Appropriate use of non-English-language skills in clinical care.

AN ESTIMATED 25 MILLION US RESIDENTS HAVE LIMited English proficiency (LEP) and in a 2006 national survey of 2022 internists, 54% reported encountering patients with LEP at least weekly, with many seeing LEP patients every day. Legal guidance related to Title VI of the Civil Rights Act requires that physicians and hospitals take reasonable steps to ensure effective communication with these patients. Hence, when a patient with LEP presents for care, the encounter must either be conducted with a clinician who speaks the patient’s language or indirectly through a trained interpreter. Untrained interpreters, such as patients’ friends or family members, are sometimes used, although this practice is risky for reasons of competence and confidentiality. While no national data are available on physicians’ non– English-language skills, in some local surveys, more than 80 percent of physicians report some proficiency in 1 or more non-English languages. Direct communication between language concordant patients and physicians is associated with improved quality, adherence and satisfaction, and reductions in emergency department utilization and costs. We recently worked with the Commission to End Health Care Disparities to develop a set of recommendations for policymakers, organizations, and clinicians to promote the appropriate use of physicians’ non–English-language skills. The recommendations were based in part on interviews with bilingual physicians in a variety of practice settings and an expert panel review using a patient safety approach to care improvement. The commission recognized that the responsibility for ensuring quality of communication ultimately rests with physicians and encouraged use of their non−English-language skills to interact in the patient’s preferred language, but cautioned against relying on inadequate language skills. The course of this work, however, revealed that language skills are often interpreted for practical purposes as a dichotomous construct—even modest skills are often deemed good enough to “get by.” In contrast, recommendations from leaders in the field have advocated for graduated measures of language proficiency. Physicians’ non–English-language skills are extremely heterogeneous, ranging from those who speak just a few words of 1 or more non-English languages to those who are native speakers and received their medical training in another language. Similarly, the communication demands of certain clinical interactions are greater than others— conversations about end-of-life care or informed consent for surgery implicitly pose greater miscommunication risks compared with more routine encounters. As a result of this variability, some physicians are probably always able to appropriately provide care to patients in languages other than English, others might be able to do so in some circumstances, and others have such limited skill that they never should attempt medical communication without an expert assistant (ie, a trained interpreter). This more nuanced understanding of language proficiency makes it similar in nature to many other skills necessary for the appropriate and effective practice of medicine. Physicians commonly have some level of skill in specific areas (rheumatology, cardiology, surgery, etc) that usually is sufficient for many routine interactions, but they also are prepared to involve an expert consultant if the clinical situation evolves to exceed their skill level. If bilingual physicians should consider trained interpreters as expert consultants, how should physicians decide whether their non–English-language skills are adequate to provide appropriate care in particular situations and when should they call for consultative assistance? This turns out not to be an easy task. A qualitative study of 20 resident physicians found that most overestimated their ability to provide care in another language. Another study of 25 physicians who provide care directly in a nonEnglish language (most often Spanish) based on skills that are frequently inadequate (ie, skills obtained in high school or middle school, “medical Spanish” courses, or during short visits abroad and reinforced only by occasional medical or nonmedical use) found the physicians value direct communication with patients very highly, and believe patients do too. However, these physicians might also underappreciate the value provided by using trained interpreters, and cli-