Challenges and opportunities caring for neurology outpatients across language differences

Abstract

Background

With over 66 million Americans who speak over 350 languages other than English at home, we sought to examine attitudes and behaviors of neurology clinicians and staff when communicating across language differences.

Methods

We conducted an electronic-enabled cross-sectional survey of clinicians and patient services coordinators working at an academic neurology outpatient clinic. Questions focused on professional medical interpreter (PMI) services usage, satisfaction, and perceived barriers to utilization.

Results

A total of 82/235 (35%) neurology clinicians and 24/52 (46%) coordinators met the study eligibility criteria. Most clinicians (96%) reported seeing at least 1 non–English-speaking patient and using PMI services (85%) in the last month. Most commonly self-reported interpretation modalities were face-to-face PMI services (39%) and patients' family members or friends (28%). Perceived barriers to using PMI included time constraints (60%) and lack of available face-to-face PMI (51%). Among patient services coordinators, 33% reported consistently asking patients their preferred language and 50% if they needed a PMI for appointments. Most respondents (77% clinicians and 71% coordinators) were satisfied with PMI services. Recommendations included having more available face-to-face PMI, greater coordinated efforts to preschedule PMI, and more education on the effective use of PMI.

Conclusions

More than 70% of outpatient neurology clinicians and patient services coordinators were satisfied with PMI. However, their perceived barriers and reported practices suggest a need for updated policies and education to improve the use of PMI services.

More than 66 million Americans, or approximately 22% of the US population, speak at least 1 of over 350 languages other than English at home.^1,2 Among them, a subset of 26 million Americans self-identify as speaking English “less than very well” and are therefore considered to have limited English proficiency (LEP).¹ To provide equitable high-quality patient care, health care systems must be well equipped to address patients' needs and preferences including as it pertains to language.³ Professional medical interpreter (PMI) services can facilitate effective communication across language differences yet remain underutilized in health care despite federal regulations aiming to assure meaningful access to language services.^4–9 This is troublesome because patients who need but do not receive PMI services tend to experience worse health outcomes and greater medical risks.^10,11 Meanwhile, PMI can contribute to greater patient satisfaction, improved health care utilization, and increased patient engagement.^12–15

In contrast to other disciplines, little is known about the weight of language barriers on the care of neurology patients.^16,17 Recognizing that neurology relies heavily on patients' histories, it is crucial to understand whether neurology practices are prepared to care for patients across language differences.¹⁸ To identify potential gaps and opportunities, this cross-sectional survey study sought to examine self-reported behaviors and attitudes of neurology clinicians and nonclinical neurology staff when serving outpatients across language difference.

Methods

Participants

A total of 235 neurology clinicians and 52 patient services coordinators at a large academic neurology outpatient clinic were invited to participate in a brief anonymous electronic-enabled survey regarding PMI services. Clinicians were defined as clinically qualified personnel involved in outpatient care including attending neurologists, clinical fellows, resident physicians, neurodiagnostic specialists, and nurses. Patient services coordinators were defined as neurology staff who assisted patients with tasks such as scheduling appointments. Clinicians and patient services coordinators invited to this study were included in analyses if they provided informed consent and answered the study survey and excluded if they opened but exited the survey or if they did not confirm caring for at least 1 outpatient per week.

