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Interpreters and communication in the clinical encounter

2000; Elsevier BV; Volume: 108; Issue: 6 Linguagem: Inglês

10.1016/s0002-9343(00)00317-x

1555-7162

Eliseo J. Pérez‐Stable, Anna Nápoles‐Springer,

Language, Discourse, Communication Strategies

Since 1965, the United States has experienced a second cycle of mass immigration, with a majority of the immigrants coming from Latin America and East Asia. Nearly 14% of the US population, almost 32 million people, speak a language other than English in their homes; in California, the proportion of non-English speakers exceeds 30%. The number of persons with limited proficiency in English is likely to increase, and this population may be at greater risk of poor outcomes of health care. Patients are not routinely asked if an interpreter is needed, and the decision to use one often depends on the clinician’s judgment. In this issue of the The American Journal of Medicine, Rivadeneyra and colleagues (1Rivadeneyra R. Elderkin-Thompson V. Cohen Silver R. Waitzkin H. Patient centeredness in medical encounters requiring an interpreter.Am J Med. 2000; 108: 470-474Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar) report a study of patient-physician communication across language barriers. In a community-clinic setting, the authors studied 38 patients who were stratified by language ability. Their hypothesis was that English-speaking physicians would be less likely to provide patient-centered encounters to patients requiring an interpreter. Patient-centered care was defined by analyzing the clinical encounter and categorizing patient “offers” and physician responses to these offers. Patient offers included any topic or question introduced by the patient during the encounter that was not a response to a direct question from the physician. Clinical encounters were videotaped and coded, and English- and Spanish-speaking patients were compared. Monolingual Spanish-speaking Latinos using interpreters were significantly less likely to make offers to their physicians in five of the six defined categories. The language barrier resulted in a significantly lower patient-centeredness score for the Spanish-speaking patients that was independent of ethnicity. This study begins to address what would seem to be intuitive. Clinical encounters that depend on an interpreter may not achieve the same amount or quality of communication when compared with language-concordant encounters. In this study, all of the patients were being seen for the first time, and thus may not have had the opportunity to develop trust in the physicians. Effective communication through an interpreter may take twice as much time, so development of trust in the physician may require several visits. However, the patients in this study were relatively young and did not have obvious chronic illness. These differences would be expected to be greater in older and chronically ill patients, as well as hospitalized patients. A study from a refugee clinic in Seattle among patients with diabetes showed that encounters that depended on interpreters did not result in differences in glucose control or the use of recommended tests (2Tocher T.M. Larson E. Quality of diabetes care for non-English speaking patients.West J Med. 1998; 168: 504-511PubMed Google Scholar). Other studies have also not demonstrated differences in outcomes, although all involved a small number of patients. Among 29 monolingual Spanish-speaking patients with diabetes or hypertension in San Francisco, language concordance with the physician did not significantly affect outcomes (3Pérez-Stable E.J. Nápoles-Springer A. Miramontes J.M. The effect of ethnicity and language on medical outcomes of patients with hypertension or diabetes.Med Care. 1997; 35: 1212-1219Crossref PubMed Scopus (222) Google Scholar). A similar study among Puerto Ricans with asthma in New York reported a trend toward fewer emergency department visits and better adherence with theophylline in language-concordant patients (4Manson A. Language concordance as a determinant of patient compliance and emergency room use in patients with asthma.Med Care. 1988; 26: 1119-1128Crossref PubMed Scopus (263) Google Scholar). Finally, monolingual Latinos were less likely to receive analgesia for long bone fractures in an emergency department in Los Angeles, but this observation was true for all Latinos and was independent of language (5Todd K.H. Samaroo N. Hoffman J.R. Ethnicity as a risk factor for inadequate emergency department analgesia.JAMA. 1993; 269: 1537-1539Crossref PubMed Scopus (663) Google Scholar). Although there has been no apparent effect on clinical outcomes, language concordance between chronically ill patients and their doctors does matter. In the Seattle study, the duration of visits was similar, although clinicians who used interpreters perceived a longer duration of visits (6Tocher T.M. Larson E. Do physicians spend more time with non-English-speaking patients?.J Gen Intern Med. 1999; 14: 303-309Crossref PubMed Scopus (50) Google Scholar). The results of the study in this issue of The Green Journal imply that much less communication was taking place between patient and clinician during encounters with interpreters. In our study, we found that language-concordant patients reported better health-related quality of life (3Pérez-Stable E.J. Nápoles-Springer A. Miramontes J.M. The effect