International and Domestic Health Equity and Leadership (IDHEAL) UCLA Emergency Medicine

LANGUAGE
Module 1
Breena R. Taira, MD, MPH


Objectives

1. Increase awareness of needs and rights of Limited English Proficiency (LEP) patients.

2. Improve knowledge of policies and laws regarding language assistance use and best practices for the care of LEP patients.

3. Demonstrate how underutilization of language assistance leads to inappropriate care and contributes to health disparities.


Case

A 77-year-old male was sent from a skilled nursing facility for “continuous crying”. The resident noted a diagnosis code for dementia in the records from the nursing facility. On interview, the patient seemed to stare blankly when asked questions. Given his Japanese surname, they thought he might speak Japanese. The medical student on the team said she studied Japanese in college and offered to try speaking with him. She reported back to her superiors that the patient gave answers but they were unintelligible. They assumed that his dementia must be advanced stage and decided to cast a broad diagnostic net, sending a variety of lab tests and a chest x-ray to check for pneumonia.

The diagnostic tests resulted but nothing was remarkable. He was admitted for a cardiac workup and had been boarding in the emergency department for 10 hours waiting for a bed in the hospital to become available. At morning sign out, the on-coming team heard his story. On rounds, the attending called a Japanese interpreter who asked him in Japanese how he was feeling. To everyone’s surprise, he answered appropriately: “I’m in pain”. “Why are you crying?” “Because my heel hurts.” His right heel had a large decubitus ulcer that had not been noted previously. He recently suffered a broken hip and his nursing facility was not changing his position in the bed, therefore he developed the decubitus ulcer. In the 10 hours that he had been in the ED, this was the first attempt to communicate with him through an interpreter. He quickly disclosed that, not only was the source of his crying the intense heel pain, but also that he was suffering ongoing neglect at the skilled nursing facility. Further, he was having difficulty speaking clearly because his dentures were left in the rehab facility. His admission for cardiac workup was cancelled, the patient received wound care, and a social work consult was called to find a new rehabilitation facility.

Through social work, the initial rehabilitation facility was reported to the state ombudsman for the neglect the patient experienced. The patient’s chart happened to be chosen for audit as the hospital prepared for a Joint Commission survey and was flagged for lack of documentation of language assistance during the initial history and physical. The team that initially evaluated the patient was made to repeat their training on a patient’s right to language assistance under title VI of the 1964 Civil Rights Act.


Discussion Questions

1. What were some of the characteristics of this patient encounter that predisposed to a failure of communication?

2. What process failure must have occurred for this to happen?

3. How do you identify a patient’s need for language assistance?


Teaching Points

1. All patient interactions should begin by ascertaining the patient’s preferred language. The patient’s preference for language assistance should be given priority over the practitioner’s assessment of the patient’s English language skills.

2. We, as health care practitioners, have not only an ethical obligation, but also a legal one based on Title VI of the Civil Rights Act to provide language assistance to limited English proficiency patients. Language assistance should be provided by someone who has verified credentials to do so, such as a certified healthcare interpreter (CHI). Use of family members to interpret is discouraged and the use of minors to interpret is expressly forbidden in many institutions.

3. Clinician use of non-English language skills when non-fluent (such as those who have taken “medical Spanish”) leads to poor patient outcomes. A team member who states they have language skills, but are not certified by the hospital as bilingual may or may not have the ability to communicate clearly. Use of certified healthcare interpreters is recommended.


Practical Questions
(The responses are intentionally excluded from the module because they meant to be specific to your own hospital environment.)

1. What options exist in your department for language assistance?

2. What type of certification is required before speaking a non-English language with patients at your institution?

3. Is there a specific policy regarding procedural consents for patients with Limited English proficiency?


Recommended Screening Question(s)

1. What is the language (spoken and written) in which you prefer to receive your healthcare? (List of languages)

2. Would you like the assistance of an interpreter during your visit? (Yes/No)


Paired reading

Diamond LC “Let’s Not Contribute to Disparities: The Best Methods for Teaching Clinicians How to Overcome Language Barriers to Health Care” J Gen Intern Med 25 (Suppl 2):189–93.


Discussion Points from the Reading

1. The persistent trend of underuse of interpreters by clinicians leads to poor quality of care and worse health outcomes for LEP patients that contribute to health disparities on the population level.

2. Short term language training programs such as “Medical Spanish” may contribute to disparities because interpreter use diminishes after these trainings, yet language fluency has not been achieved. A more inclusive curriculum about how to overcome language barriers including how to work with interpreters and how to identify problems in interpreted encounters is preferable to traditional “medical Spanish” classes.



Additional Readings

Basu G, Costa VP, Jain P. Clinicians' Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency. AMA J Ethics 2017;19:245-52.

Fernandez A, Quan J, Moffet H, Parker MM, Schillinger D, Karter AJ. Adherence to Newly Prescribed Diabetes Medications Among Insured Latino and White Patients With Diabetes. JAMA
Intern Med 2017;177:371-9.

Price-Wise G. An Intoxicating Error: Mistranslation, Medical Malpractice, and Prejudice: Center for Cultural Competence, Inc.


Taira BR. Improving Communication With Patients with Limited English Proficiency. JAMA Intern Med 2018 Mar 19 (Epub ahead of print).