In this study, we sought to determine the effect of language concordance and method of interpretation on patient satisfaction with overall clinic visit and with various provider characteristics. Four routes of communication were assessed: provider-patient language concordance, AT&T telephone interpretation, interpretation through family members, and interpretation through ad hoc interpreters.
Patients utilizing AT&T interpreters reported overall visit satisfaction identical to that of language-concordant patients, while those employing family or ad hoc interpreters were less satisfied. These differences were significant even after controlling for potentially confounding variables. Use of AT&T interpreters and language concordance were associated with comparable rates of satisfaction for all 7 of the provider characteristics evaluated; multivariate analysis did not reveal any significant differences between the two groups. Language-concordant patients tended to be more satisfied with each of the provider characteristics than either the family or other interpretation groups, but not all findings reached statistical significance. For patients receiving interpretation through family members, satisfaction was significantly less for provider listening, discussion of sensitive issues, and manner. Patients employing ad hoc interpreters were significantly less likely to be satisfied with provider listening, answers, explanations, support, skills, and manner.
Our findings confirm the association between language barriers and patient satisfaction established in prior research. In a study of emergency department patients, Carrasquillo et al. showed that non–English speaking patients were less satisfied, less likely to return to the same emergency department, and more likely to report problems with care, communication, and testing compared to English speakers.6
Morales et al. showed that Spanish-speaking Latino patients were more dissatisfied than English-speaking Latinos or non-Latino whites with medical staff listening, answering questions, providing support, and explaining medicines, procedures, and test results.5
Baker et al. found that Spanish-speaking patients who felt an interpreter was needed but was not used rated their providers as less friendly, less concerned for them as a person, and less likely to make them feel comfortable.15
Given the previously demonstrated link between dissatisfaction with care and poorer health outcomes, these findings suggest that Spanish-speaking patients not provided with an adequate means of communication with their health provider may be at particular risk.3,4
Our results indicate that language barriers can be overcome and patient satisfaction enhanced through the use of bilingual providers and adequate interpretation services.
While it would be ideal to have all patients without English proficiency see providers who spoke their native tongue, language-concordant providers are not always available. For instance, our walk-in clinic serves a large population of monolingual Spanish speakers, but only 1 out of every 5 providers can speak Spanish. In situations in which other means of communication must be employed, our study suggests that telephone interpreters may be equally effective at providing high levels of satisfactory care. In contrast, using untrained interpreters such as family or ad hoc interpreters seems to be a less acceptable way of overcoming language barriers. Proficiency of such untrained interpreters in both English and Spanish, particularly with respect to use of medical terminology, is not ensured. In addition, confidentiality issues may exist, especially when using family members.
The results of our study contrast with those of the only previous study to examine satisfaction with bilingual providers, as well as trained and untrained interpreters, among Spanish-speaking patients. Using a previsit questionnaire distributed at a primary care clinic, Kuo and Fagan asked patients to rate their past experiences with language interpretation and found the highest level of satisfaction for professional interpreters, followed by family/friend interpreters, language-concordant providers, telephone interpreters, and ad hoc interpreters.11
Several possible explanations may account for the differences in our study findings. Patients seen at an acute care clinic may have expectations regarding the role of family members in patient-provider interactions that are different from those of patients seen at a continuity clinic. Variations in provider ability to speak Spanish and mechanics of telephone interpreter use (i.e., having speakerphones available versus passing a handset back and forth) may also have existed. Assessing interpretation services after a specific clinic visit as opposed to evaluating past experiences may have led to differences in satisfaction ratings. Finally, employing a survey instrument different from that used by Kuo and Fagan may have had an impact on our study results.
The high level of satisfaction with telephone interpreters seen in our study indicates that the physical presence of a trained interpreter in the exam room may not be necessary to provide satisfactory interpretation services. This finding is consistent with the results of Hornberger et al., in which mothers at well-baby clinic visits rated remote-simultaneous interpretation superior to in-room professional interpreters.12
There are several limitations to our study. We did not examine satisfaction with professional interpreters because they were not readily available as a mode of interpretation at the time of our data collection. Furthermore, the method of interpretation used was not randomized and was determined by patient self-report. The Spanish version of our survey was not back translated from Spanish into English or tested or validated in Spanish, which may have resulted in less than optimal translation and limited its validity in our patient population. Because we evaluated walk-in clinic patients seeking care for presumably urgent needs, our findings may not be generalizable to other practice settings such as primary care, subspecialty, or surgical clinics. Data on the number of nonparticipants and how they might have differed from our study population was unavailable, but two spot checks done during the first and last month of the study showed that about half of the distributed surveys were completed and returned. We did not control for provider age, gender, level of training, specialty, or Spanish language aptitude, all of which might have influenced patient satisfaction. Because the surveys were done anonymously, we could not control for certain covariates, such as reason for and acuity of the clinic visit, that might be related to both the choice of interpretation method and satisfaction outcome. In addition, no provider-level information was collected during the survey process, so it was not possible to control for the concordance of gender and ethnicity between patient and provider. A prior study on patient satisfaction in both English- and Spanish-speaking patients did find that female gender was positively associated with patient satisfaction in women, but not men.16
Also, we did not restrict the use of proxies to assist patients in filling out the survey, and information on whether this occurred was not collected. Finally, placing surveys on patient charts prior to the patients being seen might have led to bias in how these patients were treated by their providers. However, we would have expected this to be consistent across both language-concordant and language-discordant patient-provider pairs.
Dealing with language barriers that may impact satisfaction among patients with limited English proficiency remains an increasing struggle in the medical community. It remains a challenge because of the need to provide quality care for patients, as well as to comply with Title VI. Our study suggests that bilingual providers and telephone interpreters enhance patient satisfaction compared to untrained interpreters. Further research examining satisfaction with professional interpreters versus telephone interpreters and comparing the cost per encounter for each method will help to further elucidate how best to serve this growing population of patients.