Communication breakdown: Language barriers a ‘major cause’ of disparities

When a diversifying U.S. population meets a shrinking rheumatology workforce, the result is likely to be an increased frequency of language barriers in daily clinical practice.

“One in five Americans speak another language besides English,” Norma Poll-Hunter, PhD, senior director of workforce diversity at the Association of American Medical Colleges (AAMC), said in an interview. “Most rheumatologists face language barriers, either due to basic communication or health literacy, as part of routine practice.”

Meanwhile, efforts to meet the demands of growing multilingual patient cohorts have been uneven. And attempts to track the success of these efforts are nearly nonexistent.

“Trainees receive zero instruction on providing multilingual care in their medical education,” Vinicius Domingues, MD, of Florida State University, in Daytona Beach, told Healio Rheumatology. “Absolutely nothing. You are thrown into a residency program and then you have to figure out how to do it yourself, because in medical school nothing like this is taught.”

If left unresolved, this issue could have a seismic impact on the U.S health care system.

Indeed, these communication barriers are more than a matter of convenience or comfort. According to Joel Hirsh, MD, chief of the rheumatology division at Denver Health, and associate professor of medicine at the University of Colorado School of Medicine, they can lead to material, adverse outcomes.

“Limited English proficiency (LEP) is a major cause of health care disparities,” he said in an interview. “LEP patients have worse access, compromised communication and poor health status compared with patients who are proficient in English.”

Training the rheumatology workforce in culturally competent care for LEP patients is essential. However, with so many competing priorities in medical education, multilingual care is often overlooked.

In the clinic, a combination of interpreter services and certain technologies, like translation apps, can bridge these gaps.

“Phone translation services are widely available and frequently used,” Poll-Hunter said. “And with AI, we have the opportunity to leverage new applications to better serve and communicate with patients.”

However, coverage and access to interpretation services are not equal across regions and health systems. English-speaking friends or family members of patients can be of assistance, as can multilingual staff, but these solutions also have flaws, including a lack of privacy and sensitivity surrounding confidential or personal information.

Regarding tech interventions, advances are not moving rapidly enough to meet demands. In addition, patients with poor English-language proficiency may lack not only health literacy, but tech literacy as well. Moreover, the current rheumatology workforce may have its fair share of providers who face their own limitations with technology.

Until rheumatology fellows receive more training and get up to speed on both technology and culturally competent care, some non-English speaking patients are likely to fall through the cracks.

‘No Formal Didactics’

According to Hirsh, there is a paucity of data about the training rheumatologists receive on caring for LEP patients. On the one hand, the Accreditation Council for Graduate Medical Education environment review process requires education on the reduction of health care disparities.

“However, research indicates that approximately half of residents receive no formal didactics about how to work with professional medical interpreters,” Hirsh said. “Qualitative research has identified themes of discomfort and lack of training regarding doctors’ work with LEP patients.”

Until more formal training for patients with limited English proficiency becomes standard in medical schools nationwide, clinicians are encouraged to access materials wherever they can find them.

“At the Hospital for Special Surgery, health equity is an enterprise-wide strategy that leverages ongoing training for rheumatologists and other practitioners around inclusive culture, working with diverse patient populations, implicit bias and the journey of cultural humility,” Jillian Rose-Smith, PhD, MPH, vice president and chief health equity officer at the Hospital for Special Surgery (HSS), in New York, told Healio Rheumatology. “These trainings not only offer content and context about how to provide care to diverse populations, but also provide resources that rheumatologists can use as they care for patients.”

HSS also has a language services department that specializes in language access, interpretation and translation. These materials are available at the medical facility and specifically tailored for LEP patients, along with those who are deaf or hard of hearing, blind or visually impaired.

“Furthermore, cultural competency training is available to all doctors, including rheumatologists, to enhance their ability to effectively communicate and provide care to patients from diverse backgrounds,” Bella Elogoodin, MBA, vice president of Service Excellence Operations at HSS, said in an interview. “This comprehensive training equips rheumatologists with the necessary skills and knowledge to navigate communication barriers and deliver quality care to all patients.”

However, not all health systems make such extensive accommodations. To meet the needs of LEP patients, it is also important to think bigger than just the individual doctor-patient relationship.

