A significant number of resident physicians receiving training in U.S. hospitals report they have not received instruction in key aspects of communicating with patients who do not speak English, despite federal regulations requiring adequate interpreter services for such patients. In the Sept. 6 issue of the Journal of the American Medical Association, researchers from the Massachusetts General Hospital (MGH) Institute for Health Policy report the results of a national survey on residents' education and practices when caring for patients with limited English proficiency.
"Residents need to be taught not only how to obtain trained interpreters at their hospitals but also why they should use them and how to do so more effectively," says Karen C. Lee, MD, MPH, lead author of the JAMA report. "Improved availability and proper use of trained interpreters could help improve quality of care and health outcomes for patients with limited English proficiency, who may have problems accessing the health care system and communicating with their providers. Using multilingual written materials may also enable these patients to understand what they've been asked to do after they go home" Lee worked on this study when she was associated with the MGH Center for Child and Adolescent Health Policy.
The research team mailed surveys to about 3,500 residents in the final years of their training programs at 149 academic health centers across the U.S. The survey asked residents whether they had received instruction on several topics related to the use of interpreters – including how to obtain trained medical interpreters, the legal rights of patients with limited English skills to have professional medical interpreters, and the dangers of using untrained interpreters.
Among the more than 2,000 respondents, more than half replied they had not been taught that patients with limited English proficiency have a legal right to professional interpreters. (Guidance issued in 2000 by the U.S. Department of Health and Human Services states that denial of adequate interpreter services to patients with limited English proficiency is a form of discrimination.) While 77 percent of respondents said they sometimes or often used professional interpreters when facing language barriers, 84 percent admitted to frequently using untrained interpreters, such as patients' family members and friends. More than 20 percent admitted to sometimes or often relying on children under age 12 to interpret for family members, a practice cited as particularly risky.
"The use of untrained interpreters, who may not be familiar with medical language, can cause problems." says Joel S. Weissman, PhD, of the MGH Institute for Health Policy, the senior author of the JAMA report. "And the use of children is particularly problematic because it can upset family dynamics. One can only imagine how awkward it can be when a doctor asks a 12-year-old girl about some of her grandfather's personal health problems." Weissman is an associate professor of Medicine at Harvard Medical School.
More than half the responding residents reported that lack of access to interpreters and to written materials in other languages, as well as lack of time, posed moderate or major problems in providing cross-cultural care. Residents reporting inadequate access to professional medical interpreters were 40 percent less likely to say they used such interpreters.
"As with other areas in which doctors are expected to communicate with patients, training really matters," says Weissman. Residents receiving some or a lot of training in working with interpreters were about twice as likely to use professional interpreters as those who reported little or no training. However, the only factor significantly associated with decreased use of children as interpreters was instruction in patients' legal rights to professional interpreters.
"Lack of appropriate medical interpreters not only makes it harder to make the right diagnostic and treatment choices, it also can make care more costly, since studies have shown that providers tend to order more tests in these instances," says Joseph Betancourt, MD, MPH, director of the MGH Disparities Solutions Center and a co-author of the JAMA report. "As we become an ever-more-diverse nation, we need to assure that our future physician workforce is prepared to deal with the challenges of our changing population."
Additional co-authors of the report are Jonathan Winickoff, MD, MPH, MGH Center for Child and Adolescent Health Policy; Minah Kim, PhD, Ewha Women's University, Korea; and Eric Campbell, PhD, Elyse Park, PhD, and Angela Maina of the MGH Institute of Health Policy. The study was supported by grants from The California Endowment and The Commonwealth Fund.
Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of nearly $500 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, transplantation biology and photomedicine. MGH and Brigham and Women's Hospital are founding members of Partners HealthCare System, a Boston-based integrated health care delivery system.
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