It was my first day of clinical rotations as a third-year medical student. We entered a small room in the emergency department to see a frightened woman with acute cholecystitis. One physician asked her how she was feeling, but after another physician said “Spanish-speaking only,” the first physician stopped speaking and instead approached the bedside and began to push on her abdomen. “¿Dolor? ¿Dolor?” he asked. When the patient grimaced, the first physician, apparently satisfied with his evaluation, turned and led the team out of the room. No explanation was offered to the patient. I hesitated, hoping to explain, or perhaps comfort her, but this elicited a stern look. “Hurry up—the OR starts in 20 minutes!” This was my introduction to a medical culture that normalizes undercommunication with patients of limited English proficiency. Undercommunication potentially affects large numbers of patients. According to the 2011 American Communities Survey, more than 60 million people in the United States speak a language at home other than English, and of those, 42% report that they speak English less than “very well.”1 Although regional variation in the frequency of encounters with patients of limited English proficiency is to be expected, in cities such as Los Angeles, it is the norm, not the exception. As a physician in a large institution, I am well aware that patients will typically encounter multiple physicians, nurses, and other staff members before I meet them. And yet, too frequently when I meet the patient, the preferred language has not yet been identified. I saw a patient referred for “continuous crying.” I was told that the patient was nonverbal, and that the plan was to admit to the medicine service to “rule out acute coronary syndrome.” When I took over care, the patient had been in the emergency department all day. I noted the ethnicity of the name and recognized that—as it happened—I might know the patient’s language. So I asked in that language how the patient was feeling. To everyone’s surprise, the patient answered appropriately. When asked the reason for crying, the patient described foot pain. On examination, the patient had a large sore on the heel. All day, without an interpreter, the patient had not been able to tell anyone the source of pain or receive treatment, let alone explain what had happened. After obtaining additional history with the help of a videobased interpreter, the cardiac workup was aborted, and the patient received appropriate wound care and pain control. This is surely an extreme case, but it demonstrates that undercommunication may be accepted as the norm when caring for patients with limited English proficiency. A more typical, and more insidious, scenario goes like this: a clinician who speaks a bit of Spanish tries to muddle through an interview with a Spanish-speaking patient without an interpreter. The clinician leaves the room satisfied—she has, after all, figured out that the patient’s ankle, knee, and elbow have been injured, which has enabled the ordering of every one of the appropriate radiographic images. The fact that the injuries resulted from an episode of domestic violence, however, remains undiscovered, and the patient remains in danger. The implications of compromised communication on health outcomes are not immediately apparent, so “muddling through” visits with patients with limited English proficiency becomes an ingrained and accepted practice pattern. Patients with limited English proficiency achieve less symptom control than those who are English proficient,2 are subject to more liberal use of testing,3 and have higher rates of unplanned revisits to the emergency department after hospital discharge.4 As a protection against inadequate care, federal law requires language assistance for such patients. Title VI of the 1964 US Civil Rights Act bans discrimination based on race, color, or national origin, which is interpreted to include those with limited English proficiency, and allows for federal funds to be withheld if discrimination is found.5 All health care facilities that receive federal money must provide language assistance to patients with limited English proficiency. Lack of knowledge and enforcement perpetuate undercommunication. Even when available, language assistance is underutilized.6 Although clinicians may agree in theory that clear communication is paramount, true 2-directional communication takes time, and clinicians may accept undercommunication as a trade-off in the name of efficiency.7 They may use their own nonfluent language skills, even while knowing that the patient might not completely understand them. Patients strain to express themselves in broken English, and clinicians use their 20-word Spanish vocabulary, while video interpreter machines remain unused in a back hallway. Poor communication facilitates the persistence of health disparities on a population level. Addressing undercommunication is a matter not only of social justice, but also of patient safety and quality of care. Proposed solutions should focus on changing the decision architecture: how to make it easier for clinicians to do the right thing. Hospital systems and medical offices should support clinicians in their use of language assistance. At registration, the patient’s preference for language assistance should be identified and prominently displayed in the medical record. Language assistance should be readily available and easy to use. Each patient room should have a phone with the interpreter line on speed dial. If internet-based video interpreter machines are used, the health care facility should VIEWPOINT

