Venuti, pp. 235-236) to any medical genre and sub-genre, with specific reference to the objective of the ST which needs to be fulfilled in the TT. Vermeer claims that “any translation is carried out according to a skopos” and furthermore that “every translation is based on a commission” (2000, in Venuti, p. 235). Therefore, only by bearing in mind the translation objective and brief is it possible to ascertain how to meet target audience (TA) expectations. To produce a functional translation in the sense of Nord (1997, p. 59), medical translators should aim to meet receiver-specific requirements, and ultimately the TT should reflect TA expectations and the different degree of knowledge of the recipient/s. This is why in the case of medical texts, there may be several skopoi underlying the translation brief and the aims of TT may differ from those of the ST, due to different TT sub-genre conventions. In more pragmatic terms, the translator should assess the communicative purpose of the original document in order to understand the function of the ST and whether this may map onto the TT or require modifications for the intended audience. Hence, the development of and the adherence to a translation brief is key, to reinforce con/textual understanding and to glean whether the ST communicative purpose may be retained or needs to be re-established in translation.
Categories of bio/medical translation
As regards medical text-types, it is all-important to distinguish between intralingual translation and interlingual translation. As reported by Askeave and Zethsen (2011) in their analysis of PIL translation, intralingual translation refers to translation taking place within the same language, via the reformulation of any given PU.
Example:
• ‘Tenere lontano dai bambini’ [Keep away from children]
• ‘Tenere lontano/fuori dalla portata dei bambini’ [Keep out of the reach of children]
Interlingual translation on the other hand refers to the actual translation taking place between two languages.
Example:
• ‘Keep out of the reach of children’.
• ‘Tenere lontano/fuori dalla portata dei bambini’
It is necessary to make a further classification within medical translation, so as to understand exactly what communication is taking place between which parties, and thus adjust the translation purpose and register accordingly. Let us examine PILs, for instance. PILs are package inserts containing precise health-related information relative to a specific medicinal product. They are also a simplified and adapted version of SPCs (summaries of product characteristics) directed at medical and pharmaceutical experts for the fulfilment of regulatory requirements and drug approval purposes. Based on the foregoing assumptions, intralingual translation embraces expert-to-expert communication in the case of English SPCs, and expert-to-lay conversion and rewording in the case of an English PIL intended for the general public. On the other hand, interlingual translation refers both to the expert-to-lay translation aimed at an Italian lay TA and to the actual translation from English into Italian. Two additional translation categories include expert-to-semi-expert (scientist / doctor / professional to medical student / technician / paramedic / nurse) and lay-to-lay (writer / author / journalist / blogger to reader).
Key aspects and potential pitfalls of medical translation
For the appropriate transfer of bio/medical content to the TT, medical translators should take into account a multitude of aspects in order to avoid the inaccurate relaying of the ST core meaning. It is important to outline the principal difficulties that medical translators may come across, as a greater awareness of the main challenges may prevent unpleasant outcomes at a later stage in the production chain of medical texts. Should any given translation content fail to be reliable and consistent, this may result in the violation of country-specific, EMA (European Medicines Agency, 2012) or FDA (US Food and Drug Administration, 2012) regulations in the case of clinical trial informed consent forms or in the interruption of or delay in the process of pharmaceutical labelling. It is easy to imagine how, aside from severe cost implications, similar shortcomings also entail an element of risk, since even the slightest flaw in a health-oriented context, if overlooked, may determine potentially dire and even fatal repercussions. The main aspects characterising medical texts and representing potential pitfalls are illustrated below, with particular reference to the translation of medical texts from English into Italian.
