"Getting by" in a Swiss Tertiary Hospital: the Inconspicuous Complexity of Decision-making Around Patients' Limited Language Proficiency

While the need to address language barriers to provide quality care for all is generally accepted, little is known about the complexities of decision-making around patients' limited language proficiency in everyday clinical encounters. To understand how linguistic complexities shape cross-cultural encounters by incorporating the perspective of both, patients and physicians. A qualitative hospital study with semi-structured interviews and participant-observation in a Swiss University Hospital. Thirty-two encounters were observed and 94 interviews conducted. Sixteen patients of Turkish and 16 of Albanian origin and all actors (administration, nurses, physicians, if required, interpreters) involved in the patients' entire process. Interviews were audio-recorded and transcribed verbatim. A thematic content analysis was conducted using MAXQDA. For reporting, the COREQ guidelines were used. Three themes were relevant to patients and physicians alike: Assessment of the language situation, the use of interpreters, and dealing with conversational limits. Physicians tend to assess patients' language proficiency by their body language, individual demeanor, or adequacy of responses to questions. Physicians use professional interpreters for "high-stakes" conversations, and "get by" through "low-stakes" topics by resorting to bilingual family members, for example. Patients are driven by factors like fearing costs or the wish to manage on their own. High acceptance of conversational limits by patients and physicians alike stands in stark contrast to the availability of interpreters. The decision for or against interpreter use in the "real world" of clinical care is complex and shaped by small, frequently inconspicuous decisions with potential for suboptimal health care. Physicians occupy a key position in the decision-making to initiate the process of medical interpreting. The development and testing of a conceptual framework close to practice is crucial for guiding physicians' assessment of patients' language proficiency and their decision-making on the use of interpreting services.