I picked up the next chart during my fast track shift. I read the triage note: Back pain, ESI 4. Possibly a herniated disc or some other kind of musculoskeletal back pain.  I went to meet the patient and examined her.  She was a 23 y.o. Spanish speaking woman.  I introduced myself and asked her what brought her to the Emergency Department, starting my interview in Spanish from the beginning.  She told me that she was having severe abdominal pain that had started a day before.  She pointed to her right lower quadrant.  She had peritoneal signs when I examined her, and her CT scan showed acute appendicitis.  She was taken to the OR in the next hour.  She had been mistriaged to the fast track area likely because there had been a miscommunication due to linguistically inappropriate care.  A Spanish interpreter had not been used.

My job as an ER physician is dependent on getting a history from a patient.  I need to understand their symptoms, and a detail missed could be a diagnosis missed and lead to a poor outcome.  All patients deserve linguistically appropriate care, as lives are saved when we communicate effectively with our patients.

In fact, not only do patients deserve linguistically appropriate care, it is actually mandated by Section 1557 of the Affordable Care Act.  It requires hospitals to provide patients with qualified medical interpreters free of charge, and in a timely manner.

But how are we doing?  Not too great.  Nationwide, only about 66.8% of hospitals offer language services.[1]  We are a rapidly diversifying population.  In 1990, 13.9 million people in the USA identified as limited english proficient (LEP).  By 2010, that number had grown to 25.2 million, with the top five languages being Spanish, Chinese, Vietnamese, Korean, and Tagalog. 

A look at the growing number of studies about this topic shows that compared with those who speak English proficiently, people with Limited English Proficiency (LEP) are more likely to: Misunderstand their diagnosis, treatment, and follow up plan; use medications incorrectly; lack informed consent for procedures; suffer adverse events; report a Lower Quality Healthcare experience.

A study done at six joint commission hospitals across the United States found that 49.1% of Limited English proficient patient adverse events involved some physical harm whereas only 29.5% of adverse events for patients who speak English resulted in physical harm. These adverse events were associated with greater levels of harm and were more likely to be the result of communication errors.[2]

Another study done at the University of California San Francisco demonstrated that there were higher odds of readmission for Spanish and Chinese speakers vs. English speakers.[3]

A survey of medical trainees in 2017 illustrated a “veiled curriculum” when it came to language concordant patient interactions in their education.  The trainees felt that their role models valued efficiency rather than effective communication with patients.  This article emphasizes the importance of role modeling in medical education.  It highlights the need for supervising medical staff to demonstrate best practices in the care of LEP patients, as this had the biggest impact on their trainees.[4]

It is essential that we value and take the time to provide language concordant encounters with our patients.  The population of LEP patients will continue to rise, and the medical community needs to embrace the diversity of languages in our patient population.

Keywords:

Language-concordant care, limited english proficiency, health equity

AUTHOR: Michael Tcheyan, MD is a 4th year resident at Brown Emergency Medicine Residency

FACULTY REVIEWER: Taneisha Wilson, MD

Sources:

[1]Schiaffino MK, Nara A, Mao L. Language Services In Hospitals Vary By Ownership And Location. Health Aff (Millwood). 2016 Aug 1;35(8):1399-403. doi: 10.1377/hlthaff.2015.0955. PMID: 27503963.

[2]Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007 Apr;19(2):60-7. doi: 10.1093/intqhc/mzl069. Epub 2007 Feb 2. PMID: 17277013.

[3]Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med. 2010 May-Jun;5(5):276-82. doi: 10.1002/jhm.658. PMID: 20533573.

[4]Kenison TC, Madu A, Krupat E, Ticona L, Vargas IM, Green AR. Through the Veil of Language: Exploring the Hidden Curriculum for the Care of Patients With Limited English Proficiency. Acad Med. 2017 Jan;92(1):92-100. doi: 10.1097/ACM.0000000000001211. PMID: 27166864.