Textuality and Register
Textuality is intrinsic to medical texts since the presence of certain words is connected to the topic discussed within the text. According to Halliday and Matthiessen, the textual metafunction is defined as relevance to the context (2004, p. 61). This implies that, for example, clinical textbooks, medical journals, abstracts of scientific literature, editorials and device manuals may be expected to contain medical, pharmaceutical and health-related terminology, and a successful identification and understanding of textual relationships within an LSP context is central to further aid the interpretation, and thus the translation, of the text. According to Halliday “a register is a functional variety of language” (2004, in Halliday & Matthiessen, p. 27). Register plays a key role in the linguistic patterns of medical texts and may be problematic in translation. Furthermore, translators should realise that register is not consistent across languages,which certainly applies to the translation of medical texts from English to Italian. Prospective translators should determine the need for higher or lower medical register in any given medical sub-genre; an example of differing register could be ‘rubella’ versus ‘German measles’ which are both translated into Italian as ‘rosolia’. It is crucial to establish whether higher or lower medical register is required in medical translation, given that Italian and English present synonyms both in medical parlance (LSP) and in everyday speech (LGP), as shown in the examples selected in the table below:
Italian HMR Italian LMR English HMR English LMR
aritmia alterazione del ritmo cardiaco cardiac dysrhythmia / arrhythmia irregular heartbeat
astenia debolezza asthenia weakness
bradicardia
riduzione della frequenza cardiaca bradycardia
heart slowness
epistassi
perdita di sangue dal naso / sanguinamento
nasale epistaxis
nosebleed
ipersensibilità allergia hypersensitivity allergy
ipertensione
pressione alta
hypertension
high blood pressure
ipovisione
visione ridotta / limitata hypovision
low vision
torace petto thorax chest
* HMR = higher medical register LMR = lower medical register
Each bio/medical text should be assessed at the lexical level in order to negotiate the register required in the TT, as certain terms may lack an equivalent meaning in the TT or may be translated by a variety of terms in the target language (TL). It follows that selection of the most appropriate term in translation depends on the medical sub-genre in question, and therefore on recipient-specific requirements.
Collocation
Recursive word combinations or sequences are also an archetypal factor in medical writing based on the association of co-occurring scientific and common terminology. Collocative meaning can be defined as the meaning which certain words acquire by co-occurrence and regular association. For instance, the term ‘associazioni’ by itself may mean associations, but when it collocates with ‘controindicate’, it takes on the meaning of inadvisable drug associations, thus referring to specifically contraindicated drug combinations. It is crucial to determine if collocational patterns may overlap in translation, or whether the source language (SL) collocation content should be carried across to the TL by using different phraseology in order to preserve the scientific credibility of the information provided.
Terminology
From a lexical angle, specific medical/scientific terminology is the factor that most affects the production of an accurate translation. This may include named entities (relating to specific drug names, medical/scientific boards, pharmaceutical agents and components, etc.) which cannot be replaced in translation and should therefore remain unaltered. Certain terms may also be pertinent to a particular medical specialty such as ‘scintigrafia’ (‘scintigraphy’), ‘isterectomia’ (‘hysterectomy’) or ‘fluoroscopia’ (‘fluoroscopy’), whereas others may be interdisciplinary by which are meant terms that are also related to several specialist fields, such as ‘catetere’ (‘catheter’), ‘cannula’ (‘cannula’) or ‘campione’ (‘sample’). Accordingly, from a linguistic perspective medical terminology poses a number of comprehensible problems in translation which may be overcome only over time and by acquiring considerable translating experience.
Anglicisation and loaning
Due to the predominance and pre-eminence of English in science and medicine, an assortment of terms such as ‘follow-up’, ‘onset’, ‘test’, ‘screening’, ‘kit’, ‘incidence’, ‘double-blind’, ‘borderline’, ‘matching’, ‘open-label’, ‘end-point’, ‘random’ and ‘marker’ to cite but a few, have been recently imported in Italian medical texts. Many scientific terms and neologisms have been ‘loaned’ from the English language and used to define specific notions shared and widely understood by a community of medical experts. This lexical evolution has also generated etymologically hybrid combinations to be found in numerous medical sub-genres such as ‘trial clinico’. This unusual combination is currently favoured in Italy over more traditional word associations such as ‘studio clinico’ (‘clinical study’) and ‘sperimentazione clinica’ (‘clinical experimentation’) referring to any clinical study conducted according to a specific research protocol. It also succeeds in drawing attention to the fact that the first term is of English derivation and of relatively recent usage in Italian medical writing, thus reflecting an increasingly updated approach among and within the contemporary medical and scientific community.
