Clinical Practice  |   December 2009
Eliminating Barriers for Patients With Limited English Proficiency
Author Notes
  • From the Department of Family Medicine at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine (UMDNJ-SOM) in Stratford. 
  • Address correspondence to Joshua S. Coren, DO, Associate Professor, Family Medicine, UMDNJ-SOM, 310 Creek Crossing Blvd, Hainesport, NJ 08036-2767. E-mail: 
Article Information
Practice Management / Professional Issues
Clinical Practice   |   December 2009
Eliminating Barriers for Patients With Limited English Proficiency
The Journal of the American Osteopathic Association, December 2009, Vol. 109, 634-640. doi:
The Journal of the American Osteopathic Association, December 2009, Vol. 109, 634-640. doi:

The increasing number of patients with limited English proficiency (LEP) in the United States is an important issue for patients, physicians, federal and state government agencies, and insurance carriers. Physicians can actively address this healthcare barrier by becoming familiar with established state and federal guidelines and determining when appropriate linguistic services are required for their LEP patient populations. Physicians can ensure that appropriate care is administered to LEP patients by developing and monitoring plans that include training staff to identify and work with LEP patients, providing language assistance to LEP patients, and notifying LEP patients of special services.

An area of increasing concern among physicians is providing care for patients with limited abilities to speak English.1,2 This concern is warranted by—among other factors—logistical uncertainties in treating patients who may not understand physician instructions, the risk of potential litigation in treating such patients, and the fiscal impact on medical practice of treating such patients.1,2 
Limited English proficiency (LEP) is a term used to describe individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English.3 Currently, 38 million people in the United States—roughly 12.5% of the population—are foreign born. As this number grows,4 the odds increase that LEP patients will be encountered in outpatient and surgical settings, as well as in hospital and emergency department beds. According to the 2001 Supplementary Survey by the US Census Bureau,5 33% of individuals aged 18 to 64 years who speak Spanish, and 22% of individuals in this age category who speak Asian or Pacific Island languages, reported that they spoke English either “not well” or “not at all.” Of course, not all patients who primarily speak non-English languages are foreign-born. Some of these patients may be US-born but live in relatively isolated ethnic enclaves. 
To eliminate healthcare barriers experienced by the growing number of LEP patients, it is imperative that physicians and office staff comprehend federal, state, and privatesector requirements regarding LEP patients. It is also important for physicians to assess the multicultural populations living within their practices' geographic areas and to incorporate appropriate interpretation and translation services within their practices.6 
Healthcare Barriers
There are many important and practical reasons for patients and physicians to communicate effectively and to understand each other. For example, physicians need to obtain accurate medical histories, and patients need to understand physician instructions and become an integral part of the patient-physician partnership. More often than not, LEP patients are hampered in these efforts because of language barriers. These barriers are likely to result in fewer visits to providers and delays in preventative services, fostering acquisition and exacerbation of chronic conditions and deterioration of acute symptoms leading to hospitalization.7-11 
Unresolved linguistic and cultural barriers can contribute to misunderstandings among patients regarding diagnosis, treatment, and self-care options.12 Other implications of these barriers can include inappropriate use of medications,13 lack of informed consent for procedures,14 longer hospital stays,15 poor patient satisfaction,7,8,16-18 and poor comprehension by patients of follow-up care plans.19,20 Temporary or permanent confusion, fears, and concerns among the rapidly expanding LEP population are compounded by difficulties these individuals have in accessing healthcare resources and providers.21-24 
Federal and State Regulations
A number of federal and state regulations are designed to protect LEP patients from encountering healthcare barriers. All providers who receive federal funding must abide by Title VI of the Civil Rights Act of 1964, which prohibits discrimination on the basis of race, color, or national origin.25 In 2000, President Bill Clinton issued Executive Order 13166, which reinforced the need for providers and hospitals that receive federal funding to render appropriate access and services to LEP patients.26 In addition, the Standards for Culturally and Linguistically Appropriate Services (CLAS)27 were established in 2001 by the Department of Health and Human Services' (HSS) Office of Minority Health. These LEP-related standards include the following requirement: 

Health care organizations [that receive federal funding] must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