Site

A large academic medical center located in Boston, MA. During registration, patients are asked to self-identify, “In what language do you prefer to discuss health-related concerns?” and, if the response includes a language other than English, are asked, “Do you need an interpreter?” (yes/no answer). Patients' information is verified annually for accuracy and completeness through patient registration services or via the hospital's online patient portal. Patient services coordinators and clinicians have access to patients' language preferences within their electronic medical records and are expected per hospital policy to choose a hospital-approved interpretation modality when communicating across language differences.¹⁹ At the time of this study, 5% of patients preferred discussing health-related concerns in Spanish and 4% in other non-English languages.²⁰ Our group previously identified over 25 languages preferred by patients with acute ischemic stroke at the hospital.^16,17 PMI services are accessible anytime, at all points of patient contact, at no cost to patients. At the time of this study, the hospital's preferred methods of interpretation were the following: (1) in person by one of the 33 hospital-employed PMIs who collectively spoke 11 languages, had at least 1-year of experience interpreting in health care settings, obtained national certification when available (in the United States, certification exists for Spanish, Arabic, Mandarin, Cantonese, Russian, Vietnamese, and Korean), and underwent a competency assessment every 3 years; (2) video-enabled Spanish or Portuguese interpretation by in-house PMI; or (3) if the above options were not feasible, phone interpretation by a PMI service outsourced to a national provider of health care PMI services. Federal regulations and hospital policies prohibited the use of minors and strongly discouraged the use of patients' adult family members or friends as interpreters. For in-person PMI encounters, employees were encouraged to book ahead and call to confirm patient arrival to avoid the possibility that the PMI left if the wait time was greater than 10 minutes.¹⁹ Phone and video PMI requests did not require booking or confirmation; the outpatient neurology clinic had phones in all patient rooms and 1 video-interpreting device. In the fiscal year of this study, the hospital provided 57,337 in-person, 67,731 telephone, and 7,607 video interpretations.²⁰

Survey

We designed a 12-question survey for clinicians and a 9-question survey for patient services coordinators pertaining to their outpatient neurology language-related experiences over the previous 12 months (tables 1 and 2). The survey instruments used yes/no, multiple-choice, Likert scale, and short answer formats. Data were anonymously collected through a secure web-based survey program, Research Electronic Data Capture.²¹ Electronic informed consent preceded the survey questions. Potential participants were identified through staff rosters. A unique link was emailed to potential participants asking to “complete a brief 5-minute online survey regarding opinions and usage of Medical Interpreter Services” and informing that those who completed the survey would enter a raffle to receive a $5 gift certificate to a local coffee shop. Five reminder emails were sent over 7 weeks, and 10 gift certificates were distributed. To reduce potential bias, survey responses could not be linked to a participant because no identifiers were solicited in the electronic consent form or survey.

Table 1.

Clinician questionnaire

Table 2.

Patient services coordinators questionnaire

Statistical analyses

Descriptive statistics were performed using Microsoft Excel. A grounded theory approach was used for qualitative analyses of open-ended questions to identify emerging themes.²²

Standard protocol approvals, registrations, and patient consents

The Massachusetts General Hospital Institutional Review Board reviewed and approved this study. Written informed consent was obtained electronically from all study participants.

Data availability

Data not provided in this article may be shared at the request of other investigators for the purpose of replicating procedures or results.

Results

Among invited clinicians, 93/235 (40%) consented to participate, and 83/235 (35%) remained eligible to participate after excluding 8 who opened but exited the survey and 2 who reported not seeing outpatients. In turn, 24/52 (46%) invited patient service coordinators consented and were eligible to participate.

Most clinicians reported caring for patients who “could not speak English well enough to give an adequate history” (Table 3). Although satisfied with existing PMI services, clinicians reported an underuse and voiced perceived time constraints and other barriers (Table 4). Patient service coordinators also noted satisfaction with yet inconsistent practices engaging PMI services (Table 5). The quotes below are most representative of the themes that emerged when respondents were asked to justify their satisfaction ratings. Appendix e-1 (links.lww.com/CPJ/A84) provides additional quotes to further illustrate each domain:

Table 3.

Clinician characteristics (N = 83)

Table 4.

Clinician self-reported practices, satisfaction, and barriers to using professional medical interpreters (N = 83)

Table 5.