Trust and Training

Organizations like the Global Healthy Living Foundation (GHLF) provide materials for both doctors and patients regarding multilingual care, according to Santiago Munoz Perez, MSc, BSc, manager of technology and community outreach at the GHLF.

“To get the word out on the resources available, we simply have to keep engaging the community,” told Healio Rheumatology. “There are people out there who are actively seeking this type of information. It is our job to make their search as easy as possible. By promoting these initiatives on social media or publishing informational articles on our webpage, we hope that we are consistently engaging with the community.”

For Rose-Smith, the most important by-product of this kind of community engagement is trust — something that is critical in clinical practice.

“Creating reliable community partner-ships with diverse groups allows for health care organizations and professionals to build trust, which is the currency to better understanding the needs of the community,” she said. “Sub-cultures and belief systems that are missed in translations can often be barriers to clear and effective communication.”

Understanding these issues can also help providers identify allies and support for patients beyond the exam rooms, Rose-Smith added.

“These partnerships allow for critical feedback from diverse populations that can better help accurately identify a population’s need, plan for resources and tailor the use of technology,” she said.

A more diverse rheumatology workforce can also meet LEP patient needs, according to Rose-Smith.

“Early exposure programs starting in high school and earlier have shown to be effective, as have pipeline programs that target students from underrepresented minority groups,” she said. “Mentorship and sponsorship programs to encourage career development and support could also be useful, along with providing research opportunities that impact diverse communities.”

Specifically, research projects examining disparities and social determinants of health are critical to breaking down language barriers, according to Rose-Smith.

“These areas of research often resonate with a candidate’s background, lived experiences or specific interest,” she said.

Providing scholarships, grants or other incentives that help to make medical education and trainee programs more feasible for a diverse array of candidates is another important step in the training process. Professional organizations like the American College of Rheumatology and others can adopt recruitment strategies that focus on retaining, and cultivating leadership among, these diverse clinicians.

“CreakyJoints has made guideline documents for RA available in several languages,” Domingues said. “Efforts are being made to expand those documents to other languages, as well as other diseases and conditions.”

Meanwhile, further efforts are underway to ease the burden on overworked rheumatologists, according to Domingues.

“We are trying to reach primary care and other providers who see these patients before we do,” he said. “If primary care providers can hand out pamphlets or direct patients to information about rheumatology in their language, it will make it easier for us to communicate the often complicated information we have to communicate in our specialty.”

Although many rheumatologists would support the broad range of training described, the reality is that most clinicians rely on interpreter services to communicate with patients who do not speak their language.

‘Too High a Risk for Medical Error’

When reviewing data on phone-based or in-person interpreter services, a common theme tends to emerge. In a 2018 paper published in BMC International Health and Human Rights, Lundin and colleagues wrote, “Clear formal guidelines for the use of interpreters in emergency health care need to be developed, and it is important to fulfill health professionals’ wishes for future development of prompt access to interpreters and education of interpreters and users.”

Similarly, Rayment-Jones and colleagues wrote in 2021, in the International Journal of Equity Health, “The findings of this study contribute to concerns highlighted in previous literature around interpreter services in the wider health care arena, particularly around the lack of regulation and access to high-quality interpretation.”

By law, facilities providing federally funded patient care are required to provide language assistance, according to Poll-Hunter, who noted that telephone-based interpreter services are widely available. However, as the data show, the reviews of such services are mixed. This may be due to a lack of training.

“Ideally, rheumatology fellowship training would include instructions about how to best use medical interpreters,” Hirsh said.

However, he offered a warning for rheumatologists using these services.

“The use of telephone professional interpreters can be problematic compared to in-person interpreters or language concordant providers because nonverbal patient cues are missed,” he said.

In addition, rheumatologists in search of further advice on using interpreters do not have the option to consult a robust body of data to determine best practices.

“There is not published data about how rheumatologists are caring for LEP patients in their clinics,” Hirsh said. “Rheumatologists should be using professional medical interpreters when caring for LEP patients. Working with a professional medical interpreter adds time to the visit, but the consequences of not using an interpreter include lower patient satisfaction, poor patient understanding and worse health outcomes.”

However, simply employing the services of a professional medical interpreter, and leaving them to their own devices when interpreting, is not enough, according to Poll-Hunter. Communication with the interpreter can be just as important as communication with the patient.

