Gastroenterology is unique among medical specialties in that nearly all practitioners routinely maintain both office- and procedure-based practices. A recent study at the Mayo Clinic in Rochester, MN, published in Digestive Diseases and Sciences, is the first to examine broadly and systematically the impact of patients’ limited English proficiency (LEP) on procedure-related gastroenterology care.

In an accompanying editorial, Mass General Brigham clinicians comment on the study results, its limitations, and directions for additional research. The authors are Christopher Vélez, MD, a gastroenterologist practicing in the Center for Neurointestinal Health at Massachusetts General Hospital, Christopher Kirwan, PhD, director of Medical Interpreter Services at Mass General, and Walter W. Chan, MD, PhD, director of the Center for Gastrointestinal Motility at Brigham and Women’s Hospital.

Study Highlights

Key facts about the study were:

• The researchers chose to study anorectal physiological testing of patients with chronic constipation, as such tests mainly evaluate patient-reported symptoms and require patient feedback

• 2% of the 3,298 patients included had LEP

• High-resolution anorectal manometry results were broadly similar between patients with LEP and English-proficient (EP) patients, but results of the balloon expulsion test and rectal sensory testing were more commonly abnormal among those with LEP

• Age >50, sex, and LEP independently predicted abnormal results in multivariable analyses, and LEP had the strongest influence

The authors believe the results are more likely to represent a difference in disease prevalence between the LEP and EP groups, for instance, due to referral bias than a difference in physiology or a language barrier.

Study Limitations

The Mass General Brigham editorialists call the study an “elegant” way to assess pitfalls that may arise when caring for patients with limited LEP. They also discuss the limitations of the report:

• The researchers speculate their patient population may be enriched with refugees and other individuals with an increased history of trauma or sexual violence that could influence test results, but they did not obtain such histories, and it isn’t clear whether displaced individuals in the cohort did outnumber patients who immigrated for socio-economic reasons

• The Mayo Clinic is a quaternary care center with a well-established global referral base, which may limit the generalizability of the results

• Anorectal testing is generally performed after a lengthy and complex diagnostic evaluation, so there may have been selection bias for individuals who were more experienced in navigating the healthcare system

Questions for Future Research

The editorialists note that during an anorectal examination, patients perform maneuvers that require interpretation, including some with timed parameters that don’t account for the extra time required when interpreters are involved.

The authors suggest questions for future research into the influence of LEP at different points of anorectal care, including:

• In the office, how can providers and interpreters caring for patients with LEP ensure accurate assessment of symptoms that can provoke embarrassment?

• During the examination, is over-the-phone interpretation sufficient, or should in-person interpretation be favored?

• Are pelvic floor physical therapists able to provide culturally competent instructions and interpretation?

The editorials conclude that considering the morbidity of diseases such as colorectal cancer and cirrhosis and the cost of potentially unnecessary testing, it’s essential to understand how to improve communication with patients with LEP.