Tuesday, August 15, 2006
Monday, August 14, 2006
The truly terrific and now recently graduated Jim Tomasewski points out this article in the New England Journal of Medicine entitled, "Language Barriers to Health Care," by Dr. Glenn Flores.
Here is a brief excerpt:
Inadequate communication can have tragic consequences: in one case, the misinterpretation of a single word led to a patient's delayed care and preventable quadriplegia.1 A Spanish-speaking 18-year-old had stumbled into his girlfriend's home, told her he was "intoxicado," and collapsed. When the girlfriend and her mother repeated the term, the non–Spanish-speaking paramedics took it to mean "intoxicated"; the intended meaning was "nauseated." After more than 36 hours in the hospital being worked up for a drug overdose, the comatose patient was reevaluated and given a diagnosis of intracerebellar hematoma with brain-stem compression and a subdural hematoma secondary to a ruptured artery. (The hospital ended up paying a $71 million malpractice settlement.)
In 1998, the Office for Civil Rights of the Department of Health and Human Services issued a memorandum regarding the prohibition, under Title VI of the Civil Rights Act of 1964, against discrimination on the basis of national origin — which affects persons with limited English proficiency. This memorandum states that the denial or delay of medical care because of language barriers constitutes discrimination and requires that recipients of Medicaid or Medicare funds provide adequate language assistance to patients with limited English proficiency. In 2000, a presidential executive order was issued on improving such persons' access to services. Thirteen states currently provide third-party reimbursement (through Medicaid and the State Children's Health Insurance Program) for interpreter services. Unfortunately, most of the states containing the largest numbers of patients with limited English proficiency have not followed suit, sometimes citing concerns about costs. Although the Office for Civil Rights issued guidelines in 2003 that seem to allow health care facilities to opt out of providing language services if their costs are too burdensome, Title VI provides no such exemption.
Ad hoc interpreters, including family members, friends, untrained members of the support staff, and strangers found in waiting rooms or on the street, are commonly used in clinical encounters. But such interpreters are considerably more likely than professional interpreters to commit errors that may have adverse clinical consequences.1,5 Ad hoc interpreters are also unlikely to have had training in medical terminology and confidentiality; their priorities sometimes conflict with those of patients; and their presence may inhibit discussions regarding sensitive issues such as domestic violence, substance abuse, psychiatric illness, and sexually transmitted diseases.5 It is especially risky to have children interpret, since they are unlikely to have a full command of two languages or of medical terminology; they frequently make errors of clinical consequence; and they are particularly likely to avoid sensitive issues.1,5 Given the documented risks associated with the use of ad hoc interpreters, it is of concern that the 2003 guidance from the Office for Civil Rights states that such use "may be appropriate."
Later this year, the California legislature will consider a bill prohibiting state-funded organizations from using children younger than 15 years of age as medical interpreters. Leland Yee, the California speaker pro tempore, proposed the bill, prompted by his experiences interpreting for his mother and, later, as a child psychologist. The bill requires organizations receiving state funding to establish a procedure for "providing competent interpretation services that does not involve the use of children."
Although this legislation may emerge as a state model, as an unfunded mandate, it will have limited power to improve care. Perhaps the time has come for payers to be required to reimburse providers for interpreter services. The provision of adequate language services results in optimal communication, patient satisfaction, outcomes, resource use, and patient safety.1,5 A 2002 report from the Office of Management and Budget estimated that it would cost, on average, only $4.04 (0.5 percent) more per physician visit to provide all U.S. patients who have limited English proficiency with appropriate language services for emergency-department, inpatient, outpatient, and dental visits. This seems like a small price to pay to ensure safe, high-quality health care for 49.6 million Americans.
The entire piece is well worth a read.