Patient services coordinators' self-reported practices and experiences working across language differences (N = 24)

A need to improve systems to arrange PMI services

Clinicians unanimously emphasized the importance of identifying and preparing to address patients' language needs ahead of appointments, “Patients [with language assistance needs] identified via [electronic medical records] should have in-person [interpreters set up] before appointment. Coordinators [should] ensure language-specific [interpreters] are there before appointment. Interpreters should also be [engaged] for diagnostic testing and should be automatically [involved] if a patient is scheduled for radiologic examination.”

Preference for in-house in-person interpretation

There was a general perception that the quality of in-house in-person PMI seemed better than that of outsourced phone interpreters. The language interpreted seemed to influence responses, “Very happy with all in-person services. I would say about 70% of the time I'm happy with the phone services. Typically, it is non-Spanish that we have the most trouble with over the phone. Recently had an Arabic [interpreter] that was very hard to use and I was very concerned that information was not being translated fully. We brought in a family member that knew both languages to try and confirm that the full message was being given.”

PMI as cultural allies

Respondents appreciated PMI professionalism and their role in facilitating interactions across cultural differences, “Sophisticated interpreter added extra cultural [information] and had discussed this particular patient with other interpreters.”

Variable quality of PMI services

Respondents perceived problems of misinterpretation, omission, and unfaithful interpretation, “Because I speak Spanish, I have been able to test the effectiveness of the interpreter services when they are being used by the residents. I find that while the [interpretation] is literal, it is not adequate. For example, ‘dizziness’ is frequently misinterpreted.”

Time challenges

There was general agreement of workflow problems with using in-person PMI services, and a perception of long wait times as a barrier to working with PMI, “In-person [interpreters] seem to be on tight schedules—difficult to coordinate with highly variable outpatient appointments with doctors or patients sometimes running late.”

The complexity of including clinical trainees

Teaching residents and medical students is an integral part of the hospital's mission. However, respondents found involving PMI in a teaching setting complex, “I feel bad that the interpreters in person are made to wait in the clinic when we see patients in the Resident clinic because I have to wait [un]till the Residents present the case and to have some discussion before we go and see the patient. Understandably some of our Interpreter colleagues get a bit upset by the delay.”

Using phone and video interpretation

Many survey respondents recommended improved access to phone and video equipment. Several also recommended improved technical quality of and support for phone and video interpretation, “I use interpreter services quite often by phone to call a patient to set up an appointment or to confirm appointment.”

Constraints to technology usage

Respondents identified disability-related considerations favoring in-person over other interpretation modalities, “The [video] interpreters are also generally high quality, but this method of communication can be challenging for patients with altered mental status or impaired hearing.”

Use of ad hoc interpretation

Clinicians associated turning to patients' family members or friends to assist with interpretation with time, quality, and preference considerations, “Dissatisfied that [interpretation] took so much more time than using a loved one as an interpreter and was difficult to coordinate with clinic schedule.”

Discussion

This cross-sectional survey of neurology clinicians and patient services coordinators working at a large academic medical center characterizes the challenges and opportunities to engage with PMI in neurology outpatient settings. Respondents' appreciation for, yet perception of a complexity of barriers that influenced their satisfaction and consistent engagement with PMI services aligns with reports from other medical specialties.

Clinicians in this and other studies reported satisfaction when engaging with PMI services. Similar to this study, a cross-sectional survey of clinicians working at 3 academic outpatient clinics in San Francisco suggested that most (78%) respondents were “very satisfied” or “satisfied” with the medical care they provided when engaging with PMI services.²³ An important theme captured in our qualitative analyses was that of clinicians appreciating PMI's contributions to improving cross-cultural understanding. Although PMI practice under codes of ethics and regulations that emphasize neutrality, they have also been characterized and proposed as “brokers” or “facilitators” of trust, cultural context, and continuity of care.^24,25

