An Unspoken Inequity: Communication With Patients and Families With Limited English Proficiency

“Dolor?”

My ears perked up as I overheard the Spanish word for pain while prerounding on an early weekday morning. I followed the voice of my coresident and quietly observed as she continued to ask “dolor?” while pointing to various body parts on a young child. The patient’s father was communicating back by either nodding or shaking his head. As a Dominican woman fluent in Spanish, I introduced myself and gently offered to interpret. My coresident and the patient’s family offered me grateful smiles.

Although I was happy to help my colleague and this patient, I also felt unsettled, likely because of experiences I had growing up. As a child, I went to doctors’ appointments with my grandparents and witnessed interpreter experiences that ranged from outstanding to absent altogether. I watched as they were put in the awkward position of trying to communicate in broken English, while simultaneously feigning understanding of the broken Spanish spoken by health care providers. In thinking about these memories, I became frustrated. Why don’t health care providers request and use an interpreter each time one is needed? However, I cannot deny that I too have taken “shortcuts.” For example, I remember quickly talking to an Arabic-speaking family without an interpreter, using a hand signal to indicate that I would be back later. Yet although providers are certainly part of the problem, the core issue at hand is not with me or my coresident as individuals. The reality is that our health care system and culture remain inadequately prepared to ensure equitable communication with patients and families with limited English proficiency (LEP).

The scope of this issue in the field of pediatrics cannot be underestimated. One in 4 children currently have at least 1 immigrant parent, and by 2050, this number is expected to rise to 1 in 3.^1,2  A total 15% of American children have ≥1 parent with LEP, and 10% have parents who all have LEP.³  A closer look at the data reveals that among 30% of children who are Hispanic, and 27% of children who are Asian American, both parents have LEP.³  These numbers have continued to climb over the past decade, and further increases are projected.^1–3 

A growing field of research reveals that pediatric patients who have parents with LEP face inequities in care compared with their English-speaking counterparts. For example, in a recent study, researchers noted that hospitalized children of parents with LEP were twice as likely to experience medical harm.⁴  Additionally, parental LEP has been found to be independently associated with a higher risk of return visits to the emergency department resulting in admission and worse access to and quality of health care for children with special needs.^5,6  As more disparities are documented for this vulnerable population, our responsibility as pediatricians to develop equitable communication strategies continues to grow.

It is important to note that the use of interpreters is not just a personal or organizational preference, it is legally required by title III of the American Disabilities Act.⁷  Hospitals and providers are further bound by a mandate from the Centers for Medicare and Medicaid Services, which states that interpreter services must be made available to patients not fluent in English.^8,9  The importance of these directives is underscored by existing research that reveals that the use of interpreter services can help mitigate health care disparities in patients with LEP.¹⁰  Yet the sobering reality remains that interpreter services are significantly underused in pediatric clinical practice.^11,12 

As a trainee, I have personally witnessed how individual and systems-level elements combine to undermine the use of interpretation. To start, I have received no skills-based, hands-on education regarding interpreter use; and I am not alone, as literature indicates that residents often do not receive this training.¹³  During my intern year, I will never forget the moment when a kind interpreter shared that it is best practice to look only at the patient and not the interpreter during an encounter. I remember feeling embarrassed and also frustrated that this education was not standardized for all health care providers. Without the opportunity to practice appropriate interpreter interactions in a learning environment, I suspect that many clinicians may perceive this process as awkward or unfamiliar, contributing to lack of use. Second, although technological advances have resulted in a multitude of interpretation modalities, accessibility and functionality can vary. Wait times for the type of interpreter needed, connection issues, and device failures are all examples in which technology can be a barrier to accessing services. Finally, and perhaps most central to this discussion, there seems to be a culture in medicine, and in particular during residency training, that glorifies efficiency. This can lead to physicians at all levels subconsciously deprioritizing tasks that are perceived as less urgent or too time consuming, such as a conversation using an interpreter with a family with LEP. There is no getting around it: an interpretation encounter requires more time compared with an encounter solely in English, time which some providers, whether consciously or subconsciously, are reluctant to lose in the busy clinical environment.

The field of pediatrics thus finds itself in an uncomfortable reality that must be faced: we often do not communicate equitably with patients and families with LEP, and we are not adequately committed to eliminating this disparity. Although there is no one-size-fits-all solution, there are initial steps that we can take. To start, all health care providers should undergo training regarding the importance and use of interpreters. Didactic sessions can be helpful, but there are also novel educational initiatives that have been developed, such as simulation.¹⁴  This kind of hands-on learning allows providers to simulate clinical interactions with patients with LEP (using standardized patients) and interpreters and subsequently receive targeted feedback.

Beyond education, we must also facilitate a cultural shift in how we take care of this patient population. The opportunities for improvement are many: we should better identify patients who need interpreters, invest in reliable and functional technology, and rethink the way we conduct hospital rounds for those with LEP. Trainees in particular can help lead the way in reimagining inpatient rounds by ensuring interpreters are present, inviting interpreter and family clarification, and providing a clear “rounding script” that allows for all parties (medical staff, interpreters, and families) to understand the goal and flow of rounds. Health care systems could also consider creating processes that allow for patients and families themselves to request interpreters so that they can have more autonomy in how and when communication takes place with their care team. Importantly, it is critical to involve those with LEP, as well as interpreters, in the development of all of these potential solutions via focus groups and direct participation and feedback. Finally, the importance of role modeling cannot be underestimated; we all must make time for conversations that require an interpreter until the culture shifts so that this is no longer perceived as optional.

As I reflect on the experience of interpreting for my coresident that morning, I feel unsettled, frustrated, and guilty but also profoundly saddened. I cannot imagine what it must feel like to be in a hospital and not be able to effectively communicate with your health care team, which is how I believe my grandparents must have felt for many years. As pediatricians, it is time for all of us, starting with the most senior clinician to the first-year intern, to recognize that we have come up woefully short in caring for those with LEP and that we can and must do better.