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Addressing Language Barriers in Patient-Provider Communication

Patients with limited English proficiency face significant language barriers that keep them from fully participating in their care and in patient-provider communication.

Meaningful patient-provider interactions are at the heart of a valuable clinical encounter, allowing providers to fully engage patients in the healthcare experience. But in an increasingly diverse healthcare industry, language barriers and limited English-proficiency can significantly hinder patient-provider communication.

Limited English-speaking proficiency is a widespread problem across the country. Eight percent of the 52 million Medicare beneficiaries have limited English proficiency, according to a 2017 CMS report.

Beneficiaries in urban areas are four times as likely to face language barriers as patients living rural regions, with two percent of urban-dwelling patients having limited English proficiency and eight percent of urban beneficiaries having the same limitations.

Limited English proficiency is also pervasive outside of the Medicare population. About 21 percent of the US does not have high English proficiency, per 2013 data from the United States Census Bureau (the most recent year for which the Bureau has this type of information).

Those language barriers put about 9 percent of the US population at risk for an adverse patient safety event as the result of a language discrepancy, according to a 2012 report from the Agency for Healthcare Research and Quality (AHRQ).

Patients see language barriers as a significant hurdle to managing their health. The Robert Wood Johnson Foundation reports that half of Spanish-speaking patients perceive language limitations as their biggest barriers to healthcare. Language barriers keep these patients from both engaging in seamless conversations with their doctors and interacting with the healthcare industry at large.

“In addition to difficulty understanding costs, just under half of Spanish-speaking survey respondents also say that language issues present a barrier when communicating with doctors or reading printed materials, such as forms,” RWJF stated. “During our interviews, several Spanish speakers noted that even when translators or Spanish language versions of forms are available, patients may be reluctant to ask for or use these resources.”

Immigrant patients face language challenges at a higher rate than other patients, a study published in the journal Patient Experience indicated.

“Immigrant patients experience many barriers when accessing healthcare, such as culture and language differences, lower socio-economic status, lack of knowledge, etc.,” the investigators explained. “Among these, communication barriers between healthcare providers and immigrant patients are extremely common and have significant impact and consequences.”

The researchers found language barriers adversely affected how clinicians deliver healthcare. Clinicians often drop core relationship-building elements from their patient interactions to take on a more paternalistic approach to patient care.

“They are more directive with immigrant patients and deliberately withhold information, based on the belief that immigrant patients will have limited understanding,” the team explained. “Physicians tend to give more direct advice rather than information and often make decisions for their immigrant patients.”

Some healthcare organizations have turned to translators and interpreters to support patients with limited English language proficiency. But even interpreters have their limitations, researchers found.

The report in Patient Experience revealed that language interpreters have implicit biases that can warp the message they convey to patients.

“Interpreters may intentionally or unintentionally add or subtract things; they may have attitudes and values that differ from physicians or patients; or they may have a different knowledge base or understanding of the context and may not understand the non-verbal cues of the speaker,” the researchers said.

And the RWJF report found that patients who lean on their families and friends as interpreters tend to lose trust in their providers.

At Massachusetts-based Southcoast Hospital, clinical leaders opted for onsite interpreters and telephone technologies to access a medical interpreter. Access to these services helped the hospital overcome some of the barrier associated with family interpreters, according to Southcoast Chief Medical Officer Robert Caldas, MD.

Family members carry with them an implicit bias, potentially to guard the patient’s feelings or protect the patient from bad news. Family members also usually do not have a full understanding of the healthcare industry and healthcare terminology, leaving some concepts lost in translation.

“Family members would sometimes fill in the gaps, but you never know of their level of understanding of the topic and what they’re translating to their loved ones,” Caldas told in a June interview. “It’s really important to us to make sure we have qualified, trained personnel who understand the medical terminology, understand the concepts, and can translate that into a form.”

During these encounters, the attending physician who does not share the same language as the patient must still focus on how she delivers care. Non-English-speaking patients may still look for compassion from their providers, and clinicians must offer that using body language and non-verbal cues.

“Because the sending clinician is there, people can sense someone’s non-verbal cues and messages,” Caldas explained. “The tone, the inflection even of the clinician not speaking that primary language, patients can understand that and can read that in someone.”

Beyond that, much of the heavy lifting falls on the interpreter. These individuals must be trained in medical interpreting, HIPAA privacy regulations, as well as the key interpersonal aspects of the patient-provider relationship. Each of these factors are essential to improving the patient experience even for those experiencing language barriers.

“Interpreters help so much to guide a patient through the medical process, allay their fears, and help them understand their treatment plans,” Caldas concluded. “It gives patients opportunity to ask questions. Being able to have this service and achieve all of those goals really does help give people a better level of security and comfort with their care.”

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