clinical emergency medicine, critical medical anthropology
#SacramentoKings
The Sacramento Kings leadership and ownership groups have remained patient while #blacklivesmatter and other concerned citizens do the right thing and voice their anger in response to violence and asymmetrical power of law enforcement.
Do these guys seem angry? If I shoot your loved one in the head, you are not going to peacefully protest in response…
there comes a time when the sidelines start to look a lot like the bench player for one of the teams…
I have been guilty of under communicating in the ED – we are busy and we want to move on to the next patient. However, graduate student Seiichi Villalona and PGY-3 Christian Jeanot, MD, along with undergraduate Mery Yunez Yucosa have all been working to demonstrate the value of professional video translation services in the ED.
Seiichi has concentrated on showing how issues of undercommuniqation also lead to issues of healthcare autonomy and link to the important concept of healthcare deservingness.
For what it is worth, we now have an enterprise license for the Cyracom Video Intrepreation Application for use during clinical encounters. If you want to use this service – please see the last TGH/TEAMHealth Weekly Update.
Department of Emergency Medicine, Olive View–UCLA Medical Center, Sylmar, California. ([email protected]).
It was my first day of clinical rotations as a third-year medical student. We entered a small room in the emer- gency department to see a frightened woman with acute cholecystitis. One physician asked her how she was feel- ing, but after another physician said “Spanish-speaking only,” the first physician stopped speaking and instead approached the bedside and began to push on her ab- domen. “¿Dolor? ¿Dolor?” he asked. When the patient gri- maced, 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, hop- ing 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 nor- malizes undercommunication with patients of limited English proficiency.
Undercommunication potentially affects large num- bers of patients. According to the 2011 American Com- munities 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 ad- mit 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 eth- nicity of the name and recognized that—as it hap- pened—I might know the patient’s language. So I asked in that language how the patient was feeling. To every- one’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 video- based 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 profi- ciency. 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 pa- tient’s ankle, knee, and elbow have been injured, which has enabled the ordering of every one of the appropri- ate radiographic images. The fact that the injuries re- sulted from an episode of domestic violence, however, remains undiscovered, and the patient remains in dan- ger. 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 ac- cepted 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 depart- ment after hospital discharge.4 As a protection against in- adequate 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 ori- gin, which is interpreted to include those with limited English proficiency, and allows forfederal funds to be with- held if discrimination is found.5 All health care facilities that receive federal money must provide language assis- tance to patients with limited English proficiency.
Lack of knowledge and enforcement perpetuate un- dercommunication. Even when available, language as- sistance 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 in- terpreter 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 qual- ity of care. Proposed solutions should focus on chang- ing 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 pref- erence 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 inter- preter line on speed dial. If internet-based video inter- preter machines are used, the health care facility should assure sufficient internet capacity to minimize wait times and dropped calls. Health care organizations should proactively moni- tor quality indicators for the care of patients with limited English pro- ficiency and improve their communications systems when deficien- cies are found.
Placing language assistance directly at the disposal of the pa- tient is a complementary approach. A language advocate can visit hospitalized patients with limited English efficiency to teach about the right to language assistance and how to dial an interpreter.9 Elimi- nating the clinician’s role in the decision to involve an interpreter can improve communication and promote patient autonomy.
Access to a clinician who speaks the same language as the pa-tient may also improve care and health outcomes.10 Standards, training, and credentialing for the use of languages other than English by clinicians, however, should be implemented to assure compe- tence, just as they are for physicians who perform invasive proce- dures. Clear and 2-directional communication with patients with lim- ited English proficiency should be the rule, not the exception.
Additional Contributions: I would like to acknowledge Jerome Hoffman, MD, Professor Emeritus, UCLA Department of Emergency Medicine, for his input on this article. Dr Hoffman was not compensated for his input.
REFERENCES
Torreblanca A, Karter AJ. Association of patient-physician language concordance and
glycemic control for limited-English proficiency Latinos with type 2 diabetes. JAMA Intern Med. 2017;177(3):380-387.
