(film reel clattering) - [Sunita] Welcome to EMS' weekly national news conference.

I'm Sunita Sohrabji, health editor at Ethnic Media Services and I will be your moderator for today's news briefing.

As the number of non-English speaking patients is projected to increase in the United States it becomes crucial to develop innovative methods to facilitate communication between clinicians and patients.

This week, EMS has collaborated [background music] with Stanford's Center for Health Research and Education, which is known as CARE, to present the latest data on the healthcare of non-English speaking patients, identify some of the underlying obstacles that hinder their access to care, as well as to explore potential solutions to remove barriers and improve healthcare outcomes for everyone.

Our speakers today, and we have a fantastic panel for you!

Our speakers today include Dr. Palaniappan, co-founder of Stanford CARE; and Dr. Elena V. Rios, president and CEO of the National Hispanic Medical Association.

So now, we begin with Dr. Latha Palaniappan.

Dr. Latha, welcome.

- Thank you.

And, thank you Miss Sohrabji for inviting the Center for Asian Health Research and Education at Stanford to this convening and thank you for bringing us together.

So, as Miss Sohrabji mentioned, my name is Latha Palaniappan.

I'm a professor of medicine at Stanford and I will be talking to you today about language barriers as my colleagues will also be discussing.

I spend most of my time doing research in diverse populations, on Asian, Hispanic, African American populations in the United States and worldwide.

So, as we all know, but I'll just define for all of us on the call that language barriers often occur when healthcare providers and patients do not share a native language.

So, patients and families with "limited English proficiency".

So, I'll abbreviate this as LEP throughout the slides, face exacerbated health disparities due to multiple factors, which I'll go over in detail.

And, there are promising solutions that we have that combine cultural sensitivity, accessibility, and cost effectiveness.

And, our challenge as a group is to make our populations aware that this is an issue, limited English proficiency, that people with limited English proficiency do face worse health care.

So, as Miss Sohrabji mentioned, America is multilingual and we are becoming more racially and ethnically diverse.

From 1980 to 2019, the number of people in the U.S. who spoke a language other than English at home nearly tripled and 25.5 million speak English at less than the "very well" level.

And, there's about 400 million people in the U.S., so it is a little bit less than 10%.

And, 67.2 million people in the U.S. speak a language other than English at home.

So, this is about 15%.

And also, I wanna emphasize that English proficiency does not necessarily, language proficiency, does not necessarily mean medical proficiency.

So, I would encourage everyone that is listening and everyone that is reading to use a translator whenever possible.

And, if you could just click one more time.

So, this is the percentage of households with limited English speakers by household language in 2019, and this is from the American Community Survey.

And, I was surprised to see-- if we can click one more time on this slide, there's animation.

Thank you.

The main languages in people with limited English speakers by household are Chinese, which include Mandarin and Cantonese, Korean and Vietnamese.

So, these are the top three languages of households that have limited English speakers.

And so, these are mainly Asian languages and I wanna commend Ethnic Media Services for translating in these languages, Chinese and Korean, and also Spanish.

Fourth most common is Russian, Polish, and other Slavic languages grouped.

And then, Spanish.

And then, on down the line as you can see and a very significant proportion speak another language.

So, patients with language discordant healthcare providers reported receiving less health education, worse interpersonal care, and lower patient satisfaction.

And, I do have all the references for this in the notes and I'm more than willing to share the slides after this, as well.

And, both patients and providers reported less than satisfactory access to adequate interpretation services.

And, this is a frustration in many healthcare systems due to cost-cutting measures and others.

We used to, when I was a resident, have in-person translators that were readily available maybe within 15 minutes of the visit on the floor.

And then, we moved to telephone translation where it's not as ideal 'cause you don't have the nonverbal cues and I would have to sometimes wait for up to two hours to get a telephone translator on the line.

And now, we have also remote services with video, but also this has been limited by limited access to internet services and also limited bandwidth at times.