A major source of confusion for many physicians is whether this HHS guidance applies to them. To clarify, the HHS CLAS standards apply to any entity receiving funds from the HHS, including physicians who participate in Medicare Part A or federally funded clinical trials or who provide treatment to certain other patient categories.27 Physicians enrolled only in Medicare Part B and who do not otherwise receive federal funds are not subject to the HHS requirements.28 
The CLAS standards also apply to patients needing services in American Sign Language and those covered by the Americans With Disabilities Act.27,29 Figure 1 shows a comprehensive list of the CLAS standards. 
Individual states vary in their quantity and scope of laws related to caring for LEP patients. All states have antidiscrimination laws that at least broadly encompass Title VI, Executive Order 13166, and the CLAS standards.27 In New Jersey, mandatory cultural competency training, including content for treating LEP patients, is required for all physicians and podiatrists before relicensure.30-33 Curricular integration of cultural competency is required in all New Jersey medical schools.30-33 California30,34 and Washington State30,35 require varying degrees of cultural competency training or continued medical education regarding LEP patients before physician relicensure. Many other states currently have legislation in various stages of development involving integration of cultural competency and LEP proficiency training for healthcare providers.30,36 
In addition to federal and state laws, the American Osteopathic Association,37 Accreditation Council for Graduate Medical Education,38 and American Board of Medical Specialties39 have all mandated the implementation of core competencies in medical training programs. These requirements include competencies in communication skills and professionalism, such as sensitivity to patient age, culture, disability, and sex, and recognition of cultural diversity among patient populations in served communities. The National Board of Osteopathic Medical Examiners has issued a report recommending the inclusion of core competencies in the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA).40 The Joint Commission is currently developing accreditation requirements to advance effective communication and cultural competence within the medical environment, including reducing language barriers in patient care.41 
These many efforts, however, have not been sufficient to resolve language barriers for LEP individuals. In particular, awareness of language law among providers has not been associated with use of professional interpreters by providers.42 This finding suggests that providers may still not be aware of their legal obligations to offer language access services to their LEP patients. It may also indicate that providers continue to use untrained interpreters, such as patients' family members and friends. Although federal policy for the past 40 years has mandated that meaningful language access be provided to LEP patients, this requirement has resulted in less than favorable outcomes.42 There is much room for raising awareness of this issue, as well as for creating more rigorous guidelines and enforcement mechanisms. 
To determine the extent of LEP patient needs, the HHS suggests that all physicians who receive federal funding conduct LEP assessments of their practices, focusing on the following factors43: 
  • the number or proportion of LEP persons eligible to be served or likely to be encountered by the program, activity, or service provided by the [federal funding] recipient
  • the frequency with which LEP individuals come in contact with the recipient's program, activity, or service
  • the nature and importance of the recipient's program, activity, or service
  • the resources available to the recipient and [the recipient's] costs
Although no finite numbers or time frames are recommended in the HHS guidelines,43 the following is noted about these four factors and a physician's obligation to provide services to LEP patients: 

As clarified by the guidance, the extent of Title VI obligations will be evaluated based on a four-factor test including the nature or importance of the service. In this regard, the guidance points out that documents deemed “vital” to the access of LEP persons to programs and services may oftenhave to be translated. Whether or not a document (or the information it contains or solicits) is “vital” may depend upon the importance of the program, information, encounter, or service involved, and the consequence to the LEP person if the information in question is not provided accurately or in a timely manner.

Figure 1.
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care, developed by the Office of Minority Health, US Department of Health and Human Services.27
Figure 1.
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care, developed by the Office of Minority Health, US Department of Health and Human Services.27
Providers with small practices will have considerable flexibility in determining precisely how to fulfill their obligations to ensure meaningful access for LEP patients, as noted in the following excerpt from the HHS guidelines43: 

There is no “one size fits all” solution for Title VI compliance with respect to LEP persons, and what constitutes “reasonable steps” for large providers may not be reasonable where small providers are concerned. Thus, smaller recipients with smaller budgets will not be expected to provide the same level of language services as larger recipients with larger budgets. [The HHS Office for Civil Rights] will continue to be available to provide technical assistance to HHS recipients, including sole practitioners and other small recipients, seeking to operate an effective language assistance program and to comply with Title VI.

Office Protocols
Providers can take several steps to establish procedures for identifying LEP patients. An easy identifier is the use of the US Census Bureau's “I Speak” language identification cards.44 An I Speak card lists a phrase in numerous languages to allow the patient to identify his or her preferred language. These cards should be placed in an easily viewed area in the provider's waiting room or front office. A sample format of an I Speak card can be seen at: 
Other key elements in implementing an effective LEP identification plan are language assistance measures, such as listing the language services available in the waiting room or front office, developing a plan to respond to phone calls or written communications from LEP patients, and selecting competent interpretation and translation services.45 Notices of the available healthcare resources provided at an office should also be displayed for LEP patients in the appropriate languages.45 
Because appropriate execution and eventual monitoring of the LEP protocol in the office is crucial,45 the provider must ensure that the office staff is thoroughly trained in LEP-related areas. 
Interpretation and Translation Services
Professional interpreters are the conduit for effective, efficient, and reliable communication between healthcare professionals, LEP patients, and patients' families.46 Trained medical interpreters have been shown to not only decrease clinically meaningful communication errors,47 but also to be an effective means of enhancing quality of care.48 The October 2009 launch of the first national certification program for medical interpreters aims to enhance patient safety by evaluating and ensuring the competency of medical interpreters.49 
Although interpreters are involved in the communication aspects of patient care, translators are typically used to reproduce written or printed material in other languages. Informed consents, privacy guidelines, and blood test consent forms are examples of documents that may need to be translated.27 
With regard to interpretation services, the CLAS standards provide the following recommendations27: 

