Study: Doctors’ Language Tests Spotlight Need to Provide Interpreters in Medical Settings


The U.S. population is becoming increasingly diverse. According to the U.S. Census Bureau’s American Community Survey Reports, in 2006, 13.7% of U.S. children under age 5 lived in a home where a parent or guardian spoke English less than “very well”. In medical settings, where effective communication between provider and patient is essential to quality care, language barriers have a negative impact. Research has shown that language barriers affect patient satisfaction and compliance, cost, medical errors, and risk of litigation.

While many doctors in the U.S. have some ability to communicate in a foreign language, there are no standards that determine what degree of proficiency is required to communicate effectively with patients. Often, doctors are left to determine themselves whether they’re up to the task of discussing complex medical information in a foreign language. They may not be the best judges of their own abilities.

Using professional interpreters has been shown to improve doctor-patient communication and quality of care. However, in many medical settings, it’s still common practice for a patient’s family member or another bilingual medical staff member to step in to interpret, increasing the likelihood of miscommunication from interpretation errors.

The Study

Drs. Casey Lion and Beth Ebel of Seattle Children’s Research Institute and co-investigators set out to measure the impact of an objective evaluation of medical provider Spanish-language skills on self-reported language proficiency and comfort using Spanish in a range of clinical scenarios. Their study, Impact of Language Proficiency Testing on Provider Use of Spanish for Clinical Care, published online today in the AAP’s Pediatrics.

“We were concerned that providers were willing to use Spanish language skills for clinical care, even when they weren’t proficient, and especially concerned that they were doing so in scenarios that were medically and legally complex,” said Dr. Lion.

Drs. Lion and Ebel hypothesized that providers with lower levels of Spanish proficiency would be reluctant to deliver care in Spanish after objective feedback on language proficiency, particularly in situations with complex medical and legal implications.

They enrolled 78 pediatric residents from three residency programs throughout the U.S.: University of Washington/Seattle Children’s Hospital (Seattle, WA), Johns Hopkins School of Medicine (Baltimore, MD), and Children’s Mercy Hospitals and Clinics (Kansas City, MO).  Residents completed a baseline survey rating their ability to speak about health and pediatric medicine in Spanish. After the baseline survey, each participant took a standardized, oral proficiency test. After receiving the score from the standardized test, they completed a follow-up survey to reassess their spoken Spanish proficiency and comfort using Spanish in clinical scenarios. Participants were asked if the test altered their general comfort level in speaking Spanish with patients and families.

The Findings

The researchers found that after testing, residents were not as comfortable using Spanish in straightforward clinical scenarios: prior to testing, 64% reported they were comfortable using Spanish in such a setting; after testing, only 51% reported they felt comfortable using Spanish.  Those residents who reported a difference in comfort level mostly tested at a non-proficient level. However, testing had no impact on comfort using Spanish in complex or medical-legal scenarios at any proficiency level. And, they found no changes in self-reported Spanish proficiency in any group.

Based on these results, the researchers concluded that testing decreased non-proficient residents’ comfort with using Spanish in straightforward clinical scenarios, but testing didn’t change comfort levels in more complex or legal scenarios.  Therefore, language testing may play a major role in decreasing non-proficient Spanish use and improving care for patients with limited English proficiency, especially if coupled with clear policies and easy access to professional interpreters.

The Implications

  • “Language proficiency is a testable skill, just like showing you’re competent to perform a particular surgical procedure. Like other skill-based competencies in medicine, providers’ language proficiency should be demonstrated with an objective test. Providers with non-proficient language skills can still establish rapport with families, but medical discussions should occur in the presence of an interpreter,” said Dr. Lion.
  • Good care for limited English proficient patient families requires good communication. Medical providers can offer the same outstanding care to all patients, regardless of English proficiency, if they ensure that high quality communication is occurring.  Good communication results from testing provider language ability, and implementing and enforcing policies to make interpreter access easy and routine.
  • Hospitals and clinics should test providers in their language proficiency and provide quick access to professional interpreter services.


  • National
    • According to the U.S Census Bureau, among the 55.4 million speakers of non-English languages, 15.3 million (28%) were those aged 18 to 40 who spoke Spanish.
    • About half of speakers of non-English languages also reported that they did not speak English “very well.”
  • WA  state
    • According to the U.S. Census Bureau, among the more than 1 million people  (age 5 and older) who spoke a language other than English at home, 16.5% reported that they do not speak English “very well”.
  • Seattle Children’s
    • 16% of all families at Seattle Children’s in FY 2011 were limited English proficient.
    • Of those, 58% were Spanish-speaking.

Pediatric experts available for media interviews

Casey Lion, MD, MPH is an attending physician in General Pediatrics at Seattle Children’s Hospital and a quality of care research fellow in the Department of Pediatrics at the University of Washington School of Medicine. Dr. Lion is a member of the Academic Pediatric Association and the American Academy of Pediatrics, and has a research interest in measuring and improving the quality of care for disadvantaged and vulnerable children.

Beth E. Ebel, MD, MSc, MPH is the director of the Harborview Injury Prevention and Research Center, a multidisciplinary research institute encompassing the fields of pediatrics, surgery, biostatistics, epidemiology, psychiatry, trauma care and social work, nursing, and health economics. Dr. Ebel is also an associate professor in the Department of Pediatrics at the University of Washington School of Medicine and a researcher in the Center for Child Health, Behavior and Development at Seattle Children’s Research Institute. This research was funded by a grant to Dr. Ebel from the Robert Wood Johnson Foundation.

About Seattle Children’s Interpreter Services

Seattle Children’s provide interpretation free of charge to patients and families who feel that they need help communicating in English. We do not allow relatives to provide interpretation because they may not have the technical knowledge required to interpret medical information and are not trained as interpreters. Our medical interpreters facilitate communication between patients, families and providers. Interpreters are available 24 hours a day, seven days a week.  Telephonic interpretation is available in more than 150 languages and dialects.  Each month, Seattle Children’s staff members make approximately 6,000 to 7,000 requests for in-person or phone interpreters to ensure that accurate information is exchanged and to provide timely care in a culturally sensitive fashion.

Additional Resources