Lisa Diamond, a former student in the Robert Wood Johnson Clinical Scholars Program at Yale, was completing her residency at Columbia when she observed a phenomenon that, to her, seemed “crazy.” Many of her colleagues were relying on their less-than-perfect knowledge of the Spanish language — instead of on interpreters — to communicate with their Spanish-speaking patients.

While at Yale, Diamond decided to conduct a study to understand the reasons behind their actions. Published last month, the study confirmed her suspicions: Many physicians are failing to use interpreters for a wide variety of reasons, ranging from a lack of time to the cultural atmosphere of hospitals themselves, the research found.

“Even when doctors and patients speak the same language, communication is not always perfect,” Elizabeth Bradley, professor of public health and co-author on the study, said. “Imagine when one of them is not speaking the same language.”

Previous studies had already established that physicians were not using interpreters as often as they should, Bradley said. So, instead of taking a quantitative approach, they opted for conducting in-depth interviews.

“For certain kinds of scientific inquiry, qualitative methods help you understand phenomena that can’t be understood with numbers,” Leslie Curry, a Yale Medical School research scientist and co-author on the study, explained.

The study evaluated the use of interpreters by physicians in two urban teaching hospitals, one on each coast.

Using these qualitative methods, Diamond discovered a whole host of factors that were influencing the limited use of interpreters by residents — lack of time, the cultural atmosphere of hospitals, non-English-speaking patients not understanding their federal right to an interpreter, and cultural differences between patients and their doctors.

“It is such a multi-factorial and complex problem,” Diamond said.

The residents — working long hours under difficult conditions — often did not know what else to do and looked to cut corners wherever possible, she said. It became acceptable for them to utilize their own limited language skills or the language skills of a family member or friend of the patient — sometimes in violation of confidentiality laws, Diamond explained.

Residents were often unaware, however, of the repercussions of those actions — indeed, lack of communication can lead to differential quality of care and problems ranging from misdiagnoses to longer hospital stays, she added.

Since physicians are busy and overworked as it is, to solve the problem, Diamond said changes in behavior will have to be implemented so seamlessly that physicians won’t even realize they are doing something differently.

She cited adding interpreters into the hospital order entry system, which routes orders directly to the appropriate individuals, as one way to increase interpreter use. With this new system, Diamond said, physicians could order an interpreter with as little effort as they can currently order a chest X-ray.

But Diamond was also quick to point out that solving the problem is not simple.

“Major cultural shifts are going to need to take place,” she said.

Bradley, too, emphasized the importance of finding not only a quick fix, such as an increase in the specificity of federal regulations, but also a change in “mindset.”

And both Bradley and Diamond stress the importance of strong leadership in improving quality of care. Leaders in the medical professions should prioritize the issue and hold residents accountable for their actions.

Diamond, who Curry described as having a “personal, long-standing passion” for this problem, will continue to explore the issue.

She is currently conducting a national study — for which the data has already been collected — to evaluate the kinds of services hospitals are offering to non-English-speaking patients and to assess their compliance with federal regulations. Diamond is also planning a study looking at the varying levels of language proficiency among physicians and the thresholds at which calling for an interpreter should be advised.