Language services include, as a first preference, the availability of bilingual staff who can communicate directly with patients/consumers in their preferred language. When such staff members are not available, face-to-face interpretation provided by trained staff, or contract or volunteer interpreters, is the next preference. Telephone interpreter services should be used as a supplemental system when an interpreter is needed instantly, or when services are needed in an unusual or infrequently encountered language.

Additional recommendations regarding interpretation services are as follows: 
  • Telephone language interpreters can be found via online searches using such key words as medical interpreter coupled with the provider's city and state.
  • Use of a patient's family members or friends as interpreters is discouraged unless requested by the patient. Family members or friends may misinterpret or misrepresent medical discussions and may also compromise the patient's privacy. Staff should suggest to the patient that a trained interpreter be present during the clinical encounter to ensure accurate interpretation. This offer and the patient's acceptance or rejection of the offer should be documented in the patient's file.27
  • The use of a minor for interpretation is not acceptable because of privacy issues, the shift of power from the patient to the minor, and the potential for emotional trauma to the minor.
  • Staff members should be used as interpreters only if they are fluent in the necessary language and trained in appropriate medical terminology—and if interpretation services are among the designated duties of their employment position. However, the provider should check with state health officials to find out if staff can legally be used in interpretation. Some states have laws that specifically define positions that can and cannot perform medical interpretation duties.50
  • Staff members not trained as interpreters may breach patient confidentiality,51 provide inaccurate communication,52,53 contribute to misdiagnosis,54 and reduce quality of care.55
  • Although trained medical interpreters are a valuable part of the medical team, the provider should not assume that interpreters are aware of patients' cultural values, beliefs, and behaviors.
Ideally, scheduling of patient visits should be coordinated to allow for interpreters to attend medical office visits with LEP patients. If onsite interpreter visits are not available, telephone-based interpretation by medically trained operators is provided by various commercial vendors. Although this telephone service is less expensive then onsite interpreters, lack of necessary dual headphone equipment and the potential of the interpreter missing nonverbal cultural cues over the phone are limiting factors. 
Before committing to a particular interpretation service, providers should obtain certification records, check references, compare costs, and perform background research on all available options. Other practical suggestions regarding interpretation services include medical record documentation of every patient's preferred language and the name of the interpreter or interpretation company used for each LEP patient. Figure 2 lists Web sites that provide more information about telephone interpretation and translation services. 
Many physicians are concerned about the financial implications of providing language assistance services, especially interpretation. For example, physicians receiving Medicare or Medicaid reimbursement may believe that the cost of telephone or in-person interpretation services is more expensive than the reimbursement they would receive for the office visit—because the service provided by the interpreter cannot be billed to the patient in such cases. 
A law effective in California as of January 2009 mandates that all health insurers in the state provide language assistance services to their members who have limited English proficiency.56 This law was passed to help alleviate both language and cultural barriers experienced by LEP patients in the state. 
Figure 2.
Web site resources for telephone interpretation and translation services and training.
Figure 2.
Web site resources for telephone interpretation and translation services and training.
In the absence of reimbursement, physicians should consider the substantial hidden costs associated with misunderstood instructions, missed appointments, and other consequences of not eliminating language barriers for patients. Physicians should also consider the ethical and malpractice risks of treating patients with whom they cannot effectively communicate.27 
Providing interpretation and translation services to LEP patients is an important step in eliminating healthcare barriers and providing effective healthcare. Recognizing that—regardless of language barriers—patients may forget a substantial amount of medical information provided during medical office visits, we should at least attempt to ensure that our LEP patients have appropriate services to initially comprehend the information we give them. 
