Variable Use of Interpreters when Caring for Patients with Limited English: An Exploratory Survey Reveals Disparities

From the 2019 HVPAA National Conference

Dr. Maelys Amat (Beth Israel Deaconess Medical Center), Dr. Leonor Fernández (Beth Israel Deaconess Medical Center)

Background

“Getting by” is a well-described phenomenon: Residents and other staff sometimes attempt to communicate with patients who speak limited English without interpreters, often by having family members or others interpret despite their lack of training, or by communicating in English despite limited fluency. Little is known as to how often and why clinicians make these choices in the primary care setting and what hospitals can do to support effective and equitable care. We surveyed clinicians and other clinic staff regarding their experience of delivering outpatient care to patients with limited English at this large academic medical center primary care clinic.

Objective

To understand the experience of internal medicine residents, attending physicians and other staff regarding the care of patients with limited English in a primary care setting.

Methods

We created and distributed an online anonymous open link REDCap 14 item survey to all members of the clinical care process including resident physicians, attending physicians, nursing triage staff, medical assistants, front desk and phone staff.

Results

Response rate to our survey was 48%(30/62) among attending physicians and 20%(30/149) among resident physicians in our practice. 73% of resident physicians, 63% of attending physicians and 78% of all surveyed staff reported they interacted with LEP patients without an interpreter at least sometimes and 34% of all surveyed staff reported they interacted without an interpreter half of the time or more. 78% of all surveyed staff felt that lack of an interpreter at least somewhat impaired the quality of care provided. 29% said it impaired the quality of care substantially. Among all respondents, the main reasons for not using interpreters were: wait time (67%), chose to use a family member in the place of an interpreter (54%), patient preference (38%) or the assessment that the patient speaks sufficient English (37%). 84% of respondents believe that patients with limited English have worse or much worse access to care. In free text responses, residents cited time and access to interpreting services as the biggest obstacle to caring for these patients. Many also cited issues with communicating about labs/radiology results and other follow up.

Conclusions

Our survey suggests that clinicians and other staff involved in the clinical care of patients with limited English proficiency in this academic practice get by without interpreters frequently, often communicate through family members, and recognize that these decisions may impair care.

This survey also provided valuable insight through free text comments into the particular challenges faced by residents seeing patients with limited English. Residents described time constraints and other obstacles that reduce their ability to care for patients with limited English. Some pointed out that cultural and literacy differences often added complexity to these encounters.

Clinical Implications

The survey provided important data that enabled our practice to appreciate large variability in the care of patients with Limited English, and to understand the barriers to ideal care that need to be addressed. It provided a starting point for making the case for reducing variability. It revealed that that staff often find it difficult to access interpreter services in a timely way and that the majority believe that patients with limited English have decreased access to care. The survey is informing the work of a Task Force on linguistic access to articulate standards and process for optimal care of patients with limited English.

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