From our study, we found that Spanish-speaking patients cared for by language-concordant physicians were not more likely to receive recommended screening for cardiovascular risk factors and cancer compared to those cared for by language discordant physicians. In contrast, it appears that Spanish-speaking patients were less likely to receive colorectal cancer screening and tetanus vaccination if cared for by a language concordant PCP.
Previous research has found that Latinos with limited English proficiency are less likely to receive cardiovascular risk factor and cancer screening compared to English proficient Latinos.3–5
Ethnically diverse patients are also less likely to get breast and cervical cancer screening if they have an ethnically concordant PCP.23,24
Interestingly, our study did not suggest a potential benefit between patient-physician language concordance and adherence to screening outcomes. In fact, we observed a possible detrimental association of between patient-physician language concordance and colorectal cancer screening. We found these results to be somewhat surprising as we were expecting to see the opposite trend, that is, Spanish-speaking patients having higher screening rates with Spanish-speaking physicians. There may be a few plausible reasons why patients with limited English proficiency in our study did not have higher screening rates with language concordant physicians. One possible reason for the null findings is our high rate of screening for hyperlipidemia, diabetes, cervical and breast cancer, limiting our ability to detect differences between the concordance groups.
Our most surprising finding was that the language discordant group was more likely to get colorectal cancer screening and tetanus immunizations compared to the language concordant group. Our study was not able to determine the reasons for this difference. One possibility is that Spanish-speaking physicians are not aggressive in convincing patients to undergo colorectal cancer screening. There actually may be some unrecognized obstacle for discussing colonoscopies within the language concordant group. For example, it may be that a Spanish-speaking Latino physician may not feel as comfortable talking about an invasive procedure to a patient of the same ethnic and/or cultural background compared to a non-Spanish-speaking physician using a third party interpreter. Alternatively, it could be that Spanish-speaking PCPs are more likely to explain procedures and complications of colonoscopy or side effects of vaccinations than English-speaking PCPs who may be ordering tests without detailed explanation. Also, there may be competing interests given time constraints. We found in an earlier study that Spanish-speaking physicians may be more likely to counsel on other topics such as diet or exercise in this same population.
A recent survey demonstrated low levels of colorectal cancer screening among Korean American patients with limited English proficiency cared for by Korean American physicians.25
A follow-up study conducting in-depth interviews of these physicians, mostly foreign-born, demonstrated that there were multiple barriers to recommending colorectal cancer screening.26
These included physician lack of awareness, perceived patient understanding of screening/preventive medicine, perceived patient non-compliance, hesitation to deal with abnormal results, hesitation to deal with upset patients or their families, and lack of insurance coverage. Our study, in conjunction with these previous studies, may dispel the assumption that patient-physician ethnic and/or language concordance would necessarily improve quality of care.
There were several limitations to our study. First, this was a retrospective study based solely on medical record data. However, given our primary outcome was screening, we felt the medical record would be more reliable than asking patients directly. Our study population comes exclusively from Massachusetts, which may not be representative of the Latino population in the U.S. As the assignment of patients to providers was not randomized, there are several possible confounding factors that may have accounted for our largely negative findings. This is also an extremely small sample size, particularly the number of Spanish-speaking providers, so our results were not generalizable. We also did not compare our findings with English-speaking patients, particularly those cared for by our Spanish-speaking physicians. Thus, we do not know if the observed differences are truly a function of language concordance as opposed to a function of individual providers. We tried to partially adjust for this by using generalized estimating equations. We did not have graded measure of English or Spanish language ability. This study therefore does not differentiate between patients who have different levels of English and Spanish fluency.
In past studies, patient-physician language concordance has been shown to improve some aspects of patient care, particularly patient satisfaction. However, although many clinics in this country attempt to match patients with providers who speak their language, our study does not support this practice. It remains unclear whether patient-physician language concordance does indeed lead to better outcomes. Further research is needed to examine under which conditions are optimal to improve cardiovascular and cancer screening for Spanish-speaking patients, particularly for colorectal cancer which has a low rate of screening.