 The authors have no relevant conflicts of interest or financial relationships to disclose. The opinions expressed in this article are those of the authors and not necessarily those of UMDNJ-SOM or any other organizations with which the authors are affiliated.
We thank Robert C. Like, MD, MS, director of the Center for Healthy Families and Cultural Diversity in the Department of Family Medicine at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in New Brunswick for reviewing and providing comments on earlier drafts of this article. 
Gadon M, Balch GI, Jacobs EA. Caring for patients with limited English proficiency: the perspectives of small group practitioners. J Gen Intern Med. 2007;22(suppl 2):341-346. Accessed November 20, 2009.
The Robert Wood Johnson Foundation. Physician Perspectives on Communication Barriers. Insights from Focus Groups with Physicians Who Treat Non-English Proficient and Limited English Proficient Patients. Washington, DC: Lake Snell Perry & Associates, Inc; March 2004. Accessed November 24, 2009.
Questions and answers. Limited English proficiency: a federal interagency Web site. Accessed November 24, 2009.
2007 American community survey and census data on the foreign born by state. Number of foreign born by state (1990, 2000, 2008). Migration Policy Institute Web site. Accessed November 19, 2009.
US Bureau of the Census. 2001 Supplementary Survey. Washington, DC: US Bureau of the Census; 2001. Accessed November 24, 2009.
FAQs. International Medical Interpreters Association Web site. Accessed November 24, 2009.
Morales LS, Cunningham WE, Brown JA, Liu H, Hays RD. Are Latinos less satisfied with communication by health care providers? J Gen Intern Med. 1999;14:409-417. Accessed November 20, 2009.
Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. J Gen Intern Med. 1999;14:82-87.
Weech-Maldonado R, Morales LS, Elliott M, Spritzer K, Marshall G, Hays RD. Race/ethnicity, language, and patients' assessments of care in Medicaid managed care. Health Serv Res. 2003;38:789-808. Accessed November 20, 2009.
Sarver J, Baker DW. Effect of language barriers on follow up appointments after an emergency department visit. J Gen Intern Med. 2000;15:256-264. Accessed November 20, 2009.
Fortier JP, Bishop D. Setting the Agenda for Research on Cultural Competence in Health Care: Final Report. Rockville, MD: US Department of Health and Human Services Office of Minority Health and Agency for Healthcare Research and Quality; 2003.
Monroe AD, Shirazian T. Challenging linguistic barriers to health care: students as medical interpreters. Acad Med. 2004;79:118-122.
Gandhi TK, Burstin HR, Cook EF, Puopolo AL, Haas JS, Brennan TA, et al. Drug complications in outpatients. J Gen Intern Med. 2000;15:149-154. Accessed November 20, 2009.
Schenker Y, Wang F, Selig SJ, Ng R, Fernandez A. The impact of language barriers on documentation of informed consent at a hospital with on-site interpreter services. J Gen Intern Med. 2007;22(suppl 2):294-299. Accessed November 20, 2009.
John-Baptiste A, Naglie G, Tomlinson G, Alibhai SM, Etchells E, Cheung A, et al. The effect of English language proficiency on length of stay and in-hospital mortality. J Gen Intern Med. 2004;19:221-228. Accessed November 20, 2009.
Baker DW, Hayes R, Fortier JP. Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients. Med Care. 1998;36:1461-1470.
Weech-Maldonado R, Elliott MN, Morales LS, Spritzer K, Marshall GN, Hays RD. Health plan effects on patient assessments of Medicaid managed care among racial/ethnic minorities. J Gen Intern Med. 2004;19:136-145. Accessed November 20, 2009.
Woloshin S, Bickell NA, Schwartz LM, Gany F, Welch HG. Language barriers in medicine in the United States. JAMA. 1995;273:724-728.
Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275:783-788.
Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med. 2005;20:800-806. Accessed November 20, 2009.
Solis JM, Marks G, Garcia M, Shelton D. Acculturation, access to care, and use of preventive services by Hispanics: findings from HHANES 1982-84. Am J Public Health. 1990;80(suppl):11-19. Accessed November 20, 2009.
Stein JA, Fox SA. Language preference as an indicator of mammography use among Hispanic women. J Natl Cancer Inst. 1990;82:1715-1716.
Timmins CL. The impact of language barriers on the health care of Latinos in the United States: a review of the literature and guidelines for practice. J Midwifery Womens Health. 2002;47:80-96.
Kirkman-Liff B, Mondragon D. Language of interview: relevance for research of southwest Hispanics. Am J Public Health. 1991;81:1399-1404. Accessed November 20, 2009.
42 US Code §2000d.
Executive Order 13166: Improving Access to Services for Persons With Limited English Proficiency. US Department of Justice Web site. Accessed November 19, 2009.