And so, people who have limited English proficiency are more likely to report issues with access and coordinating care.

For example, you may have a physician tell you to get a colonoscopy, but all of the materials on how to prep for a colonoscopy, the bowel prep, and all of the instructions after the colonoscopy are largely written in English.

And, the people who pick up the phone don't have access to translation services as much as care providers do.

People with limited English proficiency are four times more likely to not have health insurance.

And, the cost per case in people with limited English proficiency is 34% greater compared to people who are English proficient.

And, this is due to increased ordering of tests, likely because the history is not as attainable with people with limited English proficiency, and this results in more care utilization.

LEP populations have trouble navigating local healthcare systems leading to delay in reporting symptoms, not receiving timely care, and higher rates of undiagnosed conditions.

So, the length of stay, if an interpreter isn't used at admission or discharge, a hospital stay, is increased by three days.

There's increased 30-day readmissions, for instance, among congestive heart failure.

There's more infections, falls, surgical site infections, pressure injuries, delays in surgery, problems with medication management, decreased preventive screening like mammograms.

And, I know my colleague, Dr. Hall, has done great work on this.

And, less access to the healthcare system.

And, people with limited English proficiency are 2.4 times more likely to have problems understanding a medical situation, twice as likely to have a bad reaction to medication due to a problem understanding instructions.

For instance, taking inhalers.

If you're not taking an inhaler properly, you're more likely to have an asthma attack.

And, they're 1.9 times more likely to have an adverse physical event leading to major harm or death.

So, language barriers are an important issue to address to improve care for people with limited English proficiency.

So, what are the solutions to these problems?

One is to translate materials into patient's preferred language.

And, I'm working with a colleague at Stanford, Dr. Jison Hong, who is working with our healthcare system to translate diabetes materials into multiple languages.

And often, in our electronic healthcare system, EPIC is used and EPIC has after-visit summaries for patients but these are all in English.

So, we're working on those after-visit summaries in different languages.

Also, integrating HIPAA-compliant translation tools in tandem with interpretation services to improve healthcare delivery, patient safety, and decrease costs.

So, as I mentioned, under section 1557 of the ACA, healthcare providers are required by law to provide qualified interpreting services free of charge.

And, relying on family members and friends as informal interpreters is generally prohibited except in special circumstances like immediate emergencies.

So, as soon as possible you should have a qualified interpreter.

And, what we're finding is that in-person interpretation combined with telephone or video-based interpretation can be cost-effective and more efficient in delivering care to limited English proficient patients in healthcare systems.

It's also important to take into account cultural nuances and ensure the team is on the same page when communicating to patients and preparing treatment plans.

For instance, in some cultures- and this changes depending on acculturation and generational status- it's not appropriate to give a diagnosis of cancer, for instance, terminal cancer to a patient.

So, understanding of what the cultural nuances are and perhaps this should be communicated by the family and with the cooperation of the family as opposed to an individualistic approach that we more often take in Western systems is warranted.

And, new therapies via clinical research are not accessible due to lack of readily available translation services for trials.

So, I work in the clinical trial space and what we do to try to bring new therapies to people who are limited English proficient are we employ bilingual staff; we leverage multimedia methods such as translating consent forms and implementing trainings to help address system and individual barriers to research so that everyone can benefit from new drugs and devices and clinical trials.

And, we're also now, at Stanford, experimenting with ChatGPT and other resources to help bring services to our patients with limited English proficiency.

So, with that, I'll close and thank you and looking forward to hearing from my colleagues on the panel.

- And, we move on to Dr. Elena Rios.

Dr. Rios, welcome.

- Yeah, thank you.

So, I'm in Washington DC.

I'm president of the National Hispanic Medical Association.

And, we started the organization just because there was so many issues related to-- in the healthcare arena related to our communities, and there was no medical association to bounce off ideas, to mentor and to develop leadership.

There's lots of barriers when you think about language and health care.

You have to think about the system, the systemic barriers, and we all know there's discrimination.

