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SURGICAL PERSPECTIVES

Speaking the Same Language

Improving Language-concordant Care in Surgery

Ruiz, Andres M. BS∗,†; Allar, Benjamin G. MD†,‡; Fernandez, Alicia MD§; Bates, David W. MD, MS; Ortega, Gezzer MD, MPH

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doi: 10.1097/SLA.0000000000005217
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“One of the hardest things to do is to be the voice for someone else,” the resident remarked to the patient's son before pausing for the interpreter to relay the message: “…ser la voz de alguien mas.” On the other end of the call, a family wrestled with the prognosis of their matriarch. A vehicle collision had placed her in the Trauma ICU during a pandemic and a subsequent stroke left her reportedly locked-in. She was surrounded by a team that did not speak her language, unable to express her emotions and understanding of the situation. After nearly three weeks, a Spanish-speaking medical student recognized her ability to communicate through eye blinks and was the first to reassure her that her children were safe after the collision. In Spanish, he explained the team s understanding of her condition. Her story is not singular, but rather emblematic of how language barriers can add hardship to an already stressful situation for patients and families. In the acute situations that are commonplace for surgical teams, communication and understanding is critical for excellent patient experience and outcomes, yet as a system we are failing some of the most vulnerable populations we treat.

Trust between a physician and patient is delicate and often developed through imperceptible communication over multiple meetings. Fears, goals, and desires are difficult enough to digest and express in one s native language, let alone an unfamiliar one. Language concordant care is when a patient and provider can communicate in the same language directly. Language access refers to either language concordant care or indirect communication via a certified medical interpreter. Language discordant care replaces open communication with agreeable nods, affirmative body movements, or ad hoc interpreters and acts as a direct barrier to this trust-building. Language discordance can hide a patient's deeper concerns and obstacles, with the ultimate effect being a superficial encounter. Trust and communication are integral to surgeons profession, and their disruption could turn an otherwise fruitful interaction into a frustrating encounter. Language discordant care increases the incidence of perceived discrimination and low patient satisfaction ratings, placing physicians at higher risk of malpractice.1 For patients, language discordance has been associated with decreased medication adherence as well as higher mortality and length of stay.1,2 Patients prefer language-concordant providers and are significantly more forthcoming with questions when they are present, contributing to open dialogue and partnership in surgical decision making and care.3 Language discordant care limits patients opportunities to make the best decisions, participate actively in their recovery, their families ability to cope, and their provider s ability to heal. What passes as “good enough is often far from the care our patients deserve. Fortunately, surgeons can take immediate steps to bridge these gaps by formally assessing and improving language access by improving their own language ability and maximizing their use of existing professional language resources.

Secondary Language Assessment and Improvement

All physicians caring for patients with limited English proficiency (LEP) can begin to improve language access by learning a language commonly spoken in the community they serve. A Family Medicine residency in a predominantly Spanish-speaking city provides 100 hours of Spanish instruction during 10 days of orientation plus 1-hour interpreter lessons every other week, resulting in 98% of residents certifying as proficient.4 Moreover, cost analysis demonstrated that the program saves money even when the Spanish-speaking population percentage is as low as 25%.4

For those who speak a second language, assessment through competency exams is key in contextualizing language ability and helping to recognize one's limitations. In a recent study, a surgical residency whose residents took the Clinician Cultural and Linguistic Assessment (CCLA) increased the number of certified bilingual speakers and identified native-speaking surgical residents who were not medically proficient.5 It is critical to avoid the assumption that native language proficiency applies to medical settings and even native speakers (or heritage speakers who learned the language from their parents) should assess their medical language abilities.

Reproducing the results of successful medical language training programs is possible if residency program directors and national leadership (Association of Program Directors in Surgery, American College of Surgeons, and Accreditation Council for Graduate Medical Education) support their implementation as part of the standard educational curricula. Residents and interested faculty members should be given dedicated time and financial support for certification from their institution. Institutional buy-in may be critical because individual providers may be reluctant to certify due to the perceived notion of patients with LEP being more socially complex.6 Residents gaining competency in the secondary language potentially stand to have fewer interruptions in their workflow and an added layer of rapport with their patients. Formal assessment and improvement should replace presumed competence to guide utilization of external support.