Office of Minority Health, US Department of Health and Human Services. National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC: US Department of Health and Human Services; 2001. Accessed November 24, 2009.
Guidance to federal financial assistance recipients regarding Title VI prohibition against national origin discrimination affecting limited English proficient persons. 68 Federal Register 47311 (2003).
Americans With Disabilities Act of 1990, as amended. Americans With Disabilities Act, US Department of Justice Web site. Accessed November 20, 2009.
Youdelman MK. The medical tongue: US laws and policies on language access. Health Aff. 2008;27:424-433.
NJ Rev Stat ch 9, §144. Accessed November 24, 2009.
Like RC, Barrett TJ, Moon J. Educating physicians to provide culturally competent, patient-centered care. In: Perspectives: A View of Family Medicine in New Jersey. 2008; 7:10-20. Accessed November 20, 2009.
NJ cultural competency. State of New Jersey Web site. Accessed November 24, 2009.
Calif Bus Prof Code §2190.1.
Wash Rev Code §43.70.615.
Graves DL, Like RC, Kelly N, Hohensee A. Legislation as intervention: a survey of cultural competency policy in health care. J Health Care Law Policy. 2007;10:339-361.
Core Competency Compliance Program (CCCP), Part I. American Osteopathic Association Web site. Accessed November 24, 2009.
Outcome Project: general competencies. Accreditation Council for Graduate Medical Education Web site. Accessed November 24, 2009.
About American Board of Medical Specialties (ABMS). BoardCertified-Docs Web site. Accessed November 24, 2009.
National Board of Osteopathic Medical Examiners. Fundamental Osteopathic Medical Competencies: Guidelines for Osteopathic Medical Licensure and the Practice of Osteopathic Medicine. Chicago, IL: National Board of Osteopathic Medical Examiners; March 2009. Accessed November 24, 2009.
Developing proposed requirements to advance effective communication, cultural competence, and patient-centered care for the hospital accreditation program; August 14, 2009. The Joint Commission Web site. Accessed November 24, 2009.
Grubbs V, Chen AH, Bindman AB, Vittinghodd E, Fernandez A. Effect of awareness of language law on language access in the health care setting. J Gen Intern Med. 2006;21:683-688. Accessed November 20, 2009.
Guidance to federal financial assistance recipients regarding the Title VI prohibition against national origin discrimination affecting limited English proficient persons. US Department of Health and Human Services Web site. Accessed November 24, 2009.
Language identification flashcard. US Bureau of the Census Web site. Accessed November 19, 2009.
Coordination and review section. US Department of Justice Web site. Accessed November 24, 2009.
Haffner L. Translation is not enough. Interpreting in a medical setting. West J Med. 1992;157:255-259. Accessed November 20, 2009.
Flores G, Laws MB, Mayo SJ, Zuckerman B, Abreu M, Medina L, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111:6-14. Accessed November 20, 2009.
Jacobs EA, Lauderdale DS, Meltzer D, Shorey JM, Levinson W, Thisted RA. Impact of interpreter services on delivery of health care to limited-English-proficient patients. J Gen Intern Med. 2001;16:468-474. Accessed November 20, 2009.
Limited English speaking patients closer to being guaranteed quality, equitable healthcare [press release]. Washington, DC: National Board of Certification for Medical Interpreters; October 12, 2009. Accessed December 1, 2009.
Herndon E, Joyce L. Getting the most from language interpreters. Fam Pract Manag. 2004;11:37-40.
Haffner L. Translation is not enough—interpreting in a medical setting. In: Cross-cultural medicine—a decade later. West J Med. 1992;157:255-259. Accessed November 20, 2009.
Marcos LR. Effects of interpreters on the evaluation of psychopathology in non-English-speaking patients. Am J Psychiatry. 1979;136:171-174.
Ebden P, Carey OJ, Bhatt A, Harrison B. The bilingual consultation. Lancet. 1988;1:347 .
Vasquez C, Javier RA. The problem with interpreters: communicating with Spanish-speaking patients. Hosp Community Psychiatry. 1991;42:163-165.
Woloshin S, Schwartz LM, Katz SJ, Welch HG. Is language a barrier to the use of preventive services? J Gen Intern Med. 1997;12:472-477. Accessed November 20, 2009.
Hernandez J. California leads the nation in patient health rights. Business Wire. April 2, 2009. Accessed December 1, 2009.
Figure 1.
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care, developed by the Office of Minority Health, US Department of Health and Human Services.27
Figure 1.
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care, developed by the Office of Minority Health, US Department of Health and Human Services.27
Figure 2.
Web site resources for telephone interpretation and translation services and training.
Figure 2.
Web site resources for telephone interpretation and translation services and training.