Study explores underuse of interpreters in hospitals

Alicia Fernandez, MD

A new study has found that resident physicians at teaching hospitals underuse interpreter services — often relying on hand gestures or a limited number of words in the patient’s native language.

According to the research team, the study is the first to closely examine how resident physicians arrive at the decision of whether or not to use an interpreter. Commonly known as residents, these physicians are licensed MDs who are taking part in advanced training at a hospital under the supervision of its medical staff.

The study is published in the February 2009 issue of the “Journal of General Internal Medicine” and is available online at

The research team conducted in-depth interviews with 20 residents in internal medicine at two hospitals—one in the East and one in the West—where interpreters for up to 170 languages are readily available on site or by phone.

Research findings showed that residents recognized that they were not taking full advantage of interpreter services and they tended to depend on the patient’s family members, gestures, or their own limited second-language skills when communicating with patients with limited English proficiency—a process they often termed “getting by.”

“While there are some situations in which calling an interpreter may not be necessary, the underuse of professional interpreters has been normalized among resident physicians. We need better systems in place to help residents determine when to involve a professional interpreter so that all patients receive the quality care they deserve,” said Alicia Fernandez, MD, senior author of the study and associate professor of clinical medicine in the Division of General Internal Medicine at the University of California, San Francisco.

According to Fernandez, study findings showed that residents tended to reserve waiting for an interpreter to instances of particularly complex decision making.

Lead study author Lisa Diamond, MD, MPH, noted that “Residents found it difficult to change their practice, despite misgivings about the quality of care provided. Residents are part of an overall hospital culture that is struggling to adapt to the care of patients with limited English proficiency.”  Diamond conducted the research while a Robert Wood Johnson Foundation clinical scholar at the Yale University School of Medicine, and she is now a postdoctoral fellow at the UCSF Philip R. Lee Institute for Health Policy Studies.

Fernandez and Diamond suggest that hospitals adopt technologies that will help reduce the perception among busy doctors that seeking out an interpreter is not an efficient practice.

For example, some hospitals—such as UCSF Medical Center and San Francisco General Hospital Medical Center—are deploying video-interpreter technology in patient care areas that provides rapid access to a trained medical interpreter. The technology includes a video station where both clinician and patient can see the interpreter in real time while they are talking. UCSF has committed a portion of its state funding for telemedicine technology to install video interpreter systems at SFGH and in several city clinics.

The researchers emphasized that hospitals must offer clear guidelines for interpreter use and frame it as an issue of patient safety and quality improvement. The study findings suggest that increasing interpreter use will require interventions at both the level of the individual physician and the practice environment, and Fernandez said she applauds hospitals that already are taking steps in this direction.

Looking ahead, Fernandez said she hopes to conduct a followup study at several medical schools to see if early intervention with students translates into improved communication between doctors and their patients with limited English proficiency (LEP).

According to the United States census in 2000, the number of Americans with LEP grew by 53 percent between 1990 and 2000 to more than 22 million. In California, 20 percent of the state’s residents speak limited English.

Study co-authors are Yael Schenker, MD, of UCSF, and Leslie Curry, PhD, MPH, and Elizabeth Bradley, PhD, of Yale University.

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