“Getting by” in a Swiss Tertiary Hospital: the Inconspicuous Complexity of Decision-making Around Patients’ Limited Language Proficiency

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Abstract

<div class="section"> <a class="named-anchor" id="d187849e139">  </a> <h5 class="section-title" id="d187849e140">Background</h5> <p id="Par1">While the need to address language barriers to provide quality care for all is generally accepted, little is known about the complexities of decision-making around patients’ limited language proficiency in everyday clinical encounters. </p> </div><div class="section"> <a class="named-anchor" id="d187849e144">  </a> <h5 class="section-title" id="d187849e145">Objective</h5> <p id="Par2">To understand how linguistic complexities shape cross-cultural encounters by incorporating the perspective of both, patients and physicians. </p> </div><div class="section"> <a class="named-anchor" id="d187849e149">  </a> <h5 class="section-title" id="d187849e150">Design</h5> <p id="Par3">A qualitative hospital study with semi-structured interviews and participant-observation in a Swiss University Hospital. Thirty-two encounters were observed and 94 interviews conducted. </p> </div><div class="section"> <a class="named-anchor" id="d187849e154">  </a> <h5 class="section-title" id="d187849e155">Participants</h5> <p id="Par4">Sixteen patients of Turkish and 16 of Albanian origin and all actors (administration, nurses, physicians, if required, interpreters) involved in the patients’ entire process. </p> </div><div class="section"> <a class="named-anchor" id="d187849e159">  </a> <h5 class="section-title" id="d187849e160">Main Approach</h5> <p id="Par5">Interviews were audio-recorded and transcribed verbatim. A thematic content analysis was conducted using MAXQDA. For reporting, the COREQ guidelines were used. </p> </div><div class="section"> <a class="named-anchor" id="d187849e164">  </a> <h5 class="section-title" id="d187849e165">Key Results</h5> <p id="Par6">Three themes were relevant to patients and physicians alike: Assessment of the language situation, the use of interpreters, and dealing with conversational limits. Physicians tend to assess patients’ language proficiency by their body language, individual demeanor, or adequacy of responses to questions. Physicians use professional interpreters for “high-stakes” conversations, and “get by” through “low-stakes” topics by resorting to bilingual family members, for example. Patients are driven by factors like fearing costs or the wish to manage on their own. High acceptance of conversational limits by patients and physicians alike stands in stark contrast to the availability of interpreters. </p> </div><div class="section"> <a class="named-anchor" id="d187849e169">  </a> <h5 class="section-title" id="d187849e170">Conclusions</h5> <p id="Par7">The decision for or against interpreter use in the “real world” of clinical care is complex and shaped by small, frequently inconspicuous decisions with potential for suboptimal health care. Physicians occupy a key position in the decision-making to initiate the process of medical interpreting. The development and testing of a conceptual framework close to practice is crucial for guiding physicians’ assessment of patients’ language proficiency and their decision-making on the use of interpreting services. </p> </div>

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

Quyen Ngo-Metzger, Dara H. Sorkin, Russell Phillips … (2007)

Background Provider–patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients. Objective We examined the effects of language discordance on the degree of health education and the quality of interpersonal care that patients received, and examined its effect on patient satisfaction. We also evaluated how the presence/absence of a clinic interpreter affected these outcomes. Design Cross-sectional survey, response rate 74%. Participants A total of 2,746 Chinese and Vietnamese patients receiving care at 11 health centers in 8 cities. Measurements Provider–patient language concordance, health education received, quality of interpersonal care, patient ratings of providers, and the presence/absence of a clinic interpreter. Regression analyses were used to adjust for potential confounding. Results Patients with language-discordant providers reported receiving less health education (β = 0.17, p < 0.05) compared to those with language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care (β = 0.28, p < 0.05), and were more likely to give low ratings to their providers (odds ratio [OR] = 1.61; CI = 0.97–2.67). Using a clinic interpreter did not mitigate these effects and in fact exacerbated disparities in patients’ perceptions of their providers. Conclusion Language barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction. Having access to a clinic interpreter can facilitate the transmission of health education. However, in terms of patients’ ratings of their providers and the quality of interpersonal care, having an interpreter present does not serve as a substitute for language concordance between patient and provider.

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Getting by: underuse of interpreters by resident physicians.

Leslie A Curry, Scott Diamond, Elizabeth H Bradley … (2009)

Language barriers complicate physician-patient communication and adversely affect healthcare quality. Research suggests that physicians underuse interpreters despite evidence of benefits and even when services are readily available. The reasons underlying the underuse of interpreters are poorly understood. To understand the decision-making process of resident physicians when communicating with patients with limited English proficiency (LEP). Qualitative study using in-depth interviews. Internal medicine resident physicians (n = 20) from two urban teaching hospitals with excellent interpreter services. An interview guide was used to explore decision making about interpreter use. Four recurrent themes emerged: 1) Resident physicians recognized that they underused professional interpreters, and described this phenomenon as "getting by;" 2) Resident physicians made decisions about interpreter use by weighing the perceived value of communication in clinical decision making against their own time constraints; 3) The decision to call an interpreter could be preempted by the convenience of using family members or the resident physician's use of his/her own second language skills; 4) Resident physicians normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care. Although previous research has identified time constraints and lack of availability of interpreters as reasons for their underuse, our data suggest that the reasons are far more complex. Residents at the study institutions with interpreters readily available found it easier to "get by" without an interpreter, despite misgivings about negative implications for quality of care. Findings suggest that increasing interpreter use will require interventions targeted at both individual physicians and the practice environment.

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Cross-cultural primary care: a patient-based approach.

J Carrillo, Douglas R. Green, Joseph Betancourt (1999)

In today's multicultural society, assuring quality health care for all persons requires that physicians understand how each patient's sociocultural background affects his or her health beliefs and behaviors. Cross-cultural curricula have been developed to address these issues but are not widely used in medical education. Many curricula take a categorical and potentially stereotypic approach to "cultural competence" that weds patients of certain cultures to a set of specific, unifying characteristics. In addition, curricula frequently overlook the importance of social factors on the cross-cultural encounter. This paper discusses a patient-based cross-cultural curriculum for residents and medical students that teaches a framework for analysis of the individual patient's social context and cultural health beliefs and behaviors. The curriculum consists of five thematic units taught in four 2-hour sessions. The goal is to help physicians avoid cultural generalizations while improving their ability to understand, communicate with, and care for patients from diverse backgrounds.