中文翻译：

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改善与英语能力有限的患者的沟通

这是我作为一名三年级医学生进行临床轮换的第一天。我们进入急诊室的一个小房间，看到一位患有急性胆囊炎的妇女受到惊吓。一位医生问她感觉如何，但在另一位医生说“只会说西班牙语”之后，第一位医生不再说话，而是走到床边开始推她的腹部。“……多洛尔？?多洛尔？” 他问。当病人做鬼脸时，第一位医生显然对他的评估感到满意，转身带领团队走出了房间。没有向患者提供任何解释。我犹豫着，希望解释一下，或者安慰她，但这引起了严厉的目光。“快点——手术室在 20 分钟后开始！” 这是我对医学文化的介绍，该文化使与英语水平有限的患者沟通不足正常化。沟通不足可能会影响大量患者。根据 2011 年美国社区调查，美国有超过 6000 万人在家中说英语以外的其他语言，其中 42% 的人报告说他们的英语水平低于“非常好”1。遇到英语水平有限的患者的频率是可以预料的，在洛杉矶等城市，这是常态，而不是例外。作为一家大型机构的医生，我很清楚患者在我遇到他们之前通常会遇到多名医生、护士和其他工作人员。然而，当我与患者见面时，我经常遇到的首选语言尚未确定。我看到一个病人被称为“持续哭泣”。我被告知病人不会说话，该计划是为了“排除急性冠状动脉综合征”而接受医学服务。当我接手治疗时，病人一整天都在急诊室。我注意到了这个名字的种族，并意识到——正如它发生的那样——我可能知道病人的语言。所以我用那种语言问病人感觉如何。出乎所有人的意料，患者回答得恰到好处。当被问及哭泣的原因时，患者描述了脚痛。检查时，患者脚后跟有一个大疮。一整天，没有翻译，患者无法告诉任何人疼痛的来源或接受治疗，更不用说解释发生了什么。在基于视频的口译员的帮助下获得更多病史后，心脏检查被中止，患者接受了适当的伤​​口护理和疼痛控制。这无疑是一个极端的例子，但它表明，在照顾英语水平有限的患者时，沟通不足可能会被接受为常态。一个更典型、更阴险的场景是这样的：一位会说一点西班牙语的临床医生试图在没有翻译的情况下与一位讲西班牙语的患者面谈。临床医生满意地离开了房间——毕竟，她已经确定患者的脚踝、膝盖和肘部受伤了，这使得能够对每张适当的放射线图像进行排序。然而，伤害是由家庭暴力造成的这一事实仍未被发现，患者仍然处于危险之中。沟通不畅对健康结果的影响并不立即显现，因此，与英语水平有限的患者“混在一起”就诊成为一种根深蒂固和公认的实践模式。与英语熟练者相比，英语水平有限的患者对症状的控制程度较低，2 可以更自由地使用测试，3 并且出院后计划外再次前往急诊科的比率更高。 4 作为防止护理不足的保护措施，联邦法律要求为此类患者提供语言帮助。1964 年美国民权法案第六章禁止基于种族、肤色或国籍的歧视，这被解释为包括那些英语能力有限的人，并允许在发现歧视时扣留联邦资金。5 所有接受联邦资金的医疗保健机构都必须为英语水平有限的患者提供语言帮助。缺乏知识和执法会导致沟通不畅。即使可用，语言帮助也没有得到充分利用。6 尽管临床医生可能在理论上同意清晰的沟通是最重要的，但真正的双向沟通​​需要时间，而且临床医生可能会以效率的名义接受沟通不足作为权衡。7 他们可能会使用他们自己不流利的语言技能，即使知道患者可能不完全理解他们。患者竭力用蹩脚的英语表达自己，临床医生使用他们的 20 个单词的西班牙语词汇，而视频口译机在后走廊仍未使用。沟通不畅会导致人口层面的健康差距持续存在。解决沟通不足问题不仅关乎社会正义，而且关乎患者安全和护理质量。提议的解决方案应该专注于改变决策架构：如何让临床医生更容易做正确的事情。医院系统和医疗办公室应支持临床医生使用语言帮助。在登记时，应确定患者对语言帮助的偏好，并在病历中突出显示。语言帮助应随时可用且易于使用。每个病房都应该有一部电话，带有快速拨号的口译线。如果使用基于互联网的视频翻译机，医疗机构应 VIEWPOINT 解决沟通不足问题不仅关乎社会正义，而且关乎患者安全和护理质量。提议的解决方案应该专注于改变决策架构：如何让临床医生更容易做正确的事情。医院系统和医疗办公室应支持临床医生使用语言帮助。在登记时，应确定患者对语言帮助的偏好，并在病历中突出显示。语言帮助应随时可用且易于使用。每个病房都应该有一部电话，带有快速拨号的口译线。如果使用基于互联网的视频翻译机，医疗机构应 VIEWPOINT 解决沟通不足问题不仅关乎社会正义，而且关乎患者安全和护理质量。提议的解决方案应该专注于改变决策架构：如何让临床医生更容易做正确的事情。医院系统和医疗办公室应支持临床医生使用语言帮助。在登记时，应确定患者对语言帮助的偏好，并在病历中突出显示。语言帮助应随时可用且易于使用。每个病房都应该有一部电话，带有快速拨号的口译线。如果使用基于互联网的视频翻译机，医疗机构应 VIEWPOINT 提议的解决方案应该专注于改变决策架构：如何让临床医生更容易做正确的事情。医院系统和医疗办公室应支持临床医生使用语言帮助。在登记时，应确定患者对语言帮助的偏好，并在病历中突出显示。语言帮助应随时可用且易于使用。每个病房都应该有一部电话，带有快速拨号的口译线。如果使用基于互联网的视频翻译机，医疗机构应 VIEWPOINT 提议的解决方案应该专注于改变决策架构：如何让临床医生更容易做正确的事情。医院系统和医疗办公室应支持临床医生使用语言帮助。在登记时，应确定患者对语言帮助的偏好，并在病历中突出显示。语言帮助应随时可用且易于使用。每个病房都应该有一部电话，带有快速拨号的口译线。如果使用基于互联网的视频翻译机，医疗机构应 VIEWPOINT 患者对语言帮助的偏好应被识别并在病历中突出显示。语言帮助应随时可用且易于使用。每个病房都应该有一部电话，带有快速拨号的口译线。如果使用基于互联网的视频翻译机，医疗机构应 VIEWPOINT 患者对语言帮助的偏好应被识别并在病历中突出显示。语言帮助应随时可用且易于使用。每个病房都应该有一部电话，带有快速拨号的口译线。如果使用基于互联网的视频翻译机，医疗机构应 VIEWPOINT