title: To 'Get by' or 'get help'? A qualitative study of physicians' challenges and dilemmas when patients have limited English proficiency.
abstract: OBJECTIVE
  Encounters between patients and physicians who do not speak the same language are relatively common in Canada, particularly in urban settings; this trend is increasing worldwide. Language discordance has important effects on health outcomes, including mortality. This study sought to explore physicians' experiences of care provision in situations of language discordance in depth.
  
  
  METHODS
  Qualitative study based on individual interviews. Interview guides elicited physicians' perspectives on how they determined whether communication could proceed unaided. A descriptive qualitative approach was adopted, entailing inductive thematic analysis.
  
  
  METHODS
  22 physicians experienced in treating patients in situations of language discordance were recruited from the emergency and internal medicine departments of an urban tertiary-care hospital.
  
  
  METHODS
  Large, inner-city teaching hospital in Toronto, Canada, one of the most linguistically diverse cities internationally.
  
  
  RESULTS
  Determining when to 'get by' or 'get help' in order to facilitate communication was described as a fluid and variable process. Deciding which strategy to use depended on three inter-related factors: time/time constraints, acuity of situation and ease of use/availability of translation aids. Participants reported at times feeling conflicted about their decisions, portraying some of these clinical encounters as a 'troubling space' in which they experienced one or more dilemmas related to real versus ideal practice, responsibility and informed consent.
  
  
  CONCLUSIONS
  In situations of language discordance, a physician's decision to 'get by' (vs 'get help') rests on a judgement of whether communication can be considered 'good enough' to proceed and depends on the circumstances of the specific encounter. The tension set up between what is 'ideal' and what is practically possible can be experienced as a dilemma by physicians. The study's findings have implications for practice and policy not only in Canada but in other multilingual settings, and indicate that physicians require greater support.
authors.affiliation: Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada Department of Physical Therapy and Graduate Department of Rehabilitation Science, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Janet A
authors.initials: JA
authors.lastname: Parsons
authors.affiliation: Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Natalie A
authors.initials: NA
authors.lastname: Baker
authors.affiliation: Division of Emergency Medicine, Department of Medicine, University Health Network (Toronto General Hospital), Toronto, Ontario, Canada Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Telisha
authors.initials: T
authors.lastname: Smith-Gorvie
authors.affiliation: The Alternative Dispute Resolution Practice, Toronto, Ontario, Canada.
authors.forename: Pamela L
authors.initials: PL
authors.lastname: Hudak
mesh_terms: D002170:Canada; D003144:Communication Barriers; D005260:Female; D006801:Humans; D008297:Male; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D036301:Qualitative Research
keywords: Internal Medicine; Qualitative Research