Select the Right Interpreter

With only about 65% to 75% of health facilities adhering to requirements for language services, surgeons should be collectively advocating for robust interpretation services.7 Individual surgeons may improve care for patients with LEP by ensuring their team's proper use of available interpretation. Remote interpretation technology utilization is critical given the increasing variety and frequency of non-English languages spoken in the United States. Yet, these technological advances often go unused on rounds, substituted with imaginative physical examination commands and 1-word solicitations.8 These shortcuts are the opposite of patient-centered care, preventing early detection of clinical changes and reducing patient understanding and autonomy. Short-lived successes can redefine standard practice and serve as a model for medical students.

To avoid using professional interpreters, noncertified medical students or interns are sometimes asked to interpret. Surgical education focuses on team efficiency, and trainees may struggle to decline a formal request or informal nudge from the team's leader. Interpretation preoccupies the mind with syntax and word conversions, thereby detracting from trainees’ processing of the clinical encounter, despite appearing as if interpreting improves their clinical acumen. In these cases, the language barrier persists, and they might have been better suited observing the professional interpreter. By comparison, direct interaction with a patient by a language-certified trainee exercises their ability to deliver care in that language and effectively removes the language barrier. Therefore, it is up to senior residents, fellows, and attendings to recognize when a resident or medical student is having their learning experience enriched or when they are being used to avoid professional interpretation.

Recently, COVID restrictions on visitors effectively barred hospitals’ largest unofficial interpreter workforce by keeping family or friends from being used as ad hoc interpreters. These ad hoc interpreters should be avoided except in emergent and highly interactive situations, as they may create miscommunication and discomfort among family.9 During the pandemic, in-person certified interpreters became scarce, resulting in one Labor and Delivery ward seeing an uptick in severe laceration and C-section rates.9 Obstetric deliveries, just like any other awake procedures, are safer when an in-person interpreter is present who can not only provide spoken language interpretation but also identify non-verbal cues while providing advocacy, assurance, and encouragement to the patient.10

Modeling appropriate use of interpreters and avoiding the misuse of ad hoc interpreters can be an immediate quality improvement action for program leadership to enact. Admittedly, there are acute scenarios, especially in surgery, where obtaining quick and effective interpreters can be challenging or impractical. Some emergent situations may require a noncertified medical student, staff, or family member. We propose increased use of certified medical interpreters in nonemergent settings to improve patient understanding and communication.

Increasing a Linguistically Diverse Workforce

Improving the current ability to deliver language concordant care is critical, but a more enduring strategy would draw from this country's abundant diversity to improve language access. This diversity creates a potential for language, culture, and race/ethnicity to synergistically coincide for better outcomes and experiences of patients with similar cultural experiences. Lifelong multilingual/ cultural experiences allow communication under different mental frameworks that may be more accessible to patients with LEP.

The 2021 AAMC survey of 130 medical schools cites multiple language proficiency as one of the lowest importance factors in admission. This undoubtedly has important downstream effects, as seen in the disproportionately low number of applicants to residencies citing proficiency in the highest demand languages.11 Surgeons serving in admissions committees, especially in areas with a high proportion of patients with LEP, should advocate for weighing this more heavily, considering the “ability to communicate directly with local patients is certainly as useful and necessary to a practicing physician as a basic knowledge of organic chemistry.”6 Other surgeons can call attention to this discrepancy through research, social media, and organized political advocacy groups.

The externalities of diverse representation to produce a surgeon pool reflective of the population it serves are broad. It creates equity by expanding the informal networks by which health education is disseminated. Moreover, it gives patients with LEP a reason to trust in a system that makes an active effort to include them.

CONCLUSIONS

Surgeons can play a vital and active role in reducing the effect of language-discordant care. Leadership should consider mandating formal evaluation of second language proficiency and should sponsor educational activities to increase a multi-lingual residency. On rounds, surgeons can model the appropriate use of existing language extension tools and strike a balance between efficiency and quality. As advocates within a system, they can push for the language strengthening programs that will help current residents and their future colleagues serve patients with LEP. Investment in such programs enhances health system efficiency, increases trust, and reduces the barriers to equitable care for patients with LEP. As surgeons try to improve equitable care in all aspects of the healthcare system, we must improve our care to all patients, regardless of their preferred language.

REFERENCES

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Keywords:

complications; equity; outcomes; quality of care; safety

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