By Jerrit Tan
Hospitals, medical schools, and individual health care providers are scrambling to meet the demands of an increasingly non-English speaking patient population. Two trends will make caring for limited English proficiency (LEP) patients ever more important. First, the population of the United States is becoming increasingly diverse, with profound implications for the delivery of health services. Between 2000 and 2010, racial and ethnic minorities in the US grew by 28.8%, and the Hispanic population alone increased by 43% (US Census, 2000; US Census, 2010). In fact, the Pew Research Center reports that immigration will account for a full 82% of US population growth through 2050. According to the 2010 US Census, Spanish is the primary language spoken at home by almost 37 million people and that is more than double the number from 1990.
Secondly, pending immigration and health care reforms from the Obama administration are likely to bring an influx of Spanish speaking patients (both illegal and legal immigrants) into the formal health care system that is already short on workers who can speak Spanish. This can lead to lower patient satisfaction, poor health outcomes, and will present financial and legal challenges to providers. These sweeping changes are fueling demand from medical students and professionals for better medical Spanish language and cultural competency training tools.
Language barriers in health care contribute to health disparities. LEP patients have lower rates of physician visits and access to preventive services. When they do access care, these patients often have poorer adherence to treatment and follow-ups, less comprehension of their diagnoses and treatment after emergency room visits, decreased satisfaction with care, and increased medication complications (Manson 1988; Crane 1997; Carasquillo et al. 1999; Gandhi et al. 2000). In one example, the word “once” in English is spelled the same way as the Spanish word for eleven. Imagine the serious problems that can arise when a instructions for a medication’s dosage is misinterpreted by a Spanish speaking patient as eleven times a day instead of once a day.
Moral obligations aside, failing to provide adequate care for LEP patients will have significant financial consequences for hospitals and providers. The 2010 Affordable Care Act’s emphasis on ‘pay for performance’ over ‘pay for services delivered’ will kick in starting fiscal year 2013. Federal reimbursements for hospitals will partially depend on patient satisfaction scores. Patient satisfaction surveys given to the growing number of LEP patients will have material effect on the financial well-being of hospitals.
While interpretation services will continue to play a role in these patient-provider interactions, for areas with high non-English speaking populations, sole reliance on interpreters will inevitably lead to inefficient and inconsistent delivery of care. In states with large and growing Hispanic and Latino populations, hospitals are desperately searching to hire Spanish-speaking physicians. In California, where 33% of the population is Hispanic and there is a severe shortage of Spanish speaking providers, a special program was create that sought out graduates from Latin American countries to enter family-medicine residencies at the state’s teaching hospitals. Other states like Texas are looking at replicating the program.
Though states like California, Texas, Florida, New York, and Illinois are the usual examples used to showcase the growing language gap in health care, states like North Carolina, where the Hispanic population has increased from 76,000 in 1990 to more than half a million now, face similar situations. Midwestern states like Iowa and Wisconsin also have seen steep increases, and suffer from severe shortages of Spanish speaking providers. While finding foreign trained students is one solution to this shortage, the increasing number of American medical students and physicians who are now taking medical Spanish language training will hopefully lead to a long term solution to the language gap problem.
And health care providers are not the only ones interested, as the NIH is funding companies like LanguageMate to develop technologies that bring scalable solutions to this growing problem. The NIH has awarded over $20M in funding to the company to build products like Canopy Medical Spanish, used by individual students, medical schools, and hospitals. Canopy is a web based e-learning platform for medical Spanish language. Supported by NIH funding, and tested with medical students from Columbia University’s Medical Center and Mount Sinai School of Medicine, it is a full course that can be used in a classroom setting or by individual students and physicians.
Medical schools like the University of Kansas, Michigan State, Florida International, NYMC, and Duke have already signed on to offer Canopy to their students. The course content is based on the curriculum used by the Association of American Medical Colleges. And importantly, there is a focus on cultural competency modules like explanations of common Spanish medical slang and folk illnesses.
The changing makeup of the US population, especially the increasing number of Spanish speaking patients, will undoubtedly present challenges to our health care system. Add to this the upcoming changes from immigration and health care reform, and we are at a critical point where inaction will lead to dire human and financial consequences for the health care system. But, with this challenge come opportunities for medical students and practitioners to reap the rewards if they are able to train to provide linguistically and culturally adequate care. As we saw in states like California, those who are able to communicate in medical Spanish will find residency programs and hospitals rushing to hire them.