When we go to medical school and residency we learn about diseases.

We don't even think about the patients.

It's "well, here comes a diabetic", or "here comes a person with cancer."

And so, language, in our own profession, is part of the problem.

And, the other issue really is racism and discrimination.

Since there's so few Hispanic physicians or Black physicians or Native American physicians, some Asian physicians.

And so, you don't get the racial concordance between doctors and patients.

And so, sometimes that's a problem.

And then, there's also the problem of just relationships not being able to be done in a more personal way.

You know, when people get sick, especially elderly, they revert back to their language of comfort.

And, we've heard over and over again from the other speakers how important it is that the people that have limited English proficiency get dissatisfied with care and don't come back, and then they have the worst outcomes.

So, we're talking of disparities in this country where the majority of people in this country are from people of color that have connections to limited English proficient patients within our communities.

So, it's a really big deal.

There was a study from "Health Affairs" that just got released talking about the fact that there was lower funding for-- seen by the LEP patients, less healthcare spending.

But, the issue becomes a reality when you realize from the legal perspective, or from the policy perspective, that only 15 states actually have Medicaid, their own state Medicaid or children's health insurance programs, that reimburse for language services.

So, we need to change the system.

We need to reimburse language services for providers, for hospitals, for clinics, for doctors' offices, to actually get paid for language services.

And now, that we have more telemedicine because of COVID-19 and the rise of telemedicine and website platforms and all of the social media information that patients look at now that wasn't there 10, 15 years ago, we need to think about language services there also, and translation services.

And, that is a cost within the healthcare system.

I'm not familiar with all the different states but I can tell you that in California there has been major moves for language.

One of them is for high school students in the public schools in California to have on their diploma a special badge, badge of honor, whatever; a Good Housekeeping Seal of Approval!

That you can talk another language, that you are bilingual.

Now the testing and the requirements I'm not familiar with but I do know that the congressman who's a doctor- an emergency room doctor from Fresno, California- Dr. Arambula, he's an Assemblyman- he would like to develop the same concept for medical students or for nursing students: to have testing and requirements that are standardized for languages such as Spanish.

I mean, in California 40% of the population is Hispanic so there's quite a need.

But, also for the Asian languages that were also mentioned, Chinese, et cetera.

There are companies that have licensed to medical schools for curriculum for medical students to learn Spanish.

Canopy is one of them, and it's a company out of New York.

There's also been quite a movement within medical education over the years for students to have brown bag lunches and elective sharing of their knowledge.

Spanish speaking students, for example, teaching others in medical school about Spanish.

But, again, as was mentioned, it's not medical terminology that most Spanish speakers come from families that have Spanish in the home but they don't have fathers or mothers that are doctors and nurses.

So, we have to be careful about that.

And then, I also think that testing is important, and Kaiser Permanente is an example of a system who has required testing for certain levels of proficiency of language.

So, for the Latinos doctors in Kaiser who say they are Spanish speaking, they have to go through training and pass exams to be called on as a translator.

But, I think overall, the other issue is do we bring in more doctors from other countries that talk Spanish?

And, that's something that we have seen is hard because there's a quota system, and there's more foreign doctors that come from India and China than Latin America in this country.

And, that's a reflection of the policies of the ECFMG and Congress.

And, I don't know where you'd change that but we definitely need to see-- the need for language services could be helped by having more doctors or nurses, for example, from those countries that speak the languages that are needed here.

And then, the other thing I'll say is that there's definitely a need for reimbursement at all levels, but reimbursement especially in the poor communities that don't have top jobs or don't have-- I mean, don't have higher incomes and don't have insurance so that more community- and it's hard to think about this- but most people don't go to the doctor because they don't-- because they can't pay for it and they don't have insurance.

So, we continually need more prevention.

And, as was mentioned by CDC, our organization, the National Hispanic Medical Association does get grants for social community-based efforts working with partners in communities that are not medical.

