Language barriers complicate physician–patient communication and adversely affect healthcare quality. Research suggests that physicians underuse interpreters despite evidence of benefits and even when services are readily available. The reasons underlying the underuse of interpreters are poorly understood.
To understand the decision-making process of resident physicians when communicating with patients with limited English proficiency (LEP).
Qualitative study using in-depth interviews.
Internal medicine resident physicians (n = 20) from two urban teaching hospitals with excellent interpreter services.
An interview guide was used to explore decision making about interpreter use.
Four recurrent themes emerged: 1) Resident physicians recognized that they underused professional interpreters, and described this phenomenon as “getting by;” 2) Resident physicians made decisions about interpreter use by weighing the perceived value of communication in clinical decision making against their own time constraints; 3) The decision to call an interpreter could be preempted by the convenience of using family members or the resident physician’s use of his/her own second language skills; 4) Resident physicians normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care.
Although previous research has identified time constraints and lack of availability of interpreters as reasons for their underuse, our data suggest that the reasons are far more complex. Residents at the study institutions with interpreters readily available found it easier to “get by” without an interpreter, despite misgivings about negative implications for quality of care. Findings suggest that increasing interpreter use will require interventions targeted at both individual physicians and the practice environment.
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Dr. Diamond was supported during this research by the Robert Wood Johnson Clinical Scholars Program and the United States Department of Veterans Affairs. Dr. Schenker is a General Internal Medicine Fellow at UCSF, funded by the Department of Health and Human Services, Health Resources and Services Administration (DHHS HRSA D55HP05165). Dr. Bradley is supported by the Patrick and Catherine Weldon Donaghue Medical Research Foundation Investigator Award. Dr. Fernandez is supported by an NIH Career Development Award (K23-RR018324-01).
The data presented in this manuscript were presented at both the California Regional Society of General Internal Medicine Meeting in San Francisco, CA in March of 2008 and the Society of General Internal Medicine Annual Meeting in Pittsburgh, PA in April of 2008.
Conflict of Interest
Appendix: Standard Interview Guide with Probes
Appendix: Standard Interview Guide with Probes
Thinking back to your last rotation at [HOSPITAL], please tell me about a time when you used an interpreter (either someone informally or someone from interpreter services)? (If person says they never use interpreters, skip to #3)
Tell me about your decision to call an interpreter.
What clinical task were you trying to accomplish/why call? (e.g. inability to communicate, informed consent, end of life care, treatment planning, discharge instructions, etc.)
What’s your routine practice when caring for patients who don’t speak English well? How often do you use interpreters?
Does your resident/attending care/know about your practices?
Do you ever regret calling/not calling?
Tell me about how it worked.
Did you call interpreter services or did you get someone else who was around to help you interpret?
Probes if interpreter services was called:
Who came to help?
Perceived utility/accuracy of interaction?
How did the interaction go?
Were there any surprises?
Probes if non-professional interpreter called:
Who helped you interpret? (Nurse, medical assistant, housekeeping, family member?)
Tell me how that went.
How did you find the person to help?
Perceived utility/accuracy of interaction?
Were there any surprises?
Tell me about a time when you didn’t use an interpreter for a patient who wasn’t fluent in English? What was that like?
What clinical task were you trying to accomplish (informed consent, end of life discussion, discharge planning, etc)?
Do you think that not using an interpreter affected the task?
What made you decide not to use an interpreter?
Did you let anyone know you did not use an interpreter?
Can you think of a time that communication trouble with non-English speaking patients has lead to errors or near-misses? Tell me more about that.
What would make it easier for you to use interpreters?
Systems changes, increased staff awareness/education, training in the use of interpreters, awareness of their availability and how to get them quicker, other supports?
If you could make one recommendation to the hospital about how to better communicate with and care for patients with limited English proficiency, what would it be?
Is there anything else you think we should know about residents’ use of interpreters?
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Diamond, L.C., Schenker, Y., Curry, L. et al. Getting By: Underuse of Interpreters by Resident Physicians. J GEN INTERN MED 24, 256–262 (2009). https://doi.org/10.1007/s11606-008-0875-7