I have been guilty of under communicating in the ED – we are busy and we want to move on to the next patient. However, graduate student Seiichi Villalona and PGY-3 Christian Jeanot, MD, along with undergraduate Mery Yunez Yucosa have all been working to demonstrate the value of professional video translation services in the ED.
Seiichi has concentrated on showing how issues of undercommuniqation also lead to issues of healthcare autonomy and link to the important concept of healthcare deservingness.
For what it is worth, we now have an enterprise license for the Cyracom Video Intrepreation Application for use during clinical encounters. If you want to use this service – please see the last TGH/TEAMHealth Weekly Update.
Department of Emergency Medicine, Olive View–UCLA Medical Center, Sylmar, California. ([email protected]).
It was my first day of clinical rotations as a third-year medical student. We entered a small room in the emer- gency department to see a frightened woman with acute cholecystitis. One physician asked her how she was feel- ing, but after another physician said “Spanish-speaking only,” the first physician stopped speaking and instead approached the bedside and began to push on her ab- domen. “¿Dolor? ¿Dolor?” he asked. When the patient gri- maced, 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, hop- ing 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 nor- malizes undercommunication with patients of limited English proficiency.
Undercommunication potentially affects large num- bers of patients. According to the 2011 American Com- munities 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 ad- mit 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 eth- nicity of the name and recognized that—as it hap- pened—I might know the patient’s language. So I asked in that language how the patient was feeling. To every- one’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 video- based 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 profi- ciency. 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 pa- tient’s ankle, knee, and elbow have been injured, which has enabled the ordering of every one of the appropri- ate radiographic images. The fact that the injuries re- sulted from an episode of domestic violence, however, remains undiscovered, and the patient remains in dan- ger. 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 ac- cepted 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 depart- ment after hospital discharge.4 As a protection against in- adequate 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 ori- gin, which is interpreted to include those with limited English proficiency, and allows forfederal funds to be with- held if discrimination is found.5 All health care facilities that receive federal money must provide language assis- tance to patients with limited English proficiency.
Lack of knowledge and enforcement perpetuate un- dercommunication. Even when available, language as- sistance 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 in- terpreter 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 qual- ity of care. Proposed solutions should focus on chang- ing 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 pref- erence 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 inter- preter line on speed dial. If internet-based video inter- preter machines are used, the health care facility should assure sufficient internet capacity to minimize wait times and dropped calls. Health care organizations should proactively moni- tor quality indicators for the care of patients with limited English pro- ficiency and improve their communications systems when deficien- cies are found.
Placing language assistance directly at the disposal of the pa- tient is a complementary approach. A language advocate can visit hospitalized patients with limited English efficiency to teach about the right to language assistance and how to dial an interpreter.9 Elimi- nating the clinician’s role in the decision to involve an interpreter can improve communication and promote patient autonomy.
Access to a clinician who speaks the same language as the pa-tient may also improve care and health outcomes.10 Standards, training, and credentialing for the use of languages other than English by clinicians, however, should be implemented to assure compe- tence, just as they are for physicians who perform invasive proce- dures. Clear and 2-directional communication with patients with lim- ited English proficiency should be the rule, not the exception.
Additional Contributions: I would like to acknowledge Jerome Hoffman, MD, Professor Emeritus, UCLA Department of Emergency Medicine, for his input on this article. Dr Hoffman was not compensated for his input.
REFERENCES
Torreblanca A, Karter AJ. Association of patient-physician language concordance and
glycemic control for limited-English proficiency Latinos with type 2 diabetes. JAMA Intern Med. 2017;177(3):380-387.
Discuss patients you have seen with the undergraduate ANT4930 students this semester. This day is always a favorite for the students – even if you can only spend 15 minutes with the class, the students will get A LOT from your insight. Please help us continue making this day a success. Thanks to Rachel Semmons, Jim Gillen, Melissa Leming, Reggie Saint-Hillaire, David Wein, Tabitha Campbell and anyone I may have forgot, who have all participated in prior years.
There will be breakfast and we would love to have you even for a few minutes. Please email me at [email protected] if you know you can come – thanks!
