Table 1.

Supportive quotes for key findings

‘Getting by’ versus ‘getting help’
‘Getting by’	“If the patient speaks some English and I speak some French and a little bit of Spanish, if the answers seem appropriate to me and the patient doesn't demonstrate obvious concern about the interaction and it's relatively simple and not high-risk, then I would accept that communication is adequate.” (90703) “I rely more heavily on my physical exam if I can't communicate with them, like I'd be more cautious with testing if I can't ask a specific question and be reassured” (90708).
‘Getting help’	“But somebody with chest pain or some funny neurologic symptom that you're worried could be a stroke, [it's] extremely difficult to treat without having a solid base of communication.” (90901) “ … [I'll] look for an interpreter or some staff that can come over and help.You know, somebody who speaks that language …. if they are stable you know and don't look like I need to do anything overly quickly for them and I really can't get a story out of them, then I'll … get an interpreter first.” (90708) “So that's the problem you run into. You either try to strive to get a really good history through formal interpretation or you end up doing more testing of that person because you're worried about them more.” (90614)
Acuity, time constraints and availability of translation aids
Acuity of clinical situation	“It all depends on the clinical situation…I could almost treat a patient who cut their finger without talking to them at all… I'd want to make sure that their tetanus status was up to date, like there's a couple of things that you'd want to sort out, but by and large you could pretty much treat them without talking to them. But somebody with chest pain or some funny neurologic symptom that you're worried could be a stroke [it's] extremely difficult to treat without having a solid base of communication.” (90901) “So if a patient was sick, for example, had low pressure and a fast heart rate and still spoke no English, I would go in anyway and then just do what I consider to be paediatric medicine. Kids can't talk to you. You know they're two years old and they're crying and they're in pain—I can't get a history from a child the same way I can't get a history from someone who doesn't speak English.” (91118)
Time constraints	“When we have a whole bunch of patients and we've got a busy schedule and we're already twenty minutes behind and so forth, you know we're looking for ways to be as efficient as possible. And if it looks like this patient can give us a few nods appropriately and say a few words that … they should probably understand. We may be willing to just say okay well we've done our part.” (90616) “We sometimes take shortcuts and sometimes that's acceptable because the time that you save by taking shortcuts is justified because there are more important things that you need to spend your time doing.” (90728)
Ease of use and availability of translation aids/interpreters	“…if two people speak at the same time it can block out the sound and so it can become awkward but I would say that the two handset option is the best option followed by the speaker phone, followed lastly by the one handset option which is really, uh, it's enough to dissuade people from actually going to the language line.” (90615)“there's a tremendous amount of resistance to going to the one handset: you'd almost rather this person just spoke a few words of English. You might just be inclined to do your best, try and see that they understand what 's actually taking place.” (90728) “If you're gonna continue this encounter without getting a translator, so if I'm sharp enough to know what this person's language is and it doesn't take long, then I may do a quick search locally, literally around me physically… in a clinic, on a ward, in the Emergency Department to see if someone who works in that department can speak that language and offer translation and there's a fair chance in Toronto you'll get a person who can speak that language fairly [easily]. And then that's the better route.” (90710)
A troubling space: dilemmas experienced in practice
The ‘grey zone’	“Well, I leave that to the patient to decide whether we need some kind of facilitator or an interpreter. You know I usually don't make the decision to say “how well you are comprehending what I'm saying and how well are you able to communicate to me?” So I usually ask them “would you like to have an interpreter present?” And then they may say ‘ yes’ or ‘no’. The challenge is that in the real world we don't, we don't always end up having an interpreter readily available.” (90615) “… so I sort of assess whether I need, whether I actually have time to wait for the interpreter and then I'd call and ask for an interpreter. I do use family members which is a bit of a grey zone because if there's a se…sensitive information you're no, so you're supposed to have an objective interpreter there, so I will sometimes use family members…” (90828)
Dilemma of ‘real world’ vs ‘ideal world’ practice	“And they [patient] go ‘um thank you’. And that's it, right. And so you kind of, you know clearly it's a suboptimal communication. There are a lot of things that you would really need to discuss to have this patient-centered care ideal. But you know the time that would be required to do that would be quite extensive and so we often take shortcuts that result in non-patient-centered care… It happens all the time frankly and I think well you know, we're probably less likely to do it in a situation where we really feel that it's critical.” (90728) “To be quite honest with you the ones I personally find the most helpful are family members. Because … they can give you a little bit of the context, and then you can talk to them as well particularly if it's an elderly patient because not only do they translate for you but then they'll also say, “You know what? Grandma hasn't been doing very well for a few months now. She hasn't been preparing her meals properly, she's been losing weight … I'm concerned about Grandma.” That's far more valuable to me in some respects than a translator who's just sticking to the letter of the law, and is saying exactly what they're supposed to, without kind of any context. It's just language right? I like the bigger picture.” (90702)
Dilemma of responsibility	“We've explained what's going on and they've nodded and kind of looked at me as though they're understanding—so now it's their responsibility, it's not mine any longer. I'm not suggesting that's the way that, you know I practice, but that's what can frequently happen in this grey zone. It's just enough English proficiency to be dangerous.” (90615) “They [patients/families with LEP] don't recognize that this is a ha-, a potential hazard…I think some of the responsibility lies with the patient.” (90706) “I don't think that's a responsibility that patient's necessarily carrying… That's not something I would expect of my families … that's not a fair expectation I think.” (90708)
Dilemma of informed consent	“I can't get informed consent when I can't communicate.” (90930) “There have been circumstances in the past where we have been concerned as a group that families weren't accurately expressing our wishes to the patient or our statements to the patient and vice versa. And so there have been circumstances you know particularly in some of these [high] stakes circumstances where we will use professional translators regardless of the presence of the family to translate for just this reason.” (90707)
Making language discordance a priority	“You know, we really have to get over the language barrier business because it's not going away—it's been here for a while and I don't think we've done a particularly good job until very recently—we're starting to address it—we should be very aggressive about prioritizing this subject.” (90710)