Navigating Language Barriers under Difficult Circumstances

Key Summary Points Four factors must be considered when making decisions about language services: the clinical situation, the degree of language gap, available resources, and patient preference. As the clinical situation evolves, patient preferences and needs may shift, requiring ongoing assessment of the need for professional language assistance. Patients should be included in the decision about whether to call an interpreter. As a standard approach, patients should be informed that professional interpreters are available free of cost. Physicians using their own second-language skills must continuously assess for patient understanding. When an institution's interpreter services are inadequate, physicians should advocate for improvement. Minimum communication standards are needed for hospitalized patients with limited English proficiency. Physicians have a professional responsibility to ensure that patients with limited English proficiency receive similar care to that of patients who speak English. Mrs. A. , a 60-year-old diabetic woman who speaks Spanish, arrives in the emergency department with a chief symptom of burning with urination. Dr. B. examines her vital signs and finds that Mrs. A. has a fever. Dr. B. speaks very limited Spanish. A hospital interpreter is available, but not for 1 hour. Dr. B. wonders whether he should wait for a professional interpreter or proceed with the care of Mrs. A. using his own limited Spanish-speaking skills. This scenario is increasingly common. The proportion of the U.S. population with limited English proficiency nearly doubled from 1980 to 2000 and is projected to increase further (1). More than 20 million people in the United States speak little or no English. Federal laws mandate access to language assistance (2, 3), and hospital guidelines recommend routine use of professional interpreters (46). Interpreter services, however, are often limited and poorly integrated into clinical practice (6, 7). Clinician second-language skills and responses to language barriers vary widely (811). Many physicians feel uncertain about how best to care for patients with limited English proficiency and uneasy about the quality of care they provide (1216). Although suggestions have been made about the appropriate use of interpreters (17, 18), there has been little exploration of how to approach decisions about language services, particularly when such services are limited. We analyze common questions and provide a conceptual framework. Specifically, we describe factors that should inform the decision to call an interpreter, discuss who may be an appropriate interpreter, and offer strategies for when a professional interpreter is not available. Although we recognize that cultural barriers accompany language barriers (19), we focus on language services. We use the hypothetical case of Mrs. A. to illustrate how decisions about language services may evolve over time. What Factors Should Inform the Decision to Call an Interpreter? In this case, Dr. B. must decide whether to wait for a hospital interpreter, seek some other form of language assistance, or proceed using his own limited Spanish-speaking skills. Four factors must be considered when deciding whether to involve an interpreter: the clinical situation, degree of language gap, available resources, and patient preference. We consider each factor separately, then illustrate how they influence each other and may change during a clinical encounter. Clinical Situation Physicians commonly decide whether to use an interpreter on the basis of what information they need to make a diagnosis and provide treatment. In emergent clinical situations, physicians must provide care, even if language assistance is unavailable. In complex clinical scenarios, physicians are more likely to request an interpreter than for seemingly straightforward encounters (15). Although this approach is often reasonable, physicians also must understand the patient's perspective to accurately assess the severity and complexity of the clinical situation and address the patient's concerns (20, 21). For example, in our hypothetical case, Mrs. A. may also be experiencing severe abdominal pain and nausea. Without language assistance, Dr. B. might have missed this key information. Alternatively, Mrs. A. might have feared that her urinary symptoms were a sign of a sexually transmitted disease. Degree of Language Gap The need for an interpreter is easily recognized if the patient and physician do not share a common language. However, the degree of language gap is more difficult to assess when the patient or physician is partially fluent in the other's language. In such situations, physicians frequently attempt to get by using limited second-language skills (14, 15). Language skills are often directional, meaning that spoken ability may exceed understanding, or vice versa. For example, Dr. B. may be able to ask simple screening questions (such as Do you have abdominal pain? ) in Spanish, but not understand complex responses. In addition, vocabulary and fluency may be adequate for certain clinical scenarios but not for others. For example, Dr. B. 's vocabulary may be limited to symptoms commonly encountered in the emergency department, such as abdominal pain. Accurate assessment of one's own language skills is difficult. At a minimum, physicians providing care in a second language should be able to follow-up on a patient's responses and assess patient comprehension to avoid underestimating the language gap. Available Resources Availability, accessibility, and quality of interpreter services vary widely among institutions (6). Most hospitals have some mechanism to address language barriers for the most common languages, partly in response to laws that forbid discrimination based on primary language (2). However, institutional constraints may affect the type of interpreter available (that is, on-site professional interpreter vs. telephone interpreter vs. bilingual staff member), the wait time for an interpreter, and the quality of the interpreter. In the hypothetical case, Dr. B. has access to an on-site professional interpreter, but the wait time is 1 hour. Decisions to wait for an interpreter must balance the availability of language assistance with the urgency of the clinical situation. Patient Preference Physicians frequently make decisions about interpreter use without taking patient preferences into account. Many patients are not aware that they have a legal right to a professional interpreter at no cost (22). It can be challenging to assess patient preference in the setting of language barriers. Even when a physician has some skills in the patient's language, the power differential between physicians and patients may make it difficult for a patient to express a preference for formal language assistance over a physician's partial language skills. However, failure to elicit patient preference about use of an interpreter is associated with decreased patient satisfaction and may lead to poor adherence to treatment plans and overuse of medical services (2326). Patients should be offered a professional interpreter and be informed that interpreters are free and trained in confidentiality. Pulling the Factors Together How might Dr. B. take into account all 4 factors when deciding about language assistance for the patient? In assessing the language gap, Dr. B. discovered that Mrs. A. spoke very little English, but his Spanish was adequate to ask a few key questions and understand Mrs. A. 's yes and no responses. After the pertinent review of systems yielded negative results, Dr. B. decided that obtaining laboratory data was the appropriate next step in Mrs. A. 's care. With the help of a nurse who spoke somewhat more Spanish, he explained to Mrs. A. , I'm concerned you may have an infection. The hospital will provide a professional interpreter free of charge, but with a wait of 1 hour. I think it is important to proceed with blood and urine tests in the meantime. Mrs. A. expressed her understanding and agreement with this plan, a hospital interpreter was called, and a nurse was sent in immediately to draw Mrs. A. 's blood. The patient's blood and urine test results reveal that she has a high blood glucose level and a kidney infection. Under these circumstances, the initial decision to proceed without a professional interpreter was appropriate. However, the 4 factors informing the decision to request an interpreter will change over the course of an encounter. Because the data suggest that Mrs. A. has pyelonephritis, Dr. B. must now ensure that he has not missed anything in his initial limited history and examination, gather information about drug allergies and recent antibiotic use, explain the diagnosis and treatment to Mrs. A. , and address Mrs. A. 's questions and concerns. In reassessing his own language skills, Dr. B. will probably find that they are no longer adequate. In reassessing Mrs. A. 's preference, he may discover that she would now prefer to speak through a professional interpreter. At this stage, Dr. B. should use the hospital interpreter he requested earlier, assuming that the interpreter is now available. Mrs. A. is given intravenous fluids and antibiotics, and preparations are made for admission. Mrs. A. 's daughter arrives and offers to serve as an interpreter. The admitting physician, Dr. C. , speaks no Spanish. Dr. C. wonders whether she should accept the daughter's offer or call for a professional interpreter. Who Is an Appropriate Interpreter, and Who Decides? There are several different kinds of interpreters, each with advantages and disadvantages (Table 1). Again, the clinical situation, degree of language gap, available resources, and patient preference must be considered. Professional interpreters are the most skilled in medical interpretation, the least likely to make errors, and the only type of interpreter associated with overall improvement of care for patients with