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Good communication is essential to the efficient provision of effective medical care. Physicians need to provide information about the care plan, review medications, plan for treatment and offer detailed instructions. All patients including those with limited English-proficiency (LEP)-deserve the highest quality medical care possible and need to be fully informed. Physicians provide the best care when they possess accurate information. Their decisions determine an appropriate and cost effective care plan1 . Physicians and all health care providers should acknowledge the importance of communication in their service to the nation’s health and collaborate on efforts to improve the health of people in their communities, including people with limited English-proficiency (LEP).

Commonly, LEP patients struggle to communicate in the health care system. They may have difficulty following instructions, and may not prepare properly for procedures. They may fail to show up to appointments and make unnecessary visits to the Emergency Department. LEP patients are often reluctant to communicate concerns to a physician.

Recently a 76 year-old Latino at a Boston Hospital mentioned casually to an interpreter that he had a “funny sensation in his chest, but thought it was not important”. The interpreter persuaded the patient to contact his Primary Care Provider. The physician made arrangements to see the patient that day. The patient was then sent to the Emergency Room for an atrial flutter and was later admitted to the hospital. He was diagnosed with congestive heart failure. This condition can usually be controlled with medications, but without care the patient was at high risk of serious health problems even death. For many patients, hospitals are intimidating and imposing. Medical institutions are even more imposing to those who cannot communicate properly, as the story of this Latino patient suggests.

Another area affected by language access is patient satisfaction.2 Health care professionals and medical institutions are facing strong market competition. The availability of professional medical interpreters at the Emergency Department at Brigham and Women’s Hospital in Boston dramatically increased patient satisfaction with overall care, the explanation of care, courtesy and respect, and discharge instructions.

The current situation of linguistic access to health care is alarming.  It has led to improper diagnosis, poor patient compliance and frustrated patients and providers. The Office of Civil Rights (OCR) for the Department of Health and Human Services (DHHS) issued a policy guidance on Title VI of the Civil rights Act of 1964 in August 2000. Title VI prohibits discrimination based on an individual’s national origin, and is relevant to most LEP individuals. In addition to Title VI, the availability of language interpretation services and clear communication with LEP patients is required by some state laws 3 and regulations 4 , and health care accreditation organizations 5 . In addition to the laws and regulations, physicians who fail to ensure adequate communication with LEP patients are at risk for malpractice claims arising from injuries suffered as a result of poor communication 6 . In general, a patient has the right to participate in the development and implementation of his or her plan of care, and to be informed about diagnosis, specific treatments and procedures.

Despite these legal and medical ramifications, the medical profession often fails to bridge language barriers effectively. Physicians need to use reasonable judgment to deliver quality patient care to LEP patients. In addition, they cannot presume that some experience with other cultures or language makes them fluent and knowledgeable. A study conducted at Stanford University found major errors in 14% of Spanish speaking patient interactions (e.g. misunderstanding the duration of symptoms and confusion over terms and vocabulary) 7 with Emergency Medicine residents who had some knowledge of the Spanish Language. Overall, failure to bridge communication gaps breaches professional standard of medical care.

Strategies to Provide Services to LEP Patients

The following are some strategies for physicians to improve services to LEP patients in their medical practice. Generally, these strategies rely on good planning and are designed with the goal of reducing communication barriers that may lead to improper diagnoses and care, higher health care costs such as unnecessary lab tests and other diagnostic treatments 8 , and poor patient compliance. In addition, anticipating the needs for language assistance can substantially decrease the cost of care.

I. Needs Assessment of Medical Practice Service Area

Familiarity with new immigrants in the community or service area and their language needs benefits the planning process by anticipating need.  Commonly, government and community-based agencies, such as school department and health agencies collect data on community language needs and new immigrant groups.

II. Medical Intake Procedures

Make language needs a part of the scheduling process in your office. The information required to schedule an appointment with a physician commonly includes patient name, insurance carrier and referring physician. It would be a simple step to add one question, the question of language needs. This step could reduce the cost of language services by eliminating fees on last-minute request. In addition, having quick-reference cards in a variety of languages can assist secretaries in asking questions that would help determine the language needs.

Obtain translated standard documents, such as registration materials, financial forms and medical history, into other languages optimize the time spent with medical interpreters and would assist in getting accurate information.

III.       Skills for Competent Interpretation

Develop systems to evaluate and assess your practice’s provision of interpreter services. If you contract with an outside vendor, make certain that they provide adequate supervision and assessment of their interpreters. Consider these conditions when assessing and procuring competent interpretation services.

· Proficiency in both English and the language to interpret.

· Interpreter Certification by the State, Language Organizations such as American Translation Association (ATA) and/or Community-based organizations.

· Experience in the medical field.

· Knowledge of medical terminology.

· Ethical training including confidentiality and professional conduct.

Types of Interpreter Services

Bilingual Employees. Hiring Bilingual employees improves communication and patient satisfaction. In cases where there is a large volume of patients who speak a particular language, it is cost effective to hire a medical interpreter. 9

Contract Interpreters.  Negotiate a rate with Interpreter Agencies ahead of time. Affiliations with other physicians can benefit the negotiation. A comprehensive assessment of the agencies in your area is needed. For example, compare rates between community-based agencies and for-profit language companies.

Community-based Agencies. Engage in collaboration with community agencies in your area to develop a language pool.  Negotiating with community-based agencies that work closely with immigrants and LEP individuals can give you access to a cost-effective bank of language interpreters.

Telephone Services. In isolated areas or with last-minute requests, a company providing telephone interpretation can offer a solution. An affiliation with other medical practices can assist in the rate negotiation.

Affiliation with Hospitals. Collaborate with hospitals in your area to gain access to their interpreters.

Affiliation with Educational Institutions. Students well-versed in medical procedures and terminology, and fluent in more than one language can help bridge language barriers.

Economic Benefit of Providing Medical Interpreters*

The health benefit of providing competent medical interpreters to the non-and limited English-speaking residents is substantial. So, too, are the financial benefits in terms of reduced costs for unnecessary lab tests, x-rays, and other diagnostic and treatment services. Statistical and anecdotal evidence indicates that spending money on interpreters saves more than it costs.

Example 1: Eric Hardt, M.D., Clinical Director of Geriatrics and Medical Consultant to Interpreter Services at Boston Medical Center:

“If one thinks of an interpreter-assisted history as a diagnostic test, there are virtually no significant tests in medicine that are cheaper. Costs, in general, compare roughly to the costs of the cheapest blood test that physicians order ($28 for complete blood count). An organized system of professional medical interpreter services will lead to better access for our patients, better quality across the board, and ultimately to cost savings when all sources of waste, duplication, and missed opportunity for diagnosis and treatment will have been documented.”

Example 2: Carla Fogaren, R.N., Director of Interpreter Services at Good Samaritan Medical Center in Brockton, Massachusetts.

Ms. Fogaren was called to interpret for a 70 year old Portuguese speaking man. The man’s neighbors and the EMTs suspected that he might be suffering from a stroke or heart attack. Three minutes after speaking to the patient, Ms. Fogaren was able to determine that he was only coming down with a head cold and congestion. Without the use of an interpreter, in this case costing less than a dollar, the hospital would have utilized the following costly medical procedures to rule out heart attack and stroke:

From “Comments to MA Health Care Committee – April 8, 1999”