Education intended to reduce language barriers can also potentially contribute to disparities among LEP patients. Accordingly, institutions and/or individuals who develop and teach these courses need to take care to avoid contributing to the problem they are intending to address. This can be done by making sure that teaching interventions are of high quality and that their impact on use of interpreters and on physician’s own limited non-English language skills is monitored.
Based on our experience and review of the literature,31
we have identified five teaching topics that should be included in any high-quality educational intervention that focuses on overcoming language barriers to health care: (1) the role language barriers play in contributing to health disparities, (2) what the best interventions are for reducing the risk of disparities when caring for LEP patient populations, (3) how to work with an interpreter, (4) how to recognize when an interpretation is not going well and what to do about it, and (5) when it is appropriate and safe to use one’s own non-English language skills. In Table , we outline what should be taught under each of these topics and recommend methods for teaching them. We elaborate on each of these recommendations below. Of note, we do not recommend the course duration or minimum number of individual sessions. We believe that the content and quality of the teaching are more important than the absolute amount of time devoted to it.
Recommended Curriculum Modules for Teaching Clinicians How to Overcome Language Barriers in Health Care
For the first topic, there is plenty of evidence in the literature that language barriers or use of inappropriate interpreters leads to worse quality of care and outcomes2,32–34
and increases the risk of adverse events.5,6
The use of ad-hoc interpreters, including family members or untrained bilingual staff, can lead to misunderstandings, misdiagnoses, and medical errors.6,7
In addition, anecdotes or first person accounts in the literature of how lack of or poor interpretation can lead to poor outcomes are very powerful and should also be included in this teaching module.
The second module on the best methods of overcoming language barriers should include teaching on how non-professional or ad hoc interpreters (e.g., family, friends, untrained staff, etc.) can impair adequate communication and how professional interpreters are the best solution. In this module, the ability of professional interpreters to provide accurate, neutral, and complete information should be the focus. It is important to discuss how ad hoc interpreters likely do not have the skill or ability to provide accurate complete interpretation and that their relationship to the patient may interfere with communication and negate the confidentiality of the encounter. For example, a daughter interpreting for her father, upon hearing a cancer diagnosis, could decide not to interpret everything the physician says because she believes she is protecting him. Then the focus should be on how use of professional interpreters (via any method: in person, telephonic, or video) reduces the likelihood of this potential problem.
The third module should focus on how best to work with interpreters, including role-modeling either in person or on video vignettes and role-playing to practice this skill. Clinicians should be taught to position the interpreter next to and somewhat behind the patient, so that patient-clinician eye contact, rapport-building, and relationship are not disrupted.35
In this module, it is also a good idea to teach clinicians what to do in a situation in which they have no choice but to use an ad hoc interpreter. The focus should be on maximizing the quality of the interpretation using a non-professional interpreter. This can include making sure the clinician speaks as simply as possible to increase the likelihood that their words can be interpreted and giving the ad hoc interpreter permission to stop at any point to clarify vocabulary (in either language) or discuss any discomfort from being in the interpreter role. It should be acknowledged that there are times when ad hoc interpreters must be used, but students should be reminded why this should be avoided and that the use of children as interpreters is unethical and should never be done.36
Addressing the potential use of ad hoc interpreters highlights the importance of the fourth module, in which students are taught how to recognize when an interpreted encounter is not going well. This is most important in the context of using an ad hoc interpreter when problems of communication most likely will arise. This includes attending carefully to what is happening with the patient and the flow of information. The clinician must always attend to whether or not the patient’s expression, voice, and/or demeanor match what the interpreter is saying and if the amount of information the physician or the patient is giving is matched by what the interpreter is saying. In addition, the clinician needs to make sure that the interpreter is not interjecting his or her own opinion or agenda. If any of these happen, then the clinician should stop and clarify the interpreter’s role—to provide accurate, neutral information.
In the final module, there should be a discussion of what to do when the clinician speaks the patient’s language, but not fluently. Unfortunately, there is no research available to know how fluent a clinician needs to be to be able to safely provide care in a language other than English, and, as a result, there are no current standards for when it should be allowable.37
It is known, however, that care provided by non-fluent physicians can be as problematic as care provided by using ad hoc interpreters.11,15
So, unless a physician is fluent in the patient’s language, they should consider using a professional interpreter. However, they should always be encouraged to use their non-fluent second language skills to establish rapport and conduct a simple physical exam, but not for more complicated interactions.