Providing High-Quality Care for Limited English Proficient Patients: The Importance of Language Concordance and Interpreter Use

According to the 2000 census, approximately 47 million people in the United States speak a language other than English at home and over 21 million have limited English-language skills.1 Limited English proficient (LEP) individuals often have worse access to care2‐5 and rate their health care more negatively6‐9 compared to English speakers. Language barriers have been found to adversely impact the quality of medical care that patients receive, resulting in longer hospital stays,10 more medical errors,11 and lower patient satisfaction.12,13

One way to overcome language barriers is to provide LEP individuals with access to medical providers who speak their language. Research has shown that patients with diabetes and hypertension reported better health outcomes when their physicians spoke their native language.14 Spanish-speaking patients who saw language-concordant physicians asked more questions and had better understanding than those who saw language-discordant (non-Spanish-speaking) physicians.15 Patients with language-discordant providers have been found to be less satisfied with their care and less likely to return for follow-up care.7‐9,16 In other studies, LEP patients with language-discordant physicians had more problems understanding medication instructions,17 and had more medication-related problems.18

Although language-concordant medical visits are ideal, most LEP patients do not have access to providers who speak their language.19 Until the provider work force becomes more racially/ethnically and linguistically diverse, many LEP patients will have medical providers who speak only English. For these language-discordant medical encounters, some type of interpreter service is often used. Even with the use of an interpreter, the quality of provider–patient interpersonal care and the degree of health education received have been found to be suboptimal.20,21 However, most of the studies on language barriers and interpreter use have been conducted among Spanish-speaking patients and their monolingual English-speaking providers.

Asian Americans, many of whom are immigrants and have limited English proficiency, are one of the fastest growing demographic groups in the United States.22 Yet little is known about language barriers and interpreter use among Asian-American patients. In this study, we wanted to assess the quality of care of LEP Chinese and Vietnamese American patients who had providers who did not speak their language (language-discordant) as compared to those with language-concordant providers. We examined whether LEP patients with language-discordant providers received as much health education as those with language-concordant providers. We also examined whether language discordance was associated with lower-quality interpersonal care and lower patient satisfaction. Furthermore, for language-discordant visits, we sought to evaluate how the presence or absence of a clinic interpreter affected patients’ receipt of health education, the quality of interpersonal care, and ratings of providers.

Language barriers between providers and patients result in poor quality care. Our study found that LEP patients with language-discordant providers were less likely to receive health education compared to those with language-concordant providers. They also reported worse interpersonal care and were less satisfied overall with their providers.

In language-discordant visits without a clinic interpreter, LEP patients were significantly less likely to receive health education. When an interpreter was available, our results indicated that the degree of health education received was similar to language-concordant visits. In other words, having a clinic interpreter allowed health education to occur, whereas not having an interpreter limited the discussion of health promotion issues.

In contrast, having a clinic interpreter present during language-discordant visits did not mitigate the disparity in the quality of interpersonal care for language-discordant visits compared to language-concordant visits. In fact, patients who used an interpreter had twice the odds of rating their provider as fair or poor compared to those with language-concordant providers.

The findings of our study suggest that having language concordance between providers and patients is still the optimal situation. When a language barrier exists between doctors and patients, having a clinic interpreter present will allow the transmission of information such as health education. However, a clinic interpreter may not completely ameliorate the language barrier and may interfere with other aspects of the patient–provider relationship. Interpersonal care and patient satisfaction were lower in these visits compared to visits where patients and providers spoke the same language and did not need an intermediary person to translate.

Our findings are consistent with previous studies conducted among Spanish-speaking patients. A study of LEP Spanish speakers conducted in a hospital emergency department found that patients with language-concordant providers reported the highest levels of understanding of their diagnoses and treatment plans.20 Although having an interpreter was better than not having one, patients with language-concordant physicians reported the best outcomes. In another study of communication, language-concordant visits resulted in better interpersonal care compared to visits that required an interpreter.30 In language-discordant visits, patients were more likely to have their comments ignored by the providers, even in the presence of an interpreter. Other studies conducted among patients recruited from a walk-in clinic31 and hospital emergency department21 also found that patients who communicated through an interpreter were less satisfied with their providers overall and less satisfied with their providers’ interpersonal care compared to those with language-concordant providers.

