Item Details

The comparison of shared decision making in monolingual and bilingual health encounters

Issue: Vol 15 No. 2 (2018) Special Issue: Interpreter-Mediated Healthcare Encounters

Journal: Communication & Medicine

Subject Areas: Healthcare Communication Linguistics

DOI: 10.1558/cam.38674


In the United States, Hispanics with limited English
proficiency (LEP) experience disproportionate disparities
in health services, a phenomenon that relates to
communication and decision making. After a quality
improvement review identified a disparity in obstetric
services for Hispanic women with LEP, a pilot study
discussed here explored how LEP and the presence
of a medical interpreter affected shared decision
making in comparisons of monolingual (English) and
bilingual (English-Spanish) encounters with the same
physician. A series of 16 prenatal encounters between
physicians, patients, and medical interpreters were
recorded. First, medical visits were recorded with eight
Spanish-speaking mothers using a hospital interpreter
to speak with their physician. The same physician was
then recorded discussing a similar prenatal agenda
with a primary language English-speaking patient.
Discourse analysis was used to categorize discursive
practices in social interaction. Both encounters were
rated using the OPTION shared decision-making
scale. Results portray how shared decision making
shifts in second-language situations and the associated
practices that distinguish monolingual and
bilingual encounters. Examples of discursive practices
suggest strategies that may mark ethnolinguistic identity
and membership categorization indirectly during
health encounters.

Author: Charlene Pope, Jason Roberson

View Full Text

References :

Agency for Healthcare Research and Quality (2017) 2016 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication 17-0001. Available online:


Aranguri, C., Davidson, B. and Ramirez, R. (2006) Patterns of communication through interpreters: A detailed sociolinguistic analysis. Journal of General Internal Medicine 21 (6): 623-629.


Balakrishnan, V., Roper, J., Cossey, K., Roman, C. and Jeanmonod, R. (2016) Misidentification of English language proficiency in triage: Impact on satisfaction and door-to-room time. Journal of Immigrant & Minority Health 18 (2): 369-373.


Beach, M., Sugarman, J., Johnson, R., Arbelaez, J., Duggan, P. and Cooper, L. (2005) Do patients treated with dignity report higher satisfaction, adherence, and receipt of preventive care? Annals of Family Medicine 3 (4): 3331-3338.


Beach, M., Saha, S., Korthuis, P., Sharp, V., Cohn, J., Wilson, I., Eggly, S., Cooper, L., Roter, D., Sankar, A. and Moore, R. (2010) Differences in patient-provider communication for Hispanic vs. non-Hispanic white patients in HIV care. Journal of General Internal Medicine 25 (7): 682-687.


Beck, R., Daughtridge, R. and Sloane, P. (2002) Physician-patient communication in the primary care office: A systematic review. Journal of the American Board of Family Medicine 15 (1): 25-38.


Blay, N., Ioannou, S., Seremetkoska, M., Morris, J., Holters, G., Thomas, V. and Bronwyn, E. (2018) Healthcare interpreter utilisation: Analysis of health administrative data. BMC Health Service Research 18 (1): 348-354.


Brenner, A., Malo, T., Margolis, M., Elston Lafata, J., James, S., Vu, M. and Reuland, D. (2018) Evaluating shared decision making for lung cancer screening. JAMA Internal Medicine 178 (10): 1311-1316.


Brisset, C., Leanza, Y. and Laforest, K. (2013) Working with interpreters in health care: A systematic review and meta-ethnography of qualitative studies. Patient Education & Counseling 91 (2): 131-140.


Brooks, K., Stifani, B., Batlle, H., Nunez, M., Erlich, M. and Diaz, J. (2016) Patient perspectives on the need for and barriers to professional medical interpretation. Rhode Island Medicine 99 (1): 30-33.


