Hablamos Juntos eUpdate is a periodic electronic newsletter that focuses on current developments in improving patient-provider communication for individuals with limited English proficiency (LEP). Read about the latest language services advancements and activities of the Hablamos Juntos program, our grantees and beyond.

Three New Physician Studies on Language Barriers
New Resources for Language Services
Announcements

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High quality safe care is a top priority for physicians and health care organizations. It is an unwavering benchmark, yet many research studies show that the current health care system is faltering in its efforts to always provide high quality, safe care. Patient populations with language or cultural barriers are the most at risk. A growing body of research on health disparities between ethnic groups shows that being a member of a minority group in the United States, in and of itself, can be a barrier to health care. Patient populations unable to speak English are extremely challenging for physicians. The welcomed news is that leading national physician associations are looking for ways to make a difference as communities become more diverse and the number of patients unable to speak English increases.

Physicians are fundamental to health care delivery and patient communication is vital for safe, quality care. Understanding physician perspectives on communication barriers is imperative to effective solutions. Recently, three major physician associations released studies on the challenges their members face. This article highlights the findings from these studies to take stock of what is new since the study conducted for Hablamos Juntos by Lake, Snell and Perry (LSP) in 2004 .

Source: US Census 2000 – American Fact Finder

These statistics turn into real patients for Internal Medicine physicians. The proportion of populations with LEP and the languages they speak are represented in local physician practices. An American College of Physicians (ACP) study reports two thirds of adult physicians have LEP patient caseloads on average of about 12%; more than half (54%) see LEP patients daily or a few times a week. Nearly 2/3 of internist practices (64%) provide some language services to LEP; most often (84%) of these services are provided by a physician who is bilingual; speaks English and at least one other language. On average 39% of internist patients are over 65 years of age. Nationally, Spanish is still the most common language spoken by LEP patients. In places like New York City there are over 100 different languages spoken. Internist, s participating in the study, reported seeing LEP patients from more than 80 languages. We found, in the LSP study, that this type of language diversity translates into individual practices seeing patients who speak one of six or seven different languages.

Demographic trends are also affecting pediatricians. Nearly half (45%) of American children under age 5 are children of color. Not surprising only 13% of pediatric practices reported seeing no LEP patients according to an American Academy of Pediatrics (AAP) survey designed to learn how pediatricians are addressing language barriers. Interestingly, this study found LEP patients are concentrated in practices with female, Latino and younger pediatricians. The most common way to communicate with LEP patients are still through family members or friends; 2/3 of the time for pediatricians and more so in rural practices. In states with large LEP populations, pediatrician are more likely to use bilingual providers than professional interpreters. Less than half of pediatricians use professional interpreters and only 1/3 report having materials in the language of their patients.

In focus groups of physicians in small practices with large and recent LEP growth, an American Medical Association (AMA) study found specialists schedule interpreters in advance for LEP patients and note these encounters in the medical record. The most common strategy used by specialists was telephonic interpreter services because they had access to multiple languages and believe these individuals may be versed in medical terminology. In contrast, the ACP study found on-site (also referred to as in-person) or remote (generally accessed via telephone) interpreters provided by language agencies or contractors were least likely to be used to interpret and few practices had formal mechanisms to obtain patient primary language data.

The AMA study found physician responses to language barriers were driven by practical concerns and ambivalence about using untrained interpreters – family and friends. This study captures well the dilemma physicians face in using family and friends and how practice characteristics contribute to the type of solutions favored. Physicians understand the problems that language barriers and use of ad hoc interpreters pose to providing safe care and potential misinterpretation. It is less clear whether using untrained interpreters is connected to increased malpractice risk, the potential effects on quality of care or increased opportunity for medical errors. Nonetheless, convenience, lack of alternatives and often patient preference for family or friend interpreters make untrained interpreters the most popular solution.

These studies capture a snapshot of responses and challenges confronting physicians in practice. Each offers unique insights, with different foci and study objectives to note a number of unanswered questions that merit further research. They also report creative practical approaches emerging in physician practices like non-personnel tools such as electronic health records with multilingual patient handouts; pre-printed forms and drug information with multilingual medical phrases and cheat sheets with translations of words and phrases. Physicians and support staff able to speak a language other than English are also tapped for practices with growing LEP patient populations.

Amidst broader societal changes physicians continue to struggle on their own to deliver quality safe patient care. The struggle is basic with physicians acknowledging “near misses”, reliance on less than adequate solutions which include hand gestures, using pictures and speaking loudly as a means of improving communication with LEP patients. Oftentimes, reimbursement is seen as a key solution to compensate physicians for the additional time and effort required by LEP patients or as strategy for increasing the use of professionally trained medical interpreters. But within these studies, is the seed of doubt about the effectiveness of reimbursement strategies, in the face of time and attention constraints of busy medical practices. These studies show how few opportunities there are within office practices nationally and that physician organizations are beginning to focus on a practice concern affecting growing numbers of their members. With national associations looking more closely at this issue physicians are not alone and national associations can create opportunities that do not now exist.

The three studies discussed are:

• American College of Physicians (ACP) – “Language Services for Patients with Limited English Proficiency: Results of a National Survey of Internal Medicine Physicians”
• American Academy of Pediatrics – “Pediatricians’ Use of Language Services for Families with Limited English Proficiency”
• American Medical Association – “Caring for Patients with Limited English Proficiency: The Perspectives of Small Group Practitioners”