There are several limitations to our study. We only studied Asian-American patients who spoke Vietnamese, Cantonese, or Mandarin Chinese. Our results may not be generalizable to patients of other racial/ethnic groups who speak other languages, although the consistency of our results with other studies in Spanish-speaking populations is noteworthy. We also examined only patients who had a visit to a primary care provider within the last month. Our results may not be generalizable to those who, because of linguistic or other barriers, did not receive medical care recently. In addition, our health education measure included discussions about smoking, which may not be relevant for nonsmokers. However, it is unlikely that this affected our findings, as smokers and nonsmokers were likely to have been evenly distributed across language concordant versus discordant providers. Although we measured whether or not the patient used an interpreter provided by the clinic, we were not able to ascertain whether the interpreter was ad hoc staff or professionally trained. Ad hoc interpreters are “individuals whose primary job function in the health care setting is something other than interpretation,” whereas professional interpreters are “those individuals whose sole function in the health care setting is to interpret.”32 Studies have generally found fewer errors in medical interpretation when professional interpreters were utilized instead of ad hoc staff or family members.33‐35 Finally, because of the study’s cross-sectional design, we can only determine associations and not causality.

Nevertheless, this is 1 of the largest studies of language discordance and interpreter use among LEP patients. It has some important policy implications. First, in language-discordant visits, it is unlikely that much health education can take place without an interpreter. An interpreter is essential to overcome the language barrier and allow meaningful communication to occur. The majority of LEP patients in the United States still lack access to interpreter services.36 The use of interpreters has been linked to more appropriate medical and preventive care services37,38 and follow-up.16 Having access to professional interpreters may also be cost-saving overall, especially in the context of visits to the emergency department.39,40 The U.S. Department of Health and Human Services recognized the lack of adequate interpretation as a form of discrimination, and developed a set of mandates and guidelines for culturally and linguistically appropriate services (CLAS).41 The CLAS standards require that health care organizations offer and provide language assistance services to LEP patients, and exclude the use of family members as interpreters except by the specific request of the patient. Yet most LEP patients with language-discordant providers still do not have access to interpreters but rather “do the best they can in English.”19 In a recent study done in California, only 9% had access to a professional interpreter, whereas the majority relied on family members or friends for translation.19 The health care system needs to invest in the training of more professional interpreters and also in providing reimbursement for their services.42

However, having access to a professional interpreter is only the first step in overcoming the language barrier. Our study, similar to other studies among Spanish-speakers,20,21,31 suggests that interpersonal care and patient satisfaction may still be lower for language-discordant visits compared to visits where patients and providers are able to communicate directly without an intermediary. In fact, our findings suggest that, whereas having an interpreter present may facilitate the transmission of information, it may also negatively affect patients’ opinions about the quality of their health care providers. One way to improve interpersonal care and satisfaction may be to provide more training for interpreters and for providers. There are currently no minimum requirements for medical interpreter training. The National Council on Interpreting in Health Care recommends at least 40 hours of instruction on medical terminology, interpreting skills, ethical issues, role playing, and cultural awareness.43 In addition, providers also need more training on how to optimally use interpreters. In a recent study of clinicians who provide care to LEP patients, the majority of clinicians reported difficulties eliciting exact symptoms, explaining treatment, and eliciting patient preferences, even with the use of an interpreter.44 However, providers who had previous training on how to use interpreters appropriately were the most satisfied with their ability to communicate with LEP patients.

Although interpreters are a necessary solution to the problem of language barriers in health care, our findings suggest they are likely to be an imperfect one. It remains important that our health care system recruit and train more bilingual providers to meet the health care needs of an increasingly diverse population. Increasing recruitment and retention of bilingual students into medical school will be a first step toward providing more language-concordant care for LEP Americans.

The numbers of LEP patients in the United States are unlikely to diminish. Providers and health care systems must be prepared to take care of these patients. Ways to reimburse for professional interpreter services need to be incorporated into the current health care payment system. Furthermore, the quality of interpreter services must be monitored. Finally, federal, state, and local health organizations should provide incentives for the recruitment of bilingual medical providers to serve in geographic areas with a large number of LEP patients. These policies can lead to narrowing the gap and improving medical care for LEP patients.