“Getting By” Is Not “Good Enough”: A Resident Perspective on Communication With Families With Limited English Proficiency

Across medical specialties, families with LEP are at higher risk for poor health outcomes than families with English proficiency, such as higher rates of admission and emergency department revisits and more serious medical events and errors, as well as lower rates of satisfaction, medication adherence, and health care access.^3–5  Although the cause of these disparities is multifactorial, lack of communication and interpreter use have negative effects on patient outcomes.

As pediatricians, we understand the value of family-centered care, such as improved communication, satisfaction, and understanding of care; however, families with LEP receive fewer of these benefits. In critical care settings, these families are less likely to participate in rounds and shared decision-making, ask questions, and understand the plan of care compared with families with English proficiency.^6,7  Spanish-speaking families report lower confidence in their knowledge of discharge goals and medications.⁸  These factors likely play an important role in the worse outcomes for LEP families.

The decisions we make as providers about methods of communication influence patient outcomes. Although all interpreters make communication errors, those made by ad hoc interpreters are significantly more likely to have potential clinical consequences than those made by certified interpreters.⁹  Trained professional interpreters improve health outcomes by decreasing communication errors, increasing satisfaction with communication and clinical services, improving patient comprehension, and equalizing health care use.¹⁰  When compared with ad hoc interpreters, professional interpreters raise the quality of clinical care and level the playing field for patients and families with LEP.¹⁰ 

Understanding caregiver and provider perspectives on interpreter use during medical encounters is important in addressing individual and systemic barriers to effective communication.

There are many studies examining the interpretation preferences of families with LEP and their experiences in health care settings. Although most existing studies have been focused on Spanish-speaking families, some findings may be applied to other populations. In interviews with Latina mothers in 2 urban settings, mothers described their experiences navigating the health care system as a “battle.” They had a strong preference for bilingual providers over interpreters for decreased risk of misinterpretation and better rapport but frequently settled for providers who “got by” with limited Spanish skills because of embarrassment and fear of discrimination or being a burden.¹¹  Similar themes emerged in focus groups of Spanish-speaking families discussing family-centered rounds, with participants reporting lack of empowerment to request an interpreter or to admit they did not understand aspects of their child’s medical care.¹² 

Multiple studies reveal a strong preference for face-to-face interaction through video or in-person interpretation.^11,13  On a general pediatrics inpatient unit, all caregivers who received video interpretation reported completely understanding their child’s medical condition, followed by 93% for live interpreters and 77% for certified physicians.¹³  Preference for face-to-face interaction may not always hold true in the case of untrained interpreters. In a pediatric outpatient clinic, mothers with LEP reported higher satisfaction and understanding with telephone interpreters compared with ad hoc interpreters; however, providers believed that their patients preferred ad hoc interpretation.¹⁴  In other studies, authors agree that patients are less satisfied with ad hoc interpreters.^9,10  Families with LEP have clear preferences for interpretation in medical encounters, but this is frequently not achieved.

Although access to professional interpreters has improved, a 2010 American Academy of Pediatrics survey indicated that only 56% of providers used a certified interpreter when communicating with families with LEP.¹⁵  Limited access to in-person interpreters, technological challenges of accessing virtual interpreters, time spent waiting for interpreters of specific dialects, and the slower pace of conversation are commonly cited barriers to interpreter use. Providers consider the context of conversation, patient complexity, and perceived language proficiency when deciding to use an interpreter.^16–18  Similar to families, providers prefer face-to-face methods, and, during encounters using these modalities, are less likely to revert to speaking English with a family with LEP.¹⁹  In a 2003 study, pediatric residents consistently acknowledged that certified interpreters are the most effective method of communication but instead chose to “get by” when communicating with patients and families with LEP, using limited language skills or family members rather than an interpreter. Or worse, some residents admitted to avoiding conversations entirely.¹⁶  More recent publications reveal similar trends, with residents continuing to communicate without certified interpreters across medical specialties, regardless of proficiency.^18,20 

There is much work to be done on individual and institutional levels to ensure that patients and families with LEP receive certified interpretation. Although telephone or video interpreters are more accessible compared with in-person interpreters, they are underused and pose significant challenges. Medical interpreter certification for providers and staff is a cost-effective solution that can expand in-person interpretation services. All providers with second language skills should undergo language proficiency testing, and, if eligible, can become certified to deliver bilingual care directly to patients. Additionally, it is imperative that health care institutions not only prioritize building a diverse workforce that reflects their patient population, but also aim to better understand how to apply evidence-based communication practices that are responsive to the needs of the local community. Quality improvement initiatives can effectively tailor interventions to meet a community’s needs while creating a targeted approach to addressing barriers to appropriate interpretation at the hospital or institution level.

As noted by our personal experiences, residents face added barriers to using interpreter services, including time constraints and pressure to gain approval from their attending physicians. Teaching hospitals should incorporate interpreter-use training into residency curricula, which could improve efficiency and lead to greater interpreter use among residents. Resident feedback could be a useful tool in holding attending physicians accountable to model best practices for interpreter use and communication with families with LEP. Education on the benefits of certified interpreters and the known interpretation preferences of families with LEP should be a core component of resident education, as well as for providers and staff at all levels, and could empower trainees to advocate for appropriate interpretation for their patients.

Now more than ever, as the coronavirus disease 2019 pandemic disproportionately impacts communities of color and highlights racial disparities within our health system, consistent access to professional interpretation is a critical step toward achieving equitable health care for vulnerable populations. Everyone is entitled to meaningful access to health care services, and for patients and families with LEP, this begins with simply communicating fluently in their preferred language. “Getting by” should never be “good enough.”