In the Literature
Approximately 47 million people in the United States speak a language other than English at home, and more than 21 million have problems speaking or understanding English, according to the 2000 census. When seeking health care, patients with limited English proficiency (LEP) often have worse access to care and lower satisfaction levels compared with English speakers. A special supplementary issue of the Journal of General Internal Medicine (Nov. 2007), which includes three Commonwealth Fund–supported articles, examines language barriers in health care.
Promise in New Interpreting Method
While it has been shown that interpreting for LEP individuals can improve doctor–patient communication and facilitate the delivery of high-quality care, little is known about the relative effectiveness of different interpreting methods. In "The Impact of Medical Interpretation Method on Time and Errors," Francesca Gany, M.D., M.S., of New York University School of Medicine, and colleagues report that the use of remote simultaneous medical interpreting (RSMI)—the interpreting style used by the United Nations—results in fewer medical errors and is faster than three more commonly used interpreting methods. Kavitha Prakash, M.D., M.P.H., a 2002–03 Commonwealth Fund/Harvard University Fellow in Minority Health Policy, was a coauthor on this study.
Various interpreting methods have been used to bridge language gaps. Simultaneous interpreting is virtually a word-for-word running rendition performed almost simultaneously with the speech of the original speaker. Alternatively, with consecutive interpreting, the interpreter listens to the primary speaker then interprets after he or she is finished. The interpreter can be located in the room with the provider and patient (proximate interpretation), or outside the room and linked to the physician and patient via telecommunication (remote interpretation).
The authors find that "encounters were more accurately and quickly interpreted with RSMI than with the more commonly used methods" of remote consecutive medical interpreting, proximate consecutive medical interpreting, and proximate ad hoc interpreting (a common method that uses family or friends of patients or untrained hospital staff). For example, the researchers' analysis shows the non-RSMI interpreting approaches were associated with a 12-fold greater rate of potential medical errors of moderate or greater clinical significance, compared with RSMI. Meanwhile, RSMI encounters averaged 12.7 minutes versus 18.2 minutes for the next fastest mode, proximate ad hoc interpreting. While RSMI appears to be a promising option, the authors conclude that future studies are needed to examine comparative advantages, disadvantages, and cost-effectiveness.
Poor Overall Satisfaction Levels
In another study, "Patient Satisfaction with Different Interpreting Methods: A Randomized Controlled Trial," Gany and colleagues evaluated patients' satisfaction with several common medical interpreting approaches, including RSMI, proximate consecutive interpretation, over-the-telephone consecutive medical interpretation, and ad hoc interpretation. The team conducted a randomized controlled trial involving English, Spanish, Mandarin, and Cantonese speakers at a large New York City hospital. Language-discordant patients were randomly assigned to RSMI or one of the other interpreting methods. Patients with language-concordant providers received usual care. Seventy-one percent of patients who received RSMI reported that doctors treated them with respect, compared with 64 percent of patients who received the other methods.
Patients also rated RSMI as better than the other methods at protecting their privacy (51% vs. 38%). In measuring physician communication, language-discordant patients did not differ based on interpreting method. Patients in the language-concordant group, however, rated physicians more highly than patients using medical interpreting.
"Alarmingly, all groups reported poor satisfaction with important aspects of doctor–patient communication," the authors say, "in particular, feeling understood by their physician, understanding physicians' explanations of procedures and results, and understanding instructions for follow-up care." Results were worse, however, for patients in the interpreted medical encounter, indicating that current interpreting strategies do not completely approximate a language-concordant encounter.
Language Concordance and Quality of Care
In "Providing High-Quality Care for Limited English Proficient Patients: The Importance of Language Concordance and Interpreter Use," Quyen Ngo-Metzger, M.D., M.P.H., of the University of California, Irvine School of Medicine, and colleagues find that LEP Chinese and Vietnamese patients in cities throughout the United States reported receiving less health education and worse interpersonal care when compared with patients with language-concordant providers.
The researchers find the use of a clinic interpreter for language-discordant patients mitigated the health education effect, but not other problems, like poor quality of interpersonal care. Language-discordant patients were 61 percent more likely to rate their providers as fair or poor, compared with language-concordant patients. "Having an interpreter present," write the authors, "did not mitigate this effect, but in fact appeared to exacerbate it." Compared with language-concordant patients, language-discordant patients with an interpreter were significantly more likely to rate their providers as fair or poor compared with those without an interpreter.
One way to improve interpersonal care and satisfaction, say the authors, may be to provide more training. There are currently no minimum requirements for medical interpreter training. Providers, too, may also need more training on how best to use interpreters. Finally, the authors conclude, it is important to recruit and train more bilingual providers to meet the 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," they say.