Butow, P., Bell, M., Goldstein, D., Sze, M., Aldridge, L., Abdo, S., Mikhail, M., Dong, S., Iedema, R., Ashgari, R., Hui, R. and Eisenbruch, M. (2011) Grappling with cultural differences: Communication between oncologists and immigrant cancer patients with and without interpreters. Patient Education & Counseling 84 (3): 398-405.


Carter-Pokras, O., O’Neill, M., Cheanvechai, V., Fan, T. and Solera, A. (2004). Providing linguistically appropriate services to persons with limited English proficiency: A needs and resources investigation. American Journal of Managed Care 10: SP29-SP36.


Chen, A., Youdelman, M. and Brooks, J. (2007) The legal framework for language access in healthcare settings: Title VI and beyond. Journal of General Internal Medicine 22 (Suppl. 2): 362-367.


Cooper-Lewter, S. K. (2013) Research Brief: Latino Immigrant Families in South Carolina. Columbia: Sisters of Charity Foundation of South Carolina. Available online:


Cordella, M. (2004) The Dynamic Consultation: A Discourse Analytical Study of Doctor-Patient Communication. Amsterdam: John Benjamins.


Davidson, B. (2001) Questions in cross-linguistic medical encounters: The role of the hospital interpreter. Anthropological Quarterly 74 (4): 170-178.


Docherty, A., Bugge, C. and Watterson, A. (2012) Engagement: An indicator of difference in the perceptions of antenatal care for pregnant women from diverse socioeconomic backgrounds. Health Expectations 15 (2): 126-138.


Dysart-Gale, D. (2007) Clinicians and medical interpreters: Negotiating culturally appropriate care for patients with limited English ability. Family and Community Health 30 (3): 237-246.


Elwyn, G., Hutchings, H., Edwards, A., Rapport, F, Wensing, M., Cheung, W-Y. and Grol, R. (2005) The OPTION scale: Measuring the extent that clinicians involve patients in decision-making tasks. Health Expectations 8 (1): 34-42.


Elwyn, G., Edwards, A. and Thompson, R. (eds) (2016) Shared Decision Making in Health Care: Achieving Evidence-Based Patient Choice (3rd edition). Oxford: Oxford University Press.


Ehrlich, S. and Freed, A. (2010) The function of questions in institutional discourse. In A. Freed and S. Ehrlich (eds) ‘Why Do You Ask?’ The Function of Questions in Institutional Discourse, 3-19. New York: Oxford University Press.


Fiscella, K., Franks, P. and Doescher, M. (2002) Disparities in health care by race, ethnicity, and language among the insured: Findings from a national sample. Medical Care 40 (1): 52-59.


Flynn, S., Cooper, L. and Gary-Webb, T. (2014) The role of culture in promoting effective clinical communication, behavior change, and treatment adherence. In L. Martin and R. DiMatteo (eds) Communication, Behavior Change, and Treatment Adherence, 167-185. Oxford: Oxford University Press.


Franks, P., Fiscella, K., Shields, C., Meldrum, S., Duberstein, P., Jerant, A., Tancredi, D. and Epstein, R. (2005) Are patients’ ratings of their physicians related to health outcomes? Annals of Family Medicine 3 (3): 229-234.


Goldberg, J. (1990) Interrupting the discourse on interruptions: An analysis in terms of relationally neutral, power- and rapport-oriented acts. Journal of Pragmatics 14 (6): 883-903.


Haidet, P. and Paterniti, D. (2003) ‘Building’ a history rather than ‘taking’ one: A perspective on information sharing during the medical interview. Archives of Internal Medicine 163 (10): 1134-1140.


Haviland, A., Elliott, M., Weech-Maldonado, R., Hambarsoomian, K., Orr, N. and Hays, R. (2012) Racial/ethnic disparities in Medicare Part D experiences. Medical Care 50 (Suppl.): S40-S47.


Heritage, J. (2010) Questioning in medicine. In A. Freed and S. Ehrlich (eds) ‘Why Do You Ask?’ The Function of Questions in Institutional Discourse, 42-68. New York: Oxford University Press.