“It is important to prepare the interpreter before the encounter, if possible,” she said. “They should work as your partner in communicating with the patient.”

The first step is to provide context for the visit. According to Poll-Hunter, a rheumatologist should let the interpreter know whether they are providing routine information about health and wellness, conveying very specific information about medication doses, or delivering difficult news.

“These nuances are critical to maintaining the trust and relationship with the patient,” she said.

Beyond clinical concerns, Domingues noted that the cost of interpreter services can be an additional barrier for some rheumatology practices.

“Many practices have to pay out of pocket for a sign language translator for deaf patients,” Domingues said. “In these cases, they are essentially seeing the patient for free.”

In places where interpreter services are too costly or inaccessible, multilingual staff members may be used for translation. However, Hirsh has reservations about this approach, as well.

“The use of multilingual support staff or family members as ad hoc interpreters is not recommended,” he said, citing privacy surrounding personal information and trust as primary concerns.

The exchange of confidential information is just one problem with this scenario, according to Poll-Hunter.

“You also cannot take for granted that the family member has high language proficiency or health literacy,” she said. “Also, when you are asking about personal or private information about bodily functions, the patient may hold back critical information that will help you fully understand their symptoms or condition. There is too high a risk for medical error.”

That said, as the world becomes increasingly digitized, many experts believe that technology could eliminate these errors in human communication and the financial burden of interpretation services. However, others are not convinced.

Technological Breakdown

In a 2019 paper published in JMIR mHealth and uHealth, Panayiotou and colleagues evaluated iPad-compatible language translation apps to determine their utility in health care settings. Of the 10 apps that underwent a two-phase assessment, only two were rated as suitable for everyday communication.

“All iPad-compatible translation apps require a degree of caution and consideration when used in health care settings, and none should replace professional interpreters,” the researchers concluded. “However, some apps may be suitable for everyday conversations, such as those that enable preset phrases to be translated on subject matters that do not require a professional interpreter.”

Despite these reservations, some experts are optimistic that advancing applications could provide solutions.

“When a person is initially diagnosed with a chronic condition, they are often overwhelmed with information,” Munoz Perez said. “Technology will bring many benefits to this area, most importantly through the wider dissemination of information to patients with chronic disease.”

According to Elogoodin, the integration of technology not only facilitates the identification of patients in need of language assistance, but also enables the provision of tailored language access solutions.

HSS is on the cutting edge of this process, she said.

“When a patient expresses the need for language assistance during the initial call with the patient access team, the request is entered in EMR,” Elogoodin said. “Then an interpreter sees the request in the dashboard, connects with the patient to understand the feasibility of using various technologies, and based on this screening process determines the most suitable language access solution, which could be an on-site interpreter, or video or phone interpretation. This approach ensures that language barriers do not hinder effective communication between rheumatologists and their patients.”

Meanwhile, although Domingues hopes that tech-based solutions will ultimately improve, he stressed that web-based translation services that do not involve any human interaction can be insufficient.

“Google can help with basic communication, but we are often communicating advanced medical information, and you at least need a medical translator,” he said. “However, even these platforms are limited. When you are giving instructions on how and when to take medications, the last thing you want is for the patient to misunderstand and end up with an outcome you did not intend.”

Unfortunately, this type of miscommunication is not uncommon, according to Hirsh.

“I am a proud Luddite, so I do not think that web-based solutions or AI are going to solve this problem,” he said. “Research that has included rheumatology patients at a public health hospital showed that greater clinician computer use was associated with less positive patient affect, and lower patient ratings on quality of care and communication.”

Rose-Smith, for her part, acknowledged some reservations about the potential impact of technology.

“It is important for organizations to consider the limitations of technology and work to ensure that algorithms do not perpetuate bias that can lead to deeper disparities, inequity, and ultimately poor patient outcomes,” she said.

According to Munoz Perez, medical training and technology should not represent an either/or situation. Technology can be implemented in the training and practice of health care providers to prepare them for interacting with non-English speaking patients, he said.

Moreover, education on these topics should not stop in residency programs.

“By continuously refining and updating training programs, rheumatologists can stay abreast of evolving patient needs and communication strategies, ultimately enhancing the quality of care provided to all patients,” Elogoodin said.

