I spend a lot of my time harping about the importance of communication in the field of healthcare, whether it’s between primary services and consulting subspecialists, providers and patients, or providers and family members of patients.
The times when effective communication between patients and providers is hindered prove especially difficult. If the clinical condition precludes getting an accurate history from a patient, then we can usually rely on the objective data presented to us to come to a conclusion about how best to proceed. We ultimately hope that once we solve the underlying issues, we will in fact be able to talk to our patients and guide their care accordingly.
But what happens when the reason for poor communication is an unfeasible barrier?
2013 census data indicated that there are more than 40 million foreign-born people living in the U.S. Nearly 50 percent of this group have what is known as “limited English proficiency” (LEP), and our health care system repeatedly fails them. Without being able to effectively communicate with patients, a physician’s ability to take an appropriate history and physical becomes severely limited.
Take a patient who is presenting with chest pain. Without language coherence, it becomes difficult to localize and characterize the chest pain. Is it left-sided and sharp or sternal and dull? Did the pain start suddenly or come on gradually? Has this ever happened to the patient before—and if so, did they have a musculoskeletal injury, bad reflux, or a massive heart attack?
Additionally, the subtleties of all associated symptoms become nearly impossible to elicit. Was the chest pain associated with shortness of breath, deep breaths, movement, or none of the above? We can examine our patients and order diagnostic testing without getting an appropriate history, but every single provider will tell you that physical exams and diagnostic tests are useless without a targeted history.
Lower patient satisfaction and poorer health education are just the tip of the iceberg when it comes to the impact of language barriers on quality of health care delivered. And while providers have not been found to necessarily spend more time with non-English speaking patients, a study looking at hospital length of stay found that patients with LEP stayed for 6 percent longer than English-proficient patients.
There has been no evidence of increased hospital mortality for LEP patients; however, language barriers have been shown to negatively affect patient safety, and over half of the time, patient safety was compromised due to communication errors. Given that patients with LEP have been shown to be more likely to have poor understanding of their clinical condition—along with being more likely to suffer from adverse medication reactions—it is no surprise that their patient safety is negatively affected more than patients with proficient English speaking skills.
Yes, I am aware that most all hospitals in the U.S. have trained medical translators available for both in-person and phone interpretations. These translators have been shown to improve clinical care, in fact, reaching a level of care similar to that in patients where there is no language barrier.
But interpreters are not used to their full potential in hospitals across America. Even with something as important as informed consent for common therapeutic and diagnostic procedures, a retrospective chart review study done at a teaching hospital with on-site interpreter services, showed that LEP patients were less likely than English-speaking patients to have a full consent form documented in their chart. Why aren’t interpreters used when they are readily available?
There are any number of reasons why physicians just “get by” when it comes to LEP patients, including the increased convenience with using a family member as an interpreter or that it’s less time consuming to use what second language skills are readily available by the physician in question. The worst part of this last study? As health care providers, we let ourselves “get by” with what we can with our LEP patients—all the while, recognizing that we are not providing them with equal care.
Medical interpreters are not the end all be all to solving the health care woes of our LEP patients. Even with interpreters, no change has been demonstrated in terms of patient satisfaction and interpersonal rapport between patients and their physicians when language barriers are present. If we can’t deliver perfect health care, at the very least, we owe it to all our patients do more than just “get by.”