Overcoming language barriers to optimize patient care

May 11, 2023

Language barriers diminish the quality of the patient experience and can have a huge impact on communication, trust, decision-making and quality of subsequent care. All of these things can lessen the quality of the patient experience.. Language interpretation is a vital tool to help patients and their families understand and convey health care needs and ultimately make informed decisions.

Amelia Barwise, M.B., B.Ch., B.A.O., Ph.D., is an associate professor of medicine and assistant professor of biomedical ethics who conducts clinical and translational research within the Pulmonary and Critical Care Medicine and Bioethics research program at Mayo Clinic in Rochester, Minnesota. Her research focuses on health care disparities, especially how language barriers impact care during complex medical care services and during a patient's critical illness at the end of life. This is supported by recent studies published in Mayo Clinic Proceedings and Critical Care Medicine.

Dr. Barwise explores the role of sociocultural and communication barriers within this domain, and she is doing research to develop interventions to support these patients and address this health care disparity. To help patients better navigate the health care system, interpreters can serve as "health literacy guardians," as conveyed in a qualitative study published in Patient Education and Counseling in 2021.

"We are very lucky at Mayo Clinic to have wonderful trained and certified professional interpreters who can support bidirectional communication between clinicians and patients and families. However, there is a lot of work to do to encourage interpreter use and to support clinicians when they seek an interpreter for their patients, especially in the inpatient setting. We know that there are challenges currently," says Dr. Barwise.

During COVID-19, there was a huge shift to remote video interpretation and, unfortunately, it has been challenging to return to previous levels of in-person interpreter use, as cited in a 2021 Mayo Clinic Proceedings study. Research with physicians, nurses and interpreters has shown that in-person interpreters are very valuable, especially during goals of care conversations, decision-making conversations such as for withdrawal of care and family conferences.

Dr. Barwise hopes to promote in-person interpreter use for these types of conversations especially. Remote video interpretation is very convenient but has several drawbacks, including difficulties for those who are older, who have hearing or visual impairment, or who are confused or disoriented. In addition, having an interpreter in the room during difficult conversations can help facilitate improved understanding by capturing body language and other cues that are not obtained with an iPad.

In May 2022, Dr. Barwise was awarded federal funding from the Agency for Healthcare Research and Quality (AHRQ) to conduct a study that will develop and implement information technology to promote the use of interpreters among patients with complex illness who are hospitalized. "We are about to launch a trial using machine learning, deployed on the AMP platform, to screen inpatients for complex care needs. We anticipate this will bring interpreters to the bedside more frequently and more quickly," she says.

Dr. Barwise continues: "We hypothesize that patients identified as having language barriers plus complex care needs will benefit most from in-person interpreter services. We hope this use of AI will enhance patient-centered care for these vulnerable patients."

She uses diverse research approaches in her studies to study and mitigate health care disparities among patients with language barriers who have complex care medical needs. These approaches include qualitative, mixed methods, survey research and other quantitative methodologies. Dr. Barwise collaborates with a variety of clinicians, health services and researchers.

She also received internal funding from the Center for Health Equity and Community Engagement Research for a community-engaged study that seeks to understand the perspectives of Spanish-speaking patients, caregivers and community leaders about the challenges faced by those with language barriers during prolonged hospitalizations and the use of interpreter services. "We have just completed 37 interviews conducted in Spanish for this study, and it is exciting to get insights from these stakeholders as our previous work involved clinicians," says Dr. Barwise.

In addition to this work, Dr. Barwise is collaborating with palliative care physicians Daniel K. Partain, M.D., and Mei E. Yeow, B.M.B.S., at Mayo Clinic in Rochester, Minnesota, to develop a huddle guide for use between interpreters and clinicians prior to patient and family encounters. Both clinicians and interpreters recommend meeting before the family and patient encounter, especially when the conversation may be a sensitive and challenging one.

Dr. Barwise explains: "The huddle guide we have developed called CHECK-IN is designed to prompt the exchange of useful information between these parties. Interpreters can share essential sociocultural information with clinicians, for example, about decision-making styles, cultural considerations, family dynamics, and clinicians can highlight important medical information This may include diagnosis and prognosis, as well as the purpose of the meeting, for example, to discuss code status, goals of care, withdrawal of care or initiation of a new intervention." CHECK-IN is explained in further detail in a study in the American Journal of Hospice and Palliative Medicine.

Although interpreters at Mayo Clinic have recently been given access to Epic and can review medical records, they may have limited time and may not have sufficient information about the patient. Conducting a huddle using CHECK-IN can enhance the subsequent encounter with patients and their families.

For more information

Barwise A, et al. Differences in code status and end-of-life decision making in patients with limited English proficiency on the intensive care unit. Mayo Clinic Proceedings. 2018;93:1271.

Barwise A, et al. End-of-life decision-making for ICU patients with limited English proficiency: A qualitative study of healthcare team insights. Critical Care Medicine. 2019;47:1380.

Suarez NRE, et al. The roles of medical interpreters in intensive care unit communication: A qualitative study. Patient Education and Counseling. 2021104:1100.

Barwise A, et al. Adaptations to interpreter services for hospitalized patients during the COVID-19 pandemic. Mayo Clinic Proceedings. 2021;96:3184.

Barwise A, et al. The premise and development of CHECK IN — Check-in for exchange of clinical and key information to enhance palliative care discussions for patients with limited English proficiency. American Journal of Hospice and Palliative Medicine. 2021;38:533.

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