It began like any other routine quarterly medical staff meeting that I’d attended: the report from the hospital president, an update from the chief medical officer, presentation of new policies, etc. But when the chief nursing officer took to the podium, the energy in the room changed. She was an enthusiastic changemaker. That night, she presented the new patient surgical discharge instruction sets. The changes were immediately noticeable—better design and more engaging, with strong branding and clarity of explanation. This advancement was a huge step forward in offering our patients high-quality information regarding their postoperative care. When the CNO asked if there were any questions, I raised my hand and asked if the new documents would be offered in the three most common languages spoken in the community we serve. The response? “No. We’ll roll it out in English first and see how it goes from there. We can get it translated later.”
While this happened about 15 years ago, it’s always stuck with me. There was a cognitive clash between the excitement and acceptance of this advancement in care and the indifference towards the many patients who would be unable to derive its benefits. And at the center of it all was language.
Language is defined as the principal method of human communication, consisting of verbal, nonverbal and written expression. We live in a world in which nearly 7,000 languages exist—at least 350 languages are in use within the United States alone.1 The significance of language in delivering effective medical care cannot be overstated.
Language barriers between healthcare providers and patients who do not share a common language can drastically impact the cost and quality of care. These barriers constitute a safety risk and contribute to reducing both patient and provider satisfaction and bar effective communication between involved parties. Patients facing language barriers are more likely to consume more healthcare services and experience more adverse events.2,3
Consider the word “once.” In English, this communicates “one time and no more.” However, in Spanish, “once” connotes the number 11. Imagine what could happen if a patient who exclusively speaks Spanish was told in English to change their dressing “once a week” or take a medication “once a day” without the support of an interpreter. There could be a serious negative outcome.
Bias—the conscious (explicit) and/or unconscious (implicit) tendencies of individuals or groups to favor certain beliefs or attitudes over others—can lead to inequitable treatment or clinical decision-making and may be expressed in language usage. Communication barriers or unconsidered word choices may negatively reinforce stereotypes or assumptions about a patient’s race, ethnicity, gender or sexual orientation.
In the first installment of this series of articles, we discussed how types of bias such as information bias, misclassification bias, observer bias, recall bias and selection bias can cause errors and inequities in medical research that can have ripple effects on effective care.4
While bias may manifest in myriad ways, the bias expressed through language used by healthcare professionals is especially impactful. To deliver equitable, anti-oppressive, compassionate care, providers should be highly aware of the language we use with our patients.
Language of the medical environment
Every outward-facing aspect of a medical practice informs the messaging delivered to patients—from the website and advertising to the institutional signage, consent forms, and pre-and post-op instructions. For IRs, one of the most frequent ways language-based bias may exert itself is in the process of informed consent. Such bias may occur during the exchange of information between the physician and patient as they discuss a potential future procedure and in the physical, printed documentation that formalizes that conversation.
Established partly by the Nuremberg Code and later codified in the Declaration of Helsinki, informed consent has become a standard practice in procedural medicine.5 Twenty-five million people in the United States are not fluent in English.6 Throughout the United States, laws require licensed hospitals to implement policies to provide language assistance services to patients to eliminate communication barriers. Federal law also requires hospitals that receive federal financial assistance via Medicare, Medicaid and grant funds to ensure equitable language access.
Providers at all practice levels and types should ensure their marketing and consent forms are available in multiple languages. Further, the onus is not on the patient or their family members to provide translation services. Providers should also ensure that the documents are created at an accessible reading level and avoid common phrases of biased patient descriptions (as discussed below).
Accessibility is limited not just by what is on the page, as some patients may have hearing and visual impairments. Having supplemental reading implements, such as a magnifying glass and voice amplifiers, to enhance communication and mitigate liability risk is good practice.
By ensuring that all medical documents intended for patient usage are translated upon implementation, providers can ensure that accessibility is a key tenant of the consenting informed consent process. In hospital-based practices, start by engaging the Policy Committee and encourage them to hardwire a process for translating patient-consumed documents in the predominant languages of the community being served.
The language of patient descriptors
Word choice matters when communicating with patients and family members. Unconscious usage can have substantial implications. How often have you heard a colleague describe a patient in person as “a great case?” How we utilize language to obtain a past medical history can also be impactful. For example, “Are you a diabetic?” versus “Are you being treated for diabetes?” or “Have you ever been diagnosed with diabetes?” is an easy example of shifting emphasis. The former question—Are you a diabetic?—may be considered disrespectful by dehumanizing a patient into a disease. The latter choices preserve their humanity and are a nonjudgmental inquiry regarding their medical history.
In addition, patient-blaming medical jargon can impact your relationship and bonds of trust with your patient. These terms often blame poor health on the patient rather than acknowledging the social determinants of health and systems that may have contributed to their health outcomes. Consider whether you have ever used the following terms in conversation or notes:
- Noncompliant
- Drug-seeking behavior
- Difficult, combative, abusive patient
- Minority patient
- “Right off ‘The Boat’”
- High-risk patient
- Non-English-speaking
- Elderly
- Psychosomatic
- Uninsured
One of the most common areas of bias involves weight. The language surrounding how we describe weight is often stigmatizing and fraught with bias. Such bias may reinforce negative perceptions, discrimination and health disparities. Intentional shifts toward more respectful, nonjudgmental, objective and patient-centered language promotes effective communication in healthcare.
Conclusion
How we utilize language in engaging our patients is fraught with potential hazards. Even long-accepted practices may need to be reconsidered. A fundamental strength of interventional radiologists is our instinct to strive to see things clearly so we may deliver effective treatments. None of us want to be an impairment to delivering effective solutions. By providing intentional, language-concordant, human-centered care focusing on dignity, respect and empathy, image-guided healthcare providers can help humanize the medical experience and promote positive health outcomes.
References
- USAGov. Official language of the United States. usa.gov/official-language-of-us.
- Bischoff A, Denhaerynck K. What do language barriers cost? An exploratory study among asylum seekers in Switzerland. BMC Health Serv Res 2010. Aug;10(1):248. 10.1186/1472-6963-10-248.
- Cohen AL, Rivara F, Marcuse EK, McPhillips H, Davis R. Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics 2005. Sep;116(3):575–579. 10.1542/peds.2005-0521.
- McGinnis, HD. The language of bias. IR Quarterly. 2023. irq.sirweb.org/advocacy/the-commitment-bias.
- Bazzano LA, Durant J, Brantley PR. A modern history of informed consent and the role of key information. Ochsner J. 2021 Spring;21(1):81–85. doi: 10.31486/toj.19.0105. PMID: 33828429; PMCID: PMC7993430.
- United States Census. What languages do we Speak in the United States? census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html.
