A Better Measure of Patients’ Need for Interpreter Services

As Karliner and colleagues discuss in their article “Identification of Limited English Proficient Patients in Clinical Care”1 in the current issue of the Journal of General Internal Medicine, the matter of knowing whether or not patients need the assistance of language access services is an important one. The limited English proficient (LEP) population in the US is large and growing2 and, as has been well documented, language barriers to access to medical care contribute to poor outcomes and health disparities in the LEP population.3,4 Unfortunately, many LEP patients still go without the help of interpreters and other language access services in their health care interactions.5 There are many reasons for this, but an important one is that many health care organizations do not know that their patients need these services and therefore cannot plan accordingly, either for the provision of interpreter services or for planning efficient use of existing services. The work by Karliner and her colleagues documents a practical, accurate method for screening patients for their need for linguistic access services that will make it easier for health care organizations to collect the data they need to adequately plan for and provide linguistic access services to their LEP populations. Their results will also likely become more valuable in the future if the Joint Commission on the Accreditation of Healthcare Organizations establishes standards regarding the provision of culturally competent patient-centered care, which is currently being explored.6 A necessary first step towards providing culturally competent care is knowing the population being served within a health care organization and the needs of that population Knowing a patient’s English proficiency prior to walking into the exam room is also valuable to individual physicians. Most physicians have had the experience where a patient “gets by” with the English that they know and somewhere in the encounter it becomes clear that the communication is not adequate. Worse yet, the physician may erroneously think the communication is adequate when it is not because the patient does not really understand what is being said. The patient may be reluctant to reveal his or her lack of understanding because of embarrassment, lack of awareness of what is being missed in the interaction, fear of being discriminated against or stigmatized because they don’t speak English, or desire to avoid a delay as an interpreter is accessed. In these situations communication is impaired and both the patient and physician are at risk. If patients needing an interpreter or other linguistic access services could be identified before an encounter, the physician could enter into that encounter with the power of that knowledge and take steps optimize communication. Research involving patients with LEP would also benefit from an accurate, practical method of identifying such patients. One of the barriers to conducting high quality studies of the impact on health and health care of language barriers and interpreter services is the lack of good data on who is LEP, especially patients identified through large clinical and administrative databases.7 Two short questions together have high specificity and sensitivity in identifying patients who would benefit from interpreter and other linguistic access services. These questions could be easily incorporated into surveys and clinical and administrative database, creating valuable resources for research. Clearly, knowing the language proficiency of patients is important and the two-question combined measure of English proficiency described in this issue of JGIM is an important contribution. This measure could be used at the policy, administrative, and health care delivery levels to plan for and improve the care delivered to LEP patients and, if incorporated into clinical and administrative databases, could enhance our ability to conduct quality research in LEP populations. This does not mean that the research is not without limitations. It would be important to see how well this measure holds up against patients’ actual English proficiency when tested, rather than their reported quality of communication and understanding, but it is an important first step towards the development of practical, short tools to identify LEP patients and those who would benefit from linguistic access services. Such a tool will go a long way in efforts to provide adequate care to the growing LEP population in the US and to evaluate the quality of that care.