A 66-year-old woman with rheumatoid arthritis and atrial fibrillation is scheduled for an elective right total knee arthroplasty in a tertiary care hospital. The patient speaks mostly Spanish and understands limited English. Informed consent is obtained during a preoperative clinic visit using a certified interpreter. On the day of the procedure, the operating room is running behind schedule, and the patient's procedure is delayed by 3 hours. When the surgeon and circulating nurse visit the patient to confirm the site and side of the procedure, the certified interpreter is in the emergency department assisting with another patient and will be unavailable for an hour. The patient talks rapidly and has several questions for the team. The surgeon has taken a 3-week course in medical Spanish, and the nurse can speak short sentences in Spanish. The surgeon converses with the patient in a mixture of Spanish and English. The patient nods frequently as the surgeon speaks. Which of the following best describes the patient-provider communication in this encounter?

Question

A 66-year-old woman with rheumatoid arthritis and atrial fibrillation is scheduled for an elective right total knee arthroplasty in a tertiary care hospital.  The patient speaks mostly Spanish and understands limited English.  Informed consent is obtained during a preoperative clinic visit using a certified interpreter.  On the day of the procedure, the operating room is running behind schedule, and the patient's procedure is delayed by 3 hours.  When the surgeon and circulating nurse visit the patient to confirm the site and side of the procedure, the certified interpreter is in the emergency department assisting with another patient and will be unavailable for an hour.  The patient talks rapidly and has several questions for the team.  The surgeon has taken a 3-week course in medical Spanish, and the nurse can speak short sentences in Spanish.  The surgeon converses with the patient in a mixture of Spanish and English.  The patient nods frequently as the surgeon speaks.  Which of the following best describes the patient-provider communication in this encounter?

Quizplus · Accepted Answer

Patients with limited English proficiency (LEP) have a legal right to access health care in their preferred language. Health care institutions receiving any federal funding (eg, most hospitals) must comply with Title VI of the Civil Rights Act of 1964, which prohibits discrimination on the basis of race, color, and national origin; they are required to establish professional interpretation and translation systems (eg, qualified bilingual staff, teleconference services) for patients with LEP. Interpreter qualifications include demonstration of sufficient fluency in medical terminology and training in interpreter ethics and skills. Patients with LEP who receive professional interpreter services experience fewer errors during high-risk processes (eg, informed consent, medication reconciliation, hospital discharge). This patient was appropriately provided an interpreter during the high-risk process of informed consent. However, communication accuracy must be maintained in the presurgery encounter given the patient's questions and pending safety processes (eg, confirming procedure site and side) (Choice C). Therefore, the surgeon should provide the patient access to a certified interpreter, even if the surgery (which is not an emergency procedure) will be delayed. Ad hoc interpretation (eg, by bilingual family members or staff lacking interpreter qualification) should be avoided in non-emergency situations due to potential error and bias. Providers with partial language skills (eg, this surgeon, nurse) often overestimate their ability to accurately communicate with patients of LEP, increasing error risk. Although the surgeon and nurse can speak some Spanish, their ability to clearly convey and comprehend complex (ie, more than basic) information in Spanish is likely limited; furthermore, the surgeon's minimal training in Spanish and use of English in addressing the patient raise concern for possible miscommunication (Choices B and D). (Choice A) Asking patients to describe their understanding of communicated information, known as teach-back, is a best practice for verifying patient comprehension. However, it is not reliable in this case because of the uncertainty regarding the ability of the surgeon and nurse to accurately comprehend the patient's response. Educational objective: Hospitals are required to provide patients of limited English proficiency to access health care services in their preferred language. Interpretation services should be provided by qualified interpreters (eg, telephone or qualified bilingual staff) with demonstrated language fluency and training in interpreter skills and ethics. __________ References: The legal framework for language access in healthcare settings: Title VI and beyond. (http://www.ncbi.nlm.nih.gov/pubmed/17957427)

A 66-Year-Old Woman with Rheumatoid Arthritis and Atrial Fibrillation Is