There is a growing recognition of the importance of improving patient–physician communication and patient outcomes in cancer care (Epstein and Street 2007
). Yet little is known about how doctors circumvent language barriers when communicating with LEP patients. We find that, although 99 percent of physicians in our sample reported having cared for LEP patients in the 12 months before our survey, less than half reported good availability of trained medical interpreters or telephone language interpretation services when needed.
Our analysis finds significant structural differences (e.g., staff/group model HMO practice setting and large practice size) in predicting use of trained medical interpreters; use of telephone interpreters; and availability of these interpreter types. Physicians and office managers from small group practices have reported that high perceived cost was an important barrier to arranging for language access services, and many reported little experience using and paying for such services (Gadon, Balch, and Jacobs 2007
). Many physicians (62 percent) in our study are associated with small and solo practices and may face similar issues. In contrast, larger practice settings may have greater resources to offer trained medical interpreters or telephone services; they may also offer training to physicians and administrators on how to access and effectively use interpreters. Although the proportion of LEP patients was similar across practice settings, in larger practice settings, LEP patients may represent a larger absolute number of patients. Thus, larger practice settings may enjoy economies of scale sufficient to staff trained medical interpreters to assist physicians in their communications with LEP patients, or to contract with trained medical interpreter services at a lower per visit rate, as compared with smaller practices. Such organizations have the administrative capacity in place to identify and establish contracts with professional in-person and/or telephonic interpreter services, a level of administrative capacity that is likely lacking in many solo physician and small group offices. In addition, the staff/group model HMOs and large physician organizations are more likely to have the information technology capabilities to document and assess the prevalence of LEP patients in their enrolled populations.
Another possible explanation for the practice setting differences is greater levels of regulatory oversight. In Los Angeles, staff/group model HMOs and many of the network model managed care plans with whom larger physician organizations contract (Baumgarten 2005
) may participate in Medicaid managed care and/or Medicare Advantage. These larger organizations may be more likely to be scrutinized for compliance under California Department of Managed Health Care regulations regarding language access (California Department of Managed Health Care, http://wpso.dmhc.ca.gov/regulations/docs/2009ccr.txt
, accessed June 1, 2009; State of California, 1999
) than physicians in solo or small practices. Thus, these larger practice settings may have greater incentives to maintain good availability of trained medical interpreters and/or telephone language interpretation services available when needed. However, we lack data to analyze these potential pathways.
By identifying practice setting differences in the availability and use of trained interpreter and telephone language interpretation services, we believe we have identified mutable structural differences that may present opportunities for interventions to provide LEP patients with greater access to interpreters. Because many practices lack a sufficient number of LEP to achieve economies of scale, Medicare reimbursement for interpreters could provide additional resources needed to encourage providers to hire professional interpreters when needed (Ponce et al. 2006
We observe high rates of use, with no differences by practice setting, in the use of bilingual staff or patients' friends or family members. Other studies have found similar results regarding the prevalent use of patients' friends or family members as interpreters (Kuo and Fagan 1999
; Gadon, Balch, and Jacobs 2007
; Kuo et al. 2007
;). Such frequent reliance on patients' friends or family members as interpreters may be a result of patient or physician preferences, or limited availability of trained medical interpreters or telephone language interpretation services.
