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Resident Physicians’ Use of Professional and Nonprofessional Interpreters: A National Survey
To the Editor: In 2000, the US Department of Health and Human Services Office for Civil Rights provided guidance regarding the Civil Rights Act of 1964, stating that denial of adequate interpreter services to patients with limited English proficiency is a form of discrimination.1 Insufficient use of professional interpreters and inappropriate reliance on ad hoc interpreters, including children, may compromise quality of care.2-3 However, research suggests that resident physicians rarely use professional interpreters, relying on their own inadequate language skills or on proficient colleagues, or avoiding communication with patients and families with limited English proficiency.4 To better understand training, practices, and problems in caring for patients with limited English proficiency, we conducted a national survey of resident physicians in 2004.
Methods
Detailed methods of this survey have been previously published.5 In brief, multistage sampling was used, first selecting 157 academic health center hospitals, then randomly selecting affiliated training programs in 7 specialties, and finally selecting all residents (with certainty) from each program except internal medicine, for which we randomly selected residents within each program. The final field sample was composed of 3435 eligible residents at 149 hospitals in 563 programs. The power to detect differences of ± 10 percentage points between 2 specialties (2-sided  = .05) was 73%. Return of the survey constituted consent. The protocol was approved by the Massachusetts General Hospital institutional review board.
Residents were asked whether they had received instruction in hospital procedures for: (1) obtaining medical interpreters; (2) rights of patients with limited English proficiency to have professional medical interpreters; (3) dangers of using untrained interpreters; and (4) other interpreter-related topics (Table 1). To assess practices, we asked about frequency of use of professional and nonprofessional interpreters (Table 2). To determine whether there were racial or ethnic differences in experiences, residents were asked to self-identify race/ethnicity from a list used by the American Medical Association and the Association of American Medical Colleges.
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Table 1. Resident-Reported Instruction in Topics Related to Linguistically Competent Care
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Table 2. Factors Associated With Resident-Reported Use of Professional Interpreters and Child Interpreters—Multivariate Logistic Regression*
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Multivariate logistic regression analyses were performed to identify factors associated with use of professional and child interpreters (sometimes or often), adjusted for instruction, access to medical interpreters, other problems delivering cross-cultural care, language abilities, reported limited English proficiency prevalence, and resident's demographic characteristics and specialty. Pooled analyses were weighted to correct for nonresponse and sampling within specialty strata. All statistical analyses were performed using SPSS software version 12.0 (SPSS Inc, Chicago, Ill).
Results
Responses were obtained from 2047 (60%) of 3435 eligible respondents. No instruction or very little instruction in assessing patient literacy and delivering care through medical interpreters were reported by 55% and 35% of respondents, respectively (Table 1). Receiving no instruction in other aspects of interpreter use was reported by 24% to 67% of respondents. All reported topics of instruction varied significantly with resident-reported limited English proficiency prevalence of their patient populations (P < .001).
When facing language barriers, 77% of residents said they sometimes or often used professional interpreters, 84% used ad hoc interpretation by adult family members and friends, 77% used other hospital employees, and 22% (including 37% of pediatric and emergency medicine residents) used children. More than half said they faced moderate or big problems in delivering cross-cultural care due to lack of access to medical interpreters (54%), lack of time (58%), and lack of access to written materials in other languages (62%).
Resident-reported amount of instruction was independently associated with use of professional interpreters (odds ratio, 1.9; 95% confidence interval, 1.4-2.5), but not with use of child interpreters (Table 2). However, instruction in limited English proficiency patients' legal rights to interpreters was significantly associated with decreased use of children (odds ratio, 0.7; 95% confidence interval, 0.5-0.9). Residents who reported lack of access to medical interpreters were less likely to report frequent use of professional interpreters (odds ratio, 0.6; 95% confidence interval, 0.4-0.8).
Comment
When facing language barriers, most resident physicians used untrained interpreters even though such practices may result in medical errors2 and decreased quality of care.6 For one fifth of residents, use of child interpreters was not rare, and was associated with reported high limited English proficiency prevalence. Our results suggest that training in patients' legal rights might reduce this practice, yet only half of residents received such instruction.
Resident physicians need to know not only how to obtain trained interpreters at their institutions, but also why they should use them and how to use them effectively. Although most residents were trained in basic procedures in obtaining interpreters, many were not taught techniques that could potentially reduce misinterpretation and errors. Instruction in linguistically competent care appears to be related to the appropriate use of interpreters, suggesting that the amount of training should not be dependent on the prevalence of patients with limited English proficiency. In addition to such instruction, providing linguistically competent care may require additional institutional resources including trained interpreters and multilingual written materials.
Author Contributions: Dr Weissman had full access to all of the data and takes responsibility for the integrity and accuracy of the data analysis.
Study concept and design: Lee, Winickoff, Kim, Campbell, Betancourt, Park, Maina, Weissman.
Acquisition of data: Kim, Betancourt, Weissman.
Analysis and interpretation of data: Lee, Winickoff, Kim, Betancourt, Park, Weissman.
Drafting of the manuscript: Lee, Winickoff, Kim, Weissman.
Critical revision of the manuscript for important intellectual content: Lee, Winickoff, Kim, Campbell, Betancourt, Park, Maina, Weissman.
Obtaining funding: Campbell, Betancourt, Weissman.
Statistical analysis: Winickoff, Kim.
Administrative, technical, or material support: Kim, Maina, Weissman.
Study supervision: Lee, Winickoff, Betancourt, Park, Weissman.
Financial Disclosures: None reported.
Funding/Support: This work was supported by grants from The California Endowment and The Commonwealth Fund.
Role of the Sponsors: The funding organizations were able to review and comment on the study design and on the content of the manuscript. They had no role in the conduct of the study; collection, management, analysis, or interpretation of the data, or final approval of the manuscript.
Note: Dr Lee is now with the US Public Health Service at the US Food and Drug Administration.
Karen C. Lee, MD, MPH;
Jonathan P. Winickoff, MD, MPH
Center for Child and Adolescent Health Policy
Massachusetts General Hospital
Boston
Minah K. Kim, PhD
Ewha Womans University
Seoul, South Korea
Eric G. Campbell, PhD;
Joseph R. Betancourt, MD, MPH;
Elyse R. Park, PhD
Massachusetts General Hospital
Angela W. Maina, BS;
Joel S. Weissman, PhD
jweissman{at}partners.org
Institute for Health Policy, Department of Medicine
Massachusetts General Hospital
1. US Dept of Health and Human Services Office for Civil Rights. Title VI of the Civil Rights Act of 1964: policy guidance on the prohibition against national origin discrimination as it affects persons with limited English proficiency. Fed Regist. 2000;65:52762-52774.
2. Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111:6-14.
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3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.4. Burbano O'Leary SC, Federico S, Hampers LC. The truth about language barriers: one residency program's experience. Pediatrics. 2003;111:e569-e573.
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5. Weissman JS, Betancourt J, Campbell EG, et al. Resident physicians' preparedness to provide cross-cultural care. JAMA. 2005;294:1058-1067.
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6. Elderkin-Thompson V, Silver RC, Waitzkin H. When nurses double as interpreters: a study of Spanish-speaking patients in a US primary care setting. Soc Sci Med. 2001;52:1343-1358.
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JAMA. 2006;296:1050-1053.
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