Hsieh, E. (2006) Understanding medical interpreters: Reconceptualizing bilingual communication. Health Communication 20 (2): 177-186.


Hudelson, P., Perneger, T., Kolly, V. and Perron, N. (2012). Self-assessed competency at working with a medical interpreter is not associated with knowledge of good practice. PLoS One 7 (6): e38973.


Hughes, T., Merath, K., Chen, Q., Sun, S., Palmer, E., Idrees, J., Okunrintemi, V., Squires, M., Beal, E. and Pawlik T. (2018). Association of shared decision-making on patient-reported health outcomes and healthcare utilization. American Journal of Surgery 216 (1): 7-12.


Jiang, L., Han, C., Jiang, J. and Feng, Y. (2014) The sociological turn in the interpreter’s role: Discourse interpreting filters. Translation and Interpreting Studies 9 (2): 274-298.


Johnstone, B. (2018) Discourse Analysis (3rd edition). Hoboken, NJ: John Wiley.


Jones, R. (2018). Discourse and health communication. In D. Tannen, H. Hamilton and D. Schiffrin (eds) The Handbook of Discourse Analysis (2nd edition), 841-856. Oxford: John Wiley / Blackwell.


Kamara, D., Weil, J., Youngblom, J., Guerra, C. and Joseph, G. (2018) Cancer counseling of low-income limited English proficient Latina women using medical interpreters: Implications for shared decision-making. Journal of Genetic Counseling 27 (1): 155-168.


Karliner, L., Jacobs, E., Chen, A. and Mutha, S. (2007) Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Service Research 42 (2): 727-754.


Kirkham, C., Harris, S. and Grzybowski, S. (2005) Evidence-based prenatal care: Part I. General prenatal care and counseling issues. American Family Physician 71 (7): 1264-1266.


Kuntz, J., Safford, M., Singh, J., Phansalkar, S., Slight, S., Her, Q., Lapointe, N., Mathews, R., O’Brien, E., Brinkman, W., Hommel, K., Farmer, K., Klinger, E., Maniam, N., Sobko, H., Bailey, S., Cho, I., Rumptz, M., Vandermeer, M. and Hornbrook, M. (2014) Patient-centered interventions to improve medication management and adherence: A qualitative review of research findings. Patient Education & Counseling 97 (3): 310-326.


Leanza, Y., Boivin, I. and Rosenberg, E. (2010) Interruptions and resistance: A comparison of medical consultations with family and trained interpreters. Social Science & Medicine 70 (12): 1888-1895.


Levinson, W., Roter, D., Mulloly, J., Dull, V. and Frankel, M. (1997) Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons. Journal of the American Medical Association 277 (7): 553-559.


Lindholm, M., Hargraves, J. L., Ferguson, W. and Reed, G. (2012) Professional language interpretation and inpatient length of stay and readmission rates. Journal of General Internal Medicine 27 (10): 1294-1299.


Little, P., Everitt, H., Williamson, I., Warner, G., Moore, M., Gould, C., Ferrier, K. and Payne, S. (2001) Observational study of patient-centeredness and positive approach on outcomes of general practice consultations. The British Medical Journal 323 (7318): 908-911.


Marvel, K., Epstein, R., Flowers, K. and Beckman, H. (1999) Soliciting the patient’s agenda: Have we improved? Journal of the American Medical Association 281 (3): 283-287.


McCreaddie, M. and Payne, S. (2014) Humour in health-care interactions: A risk worth taking. Health Expectations 17 (3): 332-344.


Mehan, H. (1979) Learning Lessons: Social Organization in the Classroom. Cambridge, MA: Harvard University Press.


Melbourne, E., Sinclair, K., Durand, M., Légaré, F. and Elwyn, G. (2010) Developing a dyadic OPTION scale to measure perceptions of shared decision making. Patient Education & Counseling 78 (2): 177-183.


Menendez, M., Loeffler, M. and Ring, D. (2015) Patient satisfaction in an outpatient hand surgery office: A comparison of English- and Spanish-speaking patients. Quality Management in Health Care 24 (4): 183-189.


