To the Editor
Please find attached our letter titled “When Words Fail: Bridging the Gap in Pain Management for Limited English Proficiency Patients” in response to the article, “Differences in Acute Postoperative Opioid Use by English Proficiency, Race, and Ethnicity After Total Knee and Hip Arthroplasty.” We deeply appreciate the opportunity to engage with this critical issue and share our perspectives on improving communication and equitable care in anesthesia and perioperative medicine.The study “Differences in Acute Postoperative Opioid Use by English Proficiency, Race, and Ethnicity After Total Knee and Hip Arthroplasty”1 highlights a crucial disparity in pain management that resonates deeply as an immigrant and a trainee taking care of a diverse patient population. The findings, particularly regarding patients with Limited English Proficiency (LEP), underscore how fragile effective communication can be in health care—a fragility that particularly becomes even more apparent in pain management.
Language is the cornerstone of communication in the hospital setting. Teams rely on clear descriptions of pain to manage care effectively. When patients cannot articulate their pain or when providers misinterpret their descriptions due to cultural differences, as outlined in the article, patients suffer. Immigrants with LEP often face this challenge, as they may lack the vocabulary to convey the intensity or quality of their pain—key elements in determining appropriate opioid dosages or alternative interventions.
I have personally experienced this communication divide. As a child, I frequently served as my family’s interpreter. Even though I tried to explain their symptoms and worries, the intricacy of medical jargon and expressive cultural differences often resulted in incomplete translations. I recall moments when my parents’ pain was misunderstood simply because I lacked the vocabulary to describe their experiences fully. Translating postoperative pain was particularly challenging—how could I, as a child, communicate the difference between sharp, stabbing pain and deep, aching discomfort? Also often not highlighted, those patients experience being misunderstood. Language then instead of being the bridge that it is connecting people together ends up becoming a large, barbed wire fence between the patient and the provider.
A numerical rating scale is the most simple assessment of pain in medicine. How often do we as providers start an encounter with “what is your pain level on a scale of one to ten?” While the score itself is inherently subjective; a trend in values can be immensely helpful. The article mentions that pain scores are often missing in patients with LEP. I would have found this difficult to understand had I not recently made this mistake. We took care of a patient with LEP on an inpatient service. It surprised us to discover during a morning nursing report on rounds that his pain was a 7. As residents in the early stages of our training, we had diligently attempted to optimize his multimodals and limit escalating doses of opioids. It wasn’t until we heard a “7” that we had to reconsider whether this strategy was effective. We discussed pain with our patient using a mobile translator service. He described that his pain regimen helped but not nearly enough. He then indicated that he takes an opioid at home every 6 hours for chronic pain. We had somehow overlooked this critical piece of his history.
The study’s findings should serve as a call to action for health care systems across the country. Fast and effective professional interpreter availability and utilization in the postoperative setting can help patients accurately describe their pain and ensure providers fully understand their needs. When I was a medical student volunteer, I recall many instances where patients have frequently expressed relief at being able to articulate their symptoms without the fear of being misunderstood. This sense of being heard—of having their pain validated—is a fundamental aspect of compassionate care.
Interpreters alone are not enough. Cultural competence training for staff is equally important. Understanding how cultural backgrounds influence pain expression and treatment preferences can help bridge the gap between providers and patients. Additionally, multilingual pain assessment tools—such as visual scales or word cards—can empower LEP patients to communicate effectively, even without an interpreter.Effective communication is not a convenience but a necessity for patient safety and care. By addressing language barriers directly, we can address a large issue of equality of the health care system so that every patient receives excellent equitable care with dignity.
Beshoy A. Abdelmessih, MD
Anesthesiology PGY1 Resident Physician,
Department of Anesthesiology,
Vanderbilt University Medical Center,
Nashville, Tennessee
Vanderbilt University
Beshoy.a.abdelmessih.2@vumc.org
Jack Iasiello, MD
Anesthesiology PGY1 Resident Physician,
Department of Anesthesiology,
Vanderbilt University Medical Center,
Nashville, Tennessee