Also, special guest David Wein, MD, MBA will talk about medicine in New Zealand as well. Oh, and notice how he rocks the vest when he is there – maybe his vest feels threatened by my vest stateside!
Ok, now, stratify risk increase by level of lost exercise compared to same individuals benefit of taking a statin – any of the Emergency Medicine Sports Med interested folks want to ask for subject level data and knock out a quick quantitative model?
The TGH/USF ED Based Acute Care Research team increased our efficiency since initiating a novel operational model in Q2 2015 to enroll patients and conduct research that is synergistic to overall TGH goals while also integrating scholarly opportunities across learner types (residents, medical students, ARNP students, and premedical students) and across disciplines.
DISCLAIMER:I am working out my thoughts for an ACEP SA 2018 paper on how we designed and implemented an acute care research program based in the emergency department
10 KEY ELEMENTS TO THE SUCCESS OF THE TGH/USF ACUTE CARE RESEARCH PROGRAM
ok – so what made us more efficient? i will talk about that on the next post but in the meantime, please add comments below – especially if you are or were a member of the team!
Our group screens for HIV in the TGH ED and have identified close to 300 HIV+ patients since May 2016.
Currently, we do not initiate antiretroviral therapy (ART) when HIV positive patients are identified. However, this week, an article in JAMA adds to a growing body of evidence that ART should be and can be safely started during an acute clinical encounter based on global health data from the recently completed CASCADE Trial.
The authors conclude that:
“Conclusions and Relevance Among adults in rural Lesotho, a setting of high HIV prevalence, offering same-day home-based ART initiation to individuals who tested positive during home-based HIV testing, compared with usual care and standard clinic referral, significantly increased linkage to care at 3 months and HIV viral suppression at 12 months. These findings support the practice of offering same-day ART initiation during home-based HIV testing.”
This publication allows for a timely of our efforts to move HIV screening, linkage, and treatment forward in the ED setting.
The HIV screening algorithm was revised in 2006 by the CDC and written for an asymptomatic screening population but is being utilized in the ED as well by our group and others, as requested by the CDC that individuals be screened at any point of entry into the health care system.
In our ED, we have modified the algorithm slightly in order to obtain a viral load as quickly as possible in patients that have a reactive screen/presumptive positive in order to act more quickly on results in a vulnerable patient population with a high pretest probability for disease. We do not wait for a confirmatory prior to running a viral load analysis of the patient blood sample.
A reactive screening test will ultimately result in a viral load test (either the confirmatory test will be negative and a viral load will be needed in this equivocal setting or the confirmatory test will be positive and a viral load will be needed by those who initiate treatment and in order to stratify the degree of HIV illness that the patient has at that point in time). Therefore, since we may only get one encounter with the patient in the ED and the result may presumed to be positive, we achieve the viral load immediately. This also helps prime our site for future pathways that might be adapted to same encounter viral load results that would allow definitive positive diagnoses and, potentially, initiation of therapy during that visit.
The difference, we are learning, is that an ED population undergoing HIV screening represents both asymptomatic patients as well as patients with viral like symptoms who may be presenting with HIV clinical seroconversion or even longstanding HIV.
As a matter of fact, some of our patients diagnosed during the first year of our screening project visited the ED in the prior year with HIV consistent symptoms and another group of our acute HIV+ patients (positive screen, negative confirmatory test, positive viral load) also came in to the ED on day of diagnosis with symptoms consistent with HIV.
Above poster presented at Symposium by the Sea 2017 by Sri Palakurty
Our work now centers not just on linkage to care, but also trying to create a highly reliable system of result interpretation in the ED given the pretest probability of a patient during a specific clinical encounter.
In other words, we would like ED physicians, including myself, to trust a positive result is positive. However, the quick turn around time of the HIV Ab/Ag screen means that the effective false + rate (+ screen, neg confirmatory) has been over 10% (i.e. 10% of those with a reactive test will go on to have a negative confirmatory test). In addition, we have learned that our patients do seek diagnosis of HIV symptoms in the ED when HIV status is unknown. Given the acute nature of presentation, we also fear that a patient may present in the HIV Ag/Ab non-detectable window and haven even discovered a patient with a negative screening test but positive viral load.