Nonetheless, the underuse of PMI services reported in this study is pervasive across the continuum of health care. A survey of Spanish- and Chinese-speaking patients hospitalized at 2 urban medical centers captured that they often “got by” without an interpreter or “barely spoke” to clinicians, as physicians and nurses seemed to infrequently engage PMI services (14%–17% and 4% of the time, respectively).⁶ These patient perceptions have been further characterized by retrospective analyses of administrative health care data quantifying gaps in the provision of PMI services (as low as 3.7% of the times required) in emergency department and inpatient settings.^26–28 Although less is known about the use of PMI services in outpatient clinics, similar patterns of underuse seem to exist in these environments.^29,30 As documented in our previous study of hospitalized patients with acute ischemic stroke, not engaging PMI services can negatively influence patients' quality of care.^4,17 Furthermore, the use of ad hoc interpreters carries the risk of greater clinically significant communication errors that can result in patient morbidity and even death.³¹

Neurology clinicians in this study are not alone in their attempts to maximize time. A survey of South Carolina health service providers documented having to wait for a PMI was an important factor for clinicians to “cut corners” and use ad hoc interpreters.³² Surgical specialists providing preoperative consent for patients with LEP have volunteered relying on bilingual hospital staff, family members, or minors when the wait time for PMI services was greater than 15 minutes.³³ Certainly, there is variability in wait times after calling PMI services (for example, 19 minutes with a 17.5 SD in a busy surgical and procedural practice), yet technology-enabled PMI services have been proven to increase time efficiency (for example, the average wait time for PMI services reduced from 37 to 17 minutes after an academic medical center transitioned from face-to-face to video PMI services).^34,35

Clinicians in this and other studies seem to prefer face-to-face interpretation despite the growing availability of technology-enabled PMI services that promise to improve efficiency. We suspect that a combination of clinical, logistical, and education factors shape this preference and its associated behaviors. As perceived in this study, speech or cognitive impairments may interfere with the effectiveness of using phone or video technology.³⁶ The literature also offers examples of clinically complex encounters that require intricate conversations (such as for discharge planning and education or end-of-life care) and may be perceived as more appropriate for face-to-face interpretation.^37,38 This and other studies also raise technology-related challenges with device connectivity, audio or video quality, and access to technical support when using phone or video PMI services.³⁹ Clinicians' perceived lack of education and workflow supports to effectively use technology-enabled PMI services pose further barriers.²³ Despite these challenges, technology-enabled PMI services are expanding and can be an excellent tool to reduce the use of ad hoc interpreters, decrease time delays, and maintain patients' satisfaction.^36,40–42

Clinicians in this study voiced concerns about variability in the accuracy of interpretation by PMI. Although studies of transcribed clinical encounters have demonstrated gaps in the accuracy of interpretation by PMI, this problem decreases with greater hours of PMI training. Importantly, the greatest risk of misinterpretation with potential consequences remains when using ad hoc or no interpreters.^43,44 As neurology-specific terms or situations could pose unique challenges, there may be opportunities to enhance PMI training with neurology-specific content.

Neurology outpatient clinics offer valuable opportunities for students, residents, and fellows to learn about the practice of neurology and refine their cross-cultural care abilities. Clinicians in this study perceived logistical challenges engaging PMI services when trainees were involved in encounters. At the same time, other studies have shown that lack of time and lack of role models can interfere with trainees' cross-cultural care preparedness and delivery.⁴⁵ Interventions to maximize outpatient clinic efficiency should consider these challenges.

A unique aspect of this study was involvement of patient services coordinators. Like their clinical colleagues, these frontline staff volunteered appreciation for but inconsistent use of PMI services. Gaps in the collection and confirmation of language data and PMI service needs also emerged. In-depth interviews of patients with LEP have certainly highlighted problems communicating with “front desk” staff across language differences, with negative influences on care coordination and patient satisfaction.⁴⁶ As important clinical allies, patient services coordinators must be included in education and system redesign interventions that seek to improve the collection and use of language data and PMI services. Federal and state bodies offer guidance to advance and sustain culturally and linguistically appropriate services in health care settings.^47,48