Minimizing or eliminating such errors in language-barrier situations is essential to optimizing care. Assessing and improving health literacy for patients can go a long way in achieving that goal.

‘Ask and Review’

Although it can be difficult to gauge patient understanding of medical information, one way to assess LEP patient comprehension is to look at patient-reported outcome (PRO) data.

Konopka and colleagues retrospectively reviewed data for 16,110 patients who underwent total hip or knee arthroplasty and published the findings in the Journal of Arthroplasty in 2023. They aimed to assess PRO completion rates across demographics. Multivariate analysis results demonstrated that non-English speakers, as well as Hispanic patients, had significantly lower rates of PRO metric completion. Moreover, non-English speaking patients reported significantly lower PRO scores for most measures of pre- and post-operative care, regardless of the actual outcomes of the surgery.

“Patients undergoing TKA and non-English speaking, ethnic, and socioeconomic minorities are less likely to complete PRO metrics,” the researchers concluded.

They added that strategies to create, validate, and collect PRO metrics from these populations are sorely needed to avoid making health care disparities worse.

“Research has shown that LEP rheumatology patients are more likely to be confused by the patient reported outcomes used in rheumatology clinics,” Hirsh said.

The failure to complete PRO metrics is part of a larger conversation about health literacy, according to Poll-Hunter.

“Communication and language exist on a continuum,” she said. “Even English speakers can have difficulties with the complex terminology and physiological processes described by medical jargon.”

Understanding medications is another consideration.

“It is critical to try to explain these things to patients in the simplest terms,” Poll-Hunter said.

She suggested that, for non-native English speakers, clinicians should first get a sense of the patient’s facility with the language, even if it is minimal.

“If they do have some comfort with the language, it will be necessary to ask and review every piece of information that has been communicated,” she said. “This can help figure out whether the barrier is basic English proficiency, or a health literacy issue, or some combination of both.”

Munoz Perez added that providing information to patients in a culturally relevant and organized manner can improve the way they understand and manage their condition.

“This can be in the form of a pamphlet given out in the office, or a comprehensive online guide that explains a condition,” he said. “Additionally, as ways to inquire and gather more information about the patient’s experience begin to develop, it provides another avenue for health care providers to see which treatments or educational materials resonate the most with patients. Since chronic conditions are such an individualized experience, a single solution will not work for all patients, so learning how to segment certain treatments to specific patients will be a very powerful tool.”

The patient, too, shares some of the responsibility in this dynamic, according to Poll-Hunter.

“Patients also need to advocate for themselves,” she said. “They should not assume that their physician can provide culturally responsible and supportive materials and care.”

However, ultimately, doctors treating patients with limited English proficiency should do everything they can to ensure that communication barriers do not exist in their clinic.

“The onus is on us to make sure that we are familiar with the services, technology and resources to provide the best care possible to all of our patients,” Poll-Hunter said.

• References:
• Konopka JA, et al. J Arthroplasty. 2023;doi: 10.1016/j.arth.2023.01.005.
• Lundin C, et al. BMC Int Health Hum Rights. 2018;doi:10.1186/s12914-018-0157-3.
• Panayiotou A, et al. JMIR Mhealth Uhealth. 2019;doi:10.2196/11316.
• Rayment-Jones H, et al. Int J Equity Health. 2021;doi:10.1186/s12939-021-01570-8.

• For more information:
• Vinicius Domingues, MD, can be reached at 709 N Clyde Morris Blvd., Daytona Beach, FL 32114; email: viniciusdomingues@gmail.com; sjara@ghlf.org.
• Bella Elogoodin, MBA, and Jillian Rose-Smith, PhD, MPH, can be reached at 535 East 70th St., New York, NY 10021; email: caccian@hss.edu; hickenbottomt@hss.edu.
• Joel Hirsh, MD, can be reached at 777 Bannock St., Denver, CO 80204; email: joel.hirsh@dhha.org.
• Santiago Munoz Perez, MSc, BSc, can be reached at 515 N. Midland Ave., Upper Nyack, NY 10960; email: sjara@ghlf.org.
• Norma Poll-Hunter, PhD, can be reached at 200 Meyran Ave., Suite 300, Pittsburgh, PA 15213; email: sheiser@aamc.org.