Thus, the quicker we turn around viral load results, the more rapidly we can place patients on HIV treatment with antiretroviral therapy (ART). While prior concerns regarding resistance were expressed in earlier days of therapy, the high prevalence in the United States of HIV-1 makes these concerns less relevant. In addition, prior work on preexposure prophylaxis (PrEP) and on-demand prophylaxis has not demonstrated patterns of resistance even when drug is taken in a staccato nature.
Therefore, our group feels strongly that rapid HIV viral load testing in high risk individuals and individuals with symptoms consistent with HIV (i.e. diagnostic test in stead of screening) is critical to increasing the ED uptake of an HIV screening and treatment strategy. The development of HIV PCR test kits that turn around times less than 3 hours and run on a single cartridge are especially interesting to our efforts.
In addition, we feel that physicians should be comfortable with the results of HIV testing in the ED – meaning that the results are highly reliable and can be acted upon by prescribing ART in the acute setting, assuming there is no evidence of TB (still a concern for some of the medications but can easily be discovered through history and physical exam during the same encounter).
Barriers to ED initiation of therapy are rooted in prior complexities of treatment and persistent assumptions regarding challenges in starting therapy. Stanley et al., reviewed some of these myths in an important Annals of Emergency Medicine paper in 2017.
One of the most prevailing myths leading to difficulty starting acute HIV treatment programs revolves around the issue of drug resistance in patients that do not maintain their drug regimen.
“Certain conditions such as nonadherence allow the HIV virus to mutate to ‘beat’ or become resistant to the drug regimen that the patient is prescribed. Earlier drugs were highly susceptible to resistance; very few mutations could
easily knock out an entire drug and other drugs within the same class. Drug failure would quickly lead to virus resistance, which would limit future therapy options”
“As a consequence, physicians were worried about starting medications in patients for whom adherence might be a question for fear of hastening these resistance patterns.”
However, the success of PrEP and on-demand PrEP therapy as well as properties of new drugs such as protease inhibitors, seem to have a much higher barrier to resistance and the benefits of initiating drug likely outweigh any perceived, small risk of developing an unfounded drug resistance using newer agents.
When I was training, many patients did not start therapy until their CD4 counts dropped below 500 cells/mm3. However, the ability to decrease transmission and the improved side effect profile of ART in 2018 has made the time to initiate drugs clearly as early as possible. In 2015, the Strategic Timing of Antiretroviral Treatment (START) was published, lending strong evidence to early drug initiation.
If Emergency Medicine physicians can deal with the complexities of CAP, HCAP, HAP, & VAP antibiotic selection as well as myriad other difficult drug dosing decision made daily during a clinical shift, fairly simple algorithmic dosing will not be complicated in the future.
At our institution, the infectious disease team works with ED leadership to maintain an occupational post-exposure prophylaxis (oPEP) pathway. However, non-occupational PEP (nPEP) is not well delineated.
Currently, our HIV group is working with an adolescent medicine physician, Diane Straub, MD, MPH, who recently developed a nPEP clinic pathway which allows access to drug for even those with no insurance funding using a commercial retail pharmacy.
Another nPEP pathway was published in the above mentioned Annals article from 2017 and is also easy to follow once implemented.
The existence of CDC guidelines for nPEP and PrEP make pathway implementation in an ED potentially filled with less barriers than initiating ART in all patients with an acute HIV+ diagnosis .
However, the evidence continues to mount that the benefits of initiating ART in the acute setting outweighs the risks. In the future, a specific ED based screening algorithm that differentiates patients that need HIV testing secondary to clinical concern would be useful. That future algorithm should also include specific ED based strategies for oPEP, nPEP, PrEP and initiation of ART.
The CASCADE trial published in JAMA was also accompanied by an editorial.
This recent publication of CASCADE and the same issue editorial comments make a clear case in the context of other acute HIV literature in the setting of newer ART that we must continue to move screening, diagnostic, linkage and treatment strategies into new directions to ultimately eradicate HIV.