The prevalent use of bilingual staff not specifically trained in medical interpretation and patients' friends and family members as interpreters is noteworthy since prior studies comparing the quality of interpreting by trained medical interpreters to that of patients' family members found that, although both groups made errors, errors of clinical consequence occurred more frequently with untrained staff and patients' friends or family members (Flores et al. 2003
; Laws et al. 2004
; Flores 2005
; Karliner et al. 2007
;). Additionally, untrained interpreters have a tendency to take on inappropriate roles as advocates for certain treatment options, rather than impartially conveying information (Preloran et al. 2005
). Ideally, interpreters should facilitate communication without introducing their personal values; interpreters substituting their values or judgment for patients' is not consistent with articulated goals for patient-centered care. An additional clinical reality is that some LEP patients indicate a preference for having friends or family members interpret (Kuo and Fagan 1999
). We concur with earlier work that advocated that patients' friends or family members should participate in decision making
for patients who express such preferences (Matsumura et al. 2002
). However, involvement by family or friends should not be considered a replacement for trained medical interpreters or telephone language interpretation services in facilitating important communication tasks including information exchange (e.g., patient history and symptoms, risks and benefits of different treatment options), discussing areas of uncertainty, making decisions, enabling patient self-management, responding to patient emotions, and fostering a healing relationship (Epstein and Street 2007
A limitation of this study is that our analyses rely on physician self-report data. Because we asked physicians to recall interpreter use during the preceding 12 months, recall bias may have been an issue, though we have no reason to suspect systematic over or underreporting across practice types. Our study could not characterize the quality of the interpreter skills for physicians who reported communicating with their LEP patients without an interpreter. Additionally, this study has no measure of the quality of interpreters available to respondents, though evidence suggests there may be differences in effectiveness among different interpreter types (Flores 2005; Flores et al. 2003
; Laws et al. 2004
; Karliner et al. 2007
;). Thus, we are unable to conclusively determine the quality or proficiency of trained medical interpreters or other interpreters.
It should be noted that our survey response categories were not worded to ask specifically about “professional, in-person” interpreters: the survey response category “trained medical interpreter” was used to represent this concept. A limitation of this study is the absence of standard national or state certification associated with health care interpretation. As a corollary, levels of training among professional interpreters, both in-person and telephonic, vary widely, and physician respondents may have been unaware of actual levels of training of professional in-person or telephonic interpreter services they used. We developed categories describing interpreter services used by physicians treating women with breast cancer in Los Angeles County following review of the literature and policy reports on health care interpreting (Kuo and Fagan 1999
; Kravitz et al. 2000
; Sarver and Baker 2000
; Tanjasiri 2001
; Downing and Roat 2002
; Fagan et al. 2003
;) after discussions with staff at community-based organizations in Los Angeles County involved with the training and provision of medical interpreter services to health care organizations throughout Los Angeles County. These discussions revealed concerns that interpreters in health care settings require facility with medical terminology as well as with conventional language. Because our main goal was to understand how physicians use interpreter services in the clinical setting, we chose a taxonomy that highlighted the term medical
. With our survey, physicians reported on the availability of “trained medical
interpreters; telephonic language interpretation services; bilingual staff not specifically trained in medical interpreting; and patients' friends or family members.” While we recognize that not all providers will be able to describe the training of their interpreters, physicians serve as excellent informants for reporting use and availability of interpreters who translate both medical terms
and conventional language
. A limitation is that these categories did not specifically ask about a “professional-in-person” interpreter; instead trained medical interpreter (which could have included some in-person and some telephonic interpreters) was used. We are, however, able to distinguish provider and practice setting characteristics that predict use of these interpreter types as compared with clearly ad hoc interpreters (e.g., bilingual office staff or patients' friends or family members), for whom it is reasonable to assume no specific training in medical interpretation.
Although this study inquired about availability of interpreters when needed, the study does not further characterize the elements necessary to access professional interpreters (i.e., knowledge of interpreter services, cost of interpreter services, challenges in hiring, or scheduling interpreter services). Further study is needed to identify additional factors, particularly cost, that may influence physician use of trained medical or telephone language interpreter services (Gadon, Balch, and Jacobs 2007
This study does not specifically examine the impact of interpreters on LEP patients' satisfaction or outcomes, because we relied on provider self-report data. However, this report of providers' responses to communication barriers faced by LEP patients gives important new data on variations in use of interpreters of different types across practice settings, a topic not previously explored in the literature on physician report of strategies for communicating with LEP patients. This work will facilitate future interventions designed to improve communications with LEP patients by providing a foundation for understanding mutable structural aspects of care.