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Lorna M. Breen, MD
Medical College of Virginia, Richmond

JAMA. 1999;282:819.

According to the 1990 US Census Bureau, 31.8 million residents, or 14% of the population 5 years old and older, reported speaking a language other than English at home.¹ The most common non-English language spoken at home was Spanish (17.3 million) followed by French (1.9 million), German (1.5 million), Chinese (1.3 million), and Italian (1.3 million). Seven states—New Mexico, California, Texas, Hawaii, New York, Arizona, and New Jersey—reported that 20% or more of their residents did not speak English at home.¹

Clear communication between the physician and patient is an obvious requisite for effective health care delivery, but how is this best accomplished when English is not the common language? While it may seem that the most logical solution would be to use interpreters whenever possible, many hospitals do not employ professional interpreters.² Also, existing interpreters may be underused if physicians and nurses overestimate their own language skills or those of the patient. Some physicians may simply be uncomfortable with the potential for information distortion that can occur through an interpreter.

Another common approach to communicating with patients who do not speak English is to use ad hoc interpreters such as family members, friends, or hospital employees. While this may be convenient, the interpretations may not always be accurate. One study³ showed that between 23% to 52% of words and phrases were incorrectly translated by ad hoc interpreters. A drawback to letting family members interpret is that one sacrifices patient confidentiality. Cultural mores may lead non–English-speaking patients to withhold more information than one might otherwise expect. Friends and family often are not prepared to deal with the complexity required by an interpretation of medical information.

Perhaps the ideal solution to establishing clear channels of communication between physicians and patients would be to recruit multilingual medical personnel in hospitals serving large non–English-speaking populations. The multilingual physician can immediately evaluate a non–English-speaking patient without having to seek out and wait for an appropriate interpreter to arrive, and the fear of mistranslation or shades of meaning being misinterpreted would be removed. Studies have shown that language concordance also leads to increased patient adherence.⁴

Is it possible for busy medical students to become completely fluent in other languages? Many medical schools now offer foreign language electives. However, data suggest that these courses may not adequately prepare students for interactions with non–English-speaking patients. A study of 8 first-year resident physicians who had completed a 45-hour medical Spanish program at the Stanford University/Kaiser Emergency Medicine residency program concluded that although medical language courses may be a useful adjunct to interpreters, significant errors occur when course participants assume their language proficiency is sufficient.⁵

Keep in mind that traditional modes of communication, which may be the most readily available, are not the only option. Patient education audiotapes exist in various languages. Also, AT&T has a toll-free Language Line Service, that will connect you with an interpreter in the language of your choice (with up to 140 different languages) 24 hours a day, 7 days a week. Lastly, there has been some movement toward the use of "remote-simultaneous interpretation," which uses cellular phone technology to link trained interpreters to the people who need them most (Table 1).

View this table: [in this window] [in a new window] Table. Strategies for Communicating With Non–English-Speaking Patients

Encounters with non–English-speaking patients are common, especially in metropolitan areas with large immigrant populations. With increased recognition of the difficulties posed by multilingualism as well as the growing number of solutions, we can hope that the treatment of non–English-speaking patients will become less problematic as we enter the 21st century.

AUTHOR INFORMATION
For more information about the William Carlos Williams Poetry Contest for Medical Students, visit the MSJAMA Web site at www.ama-assn.org/msjama.

REFERENCES
1. US Bureau of the Census. US Department of Commerce Economics and Statistics Administration. Census Questionnaire Content, 1990 CQC-16. Washington, DC: US Bureau of the Census;1990. 2. Baker DW, Parker RM, Williams MV, et al. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275:783-788. FREE FULL TEXT 3. Ebden P, Bhatt A, Carey OJ, et al. The bilingual consultation. Lancet. 1988;1:347. WEB OF SCIENCE | PUBMED 4. Manson A. Language concordance as a determinant of patient compliance and emergency room use in patients with asthma. Med Care. 1988;26:1119-1128. FULL TEXT | WEB OF SCIENCE | PUBMED 5. Prince D, Nelson M. Teaching Spanish to emergency medicine residents. Acad Emerg Med. 1995;2:32-37. WEB OF SCIENCE | PUBMED 6. Putsch RW. Cross-cultural communication—the special case of interpreters in health care. JAMA. 1985;254:3344-3348. FREE FULL TEXT 7. Bal P. Communicating with non-English-speaking patients. BMJ. 1981;283:368. FREE FULL TEXT

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