Health care systems in the United States continue to face challenges in optimizing medical care for a diverse and growing multilingual patient population. Research has demonstrated numerous health disparities in the medical care provided to patients who use a non-English language for medical communication.1–3 Differences in care have led to more serious adverse events, longer hospital stays, and lower patient satisfaction for individuals who use a non-English language for medical care.1–3 A commitment to providing equitable care for non–English-speaking patients requires removing the label “limited English proficiency” (LEP) that has been widely used in clinical care and research for decades. It is time to examine the negative connotations embedded within this terminology and propose new terminology that reflects a respectful and responsive approach to providing high-quality care, regardless of patients’ language needs.
The term LEP was initially coined in 1975, after the landmark Supreme Court case Lau v Nichols when the Court unanimously decided that the lack of supplemental language education in public schools for students with LEP violated the Civil Rights Act of 1964.4 Decades later, in 2000, President Clinton signed Executive Order 13166 that required all federal agencies and organizations to provide meaningful access to language services to those with LEP.5 This federal regulation set the precedent for numerous policy decisions, including the mandated provision of language services for immigrant populations within the U.S. health care system.4,5 The term LEP is currently defined as “an individual who does not speak English as their primary language and who has a limited ability to read, write, speak, or understand English.”5 LEP provided legal terminology to help federally regulate language access in the United States. However, this label also implies flawed and problematic issues of this patient population that should not go unaddressed.
In an article published in the Journal of Immigrant and Minority Health by Ortega et al, the authors explain key concepts about the problematic assumptions of the LEP terminology.6 The language surrounding the term LEP reinforces an ethnocentric view of English as the ideal language.6 Language can be used as an instrument to demonstrate our relative positions of power or lack thereof in a particular setting.7,8 When patients who use a non-English language are labeled as LEP, it centers on English and reinforces its importance as the dominant language within the health care setting. This notion inadvertently implies that speaking English is central to good communication and thus crucial to quality services and appropriate care. This dominant language ideology contributes to further marginalization of patients who use a non-English language for medical care.
Stigmatizing labels can negatively influence clinician attitudes and behavior toward patients.8 In addition to reinforcing an ethnocentric view of English as the preferred language, another significant challenge is that the term LEP encases the individual’s language ability in a deficit orientation.6 Patients termed with having LEP come from a diverse range of linguistic backgrounds, including being fluent in more than one non-English language or being conversant in English yet still preferring an interpreter for medical discussions. The term LEP propagates a deficit-based view of these varied skills and fails to acknowledge that language ability and comfort is contextual. In some cases, patients may need or want an interpreter for clinical care but communicate socially in English quite well. A few years ago, a similar argument occurred within the U.S. education system, leading to a replacement of the term LEP student with English language learner and emergent multilingual learner.9 Educators noted that the label LEP emphasized the students’ perceived deficits rather than viewing bilingualism as a positive emerging asset.9 Labeling with terms such as “limited ability” or “limited proficiency” fails to recognize the diverse languages, language abilities, and fluidity of language application for many patients. Additionally, the term LEP is imprecise terminology because it often does not reflect the questions we ask patients when identifying their language for care. In health care settings, the questions are typically related to language preference or interpretation needs rather than an actual assessment of an individual’s ability to communicate in English. Therefore, there should be terminology that accurately depicts the questions patients are asked and is also a positive descriptor that acknowledges the contextual nature of language.
In the current health care system, language services are often viewed as an additional burden for clinicians.10,11 Previous studies have demonstrated that clinicians in multiple settings underuse professional interpreters even when language services are readily available.10,11 One study reported that fewer than one-third of outpatient physicians regularly use a trained professional interpreter when communicating with patients who use a non-English language for clinical care.11 A “language deficit” framework draws attention solely to the patient’s limited English language abilities rather than the collective communication needs of both the patient and the clinician.6 Health systems should view language as an effective diagnostic, educational, and relational tool for providing equitable care to all patients.6 Shifting away from a deficit-based viewpoint of the patient acknowledges both the patient and provider language needs. This reframes language services as not only a tool benefiting patients, but also a tool that enables clinicians who lack skills in non-English languages to efficiently care for a linguistically diverse patient population.
Instead of using limited English proficiency, we propose a shift in terminology to refer to patients as using a “language other than English” (LOE) for medical discussions. Ortega et al suggest replacing LEP with a new term called “non-English language preference” (NELP) and define the term to mean “individuals who prefer a non-English language with respect to a particular type of service, benefit, or encounter.”6 Currently, there is no consensus on which new terminology better reflects an accurate and inclusive concept of appropriate language services in medicine. We suggest LOE instead of non-English language preference because, for some individuals, a language selection is not a preference between multiple alternatives. For some individuals, there is a single language choice that is required for communication. In addition, the term LOE eliminates the need to decipher the rather vague concept of “limited English ability” embedded in the legal definition of LEP. LOE allows for the contextual nature of language, promoting a patient-centered approach that acknowledges the nuances and diversity of language needs within a medical setting.
There is a potential health care effect in using new terminology like LOE rather than LEP in clinical care, research, and advocacy efforts. Although the transition may cause some temporary confusion, moving away from the ethnocentric view of English as the primary language of health care and from a deficit view of language skills is necessary to promote an inclusive, strength-based approach to delivering multilingual care.6 Equitable and efficient language practices consider both the needs of the patient and the clinician. A new conceptualization of appropriate language care, away from the term LEP, avoids overlooking the responsibility of health care systems to address the systemic limitations that contribute to inequitable language access.6 The health care system and clinicians have a responsibility to view the communication needs as much their own burden as the patient’s. Because the health care system serves a growing multilingual population, the term LOE more appropriately reflects a necessary change toward prioritization of language services as an indispensable tool for quality patient care.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
COMPANION PAPER: A companion to this article can be found online at https://doi.org/10.1542/hpeds.2022-007019.