Mishler, E. (1984) The Discourse of Medicine: Dialectics of Medical Interviews. Norwood, NJ: Ablex Publishing.


Morales, L., Reise, S. and Hays, R. (2000) Evaluating the equivalence of care ratings by Whites and Hispanics. Medical Care 38 (5): 517-527.


National Board of Certification for Medical Interpreters. (2016a) Certified Medical Interpreter Candidate Handbook. Available online:


National Board of Certification for Medical Interpreters. (2016b) 2016 Annual Report. Available online:


Ngo-Metzger, Q., Sorkin, D., Phillips, R., Greenfield, S., Massagli, M., Clarridge, B. and Kaplan, S. (2007). Providing high-quality care for limited English proficient patients: The importance of language concordance and interpreter use. Journal of General Internal Medicine 22 (Suppl. 2): 324-330.


Nieuwenhuijze, M., Korstjens, I., de Jonge, A., de Vries, R. and Lagro-Janssen, A. (2014) On speaking terms: A Delphi study on shared decision-making in maternity care. BMC Pregnancy & Childbirth 14: 223.


Njeru, J., Boehm, D., Jacobson, D., Guzman-Corrales, L., Fan, C., Shimotsu, S. and Wieland, M. (2017) Diabetes outcome and process measures among patients who require language interpreter services in Minnesota primary care practices. Journal of Community Health 42 (4): 819-825.


October, T., Hinds, P., Wang, J., Dizon, Z., Cheng, Y. and Roter, D. (2016) Parent satisfaction with communication is associated with physician’s patient-centered communication patterns during family conferences. Pediatric Critical Care Medicine 17 (6): 490-497.


Office of the Secretary, Department of Health and Human Services (2016) 45 CFR Part 92: Nondiscrimination in health programs and activities. Federal Register 81 (96): 31376-31473. Available online:


Palmer, N., Kent, E., Forsythe, L., Arora, N., Rowland, J., Aziz, N., Blanch-Hartigan, D., Oakley-Girvan, I., Hamilton, A. and Weaver, K. (2014) Racial and ethnic disparities in patient-provider communication, quality-of-care ratings, and patient activation among long-term cancer survivors. Journal of Clinical Oncology 32 (36): 4087-4094.


Peck, B. M. and Denney, M. (2012) Disparities in the conduct of the medical encounter: The effects of physician and patient race and gender. SAGE Open 2 (3): 1-14.


Phillips, C. and Travaglia, J. (2011) Low levels of uptake of free interpreters by Australian doctors in private practice: Secondary analysis of national data. Australian Health Review 35 (4): 475-479.


Plewnia, A., Bengel, J. and Körner, M. (2016) Patient-centeredness and its impact on patient satisfaction and treatment outcomes in medical rehabilitation. Patient Education & Counseling 99 (12): 2063-2070.


Rivadeneyra, R., Elderkin-Thompson, V., Silver, R. C. and Waitzkin, H. (2000) Patient-centeredness in medical encounters requiring an interpreter. American Journal of Medicine 108 (6): 470-474.


Roberts, C., Moss, B., Wass. V., Sarangi, S. and Jones, R. (2005) Misunderstandings: A qualitative study of primary care consultations in multilingual settings, and educational implications. Medical Education 39 (5): 465-475.


Rosenberg, E., Leanza, Y. and Seller, R. (2007) Doctor-patient communication in primary care with an interpreter: Physician perceptions of professional and family interpreters. Patient Education & Counseling 67 (3): 286-292.


Rosenberg, E., Seller, R. and Leanza, Y. (2008) Through interpreters’ eyes: Comparing roles of professional and family interpreters. Patient Education Counseling 70 (1): 87-93.


Saville-Troike, S. (2003) The Ethnography of Communication: An Introduction (3rd edition). Malden, MA: Blackwell.


Schegloff, E. (2007) Sequence Organization in Interaction: A Primer in Conversation Analysis, Volume 1. Cambridge: Cambridge University Press.


