Physicians Delivering Services in a Second Language Assessing Provider Fluency and the Use of Medical Interpreters San Mateo Medical Center

Physician self-rated language ability and cultural competence are associated with patients’ reports of the quality of care they received. However, with self-assessment, inconsistency in describing and evaluating language skills represents a challenge to progress in improving clinical communication for patients with limited English proficiency. L.Diamond, D. Reuland JAMA. 2009

Limited English proficiency is associated with poorer health care processes and outcomes. Language Barriers in Health Care Settings The California Endowment 2003 DuBard CA, Gizlice Z. Am J Public Health 2008 Accumulating research shows that having a language-concordant physician is associated with improved quality and outcomes. Fernandez A, Schillinger D, Grumbach K; et al. Physician language ability and cultural competence: an exploratory study of communication with Spanish-speaking patients J Gen Intern Med. 2004

Spanish-speaking patients are less satisfied with their healthcare when cared for by non-Spanish- speaking physicians. Providers who are fluent in Spanish are more likely than their less fluent colleagues to fully elicit their patients’ problems and concerns. Even the use of professional interpreters did not enable physicians with limited or no Spanish ability to elicit patients’ problems and concerns as well as their Spanish-speaking colleagues. Fernandez A, Schillinger D, Grumbach K; et al. Physician language ability and cultural competence: an exploratory study of communication with Spanish-speaking patients J Gen Intern Med. 2004

Using professional interpreters can lead to better care for patients with limited English proficiency, but physicians who are semi- fluent often do not use professional interpreters, frequently substituting their own, limited spoken Spanish during clinical encounters. Diamond LC, Schenker Y, et al. Getting By: The underuse of interpreters by resident MDs J Gen Intern Med. 2008

Four main factors providers can consider when deciding how and when to use an interpreter in clinical settings: – the accessibility of interpreter services, – patient preferences, – the clinical scenario, – and the degree of "language gap" between patient and physician. Shin HB, Bruno R. Language use and English-speaking ability: 2000 US Census Bureau Web site. October 2003.

The Interagency Language Roundtable (ILR), has developed a standard scale for language skills in speaking, listening, writing, and translating. but this scale for describing second-language proficiency has not been widely adopted within health care, particularly for physicians. The lack of a consistent way to report fluency currently impedes the development of strategies to eliminate health care disparities, which could include matching patients with limited English proficiency to truly bilingual physicians. L. Diamond, D. Reuland JAMA. 2009

Physicians with low levels of general Spanish proficiency who develop "medical Spanish" skills are unlikely to be able to engage in health communication that requires linguistic nuance, such as clarifying understanding or engaging in shared decision-making. Even without developing policies for fluency testing, health care organizations could take the initial step of requiring physicians to use the ILR scale rather than their own words to describe their language proficiency. L. Diamond, D. Reuland JAMA. 2009

San Mateo Medical Center Signage Signage was developed informing patients with limited English proficiency of their right to an interpreter at no cost Signs were placed at more than 50 points of entry and service delivery throughout the hospital and clinics Signs were printed in the Medical Center’s 14 most commonly encountered languages

HCIN & Language Line at SMMC Progress Voice/Video Remote Interpretation equipment installed and program implemented, Spring 2006 More than 300 providers, nurses and others trained on used of the Network Physician champions helped to spread acceptance of remote interpretation 2 Spanish Interpreter positions created

The volume of interpretation encounters increased exponentially, as did the cost The variety of languages spoken by our patients would make safe, efficient and quality care impossible without remote interpretation In-person interpretation by bilingual staff is still available, but more cumbersome and less frequently utilized

Challenges Although most providers have embraced the new paradigm, there are still pockets of resistance. Some providers consider interpretation in any form invasive and time-consuming. The convenience of pulling in the nearest bilingual medical assistant still trumps use of trained interpreters for some providers

We have not yet adopted an instrument or process for assessing providers’ second- language fluency or established thresholds for the use of trained medical interpreters. Even among physician leadership, there is resistance to assessing fluency and mandating the use of trained interpreters Some providers have been “getting by” with inadequate language skills for years, but disparities in patient care are obvious.

Solutions Implement language policies. Incorporate them into contracts and evaluations. Conduct ongoing training and problem- solving for providers and other staff. Reinforce new JCAHO standards and make quality medical interpretation the standard of care for LEP patients. Use the executive team and physician champions to drive the process.

Use intermediate solutions, like having an interpreter present to support the bilingual provider, if needed, as they improve. Provide truncated Medical Interpreter training for medical staff who frequently are used as interpreters anyway. Address providers concerns about convenience, time and invasiveness and involve providers in finding solutions. Conduct surveys to measure the effect of improving language access on disparities in patient satisfaction and health outcomes.