When we first started this column the title was intended to be “Translation Barriers and Patient Outcomes”. But as we progressed we realized that not only are language barriers problematic for patient outcomes and safety, but hearing impairment that interferes with effective communication is equally problematic.
The original article by Squires et al. (Squires 2017) found that for limited English proficiency patients, only 20% of home health visits were language concordant. The study suggests that home health care services may not be meeting the demand for language services, perhaps predisposing to suboptimal patient outcomes.
Then another recent study (Karliner 2017) sought to determine if increasing access to professional interpreters improves hospital outcomes for older patients with limited English proficiency (LEP). Karliner and colleagues explored the impact of a dual-handset interpreter telephone at every bedside on a medicine floor of an academic hospital. They found a significant decrease in observed 30-day readmission rates for the LEP group during the 8-month intervention period compared with 18 months preintervention, 17.8% vs. 13.4%. The improved readmission outcome for the LEP group was not maintained during the subsequent postintervention period when the telephones became less accessible. There was no significant intervention impact on length of stay but the intervention proved to be cost-effective. After accounting for interpreter services costs, the estimated 119 readmissions averted during the intervention period were associated with estimated monthly hospital expenditure savings of $161,404.
A previous study (Nápoles 2015) had shown that inaccurate language interpretation in medical encounters is common and more frequent when untrained interpreters are used compared to professionals in-person or via videoconferencing.
Hospitals, of course, must provide interpretation services to meet Joint Commission (and other regulatory body) requirements. But also included in those requirements are the need to provide similar services for the deaf or hearing impaired patient. It was shortly after the above articles that we saw that a federal appeals court has paved the way for patients to sue a hospital for not taking steps to assure they understood what was happening to them when they got medical treatment (Musgrave 2017). “In the lawsuit, patients described how scared and confused they were when doctors and nurses used gestures or passed notes to them to explain medical procedures. The medical professionals apparently resorted to such methods because of the failure of a video system the hospital uses to communicate with the deaf. Instead of hiring sign language interpreters to come to the hospital, the hospital uses a service where interpreters at remote locations are beamed onto a TV screen. But, patients said, the image is often blurry. Or, they said, the screen goes blank. Sometimes medical professionals didn’t know how to operate it.”
Hospitals must provide signing services for the deaf and, just like language interpreters, those who sign need to be trained to deal with medical terms and concepts. But the problem goes well beyond those with significant hearing loss. Even minor degrees of hearing loss may impair communication between healthcare professionals and patients.
The problem was really emphasized by a recent article in JAMA Otolaryngology-Head & Neck Surgery (Cudmore 2017). Cudmore and colleagues conducted semi-structured interviews on 100 adults age 60 and older. Of the 100, 57 reported having some degree of hearing loss. 43 of the 100 reported mishearing a physician or nurse in a primary care or hospital setting (this did not vary by age group). They identified several themes (in order of frequency): general mishearing, consultation content, physician-patient or nurse-patient communication breakdown, hospital setting, use of language, selective deafness.
Some patients especially noted problems with similar sounding words. Others complained that the physician or nurse did not look at them while talking (we’ll bet some of these patients were lip reading) and others complained the healthcare professional spoke too fast or in too low a volume.
The accompanying editorial (Weinreich 2017) notes patients with hearing loss are missing instructions, missing diagnoses, and missing medication information. Weinreich notes that, in addition to physicians speaking too quickly or quietly, background noise may cause patients to miss messages. She notes we need to know when our patients have hearing loss and change how we communicate with hearing loss patients. She notes we need to:
Last of all, don’t assume that what is heard is actually understood. A recent article (Ginsberg 2017) noted an anecdote that was recently shared with the community: a patient was diagnosed with rheumatoid arthritis and prescribed methotrexate. The doctor told her that she "can't" get pregnant while taking methotrexate. The patient apparently took her doctor literally and grew lax in her contraceptive use, simply because she was following his orders. Obviously, the physician meant "you shouldn't get pregnant," not "you can't get pregnant." (because methotrexate may cause birth defects, as well as other problems). That emphasizes the concepts of “hear back” and “teach back” which we have stressed in our columns on health literacy and numeracy. (“Hear back” is obviously also critical in communication between healthcare professionals).
So if you are a hospital or similar medical facility, make sure you use professional interpreters and signers and meet or exceed the requirements of the regulatory bodies. In all healthcare settings you need to assess whether your patients have hearing impairment (some of us won’t admit it!). Use some of the techniques noted above in the Cudmore and Weinreich articles. And, perhaps most importantly, use hear back and teach back to make sure your patients truly understand what you are trying to communicate to them.
Some of our other columns on health literacy and numeracy:
June 2012 “Parents' Math Ability Matters”
May 7, 2013 “Drug Errors in the Home”
November 2014 “Out-of-Hospital Pediatric Medication Errors”
January 13, 2015 “More on Numeracy”
August 2017 “”
Squires A, Peng TR, Barrón-Vaya Y, Feldman P. An Exploratory Analysis of Patient-Provider Language-Concordant Home Health Care Visit Patterns. Home Health Care Management & Practice 2017; First Published March 9, 2017
Karliner LS, Pérez-Stable EJ, Gregorich SE. Convenient Access to Professional Interpreters in the Hospital Decreases Readmission Rates and Estimated Hospital Expenditures for Patients With Limited English Proficiency. Medical Care 2017; 55(3): 199-206, March 2017
Nápoles AM, Santoyo-Olsson J, Karliner LS, Gregorich SE, Pérez-Stable EJ. Inaccurate Language Interpretation and Its Clinical Significance in the Medical Encounters of Spanish-speaking Latinos. Medical Care 2015; 53(11): 940-947
Musgrave J. Deaf patients get go-ahead to sue Boynton’s Bethesda hospital. Palm Beach Post 2017; May 3, 2017
Cudmore V, Henn P, O’Tuathaigh CMP, et al. Age-Related Hearing Loss and Communication Breakdown in the Clinical Setting. JAMA Otolaryngol Head Neck Surg 2017; Published online August 24, 2017
Weinreich HM. Hearing Loss and Patient-Physician CommunicationThe Role of an Otolaryngologist. JAMA Otolaryngol Head Neck Surg 2017; Published online August 24, 2017
Ginsberg S. Say What? Dangers of Miscommunicating. When miscommunication means life or death. MedPage Today News 2017; June 11, 2017