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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Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-first Century. Washington: National Academy Press; 2001.
Shin HB, Bruno R. United States Census Report: Language Use and English-Speaking Ability: 2000. Available at: http://www.census.gov/prod/2003pubs/c2kbr-29.pdf. Accessed November 17, 2008.
Woloshin S, Schwartz LM, Katz SJ, Welch HG. Is language a barrier to the use of preventive services. J Gen Intern Med. 1997;12(8)472–7.
Diehl AK, Westwick TJ, Badgett RG, Sugarek NJ, Todd KH. Clinical and sociocultural determinants of gallstone treatment. Am J Med Sci. 1993;305(6)383–6.
Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(12):1537–9.
Cheng EM, Chen A, Cunningham W. Primary language and receipt of recommended health care among Hispanics in the United States. J Gen Intern Med. 2007;22(S2):283–8.
Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. J Gen Intern Med. 1999;14(2):82–7.
Morales LS, Cunningham WE, Brown JA, Liu H, Hays RD. Are Latinos less satisfied with communication by health care providers. J Gen Intern Med. 1999;14(7):409–17.
Wilson E, Chen AHM, Grumbach K, Wang F, Fernandez A. Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med. 2005;20(9):800–6.
Atchison KA, Black EE, Leathers R, et al. A qualitative report of patient problems and postoperative instructions. J Oral Maxillofac Surg. 2005;63(4):449–56.
John-Baptiste A, Naglie G, Tomlinson G, et al. The effect of English language proficiency on length of stay and in-hospital mortality. J Gen Intern Med. 2004;19(3):221–8.
Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: A pilot study. Int J Qual Health Care. 2007;19(2):60–7.
Marcos LR. Effects of interpreters on the evaluation of psychopathology in non- English-speaking patients. Am J Psychiatr. 1979;136(2):171–4.
Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;11(1):16–14.
Flores G. Language barriers to health care in the United States. N Engl J Med. 2006;355(3):229–31.
Bard MR, Goettler CE, Schenarts PJ, et al. Language barrier leads to the unnecessary intubation of trauma patients. Am Surgeon. 2004;70(9):783–6.
Baker DW, Hayes R, Fortier JP. Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients. Med Care. 1998;36(10):1461–70.
Jacobs EA, Lauderdale DS, Meltzer D, Shorey JM, Levinson W, Thisted RA. Impact of interpreter services on delivery of health care to limited-English-proficient patients. J Gen Intern Med. 2001;16(7):468–74.
Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–54.
Burbano O’Leary SC, Federico S, Hampers LC. The truth about language barriers: one residency program’s experience. Pediatrics. 2003;111(5 Pt 1):e569–73.
Yawman D, McIntosh S, Fernandez D, Auinger P, Allan M, Weitzman M. The use of Spanish by medical students and residents at one university hospital. Acad Med. 2006;81(5):468–73.
Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275(10):783–8.
Schenker Y, Wang F, Selig SJ, Ng R, Fernandez A. The Impact of Language Barriers on Documentation of Informed Consent at a Hospital with On-Site Interpreter Services. J Gen Intern Med. 2007;22(S2):294–299.
Lee KC, Winickoff JP, Kim MK, et al. Resident physicians’ use of professional and nonprofessional interpreters: a national survey. JAMA. 2006;296(9):1050–3.
Karliner LS, Perez-Stable EJ, Gildengorin G. The language divide. The importance of training in the use of interpreters for outpatient practice. J Gen Intern Med. 2004;19(2):175–83.
Patton MQ. Qualitative Research and Evaluation Methods. Thousand Oaks, CA: Sage Publications; 2002.
Kroon C. Written Communication - Coordinator, Interpreter Education and Quality Improvement, Yale-New Haven Hospital. June 2007 and October 2008.
Garcia-Orme G, Dao, DM. Written Communication, Director of Interpreter Services, Interpreter Services Department Supervisor, San Francisco General Hospital. March 2006 and October, 2008.
Fernandez A, Schillinger D, Grumbach K, et al. Physician language ability and cultural competence. An exploratory study of communication with Spanish-speaking patients. J Gen Intern Med. 2004;19(2):167–74.
Morse JM. The Significance of Saturation. Qual Health Res. 1995;5(2):147–9.
Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine Publishing Company; 1967.
Crabtree BF Miller WL, eds. Doing Qualitative Research (Research Methods for Primary Care). Thousand Oaks, CA: Sage Publications; 1999: 33–46.
Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758–72.
Miles MB, Huberman M. Qualitative Data Analysis, 2nd edition. Thousand Oaks, CA: Sage Publications; 1994.
Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ. 1995;311(6996):42–5.
Saba GW, Wong ST, Schillinger D, et al. Shared decision making and the experience of partnership in primary care. Annals of Family Medicine. 2006;4(1):54–62.
Rivadeneyra R, Elderkin-Thompson V, Silver RC, Waitzkin H. Patient centeredness in medical encounters requiring an interpreter. Am J Med. 2000;108(6):470–4.
Ferguson WJ. Un Poquito: The benefits and perils of knowing “a little bit” of Spanish when communicating with Spanish-speaking patients. Health Aff. 2008;27(6):1695–700.
Schenker Y, Lo B, Ettinger KM, Fernandez A. Navigating Language Barriers under Difficult Circumstances. Ann Intern Med. 2008;149(4):264–9. August 19.
Regenstein M. Measuring and Improving the Quality of Hospital Language Services: Insights from the Speaking Together Collaborative. J Gen Intern Med. 2007;22(S2):356–9.
Klein KJ, Sorra JS. The Challenge of Innovation Implementation. Acad Manage Rev. 1996;21(4):1055–80.
Schyve PM. Language Differences as a Barrier to Quality and Safety in Health Care: The Joint Commission Perspective. J Gen Intern Med. 2007;22(S2):360–1.
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
- doctor–patient relationships
- physician behavior
- decision making
- qualitative research