Here is an excerpt from last week's table of contents for JAMA concerning violence and human rights:
> Violence/Human Rights: 2 August 2006; Vol. 296, No. 5
> URL: http://jama.ama-assn.org/content/vol296/issue5/index.dtl?etoc
> This Week in JAMA
> This Week in JAMA
> JAMA 2006;296 477
> Original Contributions
> Neuropsychological Outcomes of Army Personnel Following Deployment to the
> Iraq War
> Jennifer J. Vasterling; Susan P. Proctor; Paul Amoroso; Robert Kane;
> Timothy Heeren; Roberta F. White
> JAMA 2006;296 519-529
> Approaches to Screening for Intimate Partner Violence in Health Care
> Settings: A Randomized Trial
> Harriet L. MacMillan; C. Nadine Wathen; Ellen Jamieson; Michael Boyle;
> Louise-Anne McNutt; Andrew Worster; Barbara Lent; Michelle Webb; for
> the McMaster Violence Against Women Research Group
> JAMA 2006;296 530-536
> Mental Health Problems Among Adults in Tsunami-Affected Areas in Southern
> Frits van Griensven; M. L. Somchai Chakkraband; Warunee Thienkrua;
> Wachira Pengjuntr; Barbara Lopes Cardozo; Prawate Tantipiwatanaskul;
> Philip A. Mock; Suparat Ekassawin; Anchalee Varangrat; Carol Gotway;
> Miriam Sabin; Jordan W. Tappero; for the Thailand Post-Tsunami
> Mental Health Study Group
> JAMA 2006;296 537-548
> Symptoms of Posttraumatic Stress Disorder and Depression Among Children in
> Tsunami-Affected Areas in Southern Thailand
> Warunee Thienkrua; Barbara Lopes Cardozo; M. L. Somchai Chakkraband;
> Thomas E. Guadamuz; Wachira Pengjuntr; Prawate Tantipiwatanaskul;
> Suchada Sakornsatian; Suparat Ekassawin; Benjaporn Panyayong; Anchalee
> Varangrat; Jordan W. Tappero; Merritt Schreiber; Frits van Griensven;
> for the Thailand Post-Tsunami Mental Health Study Group
> JAMA 2006;296 549-559
> Anxiety, Depression, and Posttraumatic Stress in Iranian Survivors of
> Chemical Warfare
> Farnoosh Hashemian; Kaveh Khoshnood; Mayur M. Desai; Farahnaz
> Falahati; Stanislav Kasl; Steven Southwick
> JAMA 2006;296 560-566
Thanks to Jim T. for the link.
Sunday, August 13, 2006
The New York Times has an article on the recent decision to loosen regulations on the use of prisoners to test experimental drugs. The article, entitled"Panel Suggests Using Inmates in Drug Trials"and written by Ian Urbina, states:
An influential federal panel of medical advisers has recommended that the government loosen regulations that severely limit the testing of pharmaceuticals on prison inmates, a practice that was all but stopped three decades ago after revelations of abuse.
The proposed change includes provisions intended to prevent problems that plagued earlier programs. Nevertheless, it has dredged up a painful history of medical mistreatment and incited debate among prison rights advocates and researchers about whether prisoners can truly make uncoerced decisions, given the environment they live in.
Supporters of such programs cite the possibility of benefit to prison populations, and the potential for contributing to the greater good.
Until the early 1970’s, about 90 percent of all pharmaceutical products were tested on prison inmates, federal officials say. But such research diminished sharply in 1974 after revelations of abuse at prisons like Holmesburg here, where inmates were paid hundreds of dollars a month to test items as varied as dandruff treatments and dioxin, and where they were exposed to radioactive, hallucinogenic and carcinogenic chemicals.
In addition to addressing the abuses at Holmesburg, the regulations were a reaction to revelations in 1972 surrounding what the government called the Tuskegee Study of Untreated Syphilis in the Negro Male, which was begun in the 1930’s and lasted 40 years. In it, several hundred mostly illiterate men with syphilis in rural Alabama were left untreated, even after a cure was discovered, so that researchers could study the disease. . . .
Under current regulations, passed in 1978, prisoners can participate in federally financed biomedical research if the experiment poses no more than “minimal” risks to the subjects. But a report formally presented to federal officials on Aug. 1 by the Institute of Medicine of the National Academy of Sciences advised that experiments with greater risks be permitted if they had the potential to benefit prisoners. As an added precaution, the report suggested that all studies be subject to an independent review.
“The current regulations are entirely outdated and restrictive, and prisoners are being arbitrarily excluded from research that can help them,” said Ernest D. Prentice, a University of Nebraska genetics professor and the chairman of a Health and Human Services Department committee that requested the study. Mr. Prentice said the regulation revision process would begin at the committee’s next meeting, on Nov. 2.
The discussion comes as the biomedical industry is facing a shortage of testing subjects. In the last two years, several pain medications, including Vioxx and Bextra, have been pulled off the market because early testing did not include large enough numbers of patients to catch dangerous problems.
And the committee’s report comes against the backdrop of a prison population that has more than quadrupled, to about 2.3 million, over the last 30 years and that disproportionately suffers from H.I.V. and hepatitis C, diseases that some researchers say could be better controlled if new research were permitted in prisons. . . .
The Institute of Medicine report was initiated in 2004 when the Health and Human Services Department asked the institute to look into the issue. The report said prisoners should be allowed to take part in federally financed clinical trials so long as the trials were in the later and less dangerous phase of Food and Drug Administration approval. It also recommended that at least half the subjects in such trials be nonprisoners, making it more difficult to test products that might scare off volunteers. . . .
TalkLeft has some serious concerns about this potential regulatory change and his piece also provides helpful links to the recent federal report "Ethical Considerations of Research Involving Prisoners." Thanks to TalkLeft for pointing me to this article.