Patients with limited English proficiency (LEP) have inferior health care outcomes in the United States. Beyond linguistic access, some patients may face social, cultural, insurance-related, and financial barriers to quality care. In 2022, technological innovations should allow for complete interpretation in every setting in anesthesia and surgical care to mitigate these health disparities. An incident that happened to one of the authors represents a cardinal example. In mid-2020, a Brazilian Portuguese-speaking patient with LEP who had acute COVID-19 infection presented with a foreign body. He had been home – ill, but not hospitalized, with respiratory symptoms – when he ate fish soup that included an approximately 4 cm disc-like bone that lodged at the cricopharyngeus muscle in the upper esophagus and pushed on his larynx. After a thorough history and informed consent in his language, with a tablet interpreter due to COVID-19 restrictions, he was whisked from the emergency department to the OR. At each step, there were potential barriers to safe care due to language discordance – from the moment he had to call for help and communicate with emergency medical services, to phases when he had to communicate with health care staff in the emergency department, preoperative area, OR, and PACU. His respiratory symptoms and drooling also hampered his communication, as did the full personal protective equipment we wore. Access to interpretation at every step is critical for safe care. Over the last nearly three years, these challenging but everyday situations have spurred innovation to have interpreters present physically or virtually with patients in any setting of care – and here we advocate for more.
Language discordance poses a threat to safe, high-quality care (Ann Surg 2022;275:492-5). Language discordance is a lack of a common language between the patient and health care professional, including the lack of access to language and interpreter services. In the U.S., there are over 27 million people with LEP (asamonitor.pub/3FOzuF7). People with LEP speak a non-English primary language and have difficulty communicating effectively in English (asamonitor.pub/3uP4zlq). Patients with LEP face barriers to safe, high-quality care throughout the continuum of care (Health Aff 2005;24:424-34). Particularly pertinent to anesthesiologists, patients with LEP may face poorer perioperative pain control and reduced understanding of procedural consent and post-procedural discharge instructions (Hosp Pediatr 2021;11:1199-1204; Anesth Analg September 2022). Patients with LEP have fewer preventative health visits and other physician visits even after controlling for other factors such as health status, literacy, and health insurance (asamonitor.pub/3FOzuF7). Therefore, patients with LEP may present for procedural care with greater acuity and more poorly controlled chronic conditions. They suffer large disparities in health outcomes, including more adverse events, lower satisfaction with care, and higher readmission rates (Health Serv Res 2007;42:727-54; Gen Intern Med 1999;14:82-7). Patients with LEP receive more intense and costly care. These added costs to the health system are known as “language barrier premiums” (Arch Pediatr Adolesc Med 2002;156:1108-13). Language concordant physicians and access to interpreter services reduce these disparities (J Gen Intern Med 2017;32:863-70; J Public Health 2004;94:866-9). Delays and underutilization of medical interpreters are common, despite the fact that hospitals are required to provide interpreter services (J Gen Intern Med 2009;24:256-62; BMC Health Serv Res 2017;17:456).
Given the large number of languages spoken in the diverse environment of the U.S., language concordant physicians and in-person interpreters are not always available. Anesthesiologists, surgeons, and procedural specialists experience additional challenges in providing continuous access to interpretation across the continuum of care. Patients may need interpretation as they transition between preprocedural, procedural, and postprocedural environments. Sterility in the OR poses challenges to in-person interpretation. While in-person interpretation is the gold standard, there is likely a need for an additional modality of rapid access to interpretation (BMC Health Serv Res 2017;17:456). In critical care, obstetric, and emergent airway scenarios, discussions with patients and their families may be constrained by the need for rapid, high-stakes decision-making. High-acuity events require immediate access to interpretation. Given the severe time pressure faced by physicians, nurses, and staff, time delays in interpretation are unacceptable even in non-emergent scenarios. Time delays are a disincentive and logistical challenge to safe communication: to briefly check in on a patient, confirm a clinical detail, ask an additional question, or confirm understanding. More frequent use of interpreter services has been associated with reduced length of stay in the perioperative period (J Surg Res 2022;270:178-86). In the OR, there may be gaps in interpretation during anesthesia time-outs, induction of general anesthesia and emergence – all instances when our ability to communicate clearly with patients is critical for safe care.
We need easier, faster, and more seamless access to interpretation in every setting – it should be effortless. In 2022, the technology exists to provide on-demand interpretation in any setting. What might this look like for anesthesiologists and surgeons? We would advocate for video interpretation to be immediately available as an alternative; for example, on a phone, tablet or computer, to be accessed within seconds. Telephone-only interpretation has been shown to be inferior to video interpretation and therefore should be used only if other modes are unavailable (J Gen Intern Med 2010;25:345-50). Immediate access to video interpretation may be particularly helpful for brief communications, sterile settings such as during induction of anesthesia in the OR, or for patients with less common primary languages. Patient-controlled interpretation, in which patients can immediately access interpretation themselves, is a novel approach to empower patients across settings: at the pharmacy, making appointments, clarifying discharge instructions, or within hospital walls. For written communication, as seen in patient portals, translation of materials such that patients can read and write in their native language is technically feasible. Patient-facing aspects of electronic medical record systems should be available in multiple languages. Companies that create electronic medical record systems should include multiple languages in their patient portals. We can push further and regard language discordance without interpretation as a “never event.” The logistics and costs to implement multiple modalities of interpretation and translation are surmountable but may require additional financial support from insurers. The U.S. government has provided additional focus on and support for people with LEP. These efforts include new measures by the U.S. Department of Health and Human Services announced in October 2022 and a November 21, 2022, Justice Department mandate, “Improve Access to Services for People with Limited Proficiency in English” (asamonitor.pub/3HxJK5V; asamonitor.pub/3YfKfHE).
Patients face many challenges accessing medical care in the U.S. We acknowledge that, for immigrants with LEP, language is just one component of the many barriers they face. Other more pervasive barriers exist, such as systemic racism, legal barriers to care, socioeconomic factors, and insurance status (J Hosp Med 2022;17:59-61). However, the language barrier is an area that we can concretely and immediately address. With new technological advancements, in combination with the gold standard of in-person interpretation, we can achieve a near-complete resolution to the language barrier t would result in disparities in safety, outcomes, and patient satisfaction. We need a system that works for our patients and for us. In complex fields that transition in and out of ORs and procedure rooms, immediate access to interpretation should be a central goal of equitable and safe care.
Leave a Reply
You must be logged in to post a comment.