Schouten, B. and Meeuwesen, L. (2006) Cultural differences in medical communication: A review of the literature. Patient Education and Counseling 64 (1-3): 21-34.


Schwei, R., Del Pozo, S., Agger-Gupta, N., Alvarado-Little, W., Bagchi, A., Chen, A., Diamond, L., Gany, F., Wong, D. and Jacobs, E. (2016) Changes in research on language barriers in health care since 2003: A cross-sectional review study. International Journal of Nursing Studies 54: 36-44.


Seale, C., Rivas, C. and Kelly, M. (2013) The challenge of communication in interpreted consultations in diabetes care: A mixed methods study. British Journal of General Practice 63 (607): e125-e133.


Sentell, T. and Braun, K. (2012) Low health literacy, limited English proficiency, and health status in Asians, Latinos, and other racial/ethnic groups in California. Journal of Health Communication 17 (Suppl. 3): 82-99.


Smith, D. (2010) Health care disparities for persons with limited English proficiency: Relationships from the 2006 Medical Expenditure. Panel Survey (MEPS). Journal of Health Disparities Research and Practice 3 (Art. 4): 57-67.


South Carolina Office of Rural Health (2006) South Carolina Low Country Healthy Start Impact Report. Available online:


Suurmond, J. and Seeleman, C. (2006) Shared decision-making in an intercultural context: Barriers in the interaction between physicians and immigrant patients. Patient Education and Counseling 60 (2): 253-259.


Tandon, S. D. and Parillo, K. (2005) Hispanic women’s perceptions of patient-centeredness during prenatal care: A mixed methods study. Birth 32 (4): 312-317.


Tannen, D. (2007) Talking Voices. Repetition, Dialogue, and Imagery in Conversational Discourse (2nd edition). Cambridge: Cambridge University Press.


Tucker Edmonds, B. (2014) Shared decision-making and decision support: Their role in obstetrics and gynecology. Current Opinions in Obstetrics & Gynecology 26 (6): 523-530.


US Census Bureau (2017) Selected characteristics of people at specified levels of poverty in the past 12 months. 2012-2016 American Community Survey 5-Year Estimates. American FactFinder. Available online:


US Department of Health and Human Services (2003) Guidance to Federal financial assistance recipients regarding Title VI Prohibition against national origin discrimination affecting limited English proficiency persons. Federal Register 68 (153): 47311-47322. Available online:


US Department of Health and Human Services (2013) Language Access Plan 2013. Washington, DC: US Department of Health and Human Services / Office for Civil Rights. Available online:


Van Cleave, A., Roosen-Runge, M., Miller, A., Milner, L., Karkazis, K. and Magnus, D. (2014) Quality of communication in interpreted versus non-interpreted PICU family meetings. Critical Care Medicine 42 (6): 1507-1517.


Weech-Maldonado, R., Fongwa, M., Gutierrez, P. and Hays, R. (2008) Language and regional differences in evaluations of Medicare managed care by Hispanics. Health Services Research 43 (2): 552-568.


Wilson-Stronks, A., Lee, K., Cordero, C., Kopp, A. and Galvez, E. (2008) One Size Does not Fit All: Meeting the Health Care Needs of Diverse Populations. Oakbrook Terrace, IL: The Joint Commission. Available online:


Young, R. (2005) The growing Hispanic population in South Carolina: Trends and issues. Working Paper of the Institute for Public Service and Policy Research, University of South Carolina. Available online:


Young, H., Bell, R., Epstein, R., Feldman, M. and Kravitz, R. (2008) Physicians’ shared decision-making behaviors in depression care. Archives of Internal Medicine 168 (13): 1404-1408.


Zolnierek, H., Dimatteo, M., Mondala, M., Zhang, Z., Martin, L. and Messiha, A. (2009) Development and validation of the physician-patient humor rating scale. Journal of Health Psychology 14 (8): 1163-1173.