Graeco-Latinates
The history of medicine sinks its roots in terminology of Greek and Latin origin and it is perhaps worth dwelling on the habitual use of Graeco-Latin etymons in medical texts. It is not uncommon, for example, to come across various medical terms of Greek derivation such as herpes and rachis and others of Latin derivation such as bolus, alvus, virus and placebo. A variety of terms defining specific medical and physiological conditions such as angina pectoris, diabetes mellitus, rigor mortis, algor mortis and livor mortis are currently preserved in Latin, in Italian and in English medical/scientific writing and shared by most European languages. Nowadays, the influence of Greek is still very much apparent in the use of medical terms incorporating letters of the Greek alphabet, such as ‘betabloccanti’ (‘beta blockers’), ‘omega 3’ (‘omega-3’) and ‘alfa-feto proteina’ (‘alpha-fetal protein’). On the other hand, several medical terms originating from the Greek in Italian medical texts such as ‘patologia’ (‘pathology’), ‘osteopatia’ (‘osteopathy’), ‘sindrome’ (‘syndrome’), ‘iperfosfaturia’ (‘hyperphosphaturia’), ‘iponatriemia’ (‘hyponatremia’), ‘anemia’ (‘anaemia’) were historically latinised and subsequently adapted so that nowadays only prefixes, confixes and suffixes are indicative of their Greek ancestry. Clearly, whereas such terminology is marginally easier to grasp for native Italian translators due to the fact that Italian is deeply rooted in the Latin language, prospective English mother tongue translators should endeavour to familiarise themselves with terms of radically different etymological origin.
Eponyms
Another lexis-related feature typical of medical texts is the use of eponyms, named entities historically deriving from a proper noun, more often than not coinciding with the scientific inventor of a specific clincal sign, medical condition, device or procedure. In medical writing, eponyms may be used to define anatomical parts such as ‘tube di Falloppio’ (‘Fallopian tubes’) and ‘tromba di Eustachio’ (‘Eustachian tube’ also known as ‘auditory tube’), medical disorders such as ‘linfoma di Hodgkin’ (‘Hodgkin’s lymphoma’), syndromes such as ‘sindrome di Down’ (‘Down’s syndrome’), medical techniques such as ‘manovra di Heimlich’ (‘Heimlich’s manoeuvre’) or anatomical discoveries such as ‘poligono di Willis’ (‘loop/circle of Willis’). Moreover, eponyms may be double-barrelled such as ‘reazione di Jarisch-Herxheimer’ (‘Jarisch-Herxheimer reaction’) when a discovery is produced in a joint effort by two or more scientists. However, certain eponyms may become obsolete such as ‘segno/polso di Corrigan’ (‘Corrigan’s pulse’) in that recently replaced by other more advanced scientific alternatives. Finally, acronyms may often be more apt as in the case of ‘malattia di von Willebrand’ (‘von Willebrand’s disease’) which is habitually shortened to VWD in English.
Acronyms
Medical texts are also replete with myriad acronyms and abbreviations. Some of these may be author-specific when recurring in articles and titles written by the same author such as ‘analysis’ shortened to ‘anal.’, ‘chemical’ shortened to ‘chem.’ or ‘oxidation’ shortened to ‘oxidn’. Other acronyms are considered standard abbreviations on a more general scale. For instance, it is not uncommon to come across ‘TAC’ which is an acronym of ‘tomografia assiale comupterizzata’ shortened to ‘CT’ in English and corresponding to ‘computerised tomography’. However, sometimes Italian and English may also share the same acronyms which remain unvaried in translation, such as ‘HIV’ (‘human immunodeficiency virus’), ‘IVD’ (‘in vitro diagnostics’) and ‘WBC’ (‘white blood cell/count’) which are usually retained in English and not translated via an Italian equivalent abbreviation. Other acronyms such as ‘EMG’ which is an abbreviation of ‘elettromiografia’ (‘electromyography’) happen to share the same initials but require translation. It goes without saying that acronyms require a deep understanding of the subject-matter prior to being addressed in translation.