of ethnicity and language on medical outcomes of patients with hypertension or diabetes.Med Care. 1997; 35: 1212-1219Crossref PubMed Scopus (222) Google Scholar). In another study from New York, monolingual Latino patients asked more questions and recalled more information provided by physicians when seen by a Spanish-speaking physician (7Seijo R. Gómez H. Freidenberg J. Language as a communication barrier in medical care for Hispanic patients.Hisp J Behav Sci. 1991; 13: 363-376Crossref Scopus (98) Google Scholar). That language concordance did not significantly affect intermediate outcomes may be more a reflection of sample size and clinical situation. There is also evidence that Spanish-speaking Latino patients tend to be less satisfied with their health care and the quality of communication with their physician, as compared with English-speaking Latinos (8Carrasquillo O. Orav E.J. Brennan T.A. Burstin H.R. Impact of language barriers on patient satisfaction in an emergency department.J Gen Intern Med. 1999; 14: 82-87Crossref PubMed Scopus (370) Google Scholar). More studies in this area are needed, especially as research on physician-patient interactions has tended to exclude non-English speakers (9Frayne S.M. Burns R.B. Hardt E.J. et al.The exclusion of non-English-speaking persons from research.J Gen Intern Med. 1996; 11: 39-43Crossref PubMed Scopus (79) Google Scholar). Studies of the health care of patients with limited proficiency in English have emphasized access to care, but attention has also focused on the cultural competence of clinicians. Federal and state laws now require health care systems that receive government funds to provide full language access to health care services. The 1999 version of the Health Plan Employers Data and Information Set (HEDIS 3.0) now includes an indicator for the availability of language interpretation services. Despite these mandates, access to these services remains a distant reality. Many clinicians rely on limited foreign language skills or on untrained interpreters, often resulting in inaccurate interpretation (10Baker D.W. Parker R.M. Williams M.V. et al.Use and effectiveness of interpreters in an emergency department.JAMA. 1996; 275: 783-788Crossref PubMed Google Scholar). Unfortunately, use of an interpreter has been associated with a loss of rapport and a compromised patient-provider relationship, although it is not clear if this relationship is affected by whether professional, as compared with ad-hoc, interpreters are used (11Baker D.W. Hayes R. Fortier J.P. Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients.Med Care. 1998; 36: 1461-1470Crossref PubMed Scopus (251) Google Scholar). Since the patient’s trust in an interpreter may not necessarily transfer to the clinician, the social context of the medical encounter must be examined to identify potential influences on the quality of communication and decision-making. The quality of culturally and linguistically competent care should be measured by the health outcomes, patient satisfaction, and cost effectiveness of the encounter. This approach emphasizes the need to identify the components of care that lead to the desired outcomes and that are relevant for diverse ethnic and language groups. Standards for interpretation services, for example, could be based on empiric evidence that demonstrates that certain aspects of the translation result in better outcomes. Patient-interviewing tools are available that might facilitate the collection of information that is expected to improve the nontechnical aspects of care, and in turn, the technical processes and outcomes of care (12Carrillo J.E. Green A.R. Betancourt J.R. Cross-cultural primary care a patient-based approach.Ann Intern Med. 1999; 130: 829-834Crossref PubMed Scopus (363) Google Scholar). If clinical encounters characterized by the presence of a translator are at greater risk of poor communication or less attention to patient concerns, then use of standardized patient-interviewing tools may reduce this risk. Nevertheless, clinicians must be aware of their own perceptions or attitudes that may lead to bias in the interpersonal aspects of care provided. There are many unanswered questions about the effects of interpreters on the technical and interpersonal processes of care and their outcomes. The field of medical interpretation would benefit from the establishment of professional standards with input from trained interpreters, patients, and clinicians. Standardized instruments to assess physicians’ language proficiency need to be developed and applied. Organizations that set quality indicators may eventually require that clinicians be language-concordant with their chronically ill patients whenever possible. Studies are needed to determine what occurs during medical encounters, based on patient reports as well as direct observation and analysis, in order to link specific activities with outcomes of care. We also need to determine the effects of ethnicity versus language on the technical and nontechnical aspects of care. As health care professionals, we face the daunting task of meeting the medical needs of an ethnically and linguistically diverse population. Efforts to minimize the potential deleterious effects of language barriers need to be implemented and evaluated. Providing language-accessible health care to patients with limited English skills may help to address ethnic differences in health status.