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Teaching Spanish to Pediatric Emergency Physicians
Effects on Patient Satisfaction
Suzan S. Mazor, MD;
Louis C. Hampers, MD, MBA;
Vidya T. Chande, MD;
Steven E. Krug, MD
Arch Pediatr Adolesc Med. 2002;156:693-695.
ABSTRACT
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Background Language barriers are known to negatively affect patient satisfaction.
Objective To determine whether a course of instruction in medical Spanish for
pediatric emergency department (ED) physicians is associated with an increase
in satisfaction for Spanish-speaking-only families.
Design, Setting, Participants, and Intervention Nine pediatric ED physicians completed a 10-week medical Spanish course.
Mock clinical scenarios and testing were used to establish an improvement
in each physician's ability to communicate with Spanish-speaking-only families.
Before (preintervention period) and after (postintervention period) the course,
Spanish-speaking-only families cared for by these physicians completed satisfaction
questionnaires. Professional interpreters were equally available during both
the preintervention and postintervention periods.
Main Outcome Measures Responses to patient family satisfaction questionnaires.
Results A total of 143 Spanish-speaking-only families completed satisfaction
questionnaires. Preintervention (n = 85) and postintervention (n = 58) cohorts
did not differ significantly in age, vital signs, length of ED visit, discharge
diagnosis, or self-reported English proficiency. Physicians used a professional
interpreter less often in the postintervention period (odds ratio [OR], 0.34;
95% confidence interval [CI], 0.16-0.71). Postintervention families were significantly
more likely to strongly agree that "the physician was concerned about my child"
(OR, 2.1; 95% CI, 1.0-4.2), "made me feel comfortable" (OR, 2.6; 95% CI, 1.1-4.4),
"was respectful" (OR, 3.0; 95% CI, 1.4-6.5), and "listened to what I said"
(OR, 2.9; 95% CI, 1.4-5.9).
Conclusions A 10-week medical Spanish course for pediatric ED physicians was associated
with decreased interpreter use and increased family satisfaction.
INTRODUCTION
LANGUAGE BARRIERS between emergency department (ED) physicians and patient
families are known to reduce patient compliance and quality of care.1-4 They
may also lead to a higher rate of resource utilization and increased ED visit
times.5-7 The extent
to which formal foreign language instruction to providers can mitigate any
of these effects is unknown. As important, the effects of such an intervention
on patient and family satisfaction have not been prospectively studied.
Despite the widespread availability and use of professional interpreters
in our ED, we hypothesized that an increase in physicians' Spanish-language
skills and cultural competency would be associated with an increase in satisfaction
for Spanish-speaking-only families.
SUBJECTS AND METHODS
This study was conducted in an urban, university-affiliated pediatric
ED with an annual volume of approximately 40 000 patients, 10 full-time
faculty, and 6 fellows. Although 39% of the population in our catchment area
is of Latino origin, few of our medical personnel speak Spanish. Professional
interpreters are available in the ED 18 hours each day. A telephone interpreter
service is used for translation during the remaining 6 hours.
A 10-week medical Spanish course was offered to ED faculty. Nine physicians
with moderate to poor Spanish proficiency chose to participate. The course
was conducted for 2 hours weekly and taught by an instructor from a respected
Spanish-language institute. The class emphasized medical history taking and
Hispanic cultural beliefs.
The physicians' medical Spanish proficiency was established through
scripted clinical scenarios (available from the authors on request). Actors
were recruited to portray Spanish-speaking-only parents. Before and on completion
of the course, each physician conducted 3 mock interviews. After each interview,
the physician completed a written test to identify key elements of the history.
After the course, physicians also completed questionnaires that addressed
their confidence in evaluating a range of common ED chief complaints in Spanish.
In 1-month preintervention (February 11 to March 12, 2000) and postintervention
(June 4 to July 8, 2000) periods, a previously validated family satisfaction
questionnaire6, 8 was adapted for
pediatrics and translated into Spanish. During shifts on which participating
physicians were present in the ED, consecutive Spanish-speaking-only families
were identified at triage by a registered nurse, and a questionnaire was attached
to their ED charts. The families completed their section of the questionnaire
after discharge and left it in the examination room to be collected by the
nurse.
In addition to the designation as "Spanish-speaking-only" at triage,
the questionnaire asked families to rate their own level of English proficiency.
To avoid confusion about who was the physician in charge, questions specified
(in Spanish) the attending physician or fellow as "the doctor in the gray
coat." Using a 5-point Likert scale, caregivers were asked to describe their
agreement with the following: "the physician was concerned about my child,"
"the physician made me feel comfortable," "the physician was respectful,"
and "the physician listened to what I said." For both periods, only families
who were cared for by physicians participating in the course were included
in the analysis. For each Spanish-speaking-only visit, the participating physician
completed a questionnaire addressing professional interpreter use.
The study was approved by the hospital's institutional review board.
RESULTS
When compared with preintervention performance in mock scenarios, in
the postintervention period, physicians scored higher on measures of data
gathering without the use of an interpreter (mean scores, 17.2 vs 22.4; paired t test, P = .01). In addition,
all but one of the physicians in the postintervention period expressed increased
confidence in addressing various ED chief complaints in Spanish.
A total of 143 Spanish-speaking-only families completed satisfaction
questionnaires (85 preintervention and 58 postintervention). Preintervention
and postintervention cohorts did not differ significantly in age, vital signs,
insurance status, length of ED visit, discharge diagnosis, or self-described
English proficiency (Table 1).
Family response rate was 90% and did not vary between preintervention and
postintervention periods. Each participating physician was represented in
similar proportions in both periods ( 2, P = .13). Physicians were less likely to use an interpreter in the
postintervention period (55% vs 29%; odds ratio [OR], 0.34; 95% confidence
interval [CI], 0.16-0.71).