False friends
Another major drawback facing the medical translator is represented by false friends also known as deceptive cognates, namely word pairs that may share the same orthographic pattern but not the exact same meaning in both languages, such as ‘droga’ and ‘drug’, the former explicitly meaning any addictive (soft or heavy) drugs and the latter referring to any medical substance. Likewise ‘injury’ is relayed as ‘ferita’ in Italian and not as ‘ingiuria’. Italian and English have in common several cognates that are similar in form but (relatively) divergent in meaning, hence the identification of false friends is essential in translation, as the misleading presentation of near-identical words may result in extreme TT con/textual alteration, departure from the original ST meaning and a number of evident repercussions.
Financial and regulatory implications of bio/medical translation
It is also extremely relevant to consider the financial and regulatory implications of medical translation. Translation is indispensable for the marketing of any medical device or drug abroad. Most foreign healthcare markets require medical products or drugs to provide any instruction leaflets or accompanying information in the language of the country where they are to be made available. Moreover, the enforcement of legislative schemata is also expected in the translation of any health and safety-related material for local adaptation purposes. This implies that product development inevitably gravitates around marketing and legislative issues which, in turn, have economic ramifications. Thus, translation cannot be a marginal aspect in the medical production chain, due to its impact on patient safety and, ultimately, in terms of cost. As product approval procedures are time-consuming, the translation of medical material may and should be planned well in advance, in order to avoid any delays or interruptions in the manufacturing stages and any product liability matters arising from product misuse due to inadequate translation. All materials for translation including product documentation, labels, manuals, packaging and any software or hardware components should be prepared by the pharmaceutical/medical companies. Strict adherence to a set of regulatory criteria is compulsory, and adaptation to local market standards (whether national or regional) may prove necessary in terms of regulatory harmonisation, viewed as a set of practices aimed at ensuring the safety, efficacy and quality of medical products or devices and fostering international trade as established and promoted by WHO (World Health Organisation, ‘Medical Device Regulations’, 2003) and ICH (International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use, ‘The Value and Benefits of ICH to Drug Regulatory Authorities – Advancing Harmonization for Better Health’, 2010). To this end, any translation software adopted by pharmaceutical and biomedical companies should be able to support diacritics, different characters and script and specific functions such as the country-specific conversion of postal codes, contact telephone numbers and address presentation. Last but not least, these companies should also remain consistent in their translation software of preference, in building up product-specific glossaries and in their decision to hire freelance translators or rely on in-house multilingual staff, either relying on medical experts as their main service providers or just turning to the latter for third-party reviewing and linguistic validation purposes.
Concluding remarks
As has been previously suggested, a sound command of bio/medical knowledge relating to the human anatomy, the progress and outcome of human diseases, a range of possible treatments and therapies, notions of chemistry and physics and complex surgical procedures and techniques is imperative for the production of an accurate medical translation. It is also indispensable to fully comprehend the ST content, to master the formulaic phraseology typical of any medical sub-genre, to memorise a wealth of acronyms and eponyms, to grasp LSP know-how and appropriate stylistic requirements. Indeed, all of the above constitute essential pre-requisites which may prove invaluable in the profession and experience of the prospective medical translator. However, it should also be clear that genre conventions may affect the description of a particular medical context or situation as well as the appropriate register to be selected, therefore the assessment of genre-specific conventions linked to the medical sub-genre in question is paramount. Any intentional ambiguity or missing information on the translator’s part stemming from partial con/textual misunderstanding may, at best, result in an unusable end-result. Priority should also be given to the communicative aim of the medical text as well as the intended readership, for improved accuracy and consistency of translation, especially since nowadays a gamut of medical sub-genres is directed not only at a more erudite, professional audience (for instance, for the dissemination of research papers to be published in a scientific journal) but also to a readership made up of increasingly questioning and inquisitive patients who expect to receive and, in fact demand, precise and transparent information (in the case of medical prescriptions or IFU package inserts). Prospective medical translators should focus on the goals of the TT and reflect the cultural awareness and the level of domain knowledge of the receiving audience. Lastly, it is crucial that medical translators stay current as to the latest developments in medical and pharmaceutical research, scientific news and clinical issues, ever mindful of the implications, constraints and consequences inherent in their profession.
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Italy