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Very little is known about how and when clinicians use their second language skills in patient care and when they rely on interpreters. The purpose of this study was to identify the factors most relevant to physicians' decision-making process when confronting the question of whether their language skills suffice to communicate effectively with patients in particular encounters. We conducted 25 in-depth, semi-structured telephone interviews with physicians in different practice settings who, while not native speakers, routinely interact with LEP patients using second language skills. Physicians consider a variety of factors in deciding whether to use their own language skills in clinical care, including their own and their patient's language proficiency, costs, convenience, and the clinical risk or complexity of the encounter. This study suggests the need for practical guidance and training for clinicians on the appropriate use of second language skills and interpreters in clinical care.