BACKGROUND Language barriers complicate physician-patient communication and adversely affect healthcare quality. Research suggests that physicians underuse interpreters despite evidence of benefits and even when services are readily available. The reasons underlying the underuse of interpreters are poorly understood. OBJECTIVE To understand the decision-making process of resident physicians when communicating with patients with limited English proficiency (LEP). METHODS Qualitative study using in-depth interviews. METHODS Internal medicine resident physicians (n = 20) from two urban teaching hospitals with excellent interpreter services. METHODS An interview guide was used to explore decision making about interpreter use. RESULTS Four recurrent themes emerged: 1) Resident physicians recognized that they underused professional interpreters, and described this phenomenon as "getting by;" 2) Resident physicians made decisions about interpreter use by weighing the perceived value of communication in clinical decision making against their own time constraints; 3) The decision to call an interpreter could be preempted by the convenience of using family members or the resident physician's use of his/her own second language skills; 4) Resident physicians normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care. CONCLUSIONS Although previous research has identified time constraints and lack of availability of interpreters as reasons for their underuse, our data suggest that the reasons are far more complex. Residents at the study institutions with interpreters readily available found it easier to "get by" without an interpreter, despite misgivings about negative implications for quality of care. Findings suggest that increasing interpreter use will require interventions targeted at both individual physicians and the practice environment.