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Patient Characteristics Before and After Intervention
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Families in the postintervention period were more likely to strongly
agree that "the physician was concerned about my child" (OR, 2.1; 95% CI,
1.0-4.2), "the physician made me feel comfortable" (OR, 2.6; 95% CI, 1.1-4.4),
"the physician was respectful" (OR, 3.0; 95% CI, 1.4-6.5), and "the physician
listened to what I said" (OR, 2.9; 95% CI, 1.4-5.9) (Figure 1).
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Percentage of families before and after intervention who answered
"strongly agree" to each of the following 4 questions: "the physician was
concerned about my child," "the physician made me feel comfortable," "the
physician was respectful," and "the physician listened to what I said."
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COMMENT
In our pediatric ED, a 10-week medical Spanish course for physicians
was associated with increased family satisfaction and a concomitant decreased
reliance on professional interpreters.
Our physicians acquired an ability to obtain an uncomplicated medical
history (eg, ear pain, sore throat, lacerations, vomiting, and diarrhea),
conduct an unassisted physical examination, and give common discharge instructions
without the help of an interpreter. Clearly, professional medical interpreters
perform a vital service in our ED, and all of our physicians agreed that they
would continue to use an interpreter for more complex encounters. However,
our results suggest that Spanish instruction for physicians allows this limited
resource to be more efficiently allocated. Despite the necessity of interpreters
for complicated cases, our study supports previous reports correlating interpreter
use negatively with patient satisfaction (when compared with direct communication
in the preferred language).6
We prospectively recorded an improvement in family satisfaction with
the physician. Of course, we presume that improved, direct communication is
the most likely explanation. However, satisfaction is but one element in the
definition of quality care. We are optimistic that this increase in satisfaction
also affected compliance, likelihood of follow-up, and overall disease management,
but further study of long-term outcomes would be necessary to establish such
a relationship.
This study had several methodologic limitations. The questionnaire was
in written form; thus, illiterate families were excluded. We suspect that
the benefits of provider Spanish competence would be even more pronounced
for poorly educated families, but this effect is not reflected in our results.
In addition, the translation from English to Spanish and pediatric adaptation
of our questionnaire may have compromised its previously published validity.
Although our physician participants had no definite knowledge of whether
all of the patient family questionnaires would be included in our sample,
and did not often see the patients' charts until after the patient was discharged
from the ED, they were aware that patient satisfaction would be one of the
outcome measures of our study. Therefore, it is conceivable that a Hawthorne
effect altered their approach to Spanish-speaking-only families in the postintervention
period. However, to the extent that these differences included improved communication
and cultural sensitivity, they should be counted as an affirmation of the
effectiveness of our intervention, rather than as a confounder. In addition,
our physicians were aware of the study in the preintervention period, and
one must suppose that the Hawthorne effect applied to those interactions as
well, thus preserving the internal validity of our findings.
Enrollment in our course was strongly encouraged but ultimately voluntary.
Therefore, it is likely that the physicians completing the course represented
a subset of motivated clinicians with a preexisting interest (if not competence)
in providing culturally sensitive care. Although this small sample size of
providers does not invalidate our main findings regarding an improvement in
family satisfaction, it may restrict the generalizability of this study to
other groups of practitioners.
We did not measure family satisfaction during the 10-week course. It
is possible that, in the process of acquiring cultural and linguistic competence,
a brief period existed when a combination of decreased interpreter use and
inadequate language skills actually reduced family satisfaction. However,
easy access to interpreters throughout this period minimized any such effect.
The total cost of the course (excluding the opportunity cost of physician
time) was $2000 for 9 physicians. The cost-benefit ratio of these classes
will vary with the volume of Spanish-speaking-only patients. Further investigation
may quantify the financial benefits of this and other interventions, such
as recruitment of Hispanic physicians, telephone language lines, lay interpreters,
etc. Nevertheless, because of the significant effects on family satisfaction
observed in our study, medical Spanish courses should be considered as part
of pediatric, general emergency medicine, and pediatric emergency medicine
training in areas where the local patient population is largely Hispanic.
| What This Study Adds
Language barriers are known to negatively affect patient satisfaction.
In our pediatric ED, a 10-week medical Spanish course for physicians was associated
with increased family satisfaction and a concomitant decreased reliance on
professional interpreters. Because of the significant effects on family satisfaction
observed in our study, medical Spanish courses should be considered as part
of pediatric, general emergency medicine, and pediatric emergency medicine
training in areas where the local patient population is largely Hispanic.
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AUTHOR INFORMATION
Accepted for publication March 27, 2002.
This study was supported by a grant from the Children's Memorial Hospital
Child Advocacy Committee, Chicago, Ill.
This study was presented as a poster at the Pediatric Academic Society
Meeting, Baltimore, Md, April 28, 2001.
We thank Genie Roosevelt, MD, MPH, for aid with statistical analysis.
Corresponding author and reprints: Suzan S. Mazor, MD, Division of
Emergency Medicine, Children's Memorial Hospital, 2300 Children's Plaza, Box
62, Chicago, IL 60614 (e-mail: s-mazor2{at}northwestern.edu).
From the Division of Emergency Medicine, Department of Pediatrics,
Children's Memorial Hospital, Chicago, Ill (Drs Mazor, Chande, and Krug),
and the Division of Emergency Medicine, Department of Pediatrics, The Children's
Hospital, Denver, Colo (Dr Hampers).
REFERENCES
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department. Pediatrics. 1999;103(6, pt 1):1253-1256.
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FULL TEXT
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