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Language a Widening Barrier to Health Care

Many U.S. residents don't speak English, limiting dialogue with doctors, report says

WEDNESDAY, July 19, 2006 (HealthDay News) -- One of the biggest barriers to high-quality health care for millions of U.S. residents has nothing to do with medicine.

It has to do with language.

"We're looking at 50 million people in the U.S., 19 percent of the population, who speak a language other than English at home and 22 million who have limited English proficiency, so that's a lot of people," said Dr. Glenn Flores, director of the Center for the Advancement of Underserved Children, and a professor of pediatrics, epidemiology and health policy at the Medical College of Wisconsin in Milwaukee.

And the number is growing, added Flores, who is author of a perspective article in the July 20 issue of the New England Journal of Medicine that outlines the issues and possible solutions.

Between 1990 and 2000, the number of Americans speaking a language other than English at home grew by 15.1 million (a 47 percent increase) and the number with limited English proficiency grew by 7.3 million (a 53 percent increase).

Patients who face language barriers have difficulty accessing care, receive fewer preventive services, and are less likely to follow medication directions. For example, asthmatic children with language barriers are more likely to end up intubated in intensive care.

"Patients who do not have the opportunity to have a culturally and linguistically competent physician often don't get as good care," confirmed Dr. Robert Schwartz, chairman of family medicine and community health at the University of Miami Miller School of Medicine. "It's a critical issue to be able to speak to a patient."

Schwartz's department serves a predominantly Hispanic part of Miami. And in Miami, according to the journal article, 75 percent of residents speak a language other than English at home.

Examples cited by Flores range from the near-comic to the tragic.

There was, for instance, the interpreter who mistranslated a nurse practitioner's instructions and told a mother to put oral antibiotics into her 7-year-old daughter's ear.

In another example, the mistranslation of a single word resulted in preventable quadriplegia. The patient, an 18-year-old male, said in Spanish that he felt nauseated before collapsing. A non-Spanish speaking paramedic mistook the word to mean "intoxicated," and the patient spent more than 36 hours being worked up for a drug overdose. The delay resulted in the rupture of a brain aneurysm. The case was settled for $71 million.

And one Spanish-speaking woman told a hospital resident that her 2-year-old daughter had "hit herself" falling off her tricycle. The resident misinterpreted the statement to mean abuse and contacted the appropriate authorities, who had the mother sign over custody of both her children.

The language issues are most pronounced in the emergency room and in psychiatric settings. One study found that no interpreter was used in 46 percent of emergency-room cases involving patients with limited English proficiency.

Psychiatric patients who have language barriers are more likely to receive a diagnosis of severe psychopathology, and are also more likely to leave the hospital against doctors' orders.

What can be done?

"We need to keep making the case based on the evidence, which is that you see a lot of adverse consequences," Flores said. "There's a long laundry list we've accumulated and all of this is adding up to suboptimal quality of care, excessive costs, lower patient satisfaction, medical errors, and even morbidity and death. We can do a better job."

Currently, only 13 states provide third-party reimbursement for interpreter services. Unfortunately, most of the states containing the largest numbers of patients with limited English proficiency have not followed suit, sometimes citing concerns about costs.

There is legislation in the works, including a bill in California that would prohibit state-funded organizations from using children younger than 15 years of age as medical interpreters. But more needs to be done, Flores said. One government report estimated that it would only cost, on average, $4.04 more per physician visit to provide all U.S. patients who need them with language services.

In the meantime, individual institutions do what they can. Maimonides Medical Center in New York City, for example, has about 80 languages spoken there, including Gujarati, spoken on the west coast of India, and Zapotec, a native Mexican-Indian dialect.

"About five years ago, we put up our patient bill of rights in 10 different languages and that barely scratches the surface," said CEO and President Pamela Brier.

The center relies on a network of interpreters from the existing staff and volunteers, including people who were doctors in their own country and are hoping to get into a residency program. About four years ago, the hospital hired enough people to have round-the-clock coverage in Mandarin, Cantonese and Russian.

"For all we do, we have not nailed it," Brier said. "It's going to be a life's work."

More information

Some recommendations for setting up interpreter programs in hospitals can be found at Universal Health Care.

SOURCES: Glenn Flores, M.D., director, Center for the Advancement of Underserved Children, professor, pediatrics, epidemiology and health policy, Medical College of Wisconsin, and Children's Research Institute of the Children's Hospital of Wisconsin, Milwaukee; Robert Schwartz, M.D., professor and chairman, family medicine and community health, University of Miami Miller School of Medicine; Pamela S. Brier, president and CEO, Maimonides Medical Center, New York City; July 20, 2006, New England Journal of Medicine
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