Communication gaps often occur in a healthcare setting when patients who are not proficient in English are too embarrassed or intimidated to ask for help. The problem can be compounded if a doctor assumes a patient's lack of questions means the person understood the discussion.
Posted in Operational & Staff Risks on Saturday, December 1, 2018
Other times the doctor may recognize the patient is less-than-proficient in English and seek the help of a patient’s family member. However, even that approach can affect patient safety. Consider the following scenario:
Mary Santos, age 81, was seen at the request of her daughter, a regular patient of Dr. Potter’s chiropractic practice. Mary was in town visiting family and had developed a backache and shortness of breath. She was accompanied to the office by her 14-year-old granddaughter.
After being taken to an exam room for intake and H&P, it was evident to the CA that Mary spoke only broken English and had difficulty understanding it. At times, her granddaughter answered the CA’s questions when the patient seemed to hesitate. Ultimately, the CA was able to get the information she needed through this process.
When Dr. Potter arrived and examined the patient, his interaction with the patient was the same, but he got by with the help of the granddaughter and was able to complete his questioning and examination. He told Mary she had a lumbar strain, and the shortness of breath was secondary. He advised stretching exercises and ice packs.
The next day, Mary was found on the bathroom floor by her daughter. She was doubled over with severe back pain. She was taken to the ER by ambulance. Upon further questioning by the ER’s Spanish interpreter, it was determined that the woman had exercised excessively for an 81 year old and had eaten the ice rather than applied it to her lumbar spine.
Mary was following what she thought were Dr. Potter’s orders but ended up in the hospital for three days. Though Mary suffered no long-term effects from this episode, she filed a malpractice suit against Dr. Potter and his practice. The lawsuit faulted Dr. Potter for failing to recognize that neither Mary nor her granddaughter had the language skills to understand his instructions regarding exercise and ice therapy and for neglecting to offer her the services of an interpreter.
In this case, a family member, especially a minor, should not have been considered an appropriate translator.
Beyond being part of good clinical care, the need to ensure effective doctor/patient communication and patient comprehension is a legal issue.
Under Title VI of the Civil Rights Act of 1964, all healthcare facilities and providers receiving federal financial assistance(e.g., Medicaid and CHIP) from the Department of Health and Human Services (HHS) must provide their patients with equal access to services. The following HHS standards specifically target language access in healthcare organizations:
- Must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.
- Must provide to patients in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.
- Must assure the competence of language assistance provided to patients with limited English proficiency by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except when patients request it).
- Must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. (D.C.s should consult with legal counsel about responsibilities.)
HHS issued guidelines to assist facilities and providers with compliance. These guidelines were relaxed in 2003 to encourage voluntary compliance by providers. However, they do not relieve doctors of their responsibilities to provide meaningful access to patients with limited English proficiency.
Language services may be provided to these patients through oral interpretation by an in-person interpreter, by using telephone or video services, through written translation, or through a combination of methods. Doctors have some flexibility in determining the appropriate mix of the language services they provide.
Language barriers are one part of a larger problem of health illiteracy. Along with the dynamics of the population becoming more diverse, this is a growing area of concern for healthcare practitioners. Consequently, D.C.s should address, if they haven’t already, how language barriers will impact their practices now and in the future.