Over 60 million people in the United States speak a language other than English at home, and greater than 25 million people have limited English proficiency (speak English “less than very well”) according to the American Community Survey [1]. It is inevitable that healthcare providers will work with patients whose primary language is not English at some point in their training or careers. Physicians should understand how language barriers can affect the health of their patients in order to provide better care for this population.

Studies have shown that language barriers can affect multiple components of healthcare including healthcare access, overall health status, satisfaction of care and patient safety [2, 3]. However, with over 100 different languages spoken in the United States, finding and working with appropriate interpreters can be challenging. As pediatricians, there can be an additional challenge of finding an appropriate balance while working between parents with limited English proficiency and their children who may be more fluent in English. Many pediatricians, including myself, can find language barriers to be an especially frustrating part of our work given the added time in visits and sometimes the uncertainty of whether your intended message was properly relayed to families. It may be helpful to look at why we should have some extra patience and attentiveness in these encounters.

A study looking at errors in medical interpretation and their consequences in pediatric care showed that medical interpretation errors are common. An average of 31 errors are made per clinical encounter. These errors can be categorized as errors of:

• Omission (lack of interpretation of a word or phrase from parent or clinician)
• Addition (addition of a word or phrase not mentioned in the interaction)
• Substitution (different word or phrase was used)
• Editorialization (addition of interpreter’s own views to interaction)
• False fluency (incorrect word or phrase used)

Of all the errors, 63% (~19 errors per encounter) were found to have potential clinical consequences including: alterations of the history, omitting drug dosing/frequency/duration information and instructions, omission of previous workup/interventions, poor understanding of the child’s illness or treatment by parents and lack of clarity on plans for follow-up or referrals. Use of ad hoc interpreters (non-professional including staff, family, untrained individuals) were found to have an increased likelihood of committing errors that have potential clinical consequences compared to trained hospital interpreters (77% vs. 53%) [2]. Pediatricians should especially avoid having children interpret for parents given their limited understanding and unfamiliarity with medical terminology and added burden of responsibility.

The results of the study supported the use of trained interpreter services for all patients/families with limited English proficiency. Title VI of the Civil Rights Act requires recipients of federal financial assistance to provide interpreter services for patients with limited English proficiency. Many large institutions and universities have readily accessible professional interpreters, but smaller clinics and offices may not. Different services are available including various telephone interpreting lines and video interpreting services for American sign language communication. Studies have shown that use of telephone interpreting services is not inferior to having a bilingual health care professional. Interpreters may also be a resource to bridge the gap in cultural differences or misunderstandings [3].

Here are some tips to most effectively use medical interpreters [3]:

• Meet with the interpreter before the interview to give some background information and set goals
• Speak directly to the patient and not the interpreter
• Use first-person statements and avoid saying things like “he said” or “tell her”
• Speak in short sentences
• Do not use idioms, acronyms, jargon or humor
• Insist on sentence-by-sentence interpretation to avoid tangential conversations
• Use the “teach back” method to ensure patient comprehension

Language barriers can have a significant impact on health. Although it may be difficult to work through language barriers, it is important for pediatricians to approach this challenge with patience and humility. Pediatricians should be equipped with the appropriate resources and understand that a little patience can go a long way in providing better care for this population.

Gina Lee, MD

References

1. U.S. Census Bureau. American community survey. https://www.census.gov/content/census/en/data/tables/2013/demo/2009-2013-lang-tables.html. Accessed October 30, 2019.
2. Flores G, Laws MB, Mayo SJ, et at. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111:6–14
3. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476–80.