For example, not clinics, but community-based groups who social media, and we also do just education of the community in general through health fairs and those types of thing.

And, I think that it's important to realize that so many people do need educational information in order to feel like they can-- (chuckles) that they are welcome to join the healthcare system!

But, we do need healthcare people to talk to them, whether it's community health workers, more community health workers, or more volunteers who are Spanish speaking or speaking the languages of the patients.

So, I'll stop there.

I think this has been a great opportunity to share ideas and I'll just stop there.

- Dr. Rios, a couple of questions.

First of all, we rely a lot on children to provide translation services for their parents.

How does that affect, first of all, patients' privacy?

And also, their ability to directly engage with their physicians?

- Yeah.

I think we heard that earlier too that it's really not good for the patients.

It's disrespectful really to have a mother or father have their children have to translate but, you know, at some point perhaps it's necessary for some basic information.

But when it comes to the personal information, that's not good.

And, I think that our-- again, it's the systemic changes that need to happen in our institutions, hospitals, and clinics and they should have access to some type of service, interpreter or translator service.

- [Sunita] Mm hm.

And, I think too, one of the most important things coming out of this briefing is clearly the need to create a pipeline of culturally sensitive healthcare providers.

And yet, at this point, less than 6% of our healthcare force are people of color.

What would you say about the need to create that pipeline and the barriers to creating that pipeline?

- Well, the biggest barrier right now is the U.S. Supreme Court's decision not to have race-based admissions into any higher education- - Yes.

- which is community colleges, colleges, universities, and you know you need to have at least three years of requirements to get into medical school or dental school or pharmacy school, and I think that we have to do what we can.

We have a NHMA College Health Scholars Program.

We mentor-- We have mentors from medical students to mentor pre-med students and public health students to mentor pre-public health students, and I know that Hispanic nurses, Hispanic dentists, other groups, all do the same thing.

We're very interested in having more of our professionals who have struggled through their educational career you know, to help and give back.

We also give scholarships to those students who are very interested and committed to helping our underserved communities.

They don't have to be Hispanic, but it is a scholarship for those students who made it into professional schools who need that extra funding.

Because, we all come from families that are middle class or lower-middle class and we know how hard it is to give up working and going to school for so many years.

Anyway, I think the other thing is the parents.

Parents do not realize, because many of the parents from our communities that are not professional parents, that come from lower-- Well?

From Latin American countries where they only go to school till middle school and then get married?

There's a big tradition in our communities of the values of working, the values of getting married, having a family.

And, they never know, they never thought that their family, their children, could go to medical school or dental school and in 10 years, right?

Waiting 10 years, could have a salary that's three times the average in our country.

And, it might not be that much to people but it's a lot to the families.

And eventually, most of the students who go to medical school that come from lower-income families end up helping their families, anyway.

So, it's just a matter of being able to help them even more.

So, the pipeline approach is important.

The pathways, the mentoring especially, we have found, really works.

Students can be very intelligent but be the first generation student that goes to college and don't know the first thing of how to study their science courses, especially organic chemistry.

That needs to be passed (chuckles) to get into medical school or dental school or pharmacy school.

So, we have a long way to go.

But, those programs do exist and I know that many, many institutions, all the universities and colleges that have medical schools, for example, get a lot of money to recruit and to help students prepare for the exams and interviews and all the steps needed [background music] to become a doctor or a dentist or a nurse.

So, we need to do more of that.

We need our state governments-- I know California passed a beautiful law.

I can't believe it, but they increased the taxes on the insurance companies in California to provide more residency slots in California and also to give more funding for the clinics in California and more training for pipeline programs.

And, that just happened with this-- whoever the leaders are of the health committees of the Senate and the Assembly in California along with Governor Newsom, they decided that healthcare training and education was so needed that they did that.

- Absolutely.

We have time, or I'm sorry, we should have had time for one final question but I see we're out of time!

[background music] So, thank you to all our speakers today and thank you for our reporters.

We'll see you next Friday!

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