The neurology community must be cognizant of the federal regulations to assure access to language services. Title VI of the Civil Rights Act first detailed that “no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” Executive Order 13166 Improving Access to Services for Persons with LEP subsequently clarified that “each Federal agency shall also work to ensure that recipients of Federal financial assistance provide meaningful access to their LEP beneficiaries.” It is important to emphasize that the Office of Civil Rights considers all the following entities as recipients of federal assistance from Health and Human Services and therefore subject to nondiscrimination requirements under Title VI and its implementing regulations: health care providers participating in the Children's Health Insurance Program and Medicaid programs, hospitals and nursing homes (recipients under Medicare Part A), Medicare Advantage Plans (such as health maintenance organizations and preferred provider organizations, recipients under Medicare Part C), prescription drug plan sponsors and Medicare Advantage Drug Plans (recipients under Medicare Part D), human or social service agencies, and insurers who are participating in the Marketplaces and receiving premium tax credits. Most recently, Section 1557 of the Affordable Care Act explicitly (1) prohibits discrimination on the grounds of race, color, national origin, sex, age, or disability in health programs and activities; (2) requires taking reasonable steps to provide meaningful access to language services and notifying individuals of their rights; (3) encourages developing and implementing a language access plan; and (4) prohibits low-quality interpreting services or relying on unqualified staff.⁹ As with other Affordable Care Act requirements, the language service–related regulations apply to public and private neurology practices. The cost of PMI services can range from $45–$150/h for in-person to $1.25–$3.49/min for technology-enabled PMI services and may be reimbursed by a patient's Medicaid or other federally funded medical insurance.⁹ Although automated translation services such as “Google Translate” remain free of cost and readily available, we strongly advise against the use of these services because they have been found to have serious errors.⁴⁹

This study occurred at an outpatient neurology clinic set in a large urban academic medical center with robust PMI services, which may limit generalizability. Nonetheless, there are striking similarities between these data and an analysis of the state of affairs at 8 health care centers across the United States by the Centers for Medicare & Medicaid Services.⁵⁰ Despite every outpatient neurology clinician in the institution being invited to participate, the 40% consent and 35% response rates align with the expected survey participation rates among physicians who often cite lack of time and survey burden as barriers to engagement.⁵¹ The voluntary and self-report aspects of this cross-sectional survey raise the potential for selection and recall bias. Although participants were informed that answers would remain anonymous, they may have been wary to respond honestly as some questions pertained to compliance with hospital procedures and policies. Future studies of PMI service use in neurology settings should capture the perspectives of patients and PMI; analyze actual PMI service utilization data; consider the role of language concordance; explore the gaps related to translation of documents; and most importantly test interventions to assure adequate access to language services for the growingly diverse population needing neurology care.

Neurology practices must strive to provide safe, effective, patient-centered, timely, efficient, and equitable patient care.³ We have an opportunity to advance equity by assuring adequate access to language services despite challenges such as those captured in this survey.

Appendix. Authors

Study funding

J.H. Tran received funding from the Massachusetts General Hospital Center for Community Health Improvement. N.I. Mejia received funding from NIH-NINDS 5U01NS077179 Diversity Supplement, the Massachusetts General Hospital Department of Neurology, and philanthropic support from patients and their families.

Disclosure

The authors report no disclosures relevant to the manuscript. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.

TAKE-HOME POINTS

• → More than 20% of Americans speak at least 1 of over 350 languages other than English at home.

• → Neurology practices must be well equipped to address patients' needs and preferences including as it pertains to language.

• → PMIs can facilitate effective communication across language differences yet remain underutilized in health care.

• → Participants in this cross-sectional survey voiced appreciation for, yet perception of a complexity of barriers that influenced their satisfaction and consistent engagement with PMI services in neurology outpatient clinic settings.

• → The neurology community must be aware of Federal regulations, including Section 1557 of the Affordable Care Act, that exist to assure appropriate access to language services.