Doctor A: Their preferred language was Spanish, but they needed an interpreter for complex medical discussions. He was admitted for bronchiolitis, so we didn’t feel the need to use an interpreter.
Doctor B: Dad spoke English, so we used Dad as an interpreter to inform Mom about discharge instructions and medications.
Doctor C: I looked for the video interpreting device, it was not available.
Doctor D: Do I need to use an interpreter every time I enter the room?
The comments and questions above all come from providers caring for families with limited English proficiency (LEP). The United States is becoming increasingly multilingual, with >200 languages spoken. As a result, providing linguistically competent care has become a priority in health care. The 2019 United States census survey revealed that 22% (67.3 million people) of the United States population speak a language other than English at home,1,2 more than double the 11% in 1980.1 Of those who speak a language other than English at home, 38% (25.4 million people) have LEP, meaning they speak English “less than very well.”2 The proportion of patients with LEP is projected to grow in the next decade. In November 2021, the Joint Commission published a sentinel event alert requiring health care organizations to address health care disparities by improving quality and safety.3 This alert clarified the need for organizations to collect language data, assess language needs, and meet those needs by providing respectful and effective interpreter and translation services.
The Institute of Medicine first highlighted the disparities with language barriers in their groundbreaking report in 2003.4 Patients and families with LEP are at a high risk of preventable harm, encounter barriers to accessing health care services, receive a lower quality of care, and suffer worse outcomes than English-speaking families.5,6 Families with LEP are subject to inadequate or excessive testing, experience poor follow-up and discharge instruction, are often misdiagnosed, and are subject to increased medical errors.7,8 Various federal and state laws and policies mandate that health care systems provide language access to patients with LEP; however, the reality is that many struggle to fulfill this obligation.9
An approach that may help elucidate the barriers to improving care for patients with LEP comes from Bronfenbrenner’s ecological systems theory.10 The full ecological systems theory identifies 5 environmental systems with which individuals interact; however, even breaking the system down into the individual, micro, and macro level may be illuminating (Fig 1). In the subsequent paragraphs, we discuss some challenges faced at multiple levels. Additionally, Table 1 lists potential solutions to these challenges to improve the unequal care received by families with LEP (Table 1).
Improving the Care of Patients/Families With LEP at an Individual Level
Studies have revealed that a clinician’s choice to use an interpreter service depends on time constraints.11,12 At busy times, physicians are more likely to “get by” without a professional interpreter, which leads to lower quality of care.12,13 Time pressure and stress are known to contribute to implicit bias.14 Implicit bias also leads to “categorization” rather than “individualization.”15 Individualization is when you focus on attributes of a particular patient, as opposed to categorization, when a provider perceives the patient through the filter of his or her group membership (eg, the language they speak or their race). Categorizing leads to dangerous assumptions about religion, culture, and intelligence. When we categorize someone, it becomes easy to devalue and depersonalize them. Physicians need to be open to learning and willing to build trust with language-discordant families. To build trust, one needs to be authentic, ask genuine questions, validate the other person’s concerns, and validate oneself as a health care personnel before assuming their care.16–18 In families with LEP, all these opportunities are minimized or even lost given the time constraints.12 Nonverbal cues, a crucial aspect of communication, are lost when using audio and even video devices.19 Hospitalists are often rushed to find the interpreting devices and then be on hold until an interpreter arrives, and the quality of interpretation may be poor. Even when an in-person interpreter is available at an institution, much time is lost in scheduling the interpreter services. Authenticity and building trust get lost amid focused history taking and treatment plan obligations. A culture of equity can only thrive when providers acknowledge that disparities and bias exist and take responsibility and advocate for the children of families with LEP.
Improving the Care of Patients/Families With LEP at a Microsystem Level
Inpatient linguistic services for children have unique barriers compared with outpatient and adult services. Admissions are usually unplanned, preventing previous interpreter scheduling. Children may have frequent and sudden clinical changes that require extra communication at unexpected times. Surrogate caregivers are the norm in pediatrics, increasing the complexity of communication.
Linguistic services include 2 components: verbal interpretation using an in-person or remote interpreter and translation services, which include providing written materials in patients’ preferred languages.20 Providers require training in developing skillsets on how to use an interpreter and should also be aware of the available resources in their immediate surroundings. Unfortunately, studies have revealed both lack of awareness about resources and a lack of faculty expertise in implementing a curriculum focused on appropriate linguistic care.21,22 Providing written translation documents is often forgotten as a part of linguistic care. Translation documents are not provided consistently, given their unavailability in various languages, mismatched time frames, and inconsistent use.23
Improving the Care of Patients/Families With LEP at a Macrosystem Level
Systems are defined as “invisible fabrics of interrelated actions which often take years to fully play out their effects on each other.”24 The inpatient setting is a rapidly evolving multifaceted system based on acuity, clinical context, local environment, and multidisciplinary involvement. Additionally, hospitalization is a process with a continuum of care involving multiple care providers with various transition points, including admission, transfer of service, and discharge. Various legislation mandates that health care systems provide language access to LEP patients, including Title VI of the 1964 Civil Rights Act, Section 1557 of the Affordable Care Act, Joint Commission standards, and multiple state laws. Despite the legislation, only 10% to 30% of families with LEP receive professional interpreter services.9,25 The presence of varying state laws has created variations in care among states, diseases, languages, payors, clinical settings, and institutions. Many state laws focus primarily on patient education and informed consent; some target specific health care settings, language, and medical conditions.26 The laws vary tremendously in their scope and impact and do not reflect the dynamic nature of the inpatient setting. Similarly, no standards or quality metrics exist to identify and capture language data in an inpatient setting accurately.
Multiple single-center studies have been conducted to improve the care of patients with LEP in the hospital setting22,27 ; however, multicenter studies of hospitalized children of families with LEP are negligible. The lack of clear guidelines has created wide variation within institutions impeding our ability to conduct multicenter trials and quality improvement collaborations.
The United States health care system is globally the most expensive but has poorer outcomes than other industrialized nations. The United States ranked last on performance and health care equity according to the commonwealth fund report, which uses 73 indicators in 5 domains: care process, access, administrative efficiency, equity, and health care outcomes.28 Regardless of how people look, dress, or what language they speak, access to meaningful and equitable health care is every patient’s right, and providing it is every physician’s responsibility. A cultural shift must occur, but an individual or a health care entity alone cannot solve the problem. Individuals, leaders, organizations, medical societies, and associations need to change. Yes, providing linguistic and culturally humble care is daunting, time-consuming, and unfamiliar. However, if we do not take care of this invisible fabric within our health care system, it is only a matter of time before the fabric is frayed to the point of breaking.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
Dr Rajbhandari conceptualized the project, drafted the initial manuscript, and critically reviewed and revised the manuscript; Dr Garber contributed to the drafting of the manuscript and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.