In this qualitative study, resident physicians described not using professional interpreters for their patients with LEP, a routine practice termed “getting by.” Although residents in our study knew how to access interpreter services and recognized that interpreters contribute to better care, they made decisions about interpreter use after weighing the benefits of accurate communication against competing demands on their time. For routine patient care, residents in our study reported that they got by using gestures, limited second language skills and/or family members, while often reserving the use of professional interpreters for interactions they perceived as being complex or having high stakes. Many residents in our study felt dissatisfied with the care they provided to patients with LEP and frustrated by the inequities in care they perceived.
Our interviews suggest that there are complex and interrelated factors underlying resident physician decisions about interpreter use. First, resident physicians in our study seemed to view communication mainly as a means of gathering necessary clinical data, and less as an opportunity to address the concerns of their hospitalized patients. In this view of communication, primarily weighing the clinical stakes when making the decision to call an interpreter is reasonable. Physician-centered communication, while not unusual36
, may be more common in the setting of language barriers37
. Such limited communication also has important implications for rapport building and the connection between physicians and patients that lies at the heart of the therapeutic relationship38
. Second, residents in our study were often unaware of the difficulties associated with using untrained interpreters, particularly family members, and reported discovering the disadvantages of this approach over time. Coupled with a physician-centered view of communication, this lack of awareness rendered the convenience of using family members an even more attractive option. Third, residents in our study made decisions about professional interpreter use in an environment in which underuse of interpreters was common, standards for communicating with patients with LEP were unclear, and other aspects of care were more valued. Under such circumstances, these residents found it difficult to change their individual practice, despite misgivings about the quality of care provided.
Our study suggests that increasing professional interpreter use will require interventions at both the level of the individual physician and the practice environment. At the physician level, education about the challenges of caring for patients with LEP, including the potential for adverse outcomes associated with the use of untrained interpreters, and the advantages of using professional interpreters to achieve accurate communication and improved understanding of cultural differences may help resident physicians make appropriate decisions about interpreter use25,39
. Professional standards regarding appropriate use of second language skills by resident physicians should be established to help guide those who choose to use these skills. Finally, resident physicians need role models to reinforce appropriate use of professional interpreters. Recognition from supervising physicians that appropriate use of language services will improve the safety and quality of care for patients with LEP has the potential to translate into behavior change for physicians-in-training.
At the level of the practice environment, increasing professional interpreter use requires establishing clear norms and structural changes, as has been observed in several quality improvement efforts40,41
. Hospitalized patients with LEP should have a conversation in their preferred language with their treating physician at least daily. Meeting this standard will require substantial changes in the hospital practice environment. Such changes are most likely to be successful if they are endorsed by senior hospital leadership and are viewed as patient safety and quality improvement efforts40,42
. The use of routine and novel technology, such as computer-order entry for interpreter services, wireless speaker phones, interpreter kiosks, and video interpreting, may also help to increase professional interpreter use.
Although this study has important implications for the care of patients with LEP, there are limitations to consider. We focused our recruitment on internal medicine resident physicians at two large, urban teaching hospitals. Accordingly, the experiences of our participants may not reflect the experiences of physicians who have completed their post-graduate training, resident physicians in other medical specialties, or physicians in other geographic areas. At the same time the two hospitals in which the study took place have diverse patient populations, robust interpreter services, and well-regarded residency training programs, suggesting that our findings may apply to other institutions. Additionally, all of the study participants were graduates of US medical schools and most were born in the US, which, while reflective of the demographics of the residency programs studied, is not representative of most national internal medicine residency programs. The use of interpreters by resident physicians born or trained outside of the US may differ and is an important topic for future study. The participants’ language abilities were assessed using one screening question, which has been used in previous studies but has not been validated24
. Further research is needed to develop standards for assessing language proficiency in physicians and to determine the proficiency level at which providing language-concordant care is appropriate. Finally, our study was qualitative in nature, and therefore not designed to quantify the frequency of nonuse of professional interpreters. Our findings do offer insight into why professional interpreters are underused and thus can be helpful in designing interventions to improve the use of professional interpreters.
In our study, resident physicians described complex reasons for their underuse of professional interpreters. These findings suggest that increased interpreter service availability and education for residents about how to access interpreter services are unlikely to be sufficient to change patterns of interpreter use. Quality improvement efforts that focus on integrating language services into the hospital environment while changing organizational and professional norms about communication with patients